Rapidly progressing idiopathic intracranial hypertension after a Covid-19 infection

ABSTRACT

AimsTo present a case of a previously well child with rapidly progressing idiopathic intracranial hypertension (IIH) requiring a lumboperitoneal shunt after a Covid-19 infection.MethodsA fifteen-year-old girl presented to the Children’s Emergency Department on 23th October 2021 with a history of headaches (temporal, periorbital and occipital) and reduced visual acuity. These started following a Covid-19 infection on 30th September. She was reviewed by ophthalmology in view of deteriorating visual acuity (right eye>left eye). Bilateral papilloedema and haemorrhages were noted on examination. Her visual acuity was 6/24 unaided in the right eye and 6/7.5 unaided in the left eye. During the admission her visual acuity deteriorated to 6/36 pinhole in the right eye and 6/12 pinhole in the left eye. In the right eye she lost colour vision and developed a relative afferent pupillary defect. She received acetazolamide and intravenous methylprednisolone before being transferred to Birmingham Children’s Hospital neurosurgical ward for a lumboperitoneal shunt.There has been a significant improvement since surgery. On 22nd November there was resolving papilloedema and haemorrhages. She had normalised colour vision and resolution of the afferent pupillary reflex. Her visual acuity was 0.275 in the right eye and 0.100 in the left eye (LogMAR). However, persistent deficits could have significant consequences such as the ability to obtain a driving licence.ResultsAn MRI showed bilateral papilloedema of the optic discs. An MRV showed narrowing of the bilateral traverse sinuses with gradual tapering suggestive of high intracranial pressure. Raised intracranial pressures were confirmed by lumbar puncture on two separate occasions. The pressures were beyond the limit of the manometer used (34cm H2O).ConclusionShe had two well recognised risk factors;female gender and increased BMI so is within the high-risk group. However, she had no pathognomonic signs/symptoms of IIH or Ophthalmic complaints before COVID-19, meaning this was a rapidly progressing case that coincided with a Covid-19 infection.It is not possible to declare a cause and effect relationship in this case, but there is some emerging reports of Covid-19 positive patients with refractory headaches having isolated raised intracranial pressures within the adult population.1 2The Covid-19 pandemic has also precipitated indirect consequences. Weight gain as a result of lockdown was reported, which increased her risk of IIH.ReferencesSilva MTT, Lima MA, Torezani G, et al. Isolated intracranial hypertension associated with COVID-19. Cephalalgia. 2020;40(13)1452-1458. doi10.1177/0333102420965963Ilhan B, Cokal BG, Mungan Y. Intracranial hypertension and visual loss following COVID-19 A case report. Indian J Ophthalmol. 2021;69(6)1625-1627. doi10.4103/ijo.IJO_342_21