Systemic corticosteroid therapy and its withdrawal is
one of the causes of idiopathic intracranial hypertension. Intralesional
steroids have not been reported as a cause.
A 3-year-old boy presented with complaints of
irritability for one month, nonprojectile vomiting for 4 days and medial
deviation of both eyes for 3 days. There was no history of fever,
headache, seizures or neck stiffness during this period. The child had
scalds over 75% of the body surface area one year previously. For the
hypertrophic scar due to scald, the child was receiving intralesional
injections of triamcenolone every month for last 7 months. Magnetic
resonance imaging (MRI) of brain showed buckling of bilateral
intra-orbital optic nerve with partial empty sella turcica, without
dilatation of ventricles, and without any structural abnormality or
meningeal enhancement. Magnetic resource venography was also normal. He
was treated with intravenous mannitol, oral glycerol and oral
acetazolamide. His complete blood counts were within normal limits. His
lumbar puncture done on 3rd day of admission, revealed normal CSF
pressure. CSF gram staining, cytology and biochemistry were normal.
Although the lumbar puncture and CSF pressure
recording was not done at the time of acute episode but the acute
presentation of vomiting, papilledema, medial deviation of both eyes
with normal blood pressure, and MRI findings makes the diagnosis of
idiopathic intracranial hypertension likely. Triamcenolone acetonide is
a fluorinated prednisolone derivative, with four times the potency of
hydrocortisone [1]. Due to fluoridation, it is less soluble than its
parent compound. This allows it to remain at the site of injection for
longer periods of time, establishing a prolonged duration of action [2].
This facilitates a pooling effect that can result in the slow release of
steroid, potentially increasing systemic levels of steroid [1,2]. High
systemic levels of corticosteroids are known to cause idiopathic
intracranial hypertension [3]. We suggest monitoring of signs and
symptoms of raised intracranial pressure in children receiving prolonged
intralesional steroids therapy.
References
1. Doggrell SA. Triamcinolone: new and old
indications. Expert Opin Pharmacother. 2001;2:1177-86.
2. Grumbine N, Dobrowolski C, Bernstein A.
Retrospective evaluation of postoperative intralesional steroid
injections on wound healing. J Foot Ankle Surg. 1998;37:135-44.
3. Lucky AW. Principles of the use of glucocorticosteroids in the
growing child. Pediatr Dermatol. 1984;1:226-35.