A Unique Case of Idiopathic Intracranial Hypertension in a 10-year-old with Sinusitis

Introduction: Idiopathic intracranial hypertension (IIH) is commonly diagnosed in adults who are obese, female and taking oral contraceptives. The objective of this case is to demonstrate the possibility of IIH in a child.

Case Description: A 10-year-old previously healthy female presented with acute onset headache and double vision. She developed upper respiratory symptoms for one week with nasal congestion and transient postnasal drip. One day prior to presentation, she started having episodes of double vision with a sharp jarring headache. Her parents reported that during these episodes, her left eye appeared to be looking inward while the other looked straight. She denied any fever, chills, loss of consciousness, nausea, vomiting, numbness or tingling.

On exam, her vital signs were normal. BMI was 15.1 kg/m2. She was alert and looking around with her left eye closed in no distress. Cover and uncover test showed that the left eye was deviated medially with weakness in abduction, horizontal nystagmus and monocular diplopia. Her right eye was within normal limits. There was dysmetria on finger-nose-finger testing of the left side. The remainder of her cranial nerves and neurological exam were normal. Blood counts, chemistry panel, thyroid studies and urine toxicology screen were within normal limits. The MRI of the brain showed severe pansinusitis. The MR Venogram of the brain was negative. Lumbar puncture showed an elevated opening pressure of 41 cm H2O, cell count 0, protein 21, and glucose 55. The meningitis PCR panel was negative.

Neurology consultation recommended Acetazolamide, pulse steroids, and high dose Amoxicillin. Ophthalmology was consulted the following day, improving left eye esotropia was noted with no papilledema. The ANA, CSF Lyme, CSF cultures, ACE, Anti-AchR and Anti-MUSK were negative. The patient was discharged home on high dose Amoxicillin for pansinusitis with resolution of her symptoms.

Discussion: Idiopathic intracranial hypertension (IIH) is usually a disease affecting adults. The exact mechanism of IIH remains unclear. Sinus infection is a known but rare cause of IIH documented in very few cases. The common manifestation of papilledema is not necessary to make the diagnosis. Diagnostic criteria include cranial nerve deficits, specifically CNVI and CNVII, which occurs in about 10% of patients. The normal range for opening pressure in children varies up to 28 cm H2O. With the rising incidence of childhood obesity and adolescent oral contraceptive use, IIH may become more prevalent in the pediatric population.

Conclusion: IIH can present with unique mechanisms and symptoms. It should be considered as part of the differential diagnosis in pediatric patients with sinusitis, headache and cranial nerve deficits. The measurement of opening pressure is a simple but critical marker which should be routinely checked in children and adults undergoing lumbar puncture.