A patient treated chronically with methysergide for migraine prophylaxis develops flank pain and hydronephrosis. The most likely complication is:

• A Retroperitoneal fibrosis obstructing the ureters ✓
• B Papillary necrosis from chronic analgesic use
• C Renal artery stenosis from serotonin-mediated vasoconstriction
• D Obstructive nephropathy from oxalate stones

Explanation

Methysergide, a 5-HT2 antagonist formerly used in migraine prophylaxis, is notorious for causing retroperitoneal, pulmonary and cardiac valvular fibrosis after prolonged use. Fibrotic tissue encases the ureters, producing hydronephrosis, and the reaction usually reverses if the drug is stopped early. Papillary necrosis is linked to analgesic nephropathy from NSAIDs and phenacetin, not methysergide, and stone disease is unrelated to this agent.

Reference: Katzung Basic and Clinical Pharmacology, 15th ed.

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