What urinary incontinence can hide? — Craniopharyngioma in an elderly female patient

Abstract

Background: A benign tumor invading the surrounding structures just like a malignant one — the craniopharyngioma, situated near the sellar area, a rare clinical entity, usually accompanied by both neurological and endocrine dysfunctions, challenges the young clinician faced with vague, unspecific systemic symptoms. Clinical case: A 76 year old woman previously diagnosed with coronary heart disease, type 2 diabetes mellitus and hyperthyroidism presents at the emergency department with a 6 month history of physical asthenia, difficulty maintaining balance and recurrent urinary incontinence with polachiuria. She describes the symptoms as mild at debut but with a progressive evolution which urged her to seek medical advice. On physical examination the patient appears conscientious yet somnolent, with difficulties in maintaining walking balance. She is afebrile, with a regular heart rate of 75 bpm and a blood pressure of 120/60 mm Hg. The general physical examination reveals no abnormalities in the head, neck, chest, abdomen, or extremities. A thorough neurologic examination is performed, which reveals abolished tendon reflexes. Other neurologic examinations, including sensory and motor examinations and cerebellar tests are all within normal range. Her blood test results reveal an elevated ESR (30 mm/h), hyperglycemia (173 mg/dL), increased serum triglycerides (240 mg/dL), mildly increased blood urea nitrogen (51.70 mg/dL), low serum TSH (0.007 μUl/mL) with low fT3 and T4 values. Urine exam and cultures were negative for infection. Heart and carotid artery ultrasound exams found no significant abnormalities (LVEF 55%, impaired diastolic relaxation patterns and carotid atheromatosis, without significant stenosis). The obstetric examination excluded a perineal rupture as possible cause of the patient's urinary incontinence. Finally, the CT exam reveals a sellar and subsellar tumor with multiple calcifications, near the third ventricle. The mass causes hydrocephalus with periventricular edema. The native brain MRI exam describes the tumor with a craniocaudal diameter of 4 cm and axial 2.4/1.6 cm, with mixed solid and cystic structure and an aspect of a craniopharyngioma, with frontal lobe compression, coming in close contact to the optic chiasm. Thus, the common base between neurological symptoms and endocrine dysfunctions was revealed in the clinical entity described as a brain tumor associated with pituitary deficiency. Conclusion: We are presenting a rare and unspecific symptomatology for a craniopharyngioma, the patient showing none of the common signs of nausea, vomiting and headaches. The patient had previously been misdiagnosed and treated for hyperthyroidism while actually suffering from pituitary deficiency. After diagnosing the neoplasm, she was referred for further treatment by surgical resection and radiotherapy.