PEDIATRIC PSEUDOTUMOR CEREBRI SYNDROME IN A PREPUBERTAL NON-OBESE BOY: SILENT VISUAL IMPAIRMENT AND A NORMAL BRAIN MRI - A CASE REPORT

Abstract

Background: Pseudotumor cerebri syndrome (PTCS) is characterized by elevated intracranial pressure in the setting of normal cerebrospinal fluid composition and normal or typically altered neuroimaging, once secondary causes have been excluded. In adults the disease classically affects young obese women, but in children the demographic profile is more heterogeneous, with prepubertal patients frequently being non-obese and of either sex. Early recognition is essential because untreated PTCS can cause irreversible visual loss, yet the condition is easily overlooked when the clinical presentation deviates from the adult stereotype. Case presentation: A 6-year-10-month-old prepubertal boy with a history of recurrent upper respiratory tract infections presented with a three-week history of abdominal pain, headache, vomiting, and double vision. Body mass index was 13.67 kg/m² (non-obese). Fundoscopy disclosed bilateral optic disc edema, and visual acuity was mildly reduced to 0.7 in the right eye and 0.5 in the left eye, although the child did not report visual symptoms. Magnetic resonance imaging of the brain, orbits, and whole spine was unremarkable, and computed tomography findings of low-lying cerebellar tonsils were not confirmed on MRI. Diagnostic lumbar puncture yielded clear, colorless cerebrospinal fluid with normal biochemistry and negative infectious and autoimmune workup. Acetazolamide, intravenous mannitol, and therapeutic lumbar puncture were followed by complete visual recovery (1.0 in each eye) and regression of papilledema within two weeks. Respiratory syncytial virus was treated with supportive care and amoxicillin-clavulanate because of suspected bacterial superinfection. Discussion: This case illustrates three teaching points: PTCS must be considered in prepubertal non-obese children regardless of sex; visual impairment may develop silently and recover fully with prompt treatment; and a normal brain MRI does not exclude the diagnosis, which rests on the combination of clinical features, papilledema, cerebrospinal fluid findings, and exclusion of mimics. Conclusion: Clinicians should maintain a low threshold for fundoscopy and lumbar puncture in any child with suggestive symptoms, irrespective of demographic profile, because timely treatment can prevent permanent visual loss even when the child does not report visual symptoms.