Unilateral mydriasis from ipratropium in transplant patients

Abstract

Intracranial hemorrhage (ICH) is common in autopsy series of hematopoietic cell transplantation (HCT).1 ICH often presents with third nerve signs of transtentorial herniation. Unilateral pupillary dilatation from scopolamine, used as a transdermal patch for post-HCT nausea, can be a false indicator of ICH.2 I describe similar diagnostic confusion with ipratropium/albuterol (I/A) in four patients with HCT.

I studied four men, aged 22 to 64 years (median 41 years), who had undergone allogeneic HCT 1 to 6 months previously (table). All patients had multiple complications after transplant, including two patients with alveolar hemorrhage, atrial fibrillation, and renal failure requiring dialysis. Patient 1 had enterococcal meningitis, and Patient 4 had aspergillus pulmonary infection. All four patients had recent bacteremia, and all were thrombocytopenic with platelet counts of 27,000 to 94,000/μL (median 46,000/μL) on the day of the neurologic consultation.