D. Toxic (pharmacologic) pupil
Given the unclear etiology of symptoms, ophthalmology was consulted. They felt the case was consistent with pharmacologic induced anisocoria, though the agent was unclear upon further questioning of the patient and family on possible use of hyperhidrosis wipes specifically, they admitted to using QbrexzaⓇ cloth wipes on her hands and feet at night. They did not initially consider this a medication. The patient used the wipes for the first time without supervision the previous night and did not wait for her hands to dry after using them.
In mid-2018, QbrexzaⓇ cloth (glycopyrroniumtosylate 2.4%) was approved by the U.S. FDA for topical use in cloth towelettes for primary axillary hyperhidrosis. Mydriasis was reported as an adverse event in the phase 3 trial, reported in up to 6.8% of patients. Glycopyrronium is a muscarinic anticholinergic medication. Anticholinergic mydriasis occurs via a blockade of parasympathetic muscarinic acetylcholine receptors on the iris sphincter muscle.
Hyperhidrosis cloth wipes are relatively new, and there are only a few case reports of accidental ocular exposure to topical anticholinergic treatments for hyperhidrosis. Initial non-disclosure of use of these wipes has also been reported in previous cases. As hyperhidrosis wipes become more popular and the use of anticholinergic drugs become incorporated in more topical products, it is important for the Emergency Medicine physician to be aware of this benign etiology of mydriasis for reassurance and to decrease unnecessary testing. Ultimately, this patient had complete reversal of the mydriasis with supportive care only.
This is not likely a third cranial nerve palsy as there is no ptosis or difficulty with extraocular movements. Holmes-Adie syndrome is characterized by unilateral mydriasis (tonic pupil) along with the absence of deep tendon reflexes. This patient had a normal neurological exam. Benign episodic unilateral mydriasis is a diagnosis of exclusion after other causes have been ruled out (Adie pupil, toxic exposure, intracranial pathology, etc). This is more common in women with migraine headaches. An expanding intracranial mass lesion with pupillary mydriasis usually occurs in the setting of worsening mental status and other neurological findings.
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