A 19-year-old Caucasian male comes to clinic complaining of frequent headaches that "make it impossible to do well at work or school." He cannot pinpoint when the headaches started. Recently, he has also noticed a rhythmic pulsating sound in his ears when he bends over. When he straightens, his vision dims in both eyes. He has been diagnosed with depression, attention deficit disorder, and acne vulgaris, and is currently taking fluoxetine, atomoxetine, and isotretinoin. Vital signs are normal. Ophthalmologic examination is remarkable for peripapillary flame hemorrhages, venous engorgement, and hard exudates. There is some constriction of the visual field in the inferior nasal quadrant. Visual acuity is normal. What is the most likely diagnosis?

Question

A 19-year-old Caucasian male comes to clinic complaining of frequent headaches that "make it impossible to do well at work or school."  He cannot pinpoint when the headaches started.  Recently, he has also noticed a rhythmic pulsating sound in his ears when he bends over.  When he straightens, his vision dims in both eyes.  He has been diagnosed with depression, attention deficit disorder, and acne vulgaris, and is currently taking fluoxetine, atomoxetine, and isotretinoin.  Vital signs are normal.  Ophthalmologic examination is remarkable for peripapillary flame hemorrhages, venous engorgement, and hard exudates.  There is some constriction of the visual field in the inferior nasal quadrant.  Visual acuity is normal.  What is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: Pseudotumor cerebri (Choice D), also known as idiopathic intracranial hypertension, arises from chronically elevated intracranial pressure. Papilledema is evident on examination and may lead to progressive optic atrophy and blindness. The condition is most common in obese premenopausal women, but is also thought to occur secondary to endocrine disorders (e.g., hypoparathyroidism, hypothyroidism, adrenal insufficiency, Cushing disease) and the usage of some medications (e.g., isotretinoin, all-trans-retinoic acid, minocycline, tetracycline, cimetidine, corticosteroids, danazol, tamoxifen, levothyroxine, lithium, nitrofurantoin). The patient in this case used isotretinoin, which was the likely cause of his pseudotumor cerebri. trans Tension headache (Choice A) is usually categorized as episodic or chronic. Episodic tension headaches are mild to moderate, often associated with a specific stressful event, and usually improve after treatment with over-the-counter medications. Chronic tension headaches are linked with contraction of scalp and neck muscles and may recur daily. Visual symptoms other than occasional photophobia are not common. Cluster headaches (Choice B) are sudden, severe headaches centered in the temporal and periorbital regions, and are often associated with lacrimation, nasal congestion, or nausea. Patients typically experience 1-2 cluster periods lasting for 2-3 months every year. Young and middle-aged men are most prone to cluster headaches. Visual symptoms are not common. Migraine headaches (Choice C) are recurrent throbbing or pulsatile headaches often associated with a prodrome, nausea, vomiting, photophobia, and phonophobia. When they occur, the prodromes are characterized by visual scintillations, scotomas, dizziness, or tinnitus. Subarachnoid hemorrhages (Choice E) most commonly result from head injury or the leakage of an aneurysm or arteriovenous malformation. These headaches are associated with significant pain, sudden onset, nausea and vomiting, meningeal irritation, photophobia and visual changes, and sometimes loss of consciousness or seizures. Educational Objective: Pseudotumor cerebri most commonly occurs in obese women of childbearing age. It is also thought to occur secondary to endocrine disorders and the usage of some medications, including the acne treatments isotretinoin and minocycline.

A 19-Year-Old Caucasian Male Comes to Clinic Complaining of Frequent