Severe Intracranial Hypertension Associated with Tetracycline Use in Non-Small Cell Lung Cancer

Introduction: Erlotinib has become an established treatment for patients with non-small cell lung cancer harbouring an epidermal growth factor receptor (EGFR) mutation.  Tetracycline antibiotics are commonly prescribed for erlotinib-induced acneiform rash.  A rare but morbid complication of tetracycline use is intracranial hypertension, an association which has not been reported in the oncology literature.Presentation of Case: We report a case of severe intracranial hypertension in a patient with non-small cell lung cancer.  Risk factors were prolonged tetracycline use and leptomeningeal carcinomatosis.  Initial investigations were unhelpful, necessitating a high index of suspicion.Conclusion: Tetracycline antibiotics, which are commonly prescribed for erlotinib rash, are an important risk factor for intracranial hypertension.  Our patient developed severe vision loss from papilloedema, despite normal neuroimaging and relatively low opening pressure on lumbar puncture.  Continuous intracranial pressure monitoring can be a valuable investigation in such circumstances

Tele-Neuro-Ophthalmology: An Update One Year into the COVID-19 Pandemic

Tele-neuro-ophthalmology emerged as a resource early in the COVID-19 pandemic. Since then, telehealth utilization has evolved

Optic nerve diffusion tensor imaging after acute optic neuritis predicts axonal and visual outcomes

BACKGROUND: Early markers of axonal and clinical outcomes are required for early phase testing of putative neuroprotective therapies for multiple sclerosis (MS). OBJECTIVES: To assess whether early measurement of diffusion tensor imaging (DTI) parameters (axial and radial diffusivity) within the optic nerve during and after acute demyelinating optic neuritis (ON) could predict axonal (retinal nerve fibre layer thinning and multi-focal visual evoked potential amplitude reduction) or clinical (visual acuity and visual field loss) outcomes at 6 or 12 months. METHODS: Thirty-seven patients presenting with acute, unilateral ON were studied at baseline, one, three, six and 12 months using optic nerve DTI, clinical and paraclinical markers of axonal injury and clinical visual dysfunction. RESULTS: Affected nerve axial diffusivity (AD) was reduced at baseline, 1 and 3 months. Reduced 1-month AD correlated with retinal nerve fibre layer (RNFL) thinning at 6 (R=0.38, p=0.04) and 12 months (R=0.437, p=0.008) and VEP amplitude loss at 6 (R=0.414, p=0.019) and 12 months (R=0.484, p=0.003). AD reduction at three months correlated with high contrast visual acuity at 6 (ρ = -0.519, p = 0.001) and 12 months (ρ = -0.414, p=0.011). The time-course for AD reduction for each patient was modelled using a quadratic regression. AD normalised after a median of 18 weeks and longer normalisation times were associated with more pronounced RNFL thinning and mfVEP amplitude loss at 12 months. Affected nerve radial diffusivity (RD) was unchanged until three months, after which time it remained elevated. CONCLUSIONS: These results demonstrate that AD reduces during acute ON. One month AD reduction correlates with the extent of axonal loss and persistent AD reduction at 3 months predicts poorer visual outcomes. This suggests that acute ON therapies that normalise optic nerve AD by 3 months could also promote axon survival and improve visual outcomes

Real-world effectiveness of cladribine for Australian patients with multiple sclerosis: an MSBase registry substudy

Background/objective: Observational clinical data from cladribine-treated patients with relapsing forms of multiple sclerosis (MS) were recorded in the Australian MS registry powered by the MSBase registry platform (5-year follow-up) and analysed to complement information from the pivotal cladribine clinical trials in MS. Methods: A cohort of 90 cladribine-treated patients with follow-up data reported by treating physicians and recorded in the Australian MSBase registry (database lock February 2016) were examined. Clinical data included Expanded Disability Status Scale (EDSS) scores, relapses and other disease-modifying drugs (DMDs) administered before and after cladribine treatment. Results: Mean age on starting cladribine was 47 years; mean age at MS onset was 34 years, and median baseline EDSS score was 5.25. Disability trajectories in patients with sufficient follow-up suggested an overall increasing trend prior to cladribine treatment which was reduced during the 2-year post-treatment. Approximately 80% of patients were EDSS progression-free, 65% remained relapse-free after 2 years and median time to next DMD was 1.7 years. Conclusion: These observational data suggest a disease-modifying effect in this cohort of relapsing MS patients characterised by older and more disabled patients. Since these data represent a single-arm cohort, clinical trials and larger comparative post-marketing studies are needed to validate and extend these findings

Timecourses for axial and radial diffusivity asymmetry over 12 months.

<div><p>Both timecourses were fit with quadratic lines of best fit (AD: <i>y</i> = -0.007<i>x</i>² + 0.81<i>x</i> - 3.3; RD: <i>y</i> = -0.008<i>x</i>² + 0.77<i>x</i> - 13.8). Error bars indicate 95% confidence intervals for the mean. </p> <p>* Significant interhemispheric asymmetry in axial diffusivity (p&lt;0.05).</p> <p># Significant interhemispheric asymmetry in radial diffusivity (p&lt;0.05).</p> <p>UE = Unaffected Eye.</p></div

Optic Nerve AD normalisation and axonal outcomes.

<p>Prolonged AD normalisation time was significantly correlated with mfVEP amplitude loss (ρ = -0.59, p = 0.0002) and RNFL thinning (r = -0.54, p = 0.0005) at 12 months.</p