Multiorgan dysfunction precipitated by disulfiram use and posterior reversible encephalopathy syndrome with atypical presentation: a case report

In this case report, we present a 57-year-old woman, experiencing worsening attention and concentration in the past month. She had paranoid and persecutory delusions regarding her husband. In the initial evaluation, her cardiac and liver enzymes were found to be elevated, and her blood pressure was high. She was taking antihypertensives, antidepressants, and disulfiram for the treatment of her addiction to alcohol. Her initial neurological examination was nonspecific. Mental status examination revealed distractible attention, psychomotor agitation, and poor insight. A cranial MRI revealed signal intensity changes suggestive of vasogenic edema in bilateral hemispheres and the basal ganglia. The atypical presentation of Posterior Reversible Encephalopathy Syndrome (PRES) was diagnosed. The encephalopathy presentation and peripheral toxic symptomatology were resolved following hydration and antihypertensive medication; yet, during the follow-up of the patient, motor deficits in the lower extremity were noted. An EMG examination indicated motor polyneuropathy with axonal involvement. As her muscular weakness increased, IVIG was initiated, and the symptoms of polyneuropathy improved rapidly. The multisystemic pathologies developed in a short time were indicative of potential toxicity, while other infectious, autoimmune, infiltrative, and metabolic etiology were excluded upon laboratory tests and imaging. The use of disulfiram was thought to be a key element in the development of this chain of pathologies. Based on our knowledge, this is the first case to be reported in which the cardiovascular, hepatic, muscular, central, and peripheral nervous system toxicity of disulfiram was observed simultaneously, which is the reason why we consider it important to be presented.