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Ischemic stroke in a man with naphazoline abuse history
American Journal of Emergency Medicine (2007) 25, 983.e1 – 983.e2
www.elsevier.com/locate/ajem
Case Report Ischemic stroke in a man with naphazoline abuse history Nasal vasoconstrictors are some of the most widely used over-the-counter drugs, considered by many consumers as relatively safe with few significant side effects. We report the case of a 45-year-old man who had a stroke after abuse of topical nasal naphazoline, despite having no other remarkable risk factors for an acute cardiovascular event. There are reports in the literature about the link between drug with sympaticomimetics activity and cerebrovascular events. We report a male patient who had a stroke after abuse of topical nasal naphazoline. There are reports in the literature about the link between drugs with sympaticomimetics activity and cerebrovascular events. Between 5% and 10% of all ischemic strokes occur in young adults [1]. About 10% of cerebral accidents in young adults are associated with drug abuse [2]. Naphazoline, an over-the-counter sympathomimetic drug, is often used in the symptomatic treatment of rhinitis. To our knowledge, this marks the first reported case of ischemic stroke associated with topical naphazoline abuse. A 46-year-old man presented to the emergency department with left limb paresthesias and dysarthria. He was previously healthy, except for a chronic rhinitis treated with topical naphazoline (up to 20 nasal applications per day for several years). No risk factors for cerebrovascular events were found in his clinical history. Results of his physical examination were normal; neurologic examination showed dysathria and left arm weakness. Cerebral computed tomographic scan performed 6 hours after the onset of symptoms showed negative results. An antiplatelet drug therapy was started. The neurologic symptoms improved within 24 to 48 hours. Cranial magnetic resonance imaging showed a small infarctional area in right subcortical frontal region; intracranial angiomagnetic resonance imaging excluded dissections, vascular malformations, aneurism, or vasculitis. The screening for stroke risk factors and the search of a possible source of emboli (cholesterol, LAC screening, AT III mutation, prothrombin mutation, Leiden mutation, C and S protein, basal homocysteinemia, electrocardiogram, echocardiogram, and carotids and vertebral ultrasounds) yielded
0735-6757/$ – see front matter D 2007 Elsevier Inc. All rights reserved.
normal results, except for the presence of homozygosis for the MHTFR 677TT mutation. MTHFR mutation is the only recognized cerebrovascular risk factor in our patient, but its association with atherotrombotic vascular disease is weak, especially if associated with normal homocysteine levels [3,4]. Furthermore the patient does not present any atherosclerotic lesion in the vascular districts investigated by imaging; this finding is not consistent with premature atherosclerosis as possible source of thromboembolism. Thus, we considered the abuse of naphazoline as the possible root of the problem. Cerebrovascular accidents relating to topical drugs, although rare, must be taken into consideration [5,6]. There are reports about cerebral accidents related to different kinds of topical sympathomimetic drugs [5,6], and 1 report of hemorrhagic stroke related to naphazoline use [7], probably due to vasospasm or a rapid rise in blood pressure [5]. In particular, Cantu et al [5] reported that 22 of 2500 consecutive patients who had a stroke in a neurologic reference center experienced a stroke after using an overthe-counter cough and cold sympathomimetic drug. We believe that the abuse of topical naphazoline (more than 20 times a day for years) has been the precipitating factor in the genesis of cerebral ischemia in our patient. Self-prescription medical treatment has been affected in recent years by the wide availability of over-the-counter drugs and marketing strategies. The use of over-thecounter drugs is often considered by patient as harmless; this assumption may contribute to drug abuse in particular for highly effective symptomatic drugs, such as nasal vasoconstrictor. Physicians and patients need to be aware of these potentially serious side effects when using topical sympathomimetic drugs. Giorgio Costantino MD Elisa Ceriani MD Giulia Sandrone MD Nicola Montano MD Medicina Interna II, L. Sacco Hospital Milan, Italy E-mail address: [email protected] doi:10.1016/j.ajem.2007.02.018
983.e2
References [1] Varona JF, Guerra JM, Bermejo F. Stroke in young adults. Med Clin (Barc) 2004;122:70 - 4. [2] Sloan MA, Kittner SJ, Feeser BR, et al. Illicit drug-associated ischemic stroke in the Baltimore-Washington Young Stroke Study. Neurology 1998;50:1688 - 93. [3] Kaul S, Zadeh AA, Prediman K. Homocysteine hypothesis for atherotrombotic cardiovascular disease. J Am Coll Cardiol 2006;48:914 - 23. [4] Wald DS, Law M, Morris JK. Homocysteine and cardiovascular disease: evidence on causality from a meta-analysis. BMJ 2002;325:1202 - 8.
Case Report [5] Cantu C, Arauz A, Murillo-Bonilla LM, et al. Stroke associated with sympathomimetics contained in over-the-counter cough and cold drugs. Stroke 2003;341:667 - 73. [6] Olivier P, Dugue A, Montastruc JL. Adverse cardiovascular and central neurologic reactions to sympathomimetics used as nasal decongestants: results of the French National Pharmacovigilance Survey. Therapie 2003;58:361 - 6. [7] Zavala JA, Pereira ER, Zetola VH, et al. Hemorrhagic stroke after naphazoline exposition: case report. Arq Neuropsiquiat 2004;62: 889 - 91.
www.elsevier.com/locate/ajem
Case Report Ischemic stroke in a man with naphazoline abuse history Nasal vasoconstrictors are some of the most widely used over-the-counter drugs, considered by many consumers as relatively safe with few significant side effects. We report the case of a 45-year-old man who had a stroke after abuse of topical nasal naphazoline, despite having no other remarkable risk factors for an acute cardiovascular event. There are reports in the literature about the link between drug with sympaticomimetics activity and cerebrovascular events. We report a male patient who had a stroke after abuse of topical nasal naphazoline. There are reports in the literature about the link between drugs with sympaticomimetics activity and cerebrovascular events. Between 5% and 10% of all ischemic strokes occur in young adults [1]. About 10% of cerebral accidents in young adults are associated with drug abuse [2]. Naphazoline, an over-the-counter sympathomimetic drug, is often used in the symptomatic treatment of rhinitis. To our knowledge, this marks the first reported case of ischemic stroke associated with topical naphazoline abuse. A 46-year-old man presented to the emergency department with left limb paresthesias and dysarthria. He was previously healthy, except for a chronic rhinitis treated with topical naphazoline (up to 20 nasal applications per day for several years). No risk factors for cerebrovascular events were found in his clinical history. Results of his physical examination were normal; neurologic examination showed dysathria and left arm weakness. Cerebral computed tomographic scan performed 6 hours after the onset of symptoms showed negative results. An antiplatelet drug therapy was started. The neurologic symptoms improved within 24 to 48 hours. Cranial magnetic resonance imaging showed a small infarctional area in right subcortical frontal region; intracranial angiomagnetic resonance imaging excluded dissections, vascular malformations, aneurism, or vasculitis. The screening for stroke risk factors and the search of a possible source of emboli (cholesterol, LAC screening, AT III mutation, prothrombin mutation, Leiden mutation, C and S protein, basal homocysteinemia, electrocardiogram, echocardiogram, and carotids and vertebral ultrasounds) yielded
0735-6757/$ – see front matter D 2007 Elsevier Inc. All rights reserved.
normal results, except for the presence of homozygosis for the MHTFR 677TT mutation. MTHFR mutation is the only recognized cerebrovascular risk factor in our patient, but its association with atherotrombotic vascular disease is weak, especially if associated with normal homocysteine levels [3,4]. Furthermore the patient does not present any atherosclerotic lesion in the vascular districts investigated by imaging; this finding is not consistent with premature atherosclerosis as possible source of thromboembolism. Thus, we considered the abuse of naphazoline as the possible root of the problem. Cerebrovascular accidents relating to topical drugs, although rare, must be taken into consideration [5,6]. There are reports about cerebral accidents related to different kinds of topical sympathomimetic drugs [5,6], and 1 report of hemorrhagic stroke related to naphazoline use [7], probably due to vasospasm or a rapid rise in blood pressure [5]. In particular, Cantu et al [5] reported that 22 of 2500 consecutive patients who had a stroke in a neurologic reference center experienced a stroke after using an overthe-counter cough and cold sympathomimetic drug. We believe that the abuse of topical naphazoline (more than 20 times a day for years) has been the precipitating factor in the genesis of cerebral ischemia in our patient. Self-prescription medical treatment has been affected in recent years by the wide availability of over-the-counter drugs and marketing strategies. The use of over-thecounter drugs is often considered by patient as harmless; this assumption may contribute to drug abuse in particular for highly effective symptomatic drugs, such as nasal vasoconstrictor. Physicians and patients need to be aware of these potentially serious side effects when using topical sympathomimetic drugs. Giorgio Costantino MD Elisa Ceriani MD Giulia Sandrone MD Nicola Montano MD Medicina Interna II, L. Sacco Hospital Milan, Italy E-mail address: [email protected] doi:10.1016/j.ajem.2007.02.018
983.e2
References [1] Varona JF, Guerra JM, Bermejo F. Stroke in young adults. Med Clin (Barc) 2004;122:70 - 4. [2] Sloan MA, Kittner SJ, Feeser BR, et al. Illicit drug-associated ischemic stroke in the Baltimore-Washington Young Stroke Study. Neurology 1998;50:1688 - 93. [3] Kaul S, Zadeh AA, Prediman K. Homocysteine hypothesis for atherotrombotic cardiovascular disease. J Am Coll Cardiol 2006;48:914 - 23. [4] Wald DS, Law M, Morris JK. Homocysteine and cardiovascular disease: evidence on causality from a meta-analysis. BMJ 2002;325:1202 - 8.
Case Report [5] Cantu C, Arauz A, Murillo-Bonilla LM, et al. Stroke associated with sympathomimetics contained in over-the-counter cough and cold drugs. Stroke 2003;341:667 - 73. [6] Olivier P, Dugue A, Montastruc JL. Adverse cardiovascular and central neurologic reactions to sympathomimetics used as nasal decongestants: results of the French National Pharmacovigilance Survey. Therapie 2003;58:361 - 6. [7] Zavala JA, Pereira ER, Zetola VH, et al. Hemorrhagic stroke after naphazoline exposition: case report. Arq Neuropsiquiat 2004;62: 889 - 91.