Abstract
Purpose
To report cross-reactivity between topical vitamin A derivatives and tetracycline-class antibiotics.
Observations
A 19-year old woman with a remote history of resolved secondary intracranial hypertension due to minocycline use developed intracranial hypertension while using topical tretinoin alone. Examination demonstrated bilateral optic nerve edema, a right sixth cranial nerve palsy, along with characteristic features of markedly elevated intracranial pressure on imaging. Lumbar puncture opening pressure was 60 cmH 2 O. Cessation of topical tretinoin use ensued complete resolution of symptoms and optic nerve swelling in both eyes.
Conclusions and importance
Our findings substantiate the need to avoid topical vitamin A derivatives and alternate drug classes known to be associated with drug-induced intracranial hypertension.
1
Introduction
Vitamin A derivatives and tetracycline-class antibiotics are among known medications associated with drug-induced intracranial hypertension (DIIH). Presenting symptoms including headaches, transient visual obscurations, and compressive optic neuropathy leading to irreversible severe visual impairment are well-documented. There remains a paucity of data regarding topical tretinoin and its association with secondary intracranial hypertension. Thought to be a safer option than systemic isotretinoin, topical tretinoin, or all-trans-retinoic acid, is an active intracellular metabolite of isotretinoin (13- cis -retinoic acid) often prescribed as a first-line treatment for patients with mild-to-moderate acne vulgaris. There have been two previous reports of topical formulations of vitamin A linked to intracranial hypertension. , However, to the best of our knowledge, there have been no reported cases of cross-reactivity with topical tretinoin use and alternate drug classes associated with DIIH. We report the first case of secondary intracranial hypertension associated with topical tretinoin in a patient with a remote history of tetracycline-induced intracranial hypertension.
2
Case
A 19-year old woman (BMI of 31.1) with a remote history of secondary intracranial hypertension due to minocycline use presented with headaches and worsening vision. Three years after minocycline cessation and confirmed resolution of elevated intracranial pressure, the patient was started on topical tretinoin. One year later, she developed headaches, nausea, visual obscurations, and a right sixth cranial nerve palsy. Fundus examination revealed bilateral optic nerve edema ( Fig. 1 A). MRI of the brain and orbits demonstrated characteristic features of markedly elevated intracranial pressure ( Fig. 2 A and B). MRV of the brain demonstrated severe transverse sinus stenosis without occlusion ( Fig. 2 C). Lumbar puncture (LP) opening pressure was 60 cmH 2 O with normal cerebrospinal fluid (CSF) composition. She underwent unilateral transverse sinus stenting, and was monitored closely on an outpatient basis with strong emphasis placed on complete cessation of topical tretinoin use. Humphrey visual field (HVF) 24–2 testing demonstrated significant visual field defects bilaterally upon presentation ( Fig. 3 A). After topical tretinoin cessation and cerebral venous sinus stenting, symptoms along with optic nerve edema completely resolved ( Fig. 1 B) and visual field defects continued to improve ( Fig. 3 B).
