Acute Encephalopathy Following Hyperbaric Oxygen Therapy in a Patient on Metronidazole
This case describes a patient who presented to the emergency department for an acute onset of encephalopathy following hyperbaric oxygen treatment and antibiotic therapy for radiation-induced osteonecrosis of the jaw.
Esther Baldinger is a Staff Neurologist; Igor Sirotkin and Carlos Martinez are Neuroradiologists; and Alfred Frontera is Chief of Neurology; all at C.W. Bill Young VA Medical Center in Bay Pines, Florida. Waylon Zeng, Jennifer Rizzo, and Elizabeth Murphy are Medical Students; Igor Sirotkin is Assistant Professor of Radiology; and Esther Baldinger and Alfred Frontera are Associate Professors of Neurology; all at University of Central Florida College of Medicine in Orlando. Igor Sirotkin is an Assistant Professor and Carlos Martinez is an Associate Professor of Radiology, both at the University of South Florida College of Medicine in Tampa. Correspondence: Waylon Zeng (waylonzzz@ knights.ucf.edu)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Conclusion
This patient’s highly specific MRI findings, neurologic examination consistent with confusion, ataxia, length-dependent sensory neuropathy, and 360-g cumulative dose of metronidazole over the previous 6 months suggest he experienced MIE. The mechanism of how HBOT precipitated the patient’s altered mental status, incoordination, and worsening of peripheral neuropathy is unknown. Although encephalopathy with MRI abnormalities as described is not a reported AE of HBOT, it may be unrecognized. It is possible that without HBOT the patient would have remained asymptomatic apart from his peripheral neuropathy.
We propose HBOT may exacerbate or increase the risk of a patient developing MIE. Our patient was able to safely resume HBOT after metronidazole was discontinued, suggesting that the combination was the causation for the development of encephalopathy. We do not believe any similar cases have been reported.
