Metronidazole-Induced Encephalopathy With Probable Crohn Encephalitis: A Case Report.

OBJECTIVES: Metronidazole central nervous system toxicity is a rare finding in patients receiving the medication. We report a peculiar case of metronidazole central nervous system toxicity in which both the underlying condition (Crohn disease) and the drugs used to treat it are potential causes of encephalopathy. METHODS: A 26-year-old female with 6-year history of Crohn's disease for 6 years presented acute-onset encephalopathy. We provide bibliographic evidence to support metronidazole toxicity and potential Crohn disease-associated neurologic involvement. RESULTS: The patient presented dystonia, cerebellar ataxia, and altered mental status. Magnetic resonance imaging of the brain revealed typical findings of metronidazole toxicity and white matter involvement of the centrum semiovale. Immunoelectrophoresis and immunofixation of serum and cerebrospinal fluid proteins were consistent with a systemic inflammatory process. We concluded on an association between drug toxicity and probable Crohn-associated neurologic involvement. Metronidazole was stopped and the patient was placed on vitamin therapy and diazepam to control dystonia. She deteriorated and was transferred to the intensive care unit where she expired. CONCLUSIONS: Acute behavioral changes in a young patient constitute an emergency and differential diagnoses should include infective, inflammatory, metabolic, and toxic causes. Metronidazole is a potential toxic etiology.

Anti-MDA5 antibody-positive dermatomyositis with mild encephalopathy with reversible splenial lesion: a possible rare association?

Central nervous system (CNS) involvement in dermatomyositis (DM) is seldom observed. However, there are very rare case reports of CNS involvement with juvenile dermatomyositis. Encephalopathy in DM may occur for a number of reasons, such as cerebral vasculitis and hypoperfusion/hypertensive encephalopathy, but mostly as a consequence of immunosuppressant treatment. We report here for the first time the case of a patient with two rare diseases, namely anti-MDA5 antibody-positive dermatomyositis and mild encephalopathy with reversible splenial lesion (MERS).

Severe Headache, Paraesthesias, Facial Diplegia and Pleocytosis: A Misleading Presentation of Guillain-Barré Syndrome.

Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy. Progressive limb weakness, diminished/absent reflexes, sensory disturbance, and variable autonomic dysfunction are its core clinical manifestations. Bifacial weakness with paraesthesias (BFP) is a rare regional variant of GBS and is characterized by simultaneous facial diplegia, distal paraesthesias and minimal or no motor weakness. The association of headache with classic GBS has been rarely reported in the literature, and has not yet been described in the BFP variant. Here we report a misleading case of BFP variant associated with severe headache and mild pleocytosis. The repetition of nerve conduction studies (NCS) was extremely beneficial in this confusing case. LEARNING POINTS: Bifacial weakness with paraesthesias (BFP) is a rare regional subtype of classic Guillain-Barré syndrome.Severe headache can be a symptom of the BFP variant.The association of headache, BFP and pleocytosis can be confusing, particularly if initial nerve conduction studies are unrevealing.

Anterior horn syndrome: A rare manifestation of primary Sjögren's syndrome.

The authors report an exceptional case of an anterior horn syndrome associated with Sjögren's syndrome in a 58-year-old patient with a flaccid tetraparesis revealed by asymmetric atrophy and diffuse fasciculations associated with xerostomia and xerophthalmia. The electroneuromyography objectified a diffuse anterior horn syndrome. The brain MRI and spinal cord were normal. Laboratory tests revealed positive anti-SSA and anti-SSB antibody. The salivary glands biopsy objectified lymphocytic sialadenitis grade 3 of Chisholm. The Schirmer's test was abnormally low. Diagnosis of anterior horn syndrome as part of Sjögren's syndrome was retained. The methylprednisolone bolus allowed partial clinical improvement after 12 months of evolution. Therefore, in patients with isolated anterior horn involvement, a correct diagnosis of the underlying SS is often delayed or overlooked entirely; in these instances, standard clinicoserological assessment is recommendable.

Misdiagnosed spontaneous intracranial hypotension complicated by subdural hematoma following lumbar puncture.

INTRODUCTION: Spontaneous intracranial hypotension is an infrequent cause of secondary headache due to cerebrospinal fluid (CSF) hypovolemia. OBJECTIVE: To describe a case of headache revealing spontaneous intracranial hypotension complicated by subdural hematoma following lumbar puncture. OBSERVATION: A 34-year-old man presented with acute postural headache. The first cerebral computed tomography scan was normal. Lumbar puncture showed hyperproteinorachy at 2 g/L with six lymphocytic cells. The headache became very intense. At admission, clinical examination was normal. Ophthalmological examination did not show any abnormalities. Encephalic magnetic resonance imaging (MRI) showed bilateral subdural hematoma with tonsillar descent simulating Chiari type I malformation. After surgical drainage and symptomatic treatment, the patient was discharged with no recurrence. CONCLUSION: Spontaneous intracranial hypotension is associated with simple clinical presentation, orthostatic headache, and characteristic MRI findings. Misdiagnosed, it leads to unnecessary procedures.

[Unusual acute encephalopathy in a young patient with end-stage renal disease]. / Encéphalopathie aiguë inhabituelle chez un jeune patient insuffisant chronique terminal.

Posterior reversible encephalopathy represents a neurotoxic state which can be associated to different pathological situations. The key to diagnosis are characteristic features on magnetic resonance imaging and rapidly evolving neurological symptoms if recognized and treated rapidly. Arterial hypertension and preeclampsia are the main causes of posterior reversible encephalopathy. Metabolic disorders including renal failure can also be associated with this syndrome. We report the clinical observation of an 18-year-old young patient on chronic hemodialysis who presented a status epilepticus associated with hypertensive crisis, two weeks after his transfer to peritoneal dialysis. Magnetic resonance imaging showed a typical aspect of posterior reversible encephalopathy with intracerebral haemorrhage. The evolution was favorable with a clear improvement of encephalic lesions.