BISMUTH SUBSALICYLATE TOXICITY AS A CAUSE OF PROLONGED ENCEPHALOPATHYWITH MYOCLONUS

Bismuth subsalicylate preparations are over-the-counter products for g astrointestinal complaints. Bismuth toxicity causes delirium, psychosi s, ataxia, myoclonus, and seizures and is reversible over several week s or months, when bismuth intake is stopped. We report a 54-year-old m an with a 6-week history of progressive confusion and memory difficult y and a 2-3-week history of involuntary movements and gait impairment. His encephalopathy was further characterized by marked multifocal myo clonic jerks, coarse postural tremors, postural instability, and gait ataxia. He gradually improved. Extensive toxic, metabolic, and infecti ous workup demonstrated bismuth toxicity. Spinal tap and brain magneti c resonance scan were normal. Electroencephalography showed bihemisphe ric slowing. As his encephalopathy cleared, he reported using bismuth subsalicylate long term (daily intake of 8 oz). Bismuth levels 5 weeks after cessation of bismuth were elevated and normalized after 12 week s. He followed a typical course for bismuth toxicity with subacute pro gressive encephalopathy and gradual recovery. Creutzfeldt-Jakob was st rongly considered due to his rapidly progressive encephalopathy, multi focal myoclonus, and ataxia. Due to its rarity, bismuth toxicity is of ten overlooked. We hope this presentation will increase recognition of bismuth toxicity. We believe more detailed labeling of bismuth produc ts is needed to avoid similar toxicity from this readily available pro duct.