Benign intracranial hypertension during prednisolone treatment for inflammatory bowel disease

Increased cerebrospinal fluid pressure and nephrotic syndrome: A case report and literature review

OBJECTIVE

To analyze how nephrotic syndrome (NS) correlates to increased intracranial pressure (ICP), and to present a case of an adult patient whose initial manifestation of NS was cephalalgia, with the later identification of raised ICP.

METHODS

Data were retrospectively retrieved from the patient's record, and a literature search with the keywords "nephrotic syndrome", "intracranial hypertension" and "headache" was conducted in PubMed and Embase.

RESULTS

This is a rare description of co-occurrence of NS and raised ICP in a 48-year-old man, in which ICP normalizes after NS remits. There is no known cause for the raised ICP of our patient. Ten reports (n = 13) of concomitant occurrence of increased ICP and NS were described in the literature, both in children and adults. Cerebral venous thrombosis (CVT) was the most likely underlying cause for the majority of them. For one patient, the underlying cause was meningoencephalitis. Finally, in one case, the cause is unknown, but CVT was not discarded.

CONCLUSION

The early suspicion of elevated ICP is warranted in patients with new-onset headache and NS. It is possible that NS could both directly and indirectly lead to increased ICP through yet unknown mechanisms, although this direct causal relationship cannot be currently established.

Intracranial hypertension and empty Sella from adrenal adenoma and excessive and prolonged steroid usage: a case report

BACKGROUND

There is only one documented case of intracranial hypertension (IH) and empty sella from cortisol-producing adrenal adenoma so far. And IH and empty sella caused by long-term exogenous hypercortisolism has never been reported before. The purpose of this case report is to alert clinicians to glucocorticoid-induced IH.

CASE PRESENTATION

We present retrospectively a 50-year-old woman with cortisol-secreting adrenal adenoma, who progressed to intractable intracranial hypertension and a markedly expanded empty sella due to improper treatment. In 2011, the patient presented with hypertension, lack of cortisol circadian rhythm, low ACTH, a left adrenal adenoma and a partial empty sella, but did not receive low-dose dexamethasone suppression test (LDDST) and 24-h urinary cortisol. In 2014, she exhibited truncal obesity, raised cortisol, LDDST non-suppression, high urinary free cortisol and low ACTH, proving her cortisol-producing adrenal adenoma. She was simultaneously diagnosed with unexplained IH because of papilledema and elevated intracranial pressure, and her partial empty sella changed to a complete empty sella. In 2015, she underwent adrenal adenoma resection. From 2015 to 2018, she kept taking dexamethasone at least 2 mg daily without her doctors' consent. During this period, she developed transient cerebrospinal fluid rhinorrhea, and her empty sella further worsened. After switching to low dose hydrocortisone, her papilledema disappeared completely, but optic atrophy has become irreversible.

CONCLUSIONS

The patient seems to be just an extreme case, but it may reveal and illustrate a general phenomenon: Both cortisol-producing adrenal adenoma and long-term exogenous hypercortisolism could cause varying degrees of elevated intracranial pressure and empty sella. Clinicians should remain vigilant for this phenomenon in patients with cortisol-producing adrenal adenoma or excessive and prolonged steroid usage and give them corresponding examinations to identify this complication.

Benign intracranial hypertension associated with inhaled corticosteroids in a child with asthma

A 13-year-old male asthmatic presented to the general paediatric clinic with papilloedema identified following a check-up with his optician due to blurred vision. His asthma was well controlled on a moderate dose of inhaled corticosteroid and there had been no recent increase or decrease in the dose. A diagnosis of benign intracranial hypertension (BIH) was made based on a raised cerebrospinal fluid opening pressure, papilloedema, a normal neurological examination and normal neuroimaging. The only associated risk factor was his inhaled corticosteroids. He was commenced on acetazolamide and the inhaled corticosteroid dose was reduced, resulting in resolution of his papilloedema. This case serves to highlight that steroid side effects including BIH may occur at moderate doses of inhaled corticosteroids and that inhaled corticosteroid dose should be regularly reviewed and decreased to the lowest dose that maintains asthma control.

Ocular manifestations of inflammatory bowel diseases: an update for gastroenterologists

Inflammatory bowel diseases (IBD), that includes ulcerative colitis and Crohn's disease, can affect not only the gastrointestinal tract but a wide spectrum of organs. The extra-intestinal manifestations (EIMs) are one of the most challenging aspect of IBD, playing a significant role for the lifetime care and the quality of life of patients. Ocular manifestations are the third most frequent EIMs, preceded by articular and dermatological ones. The aim of this narrative review is to describe the different types of ocular involvements, focusing on their clinical management. Uveitis and episcleritis are the most common ocular EIMs, differing for many aspects. Uveitis are unrelated with IBD activity and they even precede the onset of the intestinal disease, while episcleritis are common defined as a good mark of IBD activity. Pain is uncommon in most cases of episcleritis, while severe eye pain and photophobia are the most frequent onset of anterior uveitis. Less common but even more severe, are orbital pseudotumor or posterior segment involvement. Most of the ocular EIMs can be successfully treated with topic and oral steroids and the underlying therapy for IBD can reduce or cut out at all the recurrence of these manifestations. Symptoms are commonly not specific, in some cases being unnoticed for years leading to permanent ocular consequences. Cooperation between different specialists is crucial to avoid all the possible consequences of a non-treated EIMs, especially for ocular ones.

Pseudotumor cerebri induced by topical application of steroid: a case report

A 19-year-old man visited the neurology clinic for evaluation of a headache and pulsating tinnitus that he had experienced for 2 months. A neurological examination was normal, except for bilateral disc swelling. His medical history was notable for recently diagnosed psoriasis for which he had been applying topical hydrocortisone 2.5% three to four times a day. Neuro-imaging with a computed tomography scan and magnetic resonance imaging/magnetic resonance venography of the brain was normal, except for tortuosity of the optic nerves and dilatation of the optic nerve sheaths. Pseudotumor cerebri syndrome was suspected. Unfortunately, the patient refused a spinal tap to measure the cerebrospinal fluid opening pressure. Excessive application of topical steroid was believed to be the cause of the patient’s pseudotumor cerebri syndrome. The patient’s headache and disc swelling improved after treatment with acetazolamide and cessation of topical hydrocortisone. This is the first case report of a topical steroid associated with pseudotumor cerebri syndrome.

Novel advances in monitoring and therapeutic approaches in idiopathic intracranial hypertension

PURPOSE OF REVIEW

The current article appraises the recent developments in idiopathic intracranial hypertension (IIH), with particular attention to novel therapeutic avenues and advanced clinical assessment and monitoring with optical coherence tomography and telemetric intracranial pressure devices.

RECENT FINDINGS

The incidence of IIH is increasing. The first consensus guidelines for IIH have been published detailing investigation and management algorithms for adult IIH. Improved understanding, clinical assessment and monitoring are emerging with the use of optical coherence tomography. Intracranial pressure telemetry is providing unique insights into the physiology of raised intracranial pressure in IIH. There are now an increasing number of ongoing clinical trials evaluating weight loss methods and novel targeted therapies, such as 11ß-HSD1 inhibition and Glucagon-like peptide 1 (GLP-1) receptor agonists.

SUMMARY

Several studies are evaluating new therapies for IIH. Monitoring techniques are advancing, aiding diagnosis and allowing the clinician to accurately evaluate changes in papilloedema and intracranial pressure.

Mesalazine treatment causing resolution of intracranial hypertension secondary to ulcerative colitis: A case report

RATIONALE

The association between intracranial hypertension (ICH) and ulcerative colitis (UC) is rare. We report the unusual case of a male patient with UC and ICH in whom both conditions resolved with mesalazine therapy.

PATIENT CONCERNS

A 48-year-old Caucasian man presented to our department in June 2016 for decreased vision, transient visual obscuration, pulsatile tinnitus and headaches of 7 months duration. Bilateral optic disc swelling was found at fundus examination. Brain MRI excluded any brain tumor and lumbar puncture showed cerebrospinal fluid (CSF) opening pressure of 26 cm of water with normal CSF contents.

DIAGNOSES

Idiopathic ICH was suspected.

INTERVENTIONS

The patient was managed with oral acetazolamide. Headaches initially improved but the dosage could not be decreased under 750 mg a day without recurrence of the symptoms. Extensive review of systems showed that the patient had active UC. He was given oral mesalazine, 2000 mg a day.

OUTCOMES

The symptoms of UC and ICH quickly resolved. Acetazolamide was progressively tapered over the course of the 9 subsequent months and the patient did not show any worsening of his symptoms or papilledema.

LESSONS

UC should be added to the list of disorders associated with ICH. In case of atypical ICH with drug dependency, investigations should seek for UC. Treating efficiently UC with mesalazine may improve ICH, suggesting an underlying inflammatory process.

Impaired cerebrospinal fluid pressure

Abnormalities of cerebrospinal fluid (CSF) pressure are relatively common and may lead to a variety of symptoms, with headache usually being the most prominent one. The clinical presentation of alterations in CSF pressure may vary significantly and show a striking similitude to several primary headache syndromes. While an increase in CSF pressure may be of primary or secondary origin, a pathologic decrease of CSF pressure is usually the result of a meningeal rupture with a resulting leakage of CSF. The pathophysiologic mechanisms of idiopathic intracranial hypertension (IIH) remain largely unknown. However recent evidence indicates that an abnormality in CSF outflow and absorption is likely to play a significant role. Treatment usually consists of a combination of weight loss and a pharmacologic approach using carbonic anhydrase inhibitors. Recent results of the first randomized, double-blind, placebo-controlled trial (RCT) with acetazolamide proved its efficacy in reducing headache and visual disturbances. Clinical evidence suggests efficacy for topiramate and furosemide but no RCT has been conducted to date to confirm these results. In contrast to IIH, spontaneous intracranial hypotension frequently remits spontaneously without specific treatment. If necessary, treatment options range from conservative methods to epidural blood or fibrin sealant patches and surgical interventions.

Idiopathic intracranial hypertension, hormones, and 11β-hydroxysteroid dehydrogenases

Idiopathic intracranial hypertension (IIH) results in raised intracranial pressure (ICP) leading to papilledema, visual dysfunction, and headaches. Obese females of reproductive age are predominantly affected, but the underlying pathological mechanisms behind IIH remain unknown. This review provides an overview of pathogenic factors that could result in IIH with particular focus on hormones and the impact of obesity, including its role in neuroendocrine signaling and driving inflammation. Despite occurring almost exclusively in obese women, there have been a few studies evaluating the mechanisms by which hormones and adipokines exert their effects on ICP regulation in IIH. Research involving 11β-hydroxysteroid dehydrogenase type 1, a modulator of glucocorticoids, suggests a potential role in IIH. Improved understanding of the complex interplay between adipose signaling factors such as adipokines, steroid hormones, and ICP regulation may be key to the understanding and future management of IIH.

Understanding idiopathic intracranial hypertension: mechanisms, management, and future directions

Idiopathic intracranial hypertension is a disorder characterised by raised intracranial pressure that predominantly affects young, obese women. Pathogenesis has not been fully elucidated, but several causal factors have been proposed. Symptoms can include headaches, visual loss, pulsatile tinnitus, and back and neck pain, but the clinical presentation is highly variable. Although few studies have been done to support evidence-based management, several recent advances have the potential to enhance understanding of the causes of the disease and to guide treatment decisions. Investigators of the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) reported beneficial effects of acetazolamide in patients with mild visual loss. Studies have also established weight loss as an effective disease-modifying treatment, and further clinical trials to investigate new treatments are underway. The incidence of idiopathic intracranial hypertension is expected to increase as rates of obesity increase; efforts to reduce diagnostic delays and identify new, effective approaches to treatment will be key to meeting the needs of a growing number of patients.

[Sixth, seventh and tenth cranial nerve palsies associated with pseudotumor cerebri in a 13-year-old boy]

We describe the case of a 13-year-old boy who presented to the emergency department with an acute onset paresis of the left abducens, facial and vagus nerves. Bilateral papilledema was seen on fundoscopy. Blood tests and brain magnetic resonance imaging and angiography showed no abnormalities. A lumbar puncture revealed an elevated intracranial pressure (575mmH2O) and clear cerebrospinal fluid. The diagnosis of pseudotumor cerebri (PTC) associated with multiple cranial nerve palsies was made. Treatment with acetazolamide was initiated, resulting in progressive improvement with no sequelae and no clinical recurrence over an 8-month follow-up period. PTC in children can present with a wide spectrum of neurological signs, especially cranial nerve palsies which are most likely related to a pressure-dependent stretching mechanism. In 2007, distinctive diagnostic criteria for pediatric PTC were established, including the presence of any cranial nerve palsy in the absence of an identifiable etiology.

Orbital and optic nerve complications of inflammatory bowel disease

BACKGROUND AND AIMS

Extraintestinal manifestations of inflammatory bowel disease (IBD) can involve the orbit and the optic nerve. Although these manifestations are rare, they can be particularly serious as they can lead to permanent loss of vision. The aim of the review is to present the existing literature on IBD-related optic nerve and orbital complications.

METHODS

A literature search identified the publications reporting on incidence, clinical features and management of IBD patients with optic nerve and orbital manifestations.

RESULTS

Posterior scleritis and orbital inflammatory disease (orbital pseudotumor) are the most commonly encountered entities affecting the structures of the orbit. On the other hand, the optic nerve of IBD patients can be affected by conditions such as optic (demyelinating) neuritis ("retrobulbar" neuritis), or ischaemic optic neuropathy. Other neuro-ophthalmic manifestations that can be encountered in patients with IBD are related to increased intracranial pressure or toxicity secondary to anti tumour necrosis factor (anti-TNF) agents.

CONCLUSIONS

IBD-related optic nerve and orbital complications are rare but potentially vision-threatening. Heightened awareness and close cooperation between gastroenterologists and ophthalmologists are warranted.

Optic perineuritis as the presenting feature of Crohn disease

Crohn disease (CD) is primarily considered an inflammatory condition of the small and large intestine although associated extraintestinal inflammation is relatively common. Ocular manifestations are generally localized to the anterior chamber and ocular surface but rarely can involve the posterior pole, orbit, and optic nerve. We report a case of an otherwise healthy 42-year-old man who was diagnosed with CD after presenting with acute vision loss from optic perineuritis.

Detection of nerve fiber atrophy in apparently effectively treated papilledema in idiopathic intracranial hypertension

BACKGROUND

Since papilledema in idiopathic intracranial hypertension is a passive event not primarily affecting the visual tract, resolution with restitution ad integrum is expected if intracranial pressure is rebalanced. Retinal nerve fiber swelling due to papilledema in the acute phase and possible axon loss after long-lasting elevated intracranial pressure was investigated in a controlled cross-sectional study by scanning laser polarimetry.

METHODS

A cohort of 23 patients with idiopathic intracranial hypertension according to the modified Dandy diagnostic criteria, and 23 controls matched for age and gender were investigated. All patients received neurological and ophthalmologic examination including scanning laser polarimetry (GDx VCC). Patients were divided into groups depending on the presence of a papilledema (group 1) or the regression of the papilledema after initiation of therapy (group 2). Therapy was based on recommendations of the German Society of Neurology.

RESULTS

Scanning laser polarimetry showed an increase of nerve fiber thickness in group 1, and a decrease of the nerve fiber thickness in group 2 compared to controls. Ten of 13 patients showed signs of a regional axon loss in the deviation map of the GDx report, and six had a Nerve Fiber Index above 30. All patients with regressive papilledema and coincidence of visual field damage and pale optic disc appearance had a pathologic result in the GDx examination, but only four of ten patients with a pathologic GDx examination showed coincidence of pale optic disc appearance and visual field damage as sign of underlying optic disc atrophy.

CONCLUSION

In patients with apparently effective treatment of clinical symptoms and a regression of papilledema in idiopathic intracranial hypertension, a retinal axon loss was detected by scanning laser polarimetry. Axon loss was even present in patients without clinical evidence of optic nerve atrophy.

Intracranial hypertension in pediatric patients with acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) remains one of the most common malignancies of childhood. Between April 1999 and August 2004, 9 of 207 patients treated at a Tertiary Oncology Service for ALL presented with Intracranial Hypertension (IH). Seven of the patients met the diagnostic criteria for Idiopathic Intracranial Hypertension (IIH). Four of the patients were treated with cerebrospinal fluid (CSF) drainage alone and four required Acetazolamide. Two of the four patients who were treated with Acetazolamide required subsequently a lumbar-peritoneal (LP) shunt. One patient succumbed to his disease before receiving any specific treatment.

What is new about idiopathic intracranial hypertension? An updated review of mechanism and treatment

Idiopathic intracranial hypertension (IIH) is the syndrome of raised intracranial pressure without clinical, laboratory or radiological evidence of intracranial pathology. IIH is a relatively rare disease but rapidly increasing incidence is reported due to a global increasing incidence of obesity. Disease course is generally said to be self-limiting within a few months. However, some patients experience a disabling condition of chronic severe headache and visual disturbances for years that limit their capacity to work. Permanent visual defects are serious and not infrequent complications. The pathophysiology of IIH is still not fully understood. Advances in neuroimaging techniques have facilitated the exclusion of associated conditions that may mimic IIH. No causal treatment is yet known for IIH and existing treatment is symptomatic and rarely sufficient. The aim of this review is to provide an updated overview of this potentially disabling disease which may show a future escalating incidence due to obesity. Theories of pathogenesis, diagnostic criteria and treatment strategies are discussed.

Inflammatory bowel disease and the eye

Inflammatory bowel disease includes Crohn's disease and ulcerative colitis, and is characterized by chronic inflammation of the intestines. The advances in understanding of the inflammatory process have resulted in improved treatment of inflammatory bowel disease. The systemic complications of inflammatory bowel disease involve many organs, eyes included. The ophthalmic complications are usually of inflammatory origin. Some of these complications, like scleritis, may reflect overall disease activity. Treatment of intestinal inflammation-either medical or surgical-usually helps resolution of ophthalmic complications. This review describes recent developments in the diagnosis and management of the inflammatory bowel disease and its ophthalmic complications.

Side effects of corticosteroid therapy

BACKGROUND

Corticosteroids have been used for the treatment of inflammatory bowel disease since the late 1940s. Upwards of 80% of patients may respond acutely to treatment with these medications, although 20% or more may be refractory and others become dependent on corticosteroid use to suppress disease activity. Side effects in the acute situation are relatively minor, although significant side effects (e.g., psychosis) have been encountered; the long-term use of corticosteroids is more problematic. This creates a milieu for the potential for serious and irreversible problems. These side effects are discussed in detail. The side effects from corticosteroids emulate from exogenous hypercortisolism, which is similar to the clinical syndrome of Cushing's disease.

STUDY

PubMed search for years 1966-2000, author's personal manuscript/abstract files, and citations of known references.

CONCLUSION

Short-term corticosteroid use is associated with generally mild side effects, including cutaneous effects, electrolyte abnormalities, hypertension, hyperglycemia, pancreatitis, hematologic, immunologic, and neuropsychologic effects, although occasionally, clinically significant side effects may occur. Long-term corticosteroid use may be associated with more serious sequel, including osteoporosis, aseptic joint necrosis, adrenal insufficiency, gastrointestinal, hepatic, and ophthalmologic effects, hyperlipidemia, growth suppression, and possible congenital malformations.

Benign intracranial hypertension associated with budesonide treatment in children with Crohn's disease

Oral budesonide in adult studies is a potent corticosteroid with decreased systemic bioavailability and an improved adverse effect profile in comparison with prednisone. It has recently been introduced for the treatment of inflammatory bowel disease in Europe, Canada, and Israel. Benign intracranial hypertension has rarely been associated with corticosteroid therapy but has not been reported in association with budesonide therapy. Three adolescents with Crohn's disease and poor nutritional status developed benign intracranial hypertension while receiving oral budesonide. All three patients had previously received multiple courses of prednisone during the course of their disease, without developing intracranial hypertension. Benign intracranial hypertension resolved after medication withdrawal and did not recur with subsequent use of prednisone. Evaluation for benign intracranial hypertension should be considered in patients with inflammatory bowel disease who develop headache while receiving oral budesonide. This side effect may be associated with poor nutritional status.

APACHE II scores and deaths after upper gastrointestinal endoscopy in hospital inpatients

Advanced age and comorbidity as well as gastrointestinal (GI) disease contribute to the increased mortality after upper GI endoscopy in inpatients when compared to outpatients. The aim of this study was to measure comorbidity in inpatients undergoing endoscopy using the Acute Physiology and Chronic Health Evaluation (APACHE) II severity of disease classification and to assess the usefulness of the APACHE II system in predicting outcome. During a 10-week period, 155 consecutive inpatients undergoing upper GI endoscopy were prospectively scored using APACHE II. They were followed up for 30 days, the measured endpoint being death. Of these, 92 (59%) inpatients were admitted with GI hemorrhage, 14 (9%) were admitted for other reasons but subsequently bled, and 49 (32%) were endoscoped for reasons other than bleeding. The mean (SEM) APACHE II score in patients with GI bleeding was 8.0 (0.5), and in patients without bleeding was 6.5 (0.6; p = 0.07). Eighteen patients (12%) died within 30 days of endoscopy. APACHE scores were higher at 10.5 (1.2) in patients who died, compared to 7.1 (0.4) in those who lived (p < 0.01). Increased acute physiology scores led to this difference. Age and chronic health scores were similar in both groups. In the 18 patients who died, 9 had GI bleeding and their mean APACHE score was 13.8 (1.5); 9 had been endoscoped for other reasons and had a lower score of 7.2 (1.3; p < 0.01). These latter 9 deaths amounted to a 18% mortality in the nonbleeding group, which was greater than expected. APACHE II scores can help predict poor outcome in inpatients referred for endoscopy. However, the APACHE II system has limitations and failed to identify (by means of a high score) some patients without GI bleeding who subsequently died. A tool to measure comorbidity, such as the APACHE II system, is necessary when comparing groups of patients in different settings.

Optic disc swelling in Crohn's disease

PURPOSE

To provide a review of the causes of optic disc swelling in patients suffering from inflammatory bowel disease.

METHODS

Two illustrative cases of bilateral optic disc swelling are presented: one in a patient known to have Crohn's disease and the other in a patient whose investigations revealed the disease. The possible causes of optic disc swelling in inflammatory bowel disease, based on a literature review, are tabulated and discussed with reference to the presented cases.

RESULTS/CONCLUSIONS

Optic disc swelling is a rare complication of inflammatory bowel disease. Previously reported cases have been attributed to peripapillary inflammation, optic disc ischaemia or intracranial hypertension. Postulated causes of optic nerve ischaemia include a local vasculitis or general hypercoagulability. The underlying aetiology of intracranial hypertension is often elusive. Older studies suggest a relationship between corticosteroid treatment and/or iron deficiency anaemia, while modern imaging emphasises the need to exclude dural venous sinus thrombosis.

Papilloedema, a complication of progressive diaphyseal dysplasia: a series of three case reports

BACKGROUND/AIMS

Progressive diaphyseal dysplasia (PDD) is a rare, autosomal dominant, osteosclerotic dysplasia affecting both endochondrally and intramembranously derived bones. Severely affected patients can develop progressive stenosis of the optic canals and compressive optic neuropathy. Although raised intracranial pressure (ICP) has been described in patients with PDD in whom visual loss has occurred, the elevation of ICP in those patients has been thought to be either non-contributory or only partially responsible for the accompanying visual loss.

METHODS

Three cases were reviewed and the clinical and radiological characteristics are described here.

RESULTS

All three patients had bilateral optic disc swelling with no radiological evidence of either compressive optic neuropathy or thrombosis of the intracranial venous sinuses. The aetiology of the disc swelling was proved to be papilloedema in the first two cases and was probably the dominant cause in the third case.

CONCLUSION

The visual loss documented in at least two of the three patients reported appears to be solely attributable to raised ICP. Normalisation of the ICP has led to an improvement and stabilisation of the visual function in all three patients. Patients with PDD probably require periodic ophthalmic assessments.

Safety of corticosteroids and immunosuppressive agents in ulcerative colitis

For many years, corticosteroids have been the mainstay for treating acute ulcerative colitis. In patients with refractory disease, immunosuppressive therapy may be indicated, including azathioprine or its metabolite 6-mercaptopurine, cyclosporin and possibly methotrexate. Their benefits in ulcerative colitis must be weighed up against their possible adverse effects, the availability of surgical cure for this condition, and the long-term risk of carcinoma complicating colitis that applies in patients with chronic extensive disease. Information about the safety of corticosteroids and immunosuppressive agents has accumulated as a result of their extensive use in inflammatory bowel disease, organ transplantation and various other disorders.