Antibiotics/gadopentetic acid/gadoxetate disodium

Abstract

Tonic-clonic seizures and diffuse cerebral oedema due to medication error, and lack of efficacy: case report A 40-year-old man developed tonic-clonic seizures and diffuse cerebral oedema following unintentional direct intraventricular injection of contrast agents gadoxetate disodium and gadopentetic acid. Additionally, he exhibited lack of efficacy during treatment with vancomycin and cefotaxime for intracerebral abscess due to Streptococcus [not all dosages stated]. The man was admitted with a 1-week history of progressive headache and vomiting. A brain MRI with peripheral enhancement using gadoxetate disodium 10mL [gadolinium diethylenetriamine penta-acetic acid] and gadopentetic acid injections [Magnevist] revealed right parietal lesion, hypointense on T1-WI, hyperintense on T2-WI. Further investigations led to the diagnosis of intracerebral abscess and he underwent an emergent surgery for drainage of the septic collection. Bilateral hydrocephalus related to ventriculitis was noted in postoperative MRI. Bacteriological investigations of the septic sample revealed multisensitive Streprococcus, and he was treated with IV vancomycin and IV cefotaxime. A brain CT scan revealed an oedema around the residual cavity. He further became febrile and confused with a progressive onset of a left hemiplegia. Ciprofloxacin and vancomycin were added. He became aphasic and developed an epileptic seizure after 14 days of the surgery. A repeat brain CT scan revealed biventricular hydrocephalus associated with cerebral oedema. The man underwent a surgery to set up an external ventricular shunt (EVD) that led to an improvement of his neurological status. After 25 days of EVD, he experienced worsening of his state of consciousness. Left ventricular dilatation was noted on a brain CT scan. An imaging revealed the existence of different abscesses that developed separately inside each of the ventricles, without any communication between these structures. He then underwent another surgery to set up an EVD and an improvement was noted; however, he remained septic despite 33 days of cefotaxime and 20 days of vancomycin treatment (lack of efficacy). Hence, vancomycin was switched to rifampicin, after which his general and neurologic status improved and he regained perfect state of consciousness. A brain MRI demonstrated extensive abnormal enhancement inside the right lateral ventricle, on the basal cisterns and leptomeningeal enhancement. Based on these findings and the observation that he developed tonic-clonic seizure shortly following administration of contrast agents injections during MRI, inadvertent intraventricular administration of the contrast agents was noted that led to neurotoxicity. The injection was administered through a ventricular catheter, which was thought to be a venous tube located in the right forearm. Thereafter, his condition worsened and he opened eyes only to pain with no motor or verbal responses. After 24h of the last MRI, a head CT scan revealed diffuse cerebral oedema with crowding of the basal cisterns. The ventriculostomy pressure valve was set to zero; however, he experienced several episodes of status epilepticus with persistent postictal coma and labile BP that varied between systolic of 17 and 6. Two days later, he died due to cardiorespiratory arrest.