Bismuth (Bi) is used for the treatment of different gastrointestinal symptoms and disorders such as
gastric ulcers. In Germany, Bi medication is available without prescription as over-the-counter-medication even though it can cause severe
myoclonic encephalopathy if ingested chronically in high doses. We report a 49 year-old woman with chronic
gastric ulcers and 5 years of Bi abuse who developed the typical
clinical course of Bi
encephalopathy. She presented with progressive
dementia,
dysarthria and
myoclonic jerks one week after increasing the Bi dosage. The EEG showed generalized spike-wave complexes suggesting that the
myoclonus was epileptic in nature. Bi intake was stopped and
valproate was given, which decreased the frequency of the
myoclonic jerks. Administration of the
metal chelator D,L-2,3-dimercaptopropane- 1-sulfonic
acid (
DMPS) led to increased urine excretion of Bi, but was accompanied by a
clinical deterioration which resulted in it being discontinued. The subsequent clinical recovery of the patient was documented over 40 days by EEG, video and neuropsychological testing. A time lag of two weeks was observed between falling plasma levels and clinical improvement. In conclusion, Bi-induced
encephalopathy is a differential diagnosis for
myoclonic encephalopathies. Treatment with
metal chelators may aggravate the
encephalopathy. The over-the-counter availability of medications containing Bi should be questioned. (Published with video sequence.)