Idiopathic Intracranial Hypertension Associated with Short-duration Minocycline for Acne Vulgaris

Objective: Idiopathic intracranial hypertension (IIH) is a syndrome of elevated intracranial pressure without clinical, laboratory or radiologic evidence of intracranial pathology. The most significant consequence of untreated IIH is permanent visual defects. While often described in relation to obesity, IIH has also been reported in association with medication exposures, such as the tetracycline family and retinoids. There are several case reports documenting minocy-cline-associated IIH after several weeks to months of treatment. We report a case of IIH in which symptoms began on the ninth day of minocycline therapy. Case Report: A 12-year-old non-obese boy presented to the emergency department (ED) with a chief complaint of distance diplopia. Two weeks prior to presentation, he had been started on a course of minocycline therapy for acne vulgaris. Six days prior to presentation (day 9 of therapy), he had stopped taking the minocycline due to headache. Three days prior to presentation he developed distance diplopia. In the ED, the patient's vitals signs included a blood pressure of 116/68 mm Hg, heart rate 117 beats/minute, respirations 20 breaths/minute, and temperature 37.4 degrees Celsius. Ophthalmologic evaluation revealed bilateral papilledema. Non-contrast brain computed tomography was normal. Blood and urine laboratory tests were unremarkable. Lumbar puncture was performed in the flexed left lateral decubitus position. Cerebrospinal fluid (CSF) opening pressure was 44 cm H20 (normal < 20 cm H sub(2)0). CSF was obtained for analysis and was drained therapeutically to achieve a closing pressure of 18 cm H20. CSF leukocyte count was 1 cell/microliter. CSF red blood cell count was zero. CSF protein and glucose were 23 mg/dL (normal 15-45 mg/dL) and 56 mg/dL (normal 60 - 80 mg/dL), respectively. CSF analysis for Lyme antibodies was negative. CSF gram stain and bacterial culture were negative. The patient was discharged home from the ED on acetazolamide 250 mg twice daily with neurology and ophthalmology follow-up. Conclusion: IIH may occur in association with daily minocycline therapy of short duration. Although classically described in obese patients, the occurrence of medication-associated IIH with certain therapeutics should prompt physician awareness of this complication, and promote vigilant screening.