Toxic-metabolic encephalopathy induced by metronidazole and disulfiram: classics never die

A 53-year-old male with recovering alcohol dependency, diagnosed with bipolar disorder and recurrent episodes of diverticulitis, came to the emergency department with disorientation and confusion after 3 days of treatment with metronidazole 250 mg/12 hours and ciprofloxacin 500 mg/12 hours for acute diverticulitis. In the hospital emergency department, he presented moments of agitation, fluctuations of attitude, increased basal tremor, with rhythmic movement of the left arm and leg, as well as generalised rigidity with an episode of tonic-clonic seizure of 1.5-2 min duration. After performing different diagnostic tests, significant brain findings were ruled out. The pharmacy department recommended the discontinuation of one of the two drugs. As a result, the on-call doctor adjusted the patient's treatment: disulfiram and previous antibiotic therapy (metronidazole and ciprofloxacin) were discontinued, and amoxicillin/clavulanic acid 2 g/8 hour was prescribed instead. The patient progressed well and fully recovered.