Dear Joaquin,

it is possible. Especially in the elderly patients penetration of metronidazole in to the CNS is higher. This is seen particulary in psychiatric patients and is higher in patients who take these medications (metronidazole and nitrofurantoin). This problem, why hydrophillic substance penetrates in to the CNS can be explained by differences in the volume of distribution, which is different for those patients. From these differences there are serious adverse events more possible and can be even life threatening, because we are in big lack of these data.

I work as psychiatric clinical pharmacist and usually deal with these patients and adverse events. It is easy to say according to the guidelines use nitrofurantoin and metronidazol, however these patients are different and i guess that cooperation between clinical pharmacist and clinician is the best possible choice for the best clinical outcomes.

If You want Joaquin we can write case report together, it is very useful paper (see my papers on this topic; CNS and antimicrobial agents and adverse events. In this case (your case) the relationship between effect (event) and C ss (in stable state) in evident and from maximal concentracion we can establish relationship. In my view and with use of Naranjo Scale this is at least possible (6-8 points). Because of serial adverse event rechallenging of drug is impossible in this case, which will establish even more evident relationship between event and drug. However please check also other important things, such as creatinine, liver enzymes, OTC drugs, nutrition.

I hope that my answer was helpful for You, however If you want we can write case report together.

Regards,

Matej

 Thanks for your answer

I am awaiting the response of a neurologist on the possible mechanism of injury that results in cervical contracture

Then it may be interesting to communicate the case, and if you want we can assess it together. For me this collaboration through ResearchGate is a new experience.

Joaquin take the all data together, collect them and after contact me on message private (via). I think I also have the right Journal for this case report in my mind, within Psychiatry with IF=3. However, this case report is interesting and explanation will nice in term how to prevent this event, although all guidelines for infections are respected. In this light this new knowledge is wonderful to protect these events in near future. 

Regards from Ljubljana

 In the next days I will try to write and send you the draft of article. Please tell me your particular email.

At least we discuss case

Deal Joaquin!

Write a manuscript with about of 1000 words and after we will finish together and make editing according to the journal's instructions. 

I really appreciate the RG cohorts and taking the clinical discussion on ADR case report and even the possible publication co-operation. yes it is very interesting case and being a senior pharmacologist please revert if you need any possible mechanism involved in this case.All the best wishes. 

Thank you for your offer but I have already made contact with another investigator for this case. We may collaborate on a next occasion