Radiological findings often lead to clinical diagnosis. A case of disulfiram ethanol reaction with stroke

A 40-year-old man with a history of alcohol dependence was brought to the emergency department with right lower limb ataxia after a week of heavy drinking. He was found unconscious in a pub. Magnetic resonance imaging axial diffusion [Figure 1a] and flair images [Figure 1b] show symmetric diffusion restriction involving globus pallidi with corresponding flair hyperintensities with right thalamus acute infarct. T 1 weighted image [Figure 1c] was normal. Susceptibility weighted imaging image [Figure 1d] shows punctuate hemorrhages within globus pallidi.

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Figure 1:

(a) MRI axial diffusion and (b) flair images show symmetric diffusion restriction involving globus pallidi with corresponding flair hyperintensities with right thalamus acute infarct. (c) T 1 weighted image was normal. (d) SWI image shows punctuate haemorrhages within globus pallidi. SWI: Susceptibility weighted imaging.

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Bilateral globus pallidus infarcts are rare, and differentials like carbon monoxide poisoning, COVID-19 hypoxia, methylmalonic acidemia, cocaine, and disulfiram toxicity¹ were ruled out in the initial evaluation. With radiological information leading to further questioning of his wife, she admitted to having secretly given him disulfiram for five days to deter his drinking, causing a disulfiram-ethanol reaction and an ischemic stroke. This case underscores the role of thorough history assessment and radiology in uncovering these critical details.