Review Question - QID 221237

This patient with severe acne most likely started isotretinoin and is now presenting with papilledema, headache, blurry vision, and diplopia. These symptoms are consistent with a diagnosis of idiopathic intracranial hypertension.

Idiopathic intracranial hypertension is characterized by an increase in intracranial pressure without an identifiable cause. Risk factors include obesity as well as medications such as isotretinoin or oral contraceptive pills. Patients often present with symptoms that include headache, blurry vision, and tinnitus. Fundoscopic examination typically reveals bilateral papilledema. If left untreated, a complication of this condition is vision loss. Management should first involve imaging of the brain to exclude elevated cerebrospinal fluid pressure due to other causes such as a brain tumor, dural sinus thrombosis, or hydrocephalus. The diagnosis is made via lumbar puncture, revealing increased opening pressure. Lumbar puncture can also result in therapeutic relief. The specimen should be sent for Gram stain, culture, and viral PCR to rule out other etiologies. Long-term treatment is centered on weight loss and avoiding causative agents. Acetazolamide and serial lumbar punctures are other treatments.

Boyter reviews the evidence regarding the clinical presentation and management of patients with idiopathic intracranial hypertension. They found that the condition is most common among obese women in their 20s. They recommend referral for patients to see a neurologist for ongoing management of headaches, as well as an ophthalmologist for monitoring of papilledema.

Figure/Illustration A is a funduscopic exam that demonstrates blurring of the optic disc margin (yellow circle). This finding is consistent with increased intracranial pressure.

Incorrect Answers:
Answer 1: Cerebrovascular accidents can be embolic or hemorrhagic in nature and often result in persistent neurologic deficits in a patient with cerebrovascular risk factors such as diabetes, hypertension, or hyperlipidemia. This young, healthy patient with intermittent headache and neurologic symptoms without a family history of hypercoagulable state is unlikely to have suffered from a cerebrovascular accident.

Answer 2: Giant cell arteritis (GCA) is a vasculitis that is typically seen in elderly patients and presents with tenderness of the ipsilateral temple and elevated inflammatory markers. Many patients with GCA also have constitutional symptoms such as weight loss, fever, fatigue, anorexia, and malaise in addition to symptoms such as new-onset headache or jaw claudication.

Answer 4: Meniere disease affects the inner ear and is characterized by severe episodes of vertigo, tinnitus, hearing loss, and fullness in the ear. Patients are often women between the ages of 40 and 60. Headaches and blurry vision are not a classic part of the clinical presentation.

Answer 5: Migraines can be incapacitating, with associated photophobia and phonophobia. In some cases, patients may present with an aura that precedes or occurs during the migraine. The presence of papilledema suggests elevated intracranial pressure and is not typically seen in migraines.

Bullet Summary:
Idiopathic intracranial hypertension may be a side effect of isotretinoin.