Pseudotumor cerebri in patient on leuprolide acetate for central precocious puberty

Central precocious puberty (CPP) is amenable to management with GnRH analogues that operate on physiological principles by desensitizing the signaling pathway to gonadotrophin production [6]. The aims of the treatment are to halt and perhaps reverse the secondary sex characteristics of puberty, prevent early onset of menses in girls and attenuate the loss of height potential consequent upon advanced skeletal maturation [1, 2]. Adverse effects of GnRHa therapy are rare, and the associations of most reported adverse events with the GnRHa molecule itself are unclear. Decades of experience have shown that GnRHa treatment is both safe and efficacious. Common side effects mentioned in literature related to use of GnRHa in children are Allergic or local reactions to GnRH injection, withdrawal bleeding, hot flushes, convulsions, slipped capital femoral epiphysis, while prolonged QT interval and Pituitary apoplexy which is rare was reported in adult males, with prostate cancer treated with GnRHa [2, 7]. Pseudotumor cerebri associated to leuprolide acetate a GnRH analogue is an extremely rare event with only few cases reported in the literature.

Pseudotumor cerebri (PTC), is a syndrome that presents with clinical features of elevated intracranial pressure without radiological evidence of an intracranial mass, infection, vascular abnormality, hydrocephalus or changes in the level of consciousness [8‐10]. Systemic diseases and drug exposure are associated with pseudotumor cerebri (secondary pseudotumor). PTC in children can present with headache, nausea, vomiting, blurred vision, diplopia, neck stiffness, photophobia, and retro-orbital pain. Our patient presented with partial visual loss and papilledema with no headache after 2 months of leuprolide acetate administration (3.75 mg).Although headache has been reported in 62–91% of cases there are also reports of PTC without headache [11‐13]. After stopping the leuprolide acetate the visual acuity as well as papilledema resolved 6 weeks after starting treatment with acetazolamide which is the recommended treatment for PTC [13]. With prompt diagnosis and medical management, most children with mild-to-moderate disc swelling and visual field defects have complete resolution of disc swelling and visual abnormalities [11] as observed in our patient. In our case, after cessation of treatment for precocious puberty, and initiating standard treatment for PTC causing normalization of eye examination highly suggested the cause of GnRH analogues in the pathology. This rare adverse effect of Leuprolide acetate was reported to the distributor company of this drug. The question arises, Should GnRHa therapy be restarted after cessation of symptoms? The answer to this question is unknown. In conclusion if a patient presents with complaints such as headache, nausea, vomiting, and double vision in pediatric patients treated with GnRH analogue one should highly consider the presence of pseudotumor cerebri (PTC) and fundus examination should be performed.