Biomed&
fhannacuther (1992) 46,171-172
Q Elsevier, Paris
A Donnet, H Dufour, N Graziani, F Grisoli Service de neurochirurgie, H6pital de la Timone, rue St Pierre, I3005 Marseille, France
(Received 7 February 1992; accepted 19 March 1992)
Summary - A case is reported of a M-year-old girl who developed benign intracranial hypertension, with severe bilateral papilledema after minocyc~ine therapy. A lum~pe~toneai bypass was carried out in view of the oph~olo~c signs and the pressure of cerebrospinal fluid. bealga ~nt~eranial
h~ertension I mtn~ycline
R&urn6 - Minocycline et intervention intracranieone bhigne. Nous rapportons le cas d’une patiente de I6 uns qui dciveloppa un tableau d’hypertension intracranienne bknigne apt&s la prise de minocycline. Une dirivation lombo-pkitonhle fut mise en place en raison de la gravitk des signes oculaires et de i’importance de la pression du liquide cgphalo-rachidien. hypertension intracranienne bhigne I minocycline
Among the antibiotics, tetracyclines have often been implicated as the causative factor of benign intracranial hypertension.
Case report A 16-year-old girl was hospitalized on March 29, 1991 after sudden onset of severe headache, photophobia, and horizontal diplopia. The only significant incident in her medical history was appendicitis-related pe~tonitis at the age of six. Neurologic examination revealed a left sixth cranial nerve palsy. Ophthalscopic examination showed bilateral papilledema with hemorrhagic spikes predominantly along the papillary margin. Visual acuity was severely diminished (RE: 2110’; LB: S/10’). CT-scan and magnetic resonance imaging of the brain were normal. EEG showed slow poorly organized wave patterns but no specific abnormality was detected. Cerebral angiography was normal. Lumbar puncture yielded a clear cerebrospinal fluid (0 elements; 0.22 g of pro-
tein). CSF pressure was high (90 cm water). The diagnosis of benign in~acr~ial hy~rtension was proposed and a lumbope~toneal bypass was undertaken on April 4, 1991. One week later, a clear improvement in visual acuity (RE: 4110’; LE: 700’) and fundoscopic findings was noted. Questioning revealed that the patient had been taking minocycline (Mestacine @ 100 mg x 2) for six weeks as treatment for acne. The patient’s clinical condition continued to improve but eight months later diplopia in the lateral vision persisted. Ophthalscopic exa~nationdemonstrated regular papillary marpinz on the right and left. No discoloration of the left temporal region was noted. Abnormalities in the visual field remained with bilateral fascicular defects consisting of upper scotomas on the right and lower scotomas on the left.
Discussion Benign intracranial hypertension or pseudotumor cerebri are terms used for the syndrome of increased intracranial pressure and papilledema in
172 a patient with normal CSF composition and normal neuroradiologic studies [2. 6]. Benign intracranial hypertension is a wellknown adverse effect of tetracyline in children and its use is not recommended before the age of eight years [4]. This side-effect is uncommon in adults, only 16 such cases have been reported in the literature. It generally occurs in young women undergoing antibiotherapy for acne and consists of intracranial hypertension that regresses rapidly when treatment is discontinued. However, tetracycline therapy may be associated with benign intracranial hypertension in the older, postmenopausal woman [5]. However, in two cases, papilledema persisted for more than 1 year after the initial manifestations 191. Brain CT-scan may be either normal [ 1, 2, 91 or show small ventricles [8]. The delay between intake of the drug and the first symptoms varies from a few days to a few months [9]. Doses prescribed are generally low, ranging from 100 mg-2 g. In the cases reported in the literature, medical treatment using prednisolone acetazolamide and glycerol has always been associated with discontinuation of the offending agent. In our patient, a lumboperitoneal bypass was carried out in view of the opththalmologic signs and the pressure of cerebrospinal Ruid. The pathophysiology of this complication is unclear, but minocycline penetrates the blood-barrier more readily than other tetracyclines and attains higher CSF levels [2, 71. Adjuvant treatment with pyridoxine has been im-
plicated as a facilitating factor [3, 41; although the case described by Bove [l] as well as our own case involved minocycline alone.
eferences Bove L, Compagnoni L, Lanzetti A, Nappo A (I 990)
Rev Neural (Paris) 146, 2-158 Delaney RAf Narayanaswamy TR (1990) Pseudotumor cerebri and acne. Mil Med 155, 5 1I Giles CL, Soble AR (1971) Intracranial hypertension and tetracycline therapy. Am J Ophtalmol 72, 981 Lubetski C, Sansofn M, Cohen D, Schaison-Cusin M, Lhermitte F, Lyon-Caen 0 (1988) Hypertension intracrpanienne benigne et minocycline. Rev Neurol (Paris)
144-3, 218
Meacock DJ, Hewer RL (1981) benign intracranila hypertension.
Tetracycline
and
Br Med J 282,
1240
Minute110 JS, Dimayuga R (1988) Pseudotumor cerebri, a rare adverse reaction to tetracycline therapy. J Periodontol al Res 59, 12, 848 Monaco F, Agnetti V, Mutani R (1978) Benign intracranial hypertension after Minocycline therapy. Eur Neural 17, 48 Pearson MG, Littlewood SM, Bowden AN (1981) Tetracycline and benign intracranial hypertension. Br Med J 282, 568 Walters BN, Gubbay SS (1981) Tetracycline and benign intracranial hypertension: report of five cases. Br Med J 282, 19
fhannacuther (1992) 46,171-172
Q Elsevier, Paris
A Donnet, H Dufour, N Graziani, F Grisoli Service de neurochirurgie, H6pital de la Timone, rue St Pierre, I3005 Marseille, France
(Received 7 February 1992; accepted 19 March 1992)
Summary - A case is reported of a M-year-old girl who developed benign intracranial hypertension, with severe bilateral papilledema after minocyc~ine therapy. A lum~pe~toneai bypass was carried out in view of the oph~olo~c signs and the pressure of cerebrospinal fluid. bealga ~nt~eranial
h~ertension I mtn~ycline
R&urn6 - Minocycline et intervention intracranieone bhigne. Nous rapportons le cas d’une patiente de I6 uns qui dciveloppa un tableau d’hypertension intracranienne bknigne apt&s la prise de minocycline. Une dirivation lombo-pkitonhle fut mise en place en raison de la gravitk des signes oculaires et de i’importance de la pression du liquide cgphalo-rachidien. hypertension intracranienne bhigne I minocycline
Among the antibiotics, tetracyclines have often been implicated as the causative factor of benign intracranial hypertension.
Case report A 16-year-old girl was hospitalized on March 29, 1991 after sudden onset of severe headache, photophobia, and horizontal diplopia. The only significant incident in her medical history was appendicitis-related pe~tonitis at the age of six. Neurologic examination revealed a left sixth cranial nerve palsy. Ophthalscopic examination showed bilateral papilledema with hemorrhagic spikes predominantly along the papillary margin. Visual acuity was severely diminished (RE: 2110’; LB: S/10’). CT-scan and magnetic resonance imaging of the brain were normal. EEG showed slow poorly organized wave patterns but no specific abnormality was detected. Cerebral angiography was normal. Lumbar puncture yielded a clear cerebrospinal fluid (0 elements; 0.22 g of pro-
tein). CSF pressure was high (90 cm water). The diagnosis of benign in~acr~ial hy~rtension was proposed and a lumbope~toneal bypass was undertaken on April 4, 1991. One week later, a clear improvement in visual acuity (RE: 4110’; LE: 700’) and fundoscopic findings was noted. Questioning revealed that the patient had been taking minocycline (Mestacine @ 100 mg x 2) for six weeks as treatment for acne. The patient’s clinical condition continued to improve but eight months later diplopia in the lateral vision persisted. Ophthalscopic exa~nationdemonstrated regular papillary marpinz on the right and left. No discoloration of the left temporal region was noted. Abnormalities in the visual field remained with bilateral fascicular defects consisting of upper scotomas on the right and lower scotomas on the left.
Discussion Benign intracranial hypertension or pseudotumor cerebri are terms used for the syndrome of increased intracranial pressure and papilledema in
172 a patient with normal CSF composition and normal neuroradiologic studies [2. 6]. Benign intracranial hypertension is a wellknown adverse effect of tetracyline in children and its use is not recommended before the age of eight years [4]. This side-effect is uncommon in adults, only 16 such cases have been reported in the literature. It generally occurs in young women undergoing antibiotherapy for acne and consists of intracranial hypertension that regresses rapidly when treatment is discontinued. However, tetracycline therapy may be associated with benign intracranial hypertension in the older, postmenopausal woman [5]. However, in two cases, papilledema persisted for more than 1 year after the initial manifestations 191. Brain CT-scan may be either normal [ 1, 2, 91 or show small ventricles [8]. The delay between intake of the drug and the first symptoms varies from a few days to a few months [9]. Doses prescribed are generally low, ranging from 100 mg-2 g. In the cases reported in the literature, medical treatment using prednisolone acetazolamide and glycerol has always been associated with discontinuation of the offending agent. In our patient, a lumboperitoneal bypass was carried out in view of the opththalmologic signs and the pressure of cerebrospinal Ruid. The pathophysiology of this complication is unclear, but minocycline penetrates the blood-barrier more readily than other tetracyclines and attains higher CSF levels [2, 71. Adjuvant treatment with pyridoxine has been im-
plicated as a facilitating factor [3, 41; although the case described by Bove [l] as well as our own case involved minocycline alone.
eferences Bove L, Compagnoni L, Lanzetti A, Nappo A (I 990)
Rev Neural (Paris) 146, 2-158 Delaney RAf Narayanaswamy TR (1990) Pseudotumor cerebri and acne. Mil Med 155, 5 1I Giles CL, Soble AR (1971) Intracranial hypertension and tetracycline therapy. Am J Ophtalmol 72, 981 Lubetski C, Sansofn M, Cohen D, Schaison-Cusin M, Lhermitte F, Lyon-Caen 0 (1988) Hypertension intracrpanienne benigne et minocycline. Rev Neurol (Paris)
144-3, 218
Meacock DJ, Hewer RL (1981) benign intracranila hypertension.
Tetracycline
and
Br Med J 282,
1240
Minute110 JS, Dimayuga R (1988) Pseudotumor cerebri, a rare adverse reaction to tetracycline therapy. J Periodontol al Res 59, 12, 848 Monaco F, Agnetti V, Mutani R (1978) Benign intracranial hypertension after Minocycline therapy. Eur Neural 17, 48 Pearson MG, Littlewood SM, Bowden AN (1981) Tetracycline and benign intracranial hypertension. Br Med J 282, 568 Walters BN, Gubbay SS (1981) Tetracycline and benign intracranial hypertension: report of five cases. Br Med J 282, 19
