Division of Neurology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
Received date: October 26, 2015; Accepted date: October 30, 2015; Published date: October 31, 2015
Citation: Jitprapaikulsan J, Srivanitchapoom P (2015) Combined Encephalopathies in Severe Malnutrition and Liver Abscess Treated with Metronidazole. J Neurol Neurophysiol 6:i104. doi:10.4172/2155-9562.1000i104
Copyright: © 2015 Jitprapaikulsan J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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A 69-year-old woman presented with deterioration of level of consciousness and ataxia for 2 weeks. She was diagnosed pyogenic liver abscess 3 months ago and had developed severe malnutrition since then. Liver abscess was successfully treated with ceftriaxone and metronidazole 1 month ago. Drowsiness, horizontal nystagmus, cerebellar dysarthria and ataxia were observed. She was clinically diagnosed Wernicke’s encephalopathy (WE). Interestingly, her brain MRI showed a combination of typical finding  including mammillary bodies (Figure 1A and 1B; black arrow), and pontine tegmentum hyperintensities (Figure 1C; head arrow). Atypical findings of red nucleus (Figure 1A; white arrow), splenium (Figure 1B; head arrow), and dentate nucleus hyperintensities (Figure 1C; black arrow) of WE which were described in metronidazole-induced encephalopathy (MIE) . Gradient echo sequence showed small bleeding in left dentate nucleus (Figure 1D; arrow). Combined WE with MIE were diagnosed. All neurological symptoms were disappeared after intravenous infusion of thiamine. Combined WE and MIE are a rare condition but they can concomitantly occur in the setting of severe malnutrition with history of taking metronidazole. In addition, bbleeding in dentate nucleus has never been described in literature.