Metronidazole-induced Encephalopathy that Developed after Liver Transplantation

Abstract

The patient was a 57-year-old man with a history of liver transplantation from a living donor for decompensated liver cirrhosis due to Budd-Chiari syndrome at the age of 46 years. Although he had repeated enterocolitis and hepatic encephalopathy due to portal hypertension caused by postoperative portal vein stenosis, there were no signs of hepatic failure, and he was being followed on an ambulatory basis. While on steroid therapy for acute interstitial pneumonitis, he developed Clostridium difficile enterocolitis. The symptoms of enterocolitis were improved by oral metronidazole, but the symptoms of enterocolitis were not completely cured, and oral metronidazole 1 g/day was resumed and continued. Approximately two months later, difficulty in oral medication management, dysarthria, and finger tremor appeared. One week after the symptoms appeared, aggravation of consciousness disturbance was observed. Magnetic resonance imaging of the head showed bilaterally symmetrical high signal intensity areas in the dentate nucleus of the cerebellum. The patient was diagnosed as having metronidazole-induced encephalopathy. Metronidazole was discontinued immediately, and the patient's level of consciousness improved gradually. The development of metronidazole-induced encephalopathy is rare, and there have been few reports related to liver transplantation and liver injury. This case is reported together with a review of the literature.