Double adverse drug reaction: Recombinant human growth hormone and idiopathic intracranial hypertension - acetazolamide and metabolic acidosis: a case report

A Case of Idiopathic Intracranial Hypertension with Papilledema Secondary to Recombinant Human Growth Hormone Treatment

Purpose: To report a child with idiopathic intracranial hypertension secondary to recombinant human growth hormone treatment.Case summary: An 11-year-old girl presented with blurred vision in both eyes starting 6 weeks earlier. She did not have any underlying disease and her body mass index was normal. She had started recombinant human growth hormone injections for idiopathic short stature 3 months earlier. The best corrected visual acuity was 20/25 in both eyes. Fundoscopy revealed bilateral disc edema with peripapillary hemorrhage and increased tortuosity of the retinal vessels. Bilateral enlargement of the blind spot was found on automated visual field examination. Magnetic resonance imaging and venography of the brain showed no evidence of structural or vascular lesions related to increased intracranial pressure. A lumbar puncture showed an elevated opening pressure of 26 cmH2O with normal cerebrospinal fluid constituents. She was diagnosed with growth hormone-related idiopathic intracranial hypertension and it was recommended that the growth hormone injection be discontinued and oral acetazolamide started. After 4 weeks of treatment, the optic disc edema and visual field defect improved. At the 2-year follow-up, she had a normal visual field with a normal optic nerve in both eyes.Conclusions: Ophthalmologists should be aware of the clinical features and treatment of idiopathic intracranial hypertension secondary to recombinant human growth hormone treatment, which is a very rare, vision-threatening complication. Complete neuro-ophthalmological examinations should be performed immediately in children complaining of visual disturbances or headache during treatment with recombinant human growth hormone.

Comparative study of oral and intranasal puerarin for prevention of brain injury induced by acute high-altitude hypoxia

Human activities in the areas of high altitude have increased significantly recently. Brain is highly sensitive to changing of oxygen pressure due to high altitude, and this physiological response may lead to serious brain injury, such as learning and memory disabilities. Puerarin is a phytoestrogen with many pharmacological activities, such as treatment of neurological disorders. However, most of current drugs can not easily enter brain through the blood-brain barrier (BBB). The nose-to-brain route can bypass BBB for brain-targeting. Here, thermosensitive in situ hydrogels (TISGs) of puerarin were prepared with poloxamers 407, poloxamers 188 and propylene glycol to improve bioavailability and brain targeting. In vitro drug release in simulated nasal fluids, rheological properties and cilia toxicity of puerarin TISGs were explored. The pharmacodynamics and pharmacokinetics of puerarin by intranasal (i.n.) and oral (p.o.) administrations were also evaluated. The viscosity of puerarin TISGs tended to increase obviously with increased temperature. The puerarin release profile and transmucosal process of puerarin TISGs could be described with the first-order kinetics equation, depending on drug diffusion. The cilia toxicity of puerarin TISGs was not obvious. Rat models of hypobarism/hypoxia-induced brain injury were established with a hypobaric simulation chamber. Morris water maze and open filed tests indicated that puerarin TISGs improved the spatial memory and spontaneous exploratory behavior of the rats suffering from hypoxia-induced brain injury. Furthermore, puerarin TISGs decreased the level of oxidative stress cytokines (malondialdehyde (MDA) and glutathione (GSH)) in the peripheral circulation, alleviated the cerebral histological lesions, and relieved the expression of hypoxia-inducible factor-1α (HIF-1α). Intranasal puerarin TISGs were absorbed quickly with a shorter T_max (10.0 ± 5.7 min) compared to that of oral puerarin (36 ± 13.4 min). In addition, the relative bioavailability of i.n. puerarin TISGs was high to 300% compared to oral administration of puerarin. The area under the curve (AUC) of brain after i.n. administration of puerarin TISGs was 954.5 ± 335.1 h.ng/mL, while no puerarin was detected in the brain after oral administration. Therefore, i.n. puerarin TISGs led to excellent brain targeting effect. Puerarin TISGs are an effective neuroprotector formulation for prevention of brain injury induced by acute high-altitude hypoxia.

Pseudotumor Cerebri in a Child with Idiopathic Growth Hormone Insufficiency Two Months after Initiation of Recombinant Human Growth Hormone Treatment

Purpose. To report a rare case of pseudotumor cerebri (PTC) in a child two months after receiving treatment with recombinant human growth hormone (rhGH) and to emphasize the need of close collaboration between ophthalmologists and pediatric endocrinologists in monitoring children receiving rhGH. Methods. A 12-year-old boy with congenital hypothyroidism started treatment with rhGH on a dose of 1,5 mg/daily IM (4.5 IU daily). Eight weeks later, he was complaining of severe headache without any other accompanying symptoms. The child was further investigated with computed tomography scan and lumbar puncture. Results. Computed tomography scan showed normal ventricular size and lumbar puncture revealed an elevated opening pressure of 360 mm H₂O. RhGH was discontinued and acetazolamide 250 mg per os twice daily was initiated. Eight weeks later, the papilledema was resolved. Conclusions. There appears to be a causal relationship between the initiation of treatment with rhGH and the development of PTC. All children receiving rhGH should have a complete ophthalmological examination if they report headache or visual disturbances shortly after the treatment. Discontinuation of rhGH and initiation of treatment with acetazolamide may be needed and regular follow-up examinations by an ophthalmologist should be recommended.