Authored by Guntel Murat*
Abstract
Introduction: Isotretinoin (13-cis-retinoic acid (RA) is commonly used medication for the treatment of severe cystic acne that does not respond other therapies. Isotretinoin treatment has been associated with rare but serious complications such as cerebral thromboembolism.
Case Report: A healthy 27-year-old woman, with no significant past medical history, presented with sudden onset of headache, vomiting, right hemiparesis and unconsciousness associated with convulsions. She had a history of taking isotretinoin for acne for the last 2 months. A magnetic resonance scan of her brain showed the presence of cerebral infarction of left thalamic area, magnetic resonance venography ultimately revealed left transverse sinus thrombosis. Treatment with anticoagulation recovered her from headache but not from hemiparesis.
Conclusion: Isotretinoin is one of the most used treatment modalities in many patients with acne. However, isotretinoin use can be associated with life-threating thrombotic side effects especially in young patients. Physicians must be more alert to be aware of this side effect.
Keywords: Isotretinoin; Complication; Cerebral venous thromboembolism
Introduction
Isotretinoin (13-cis-retinoic acid (RA) is commonly used medication for the treatment of severe cystic acne that does not respond other therapies. Isotretinoin treatment has been associated with neurological side effects such as; headache, insomnia, seizures, pseudotumor cerebri, muscle and joints pains, and rarely thrombotic-thromboembolic or hemorrhagic events [1,2]. Canadian Adverse Reaction Newsletter has mentioned 11 cases of thromboembolic events, strokes and myocardial infarction between 1983-2005 [3]. We report a case presented with right hemiparesis due to left transverse venous sinus occlusion associated with isotretinoin use for acne.
Case Report
The patient is a 27-year-old woman presented with the sudden onset “worst headache of her life”, vomiting, weakness of the right side of her face, arm and leg, unconsciousness associated with convulsions. Her medical history was unremarkable except for acne. She had been treated with oral isotretinoin 20 mg three times daily for the previous 8 weeks. A review of system was negative. There was no family history of cancer, neurologic and hematologic disorders , cardiac problems. Her initial physical examination was negative. On admission, her initial vital signs were temperature 36.8 C, heart rate 88, respiratory rate 21, and blood pressure 120/72. Physical examination showed right upper and lower extremity weakness of a pyramidal pattern, right –sided facial motor and sensory impairment to touch and pin prick over the V1 and V2 distribution (Figure 1).
She had right sided hemihypoestesia and, severe broca aphasia. She was also quite restless and had intermittent disorientation due to convulsions. She consecutively developed severe focal seizure.
A detailed clinical investigation of all systems, including cardiovascular and hematologic assessment was unremarkable. Total blood count, erythrocyte sedimentation rate (ESR), C- reactive protein (CRP), creatinine kinase and electrolytes were normal.
Serum protein electrophoresis, autoimmune markers, work-up for vasculitis, hypercoagulable screening including anti-phospholipid antibodies, antithrombin III deficiency, protein C and S, activated protein C resistances, hyper homocysteinemia, factor V leiden and prothrombotic gene mutation were all unremarkable. DNA testing for genetic thombophilic predisposion were also negative.
Contrast-enhanced brain magnetic resonance imaging revealed a left temporal and superior frontal subacute infarct (Figure 3), diffusion-weighted magnetic resonance imaging showed hyperintense diffusion restriction at the same area (Figure 4a and 4b). Magnetic resonance venography (MRV) of the brain revealed extensive sub-acute transverse sinus thrombosis (Figure 5). Doppler ultrasonography did not show any lesion on cervical arteries. Transthoracic and transesophageal cardiac ultrasound excluded thrombus or cardiac abnormalities.
At that time isotretinoin was discontinued and low molecular weight heparine, followed by oral warfarin was initiated to treat a suspected case of subacute cerebral venous infraction due to cerebral venous thrombosis (CVT) and antiepileptic drugs for acute symptomatic seizures (levetiracetam at 1,000 mg/day). One day later, and in spite of the treatment, the patient continued to have partial seizures with or without impairment of consciousness. Levetiracetam 2000 mg/day were necessary in order to control the seizures. She made remarkable clinical recovery 8 weeks later.
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