Commentary.

The report by Reddy describes the rather peculiar case of a young woman who developed pseudotumor cerebri syndrome in the context of weight gain and self medication.[1] The case highlights the potential dangers of over-the-counter self-medication practices in India. Both the drugs (dexamethasone, cyproheptadine) implicated in this incident of pseudotumor cerebri syndrome would not be available without a doctor's prescription in most of the developed nations. As India and other developing countries grapple with complex issues arising from large socio-economic and regional variations, it seems unlikely that they will simply emulate the Western model of relatively tight and rigorously enforced state regulation of most medicines. Importantly, self medication may take many forms including the sharing of pharmaceuticals with family and friends, using leftover medicines or resubmitting unused, old prescriptions to obtain a drug.[2] Therefore, special emphasis should be placed on educating the public on the benefits of proper diagnostic evaluation and treatment, if applicable, by a medical professional. It would also be helpful if the public could be made more aware of the fact that medicines are usually only approved for a limited number of indications. Furthermore, the health risks of self medication in special populations, such as children, elderly individuals, or women of child-bearing age, should be widely publicized.

There is hardly another disease in women in which the association with obesity or recent weight gain is as strong as in idiopathic intracranial hypertension (IIH). The percentage of overweight and obese individuals among IIH patients is estimated at roughly 90%. Conversely, obesity increases the risk of developing IIH by approximately 20 times. Most affected are women of child-bearing age. Despite the clear linkage between obesity and IIH, the underlying pathogenetic mechanisms remain largely unknown.[34]

The ‘Idiopathic Intracranial Hypertension Treatment Trial’, which is currently underway, seeks to more precisely elucidate the etiology of IIH. The study focuses especially on the contribution of genetic factors and vitamin A metabolism to IIH.[5]

Medications commonly associated with increased appetite and weight gain include the progesterone derivative megestrol acetate, the first-generation antihistamine cyproheptadine, dronabinol (synthetic THC), some antidepressants such as mirtazapine, as well as most atypical antipsychotics.[6] In certain clinical situations these compounds may be useful to facilitate weight gain. However, most of these uses would be “off-label”. In the case reported by Reddy,[1] symptoms of pseudotumor cerebri syndrome developed after withdrawal from the chronic corticosteroids. In principle, steroid withdrawal may precipitate pseudotumor cerebri syndrome.[4] However, the patient described by Reddy[1] only started to display symptoms at around two months after discontinuation of dexamethasone and cyproheptadine. This timing strongly argues against a direct link between the patient's symptoms and discontinuation of dexamethasone.

Since obesity is on the rise around the globe, a further significant increase in the prevalence of IIH is foreseen for the coming years. The clinical course of IIH is inherently variable. In many instances, the visual disturbances associated with IIH do not resolve completely. Persistent visual problems have been found in approximately 25% of the cases. Recurrences and chronic syndromes are not infrequent.[34] Accumulating evidence indicates that IIH patients also suffer from significant olfactory dysfunction. Indeed, the prevalence of absolute hyposmia reached 80% in a sample of acute IIH patients in a recent study.[7] In this context, it is also worth mentioning the morphological studies of olfactory bulb volume (OBV) in IIH. During periods of increased disease activity, OBV is significantly reduced, which nicely fits with the functional deficits demonstrated by olfactometry.[8] Considering that patients suffering from IIH may already have to cope with obesity, chronic headache and frequent visual disturbances, the additional olfactory dysfunction may present a major health disturbance.