https://openworks.mdanderson.org/edwk22/1005/thumbnail.jp

Fatima, Huda

Kebriaei, Partow

Qazilbash, Muzaffar H

English

OpenWorks @ MD Anderson

Cephalosporin Induced Neurotoxicity-A Rare Cause of Acute EncephalopathyNames of authors: 1. Huda Fatima, 2. Partow Kebriaei 3. Muzaffar H. QazilbashAffiliation: 1. Mercy St. Vincent Medical Center, Toledo, Ohio, 2-3. MdAnderson Cancer Center, Texas.CASE: A 63 year old male with history ofmelanoma, marginal lymph zone lymphoma,recently treated for AML with stem celltransplant on 1/6/21, was hospitalized fordiarrhea related to GI GVHD and sapovirusinfection. He was treated with steroid taperalong with tacrolimus for GVHD, and withnitazoxanide and immunoglobulins forsapovirus colitis and was started on IVcefepime for concern of sepsis secondary topneumonia. He started displaying signs ofconfusion and expressive aphasia. Heunderwent bronchoscopy, BAL culturesgrew Stenotrophomonas but he remainedasymptomatic on room air. CT head andMRI brain did not show any acuteabnormality. Neuro-oncology was consultedand EEG showed intermittent diffuseslowing, suggestive of widespread cerebraldisturbance but no epileptiform discharges.Lumbar puncture CSF studies were negativefor bacterial or viral meningitis. Despitebeing on broad spectrum antibioticsincluding cephalosporins, patient’smentation continued to deteriorate withdystonia, stereotypical movements, religiousdelusions, emotional lability. He was treatedwith IV benzodiazepine and haloperidolrecommended by Psychiatry with concernfor diagnosis of possible hyperactivecatatonia. Cephalosporins were discontinuedon 3/20/22 due to possible risk ofcontributing to encephalopathy. Patientshowed marked improvement in mentationwithin 36 hours. The ultimate workingdiagnosis was cephalosporin inducedtoxicity.CLINICAL AND IMAGING FINDINGS:• Reduced consciousness• Confusion• Psychosis (hallucinations, delusions)• Agitation• Convulsion• Tremor• Delirium• Coma• Myoclonus• Cerebellar toxicity• Language dysfunction• EEG: Tri-phasic waves/ Multi-focal sharp waves/ Non-convulsive status epilepticus / Generalized slowing/ Myoclonic status epilepticusPREDISPOSING FACTORS:• Older age group• Reduced renal clearance• Underlying neurological disease• Increased inflammation of blood brain barrier• Critically sick• Supratherapeutic dosingMECHANISM OF ACTION:Upon crossing the BBB,cephalosporins may inhibitGABA release orcompetitively antagonizegamma-aminobutyric acid(GABA) A receptors; thisresulting excitatorypotential manifests asaltered mentation.DIFFERENTIAL DIAGNOSES:• Steroid induced psychosis• Seizure like activity• Toxic encephalopathy due to drug overdose/ toxins• Metabolic encephalopathy due to sepsis/ infections etc.• Acute delirium• Posterior Reversible EncephelopathySyndrome due to tacrolimus.TREATMENT:• Antibioticdiscontinuation• Antibiotic-free intervalwith dose reduction• Hemodialysis• BenzodiazepineCITATIONS:1. Payne LE, Gagnon DJ, Riker RR, et al. Cefepime-induced neurotoxicity: a systematic review. Crit Care. 2017;21(1):276. Published 2017 Nov 14. doi:10.1186/s13054-017-1856-12. Keerty D, Shareef NA, Ramsakal A, Haynes E, Syed M. Cefepime-Induced Encephalopathy. Cureus. 2021;13(2):e13125. Published 2021 Feb 4. doi:10.7759/cureus.13125

Cephalosporin Induced Neurotoxicity-A Rare Cause of Acute Encephalopathy

https://openworks.mdanderson.org/cgi/viewcontent.cgi?article=1005&context=edwk22

Cephalosporin Induced Neurotoxicity-A Rare Cause of Acute Encephalopathy

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