Butorphanol-midazolam combination therapy for the treatment of intracranial hypertension in a patient with tuberculous meningitis: a case study
© Kataoka and Ueno; licensee Springer. 2013
Received: 20 June 2013
Accepted: 2 September 2013
Published: 8 September 2013
Intracranial hypertension, which often occurs in patients with tuberculous meningitis, is associated with high morbidity and mortality. We describe a patient with tuberculous meningitis who had intracranial hypertension -induced fulminant headache that responded to intravenous butorphanol-midazolam combination therapy.
A 50-year-old woman with a fever and headache for 24 days was given a diagnosis of tuberculous meningitis on the basis of the results of polymerase chain reaction amplification and Ziehl-Neelsen staining. Headache with vomiting developed despite administration of steroids, osmotic, and antituberculosis treatments. The patient was admitted in a confusional state. The initial pressure (420 mmHg) in cerebrospinal fluid was increased. She was given intravenous mannitol, dexamethasone, pentazocine and diazepam, or she was sedated with propofol, with no response. Next, a combination of butorphanol and midazolam was infused intravenously and finally resolved the confusional state. The initial pressure decreased, and she no longer complained of headache requiring medication.
Discussion and evaluation
The butorphanol-midazolam combination therapy may have reduced intracranial pressure, leading to down-regulation of headache. Sedation induced by such combination of drugs was not accompanied by amnesia or impaired psychomotor function.
The butorphanol-midazolam combination therapy might be an option for the management of intracranial hypertension in central nervous system infections.
Tuberculosis is one of the most devastating infectious diseases worldwide. The global incidence of tuberculosis peaked around 2004 and has decreased at a rate of less than 1% per year (Lawn and Zumla 2011). However, the incidence and prevalence of tuberculosis is high in most developing countries, including those in Asia (Lawn and Zumla 2011). At present, the incidence of tuberculosis in Japan is lower than that in developing countries in Asia (Lawn and Zumla 2011), but is higher among older people as compared with Europe and North American (Global Tuberculosis Control 2008 2013). Central nervous system involvement, while rare, is the most severe form of tuberculosis. Reportedly, about 10 percent of patients with tuberculosis have central nervous system involvement (Murthy 2005). Tuberculous meningitis (TBM) is primarily a disease of the meninges, which can cause edema, infarction, or hydrocephalus, and multiple pathological changes lead to elevated intracranial pressure (Murthy 2005). Intracranial hypertension (ICH), which often occurs in patients with TBM, is associated with high morbidity and mortality (Murthy 2005). ICH can be managed by osmotic treatment with mannitol or hypertonic saline or by anti-inflammatory and immunomodulatory treatment with steroids. ICH must be treated with these options in addition to antituberculosis therapy to avoid complications; however, surgical intervention including ventriculo-peritoneal shunt is a second option reserved for patients who do not respond to pharmacological therapy (Murthy 2005). We describe a patient with TBM who had ICH-induced fulminant headache that responded to intravenous butorphanol-midazolam combination therapy. This case suggests that this combination therapy can be an alternative treatment for the management of ICH in patients who do not respond to osmotic therapy or steroids, which have been recommended for the medical management of ICH associated with tuberculous meningitis.
This report describes a patient with intolerable, refractory, fulminant headache caused by ICH without hydrocephalus. The headache finally responded to intravenous butorphanol-midazolam combination therapy. To our knowledge, this is the first time to document the use of this combination therapy in a patient with severe headache.
ICH is well known to frequently cause headache (Murthy 2005). TBM is primarily a disease of the meninges associated with multiple potential causes of ICH, such as cerebral edema, hydrocephalus, infarction, adhesion formation of the basal subarachnoid cisterns, or tuberculoma (Murthy 2005). These changes were not found on CT or MRI studies in our patient, except for enhancement of the colloid plexus. We speculate that an imbalance between CSF production and absorption caused by the colloid plexus lesions may have contributed to ICH, leading to the fulminant headache.
Osmotic therapy or steroids have been recommended for the medical management of ICH associated with TBM (Murthy 2005), but these treatments failed to resolve the intolerable, refractory, fulminant headache caused by ICH without hydrocephalus in our patient. We tried high-dose intravenous propofol, but adequate sedation could not be induced because of the intense headache. Intravenous butorphanol-midazolam combination therapy was finally able to control the headache. Midazolam or butorphanol is widely used as a sedative or analgesic, and the combination of these two medications is also useful for sedation (Dershwitz et al. 1991). Midazolam is a benzodiazepine derivative that stimulates γ-aminobutyric acid-A (GABA-A) receptors by enhancing channel opening (Bai et al. 1999), and its agonist activity leads to generalized inhibition of neuronal firing (Enna and Mohler 1987). Similar to midazolam, propofol is effective for the management of refractory headache (Mendes et al. 2002). Butorphanol is believed to act as a partial agonist at kappa opioid receptors (Wood et al. 1983), and the resulting kappa-type opioid produces sedation (Abboud et al. 1987). The mechanism by which butorphanol-midazolam combination therapy alleviated headache remains uncertain, but may have involved a reduction in intracranial pressure or down-regulation of headache. The consciousness of our patient was clear after the withdrawal of the combination therapy. Sedation induced by such combination of drugs was not accompanied by amnesia or impaired psychomotor function (Dershwitz et al. 1991), and the combination therapy may have no neurophysiological effect when used as a supplement to propofol-induced anesthesia.
Butorphanol-midazolam combination therapy may be useful for ICH-induced fulminant headache in patients who do not respond to recommended osmotic or steroids treatments for ICH. The efficacy of low-dose butorphanol-midazolam combination therapy without the need for mechanical ventilation is unknown, but the treatment might be an option for the management of ICH or ICH-induced headache because of potent analgesic and anxiolytic efficacy in patients with central nervous system infections.
Written informed consent was obtained from the patient for publication of this case and any accompanying images.
HK was responsible for the overall study design, and wrote the manuscript. HK contributed to analysis and interpretation of data. HK and SU contributed to drafting and critical revision of part of the submitted materials. HK and SU involved in the treatment of the patient shown in the manuscript and read and approved the final manuscript.
- Abboud TK, Moore M, Zhu J, Murakawa K, Minehart M, Longhitano M: Epidural butorphanol or morphine for the relief of post-cesarean section pain: ventilatory responses to carbon dioxide. Anesth Analg 1987, 66: 887-93.Google Scholar
- Bai D, Pennefather PS, MacDonald JF, Orser BA: The general anesthetic propofol slows deactivation and desensitization of GABA(A) receptors. J Neurosci 1999, 19: 10635-46.Google Scholar
- Dershwitz M, Rosow CE, DiBiase PM, Zaslavsky A: Comparison of the sedative effects of butorphanol andmidazolam. Anesthesiology 1991, 74: 717-24. 10.1097/00000542-199104000-00016View ArticleGoogle Scholar
- Enna SJ, Mohler H: γ-Aminobutyric acid (GABA) receptors and their association with benzodiazepine recognition sites. In Psychopharmacology: The Third Generation of Progress. Edited by: Meltzer HY. New York, NY: Raven; 1987:265-272.Google Scholar
- Global Tuberculosis Control (2008): Global Tuberculosis Control (2008). Geneva: World Health Organization; 2013. http://www.who.int/tb/publications/global_report/2008/en/index.html Google Scholar
- Lawn SD, Zumla AI: Tuberculosis. Lancet 2011, 378: 57-72. 10.1016/S0140-6736(10)62173-3View ArticleGoogle Scholar
- Mendes PM, Silberstein SD, Young WB, Rozen TD, Paolone MF: Intravenous propofol in the treatment of refractory headache. Headache 2002, 42: 638-41. 10.1046/j.1526-4610.2002.02151.xView ArticleGoogle Scholar
- Murthy JM: Management of intracranial pressure in tuberculous meningitis. Neurocrit Care 2005, 2: 306-12. 10.1385/NCC:2:3:306View ArticleGoogle Scholar
- Wood PL, Sanschagrin D, Richard JW, Thakur M: Multiple opiate receptor affinities of kappa and agonist/antagonist analgesics: in vivo assessment. J Pharmacol Exp Ther 1983, 226: 545-50.Google Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.