PC1190: Acute Visual Disturbances and Ataxia Secondary to Attempted COVID-19 Prophylaxis with Ivermectin

Introduction: Ivermectin is an antiparasitic agent listed as an essential medication by the World Health Organization. Ivermectin’s utilization has increased due to popular perception of its potential utility for COVID-19 management. Poison Control Central (PCC) calls regarding ivermectin toxicity have increased 245% since pre-pandemic baselines. However, oral ivermectin toxicity in children has not been well explored. We describe our experience caring for a young girl with acute ivermectin toxicity.

Case Description: A previously healthy 9-year-old female was transferred from a standalone emergency department with acute vision changes and ataxia. Twelve hours prior to presentation, the patient ingested ten times the recommended dose, 60 mg (1mg/kg), of veterinary ivermectin for prophylaxis after her mother was diagnosed with a COVID-19 infection. Therapeutic dose is normally 0.1 mg/kg. Ten hours post-administration, she developed new-onset blurry vision, perceived red dots in her peripheral vision, dizziness, and balance issues. Both of her parents were undergoing evaluation for similar symptoms. Past medical history is negative for vision difficulties or recent head trauma. Four months prior, the patient received ivermectin for COVID-19 prophylaxis without developing similar symptoms.

On physical examination, vital signs were age-appropriate. Ophthalmologic exam revealed pulsating pupils bilaterally, bilateral diplopia of peripheral vision, and 20/70 vision bilaterally. Neurological exam revealed dysmetria on finger-to-nose testing, an ataxic gait, positive Romberg, and an inability to perform tandem or tiptoe walk due to unsteadiness. Outside labs showed mild eosinophilia of 5.2% and an anion gap of 14.9 (Figure 1).

Initial management included contacting PCC for guidance and obtaining an ophthalmology consult. The patient was admitted for further monitoring. Over 10 hours her ataxia and dysmetria steadily improved, her vision returned to 20/25 bilaterally and her pulsating pupils resolved. Social work was contacted and child protective services planned a home visit following discharge. The patient was discharged home with complete resolution of symptoms.

Discussion: Ivermectin has a dose-dependent neurotoxicity side effect profile. Ivermectin stimulates glutamate-gated chloride channels on nerve and muscle cells, hyperpolarizing them and preventing action potentials. Normally, at therapeutic doses, Multi-Drug Resistant-1 channels in the blood-brain barrier remove ivermectin, preventing CNS toxicity. A prior case report illustrates a 6-year-old patient that presented with seizures, altered mental status, and hemodynamic collapse requiring intubation following accidental ingestion of 600 mg (30mg/kg) topical ivermectin, 100-times the intended dose. Our case supports that children may develop neurotoxicity from smaller ivermectin ingestions. Therapy includes clinical observation with supportive measures.

Conclusion: We present a case of a 6-year-old female with neurotoxicity following a ten-fold overdose of ivermectin for COVID-19 prophylaxis. With the increasing off-label use of ivermectin for attempted COVID-19 prophylaxis, we use this example to illustrate the symptoms of ivermectin toxicity in children to help identify ingestion events earlier.