Clinical Review Lesson of the week

Doxycycline induced intracranial hypertension

BMJ 2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7390.641 (Published 22 March 2003) Cite this as: BMJ 2003;326:641
  1. J Lochhead, specialist registrar,
  2. J S Elston, consultant ([email protected])
  1. Department of Ophthalmology, Oxford Eye Hospital, Radcliffe Infirmary, Oxford OX2 6HE
  1. Correspondence to: J S Elston
  • Accepted 25 November 2002

Doxycycline prescribed for malaria prophylaxis may cause intracranial hypertension that threatens sight

Preventing malaria in travellers is difficult because of the widespread emergence of drug resistance and the increasing popularity of travel to endemic locations. Mefloquine is the most effective recommended antimalarial, but doxycycline (a tetracycline derivative) is being increasingly used in areas where there is resistance to mefloquine or in patients who have side effects to this drug.1

Intracranial hypertension is a well recognised side effect of tetracyclines and has been associated with the medium to long term use of minocycline for acne vulgaris.26 We report on two patients with acute onset of severe intracranial hypertension associated with doxycycline, in one instance causing permanent loss of most vision.

Case reports

Case 1—A 21 year old Afro-Caribbean woman who had been on holiday in Uganda for three weeks complained of headaches and blurred vision. She had been taking doxycycline 100 mg once daily for malaria prophylaxis throughout this period. Her vision was 6/9 in the right eye and 6/5 in the left. She had severe papilloedema with associated haemorrhages and cotton wool spots, more so in the right eye. A magnetic resonance imaging scan of the brain was normal. A lumbar puncture had an opening pressure of 52.5 cm H2O. All other investigations were normal. Intracranial hypertension was diagnosed and the doxycycline stopped. Oral acetazolamide 250 mg four times daily was started. Her visual fields were normal. Symptoms gradually improved, and the lumbar puncture was repeated after three weeks. The opening pressure was still high …

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