Neuro-Behçet’s disease mimicking cerebral abscess complicated by metronidazole-induced encephalopathy

This is the report of a 32-year-old man with Behçet’s disease described dizziness, double vision and headache. The cranial MRI demonstrated a ring enhancing nodular lesion in left medial occipital lobe, and T2 hyperintense lesion in diencephalon mimicking abscesses. A stereotactic biopsy was performed. The histology showed features of neuro-Behçet’s disease and an abscess was ruled out. During the procedure till the histopathologic results were gathered he was given ceftriaxone and metronidazole when cerebellar signs appeared. Cranial MRI showed additional symmetrical hyperintensities in bilateral cerebellar dentate nuclei which was attributed to metronidazole toxicity. Repeat MRI performed forty days later showed complete resolution of both dentate hyperintensities and diencephalic and occipital ring enhancing lesions. This is the first case of neuro-Behcet’s disease complicated by metronidazoleinduced encephalopathy. This case also showed that nodular ring enhancing lesions can be seen in neuro-Behçet’s disease and can lead to difficulties in diagnosis and management. INTRODUCTION Neurology Asia 2015; 20(3) : 291 – 295 Address correspondence to: Nese Celebisoy, M.D., Ege University Faculty of Medicine, Neurology Department, Ankara Street, 35100, Bornova, Izmir, Turkey. Tel:+905332654508, e-mail:nes‚ [email protected], [email protected] Behçet’s disease (BD) is a chronic, relapsing multisystem inflammatory disorder first described by the Turkish dermatologist Hulusi Behçet in 1937. Inflammatory perivasculitis can arise in almost any tissue. Nervous system involvement is one of the most serious manifestations of BD and has been reported to occur in 5.3% up to 59% in hospital based series, usually after systemic manifestations from months to years. Two different patterns of Central nervous system (CNS) involvement have been defined: parenchymal and nonparenchymal or vascular. Vascular BD can be confirmed by computed tomographic angiography, magnetic resonance angiography, or magnetic resonance venography. Magnetic resonance imaging (MRI) is the examination of choice for the study of parenchymal involvement in BD. Mesodiencephalic junction, cerebellar peduncles, pons, medulla, basal ganglia, internal capsule, and cerebral hemispheres are the commonly involved sites. We describe a case of parenchymal BD with nodular abscess-like lesions who was diagnosed with stereotactic brain biopsy. As an infection could not be excluded before the histopathologic examination he was treated with ceftriaxone and metronidazole which caused metronidazoleinduced encephalopathy.