Minocycline-associated Idiopathic Intracranial Hypertension In A Patient Presenting To The Emergency Department

摘要

Introduction Idiopathic intracranial hypertension (IIH) is a condition characterized by signs and symptoms of increased intracranial pressure (ICP), such as headache, papilledema and increased cerebrospinal fluid (CSF) pressure, in the presence of an otherwise normal neurological examination (1). On assessment, patients will exhibit normal CSF composition, normal neuroradiological imaging studies (in particular, computed tomography (CT) and/or magnetic resonance imaging (MRI)), and the absence of specific systemic or structural etiologies to explain the increased ICP (2).Originally described by Quincke as “serous meningitis” (3) and also referred to as pseudotumor cerebri or benign intracranial hypertension, epidemiological studies of IIH suggest a crude annual incidence rate of 0.9-1.7 per 100,000 persons (4,5,6). Several associations have been suggested, including female gender, obesity or recent weight gain, endocrinopathies, and medication use (1,7,8). We report a case of minocycline-associated IIH in a young female presenting to the emergency department for evaluation of headaches with visual changes. Report of a Case A thin (BMI= 19.5 kg/m2) 17 year old female presented to the emergency department with a bitemporal throbbing headache, intermittently present for 10-14 days. The headache was exacerbated with reading and worsened in severity from morning to evening. The patient experienced nausea without emesis during the most severe exacerbations, and obtained transient pain relief from acetaminophen with codeine.Within 3-5 days prior to presentation, the patient began to observe sporadic episodes of self-limited horizontal diplopia, usually occurring in conjunction with her most severe headaches or in the evening. Like the headaches, these episodes were exacerbated by reading, and were occasionally accompanied by mild visual blurring without a specific field defect. Although she obtained no relief from medications, the diplopia resolved when either eye was closed during an attack. The patient historically used contact lenses without regard for which eye each lens was designated for, but did not feel that switching contact lenses between eyes altered her symptoms. She denied fever, chills, infectious complaints, neck stiffness, weight change or other symptoms.Her past medical history was significant for exercise-induces asthma, menstrual irregularities, and acne vulgaris. Other than acetaminophen or acetaminophen with codeine, she had been receiving minocycline for approximately 16 weeks prior to presentation. She stopped the minocycline on the day of presentation and denied any other medication use, including oral contraceptives. Her family history included maternal migraines and Von Willebrand's Disease, as well as an aunt with a pituitary tumor (type unknown) but no other family history of endocrine or other malignancies.On ExaminationPhysical examination revealed slightly swollen, mildly hyperemic optic discs with single flame hemorrhages present in each eye and an otherwise normal neurological and general examination. Visual acuity and field were at that time grossly normal and confirmed by an ophthalmologist. Laboratory studies, including CBC, ESR, coagulation studies and urinalysis were normal, and urine HCG was negative. Lumbar puncture revealed an opening pressure of 255 mm H2O with normal cell count, glucose and protein. Head CT (Figure 1) was normal, and head MRI (Figure 2) with MR venous angiography (Figure 3) obtained after referral to a neurologist were normal.