Objective: Present and discuss a case report showing neurotoxicity peripheral and central nervous system–associated with metronidazole use.

Background: Due to the extensive clinical use of metronidazole and the limited recognition of its complications. It is essential to report this case.

Method: Case Report

Results: A 79-years-old female presented with a 3 months history of vertigo, slurring of speech and unsteady gait. There was no history of diabetes mellitus or alcohol consumption. She had been taking oral metronidazole 500 mg 3 times a day and ciprofloxacin 500 mg twice a day for a fistulized right psoas abscess and infectious aortitis since 1 month before symptoms. She presented confusion, progressive painful paresthesias involving lower limbs and severe impairment gait of 3 weeks’ duration. On admission, the estimated cumulative metronidazole dose was about 180 g. She was unable to stand or walk. She was disoriented. She had staccato speech. Deep tendon reflexes: ankle were absent with plantar flexor response. She had loss of pinprick sensation below the knees. She presented dysmetria and dysdiadochokinesia and severe trunk and gait ataxia. MRI brain on T2 and FLAIR images showed bilateral symmetrical hyperintensities involving the dentate nucleus of the cerebellum and dorsal pons.(Fig 1) Based on these findings, metronidazole toxicity was suspected, and the drug was discontinued. She experienced a marked improvement evident during the first week. Her orientation, speech and gait returned to normal but a limb burning sensation was not completely relieved. A MRI brain realized 6 weeks after showed near-complete resolution of lesions within the dentate nuclei and dorsal pons.(Fig 2). A MRI brain taken 3 month after showed complete resolution of the cerebellar dentate lesions (Fig 3). Peripheral neuropathy persisted, even 6 months after discharge. In our case, the diagnosis was made clinically, ruling out other clinical and radiological differentials diagnosis and was supported by the MRI findings.

Conclusion: Recognition of metronidazole-induced neurotoxicity depends upon high clinical suspicion, it must be considered whenever a patient using metronidazole experiences a subacute cerebellar syndrome, encephalopathy or polyneuropathy and specific MRI abnormalities of bilateral increased T2/FLAIR signal of the dentate nuclei. The most remarkable feature is complete or near-complete resolution of symptoms and of the original lesions on follow-up MRIs.

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