Benign Intracranial Hypertension Secondary to Intranasal Corticosteroid Administration
Akhil P R1*, Jino Vincent2, Siby Gopinath3
1Pharm D Intern, Department of Pharmacy Practice, Amrita School of Pharmacy,
Amrita Vishwa Vidyapeetham, Kochi, Kerala, India – 682041.
2Senior Resident, Department of Neurology, Amrita School of Medicine,
Amrita Vishwa Vidyapeetham, Kochi, Kerala, India – 682041.
3Professor, Department of Neurology, Amrita Advanced Centre for Epilepsy, Amrita Comprehensive Sleep Centre,
Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India – 682041.
*Corresponding Author E-mail: prakhil9397@gmail.com
ABSTRACT:
Steroids have been used for a wide spectrum of indications in clinical practice. The potential benefits of steroids outweigh the complications in most settings. Steroids have been used over the counter in our country for allergy and arthritis. Here we present a case of a young girl who presented with headache, tinnitus, vomiting, and papilledema, visual field defect in perimetry with elevated IOP, presumed secondary to intranasal steroid use for allergic rhinitis. There are case reports suggesting a causal relationship between steroids and benign intracranial hypertension. Here patient on follow-up had significant improvement on stopping steroid spray. This case report is to highlight the need for awareness of the possibility of benign intracranial hypertension in patients who are on inhalational steroids.
KEYWORDS: Inhalational steroids, fluticasone, intracranial hypertension.
INTRODUCTION:
Benign intracranial hypertension (BIH) is a disorder identified by elevated intracranial pressure (ICP) along with usual cerebrospinal fluid (CSF) components and no other features identified on imaging. This disorder is well pronounced in children, middle aged obese women. Elevated CSF pressure with usual CSF cytology and biochemical study is a criterion for diagnosis of BIH1. Inhaled Corticosteroids (ICS) are designer drugs that are synthesised from basic steroid molecules. These steroids molecules act within the cell nucleus and thereby affect the gene transcription2,3. ICS have been in the forefront for the management of asthma and allergic rhinitis for ages and now it is being used extensively in the management of patients with chronic diseases. Adverse effects are more commonly seen with prolonged treatment duration and at increased doses of the drug.
CASE HISTORY:
A 19-year-old female nursing student presented with complaints of headache for 4 days. She was complaining of heaviness of the head and when the pain is very severe, she gets nausea and vomiting, followed by transient relief. She was complaining of pulsatile tinnitus episodically for the past few days. No history of fever or altered sensorium. No complaints of photophobia, phonophobia or flashes of light. No nocturnal worsening of headache, diplopia or abnormal colour vision.
Fig 1. Right eye Inferior temporal deficit |
Fig. 2 MRV - Normal |
No history of menstrual abnormality. Her examination revealed bilateral papilledema with visual acuity of 6/6. There was no colour vision abnormality. There was no other localizing neurological deficit.
Possibilities of 1. Cortical venous thrombosis 2. Idiopathic intracranial hypertension 3. Meningitis (a rare possibility) was considered. Hemogram was normal. MRI with MRV showed bilateral distal transverse sinuses show smooth narrowing, however, no thrombus was seen. Perimetry showed scotoma in the right inferior field. CSF study was done which showed elevated opening pressure of 44cm Hg. CSF routines were normal. So, the possibility of BIH was considered high and she was started on tablet acetazolamide and injection mannitol.
On the second day, she had a significant resolution of symptoms. The mother disclosed that she is taking fluticasone nasal spray on a PRN basis for the past few days for her allergic rhinitis. The possibility of steroid-induced benign intracranial hypertension was considered and fluticasone was discontinued. She was started on alternate medications for her allergic rhinitis and was discharged on acetazolamide. The patient was followed up after 4 weeks and she was asymptomatic. Repeat CSF manometry was done and it showed a significant reduction. Her CSF opening pressure was 21cm Hg.
We hypothesize that nasal fluticasone propionate was the reason for the cause of this benign intracranial hypertension because of the temporal relationship between symptoms to its administration. After the discontinuation of the drug her symptoms were resolved, though she was on acetazolamide also due to high opening pressure and field defects as documented in perimetry. The event of benign intracranial hypertension is well recorded with corticosteroids when administered systemically or topically, coincidentally even with their withdrawal.
DISCUSSION:
Steroids are known to have a plethora of physiological effects. Regulation of homeostasis and stress are controlled by glucocorticoids while mineralocorticoids function to regulate sodium-water balance. The term corticosteroid is used to describe the compounds that are naturally occurring as well as synthetic molecules. The indication for steroid usage varies with diagnosis and co-morbid conditions. Certain steroid drugs cannot be used if the patient has hypertension as it may possess added mineralocorticoid action that can affect the blood pressure4,5.
Steroid therapy is known to cause Hypothalamic-Pituitary-Adrenal (HPA) axis suppression and hence the therapy is always strategically tapered over weeks to months to minimize its risk. Long-term use of corticosteroids is related to more serious effects which can be often avoided by using targeted drug delivery such as topical administration or oral inhalation of corticosteroids2. The metabolism of corticosteroids is regulated by the hepatic P450 system. Inhaled, topical, intra-articular, or epidural routes help in bypassing its first-pass effect6,7. Various types of Steroid preparations are oral, inhaled, nasal, topical, intraarticular, epidural and ocular glucocorticoid preparations5.
Presently, inhaled/intranasal corticosteroids (ICSs) are the most acceptable and commonly prescribed treatment option available for allergic airway diseases8. But it is of importance to know that with inhaled corticosteroids, about 60–90% of the administered dose is swallowed, absorbed from the gastrointestinal tract, and reach the systemic circulation8. The pharmacological actions of inhaled corticosteroids are exerted locally in the airways, although they can still elicit systemic effects based on the factors that affect the bioavailability of each agent2. ICS are commonly known to cause side effects like oral candidiasis and dysphonia, which can be prevented using holding chambers and regular mouth rinsing after drug administration. Despite having a better risk/benefit ratio as compared to their systemic counterparts, ICS possesses risks that are associated with the dose and duration of the therapy, which includes HPA-axis suppression, reduced bone mineral density, and impaired endocrine and hematologic functions9.
The steroid molecule, after crossing the cell membranes, binds to the glucocorticoid receptors within the cell and induces a conformational change, and this complex moves inside the nucleus and binds with the glucocorticoid response elements (GREs), which either causes trans repression or transactivation of RNA and protein synthesis10. Thus, steroids mediate the inhibition of transcription factors that control the synthesis of pro-inflammatory mediators, and immune cells10-16. It also inhibits phospholipase A2 which is involved in immune mediatory responses6. In addition, these molecules also inhibit the expression of inflammatory markers such as cytokines, tumour necrosis factor and various interleukins2.
Chronic treatment and high doses of corticosteroids are known to cause adverse effects as well as toxicities17. Factually, short term use of systemic corticosteroids was not believed to cause any significant side effects, but this safety claim is refuted by very few studies17. Within a month of initiation of therapy, the patient may experience increased risk of adverse effects such as secondary infections, sepsis, fractures and thromboembolic disorders as reported by several studies17,18. Hyperglycaemia, oedema, blood pressure disturbances are the interim effects of corticosteroids, while gastrointestinal bleeding, high risk of secondary infections and impaired wound healing, psychiatric problems and electrolyte imbalances (hypokalaemia and hyperkalaemia) are the more serious side effects2.
Certain drugs (corticosteroids, tetracyclines, lithium, nitrofurantoin, nalidixic acid, oral contraceptives, cyclosporine, levonorgestrel, tamoxifen) are known to trigger or aggravate BIH19. Exact mechanism for steroids causing BIH is not known. But studies have postulated weight gain and hormonal imbalance associated with steroid use as potential risk factors and in some cases increasing the dose of steroids followed by slow tapering has helped, further solidifying the argument of an underlying endocrine abnormality20-23.
CONCLUSION:
Evidences of a causal relationship between intranasal fluticasone and benign intracranial hypertension are reported in very few studies, but CSF pressure was not recorded24. This case gives conclusive evidence of BIH with elevated ICP and visual field defects, and questions the conventional belief that short course of inhaled or topical steroids are safer than chronic or systemic steroids. Although rare, it is of utmost importance to acknowledge the fact that non-systemic steroids (inhalational or topical) play a major role in the occurrence of serious adverse effects.
CONFLICT OF INTEREST:
There are no conflicts of interest.
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Received on 22.05.2021 Modified on 28.11.2021
Accepted on 10.02.2022 © RJPT All right reserved
Research J. Pharm. and Tech 2022; 15(12):5548-5550.
DOI: 10.52711/0974-360X.2022.00936