Pregunta 92. Cuál es la causa de la encefalopatia de esta paciente?


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A 58-year-old woman with a history of chronic kidney disease, diabetes mellitus, hypertension, and coronary artery disease is admitted to the ICU with urosepsis where she receives cefepime and vancomycin. Neurology consult reveals poor attention, inconsistent answers, and somnolence, but the patient can follow simple commands. Examination reveals spontaneous irregular, asymmetric myoclonus of the arms and face that are enhanced with muscle movement. EEG shows global diffuse slowing, and an MRI scan of the brain shows chronic severe microvascular disease but no acute changes. Results of laboratory studies reveal a serum creatinine of 2.2 mg/dL, WBC of 12 × 109/L, and normal liver function studies, including ammonia, thyroid studies, and antibodies. Which of the following is the most likely explanation for the patient’s presentation?

A. Myoclonic encephalopathy associated with cefepime and chronic renal disease **
B. Postanoxic myoclonus (Lance-Adams syndrome) due to a hypotensive episode
C. Meningoencephalitis due to viral or bacterial pathogens
D. Hypertensive encephalopathy due to poorly controlled blood pressure
E. Uremic encephalopathy due to acute on chronic renal disease
** = Your answer

Antibiotics are an underrecognized class of medications associated with acute neurologic complications in the hospital. Cephalosporin and penicillin have been associated with encephalopathy, often occurring with seizures and/or myoclonus. The shared β-lactam ring structure among penicillin, cephalosporins, and carbapenems are believed to decrease release of the neurotransmitter GABA from nerve terminals and lower the threshold for seizure generation. The known neurotoxic effects of β-lactam antibiotics include slurred speech, tremor, encephalopathy, and seizures, and reported risk factors include significant renal injury, damage to the blood-brain barrier, preexisting CNS disease, and old age. All penicillin can produce encephalopathy, myoclonus, and seizures if given in high enough doses or in patients with renal failure. All four generations of cephalosporins have been associated with neurologic complications. Truncal asterixis, or negative myoclonus involving the trunk and lower extremities, has been reported in a patient with chronic renal failure treated with ceftazidime for cellulitis. Cephalosporin toxicity is often associated with renal failure. Cefepime, a fourth-generation cephalosporin, has been increasingly recognized as a cause of reversible encephalopathy, myoclonus, and sometimes seizures in the setting of concomitant renal disease. Additional clinical features include hallucinations, agitation, and coma. Hemodialysis may be effective if urgent clearance is necessary, as may be the case when nonconvulsive status epilepticus secondary to cefepime neurotoxicity is refractory to antiepileptic drug therapy.
* Hocker S. Neurologic complications of drug therapies. #C20 | Neurologic Complications of Medical and Surgical Therapies C20 AAN 2017

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