Volume 92 Number 4
Clinical notes
679
T a b l e I. D a t a f r o m p e r i o d o f m a x i m a l free w a t e r c l e a r a n c e d u r i n g h y p o t o n i c diuresis All values are in m l / m i n / d l
o f g l o m e r u l a r filtration rate
(C~o + C~)
Percentage o f sodium reabsorption in distal tubule (C.2o/ CH~o+ CN~)X 100
19.8 _+3.2 31.5 30.7 +_3.7
86.0 _+5.0 89.2 84.7 +0.6
Distal load
Control children ~' Patient Children with distal tubular acidosis and proximal bicarbonate wasting ~
Urine volume
Osmolar clearance
Free water clearance
22.1 +3.8 34.9 33.4 _+3.2
4.5 • 1.0 6.8 7.3 _+0.6
17.3 _+3.5 28.1 26.1 _+3.1
ume of urine in milliliters per minute, U ~ = concentration of sodium in the urine, and Ps~ = concentration of sodium in plasma. The results are given in Table I and are compared to the normal values obtained by Rodriguez-Soriano et aP in seven young children and to the values obtained by the same authors in three children with distal tubular acidosis and proximal bicarbonate wasting. ~ It is clear that fractional sodium reabsorption in the distal tubule, as represented by (CH~o/CH.,o + C,~ • 100) is wthin the normal range. However (C~2o + C~), which estimates sodium delivery to the distal tubule, is much higher in our patient than in normal children and is similar to the observations in three children with acidosis and proximal sodium bicarbonate wasting. e, Our data are clearly in favor of a proximal tubular defect in pseudohypoaldosteronism , but require confirmation in other patients with this disease. The results may help in determining whether pseudohypoaldosteronism is a single entity. 7 W. Proesmans, M.D. Binda ki Muaka, M.D. L. Corbeel, M.D. R. Eeckels, M.D. Department of Paediatrics University of Leuven Belgium REFERENCES 1. Royer P, Donnette J, Mathieu H, et al: Ann Pediatr 39:596, 1963. 2. Proesmans W, Geussens H, Corbeel L, and Eeckels R: Am J Dis Child 126:510, 1973. 3. Postel-Vinay M-C, Alberti G, Ricourt C, et al: J Clin Endocriuol Metab 39:1038, 1974. 4. Tieder M, Vure E, Gilboa Y, et al: Arch Fr Pediatr 33:485, 1976. 5. Chaimovitz C, Levi J, Better C, et al: Pediatr Res 7:89, 1973. 6. Rodriguez-Soriano J, Vallo A, and Crarcia-Fuentes M: J PEDIATR 86:524, 1975. 7. R/3sler A, Theodor R, Crazit E, et al: Lancet 1:959, 1973.
Sodium clearance
2.5 • 3.4 4.6 _+0.6
of sodium
Tetracycline-associated intracranial hypertension in an adolescent: A complication of systemic acne therapy Tetracycline is the currently recommended therapy for acne vulgaris in adolescents because of its suppression of inflammatory lesions and the rarity of severe side-effects.' In this age group, adverse effects from tetracycline have been limited to monilial vaginitis. The present case is reported to alert the pediatrician to the more serious complication of intracranial hypertension. CASE REPORT Patient C. J., a 14-year-old girl, three years post-menarche, was treated with tetracycline, 1 gm/day, for moderately severe acne since June, 1976. Six months later she noted the sudden onset of daily severe frontal nonthrobbing headaches accompanied by nausea, vomiting, and diplopia. At another hospital examination revealed bilateral blurring of the optic disc margins, fundal vein engorgement without venous pulsations, and weakness of the right lateral rectus muscle. Laboratory values were all within normal limits. A lumbar puncture was performed; the opening pressure was 400 mm H~O. Spinal fluid was acellular and xanthochromic; glucose concentration was 59 mg/dl and protein 31 mg/dl with normal electrophoresis, Cultures were negative for all organisms. A computer axial tomograph study of the head revealed no abnormalities. An electroencephalogram showed "slightly excessive" (3 to 6/ second) posterior activity without dominant lateralization. There was no arteriovenous malformation, aneurysm, or arterial vasospasm on cerebral angiography.. A presumptive diagnosis of benig n intracranial hypertension (pseudotumor cerebri) was made and the patient was discharged with no c h a n g e in medications except for the addition of Empirin with codeine, which was taken only intermittently arid afforded minimal relief. The symptoms disappeared following the lumbar puncture, only to return two days later. In February, 1977, the patient was seen at the Stanford Youth Clinic. Her only medications within the previous year had been
0022-3476/78/0492-0679500.20/0 9 1978 The C. V. Mosby Co.
680
The Journal of Pediatrics April 1978
Clinical notes
tetracycline, 1 gm daily, and analgesics as mentioned. Blood pJcessure was normal. Extraocular movements were full with no diplopia on lateral gaze. Funduscopic examination disclosed severely blurred disc margins bilaterally with engorged, nonpulsatile veins. The neck was supple. Skin was clear. Neurotogic examination revealed a clear sensorium, full orientation, and no signs of focal neuropath01ogy. Tetracycline therapy was discontinued. Over the following two weeks, there was a progressive decrease in frequency and severity of headaches. F u n d u s examination at the end of the second week showed decreased venous engorgement and clear optic discs. A n electroencephalogram was completely normal. On further follow-up, the patient reported that her headaches had completely cleared. She had no further episodes of diplopia or vomiting. Her acne has not recurred. DISCUSSION The rapid reversal of the patient's two-month course of nearly constant headaches, with concomitant return of the appearance of the fundi to normal, strongly implicates tetracycline as the etiologic factor in the elevation of intracranial pressure. Tetracycline-associated intracranial hypertension is well known in infants, in whom it.presents as the "bulging fontanel syndrome. ''~ Although the .dosage in this case exceeds that recommended for acne therapy, Other cases have not been dose related. Only three other cases in individuals whose sutures had fused have been reported2 -~ In two, the syndrome occurred early and was preceded by a hypersensitivity reaction. The third, a 16-year-old girl; also noted onset of headache and visual disturbances five to six months after beginning ther~ipy. Adolescents have received tetracycline for the treatment of ache for over 25 years; it is estimated that 10% of the tetracycline produced for h u m a n use in the United States is prescribed for this purpose. Pseudotumor cerebri is a rare, but Serious, complication which should be considered in the patient receiving tetracycline Who exPeriences severe headaches. Bradley Hall Stuart, M.D. Graduate Medical Student Iris F. Litt, M.D. Associate Professor of Pediatrics Director, Adolescent Medicine StanJbrd University Medical Center StanJbrd, CA 94305
Familial 14/15 translocation chromosome carriers detected by fetal propositus In various surveys of Robertsonian translocations involving D chromosomes, 1-:' the majority of such translocations have been chromosomes 13/14 with a small percentage being 14/15. None of the phenotypically normal translocation chromosome carriers have been ascertained by virtue of the birth of a trisomy syndrome. This report describes a family comprised of numerous phenotypically normal individuals with 14/15 balanced translocati0ns. The propositus was a fetus whose translocation status was detected by amniocentesis performed because of age of the parents. CASE REPORT
Mr. and Mrs. G, 40 and 36 years of age, respectively, were referred for amniocentesis during her sixth pregnancy. The five previous pregnancies had resulted in four living normal children; the fourth pregnancy, in 1970, ended in a spontaneous abortion at two months' gestation. Ultrasonography and a!pha-fetoprotein levels were normal at the sixteenth week Of the pregnancy. Chromosome evaluation revealed a fetus with 45,XX + t(14q; 15q). Peripheral lymphocyte cultures demonstrated that Mrs. G, three of her four children, and Mrs. G's father were balanced 14/15 transloc/~tion chromosome carriers (Figs. 1 and 2). The parents were reassured by the normal phenotypes of the living familial carriers and the pregnancy was continued. After a term gestation and normal verteX delivery, a healthy and physically normal infant female, with birth weight 4.3 kg, was born on August 12, 1977.
Partial support by The National Foundation-March of Dimes, Medical Service Program Grant C-152, and the New Jersey State Department of Health Grant.
KEY (~ 14/15 TRANSLOCATION CARRIER (~) NORMAL CHROMOSOMES
REFERENCES
1. American Academy of Pediatrics, Committee on Drugs: The treatment of acne with antibiotics, Pediatrics 48:663, 1971. 2. Fields JP: Bulging fontanel: A complication of tetracycline therapy in infants, J PEDIATR 58:74, 1961. 3. Maroon JC, and Mealy J: Benign intracranial hypertension: Sequel to tetracycline therapy in a child, J A M A 216:1479, 197E 4. Koch-Weser J, and Gilmore EB: Benign intracranial hypertension in an adult .after tetracycfine therapy, J A M A 200:345, 1967. 5. Giles CL, a n d Soble AR: Intracranial hypertenfion and tetracycline therapy, Am J Ophthal 72:981, 1971.
PEDIGREE OF G FAMILY Fig. I. Pedigree of the G family illustrating transmission of 14/15 translocation chromosome carrier state from m a t e r n a l grandfather to mother to offspring. 0022-3476/78/0492-0680500.20/0 9 1978 The C. V. Mosby Co.