Chronic Cough as the Presenting Symptom of Hydrocephalus

Selmin Karatayli-Ozgursoy, MD; Jacob Dominik, MD; Benjamin Eidelman, MD; Juan C. Guarderas, MD

Disclosures

South Med J. 2010;103(6):574-577. 

In This Article

Case Report

A 48-year-old female patient presented to the department of otorhinolaryngology with a one-year history of chronic cough. Her primary physician had prescribed various courses of antibiotics and cough medicines without benefit. The cough was present throughout the waking hours, occasionally disrupted her sleep, and was particularly noticeable if she reclined after eating. The patient was prescribed omeprazole as treatment for possible gastroesophageal reflux disease, but the cough persisted. Finally, she was referred to the department of allergy-internal medicine for evaluation and treatment.

The patient's history was negative with respect to allergy, sinus, and pulmonary conditions except for allergic rhinoconjunctivitis occurring when exposed to cats. She denied dysphonia, dysphagia, heartburn, reflux, and any pulmonary or cardiovascular symptoms. She was a lifetime nonsmoker with a history of a 12-pound weight loss, attributed to participation in a "detoxification program." Family history was noncontributory, as were other aspects of her past medical and surgical history.

In addition to her persistent cough, the patient related that she had a sense of weakness and numbness in her arms and legs. Her gait was compromised, and she complained of a sensation of heaviness in the legs with a tendency to drag her feet. She had also noted slowness in her response times during conversation.

Otolaryngological examination and heart and lung examinations were normal. Laboratory studies were unremarkable for complete blood count, chemistry panel, serum iron, vitamin B12, folic acid level, serum protein electrophoresis, antinuclear antibody and C-reactive protein tests, paraneoplastic panel, myasthenia gravis serology, and limited specific IgE allergy blood tests. Computed tomography (CT), chest x-rays, and pulmonary function tests were normal.

Neurological consultation was requested, and the specific neurological history was negative for syncope, presyncope, alterations of consciousness, confusion, hallucinations, orthostasis, headaches, visual problems, neck or back pain, and bowel or bladder problems. The neurological examination revealed intact cognition, no papilledema, decreased distal sensation to pinprick in the lower extremities and bilateral, mild proximal weakness with minimal exaggeration of stretch reflexes. An apraxia of gait was noted with poor initiation, reduced foot clearance, and decreased stride length. The patient's arm swing was reduced, and she had difficulty walking backwards and sideways. The remainder of the neurological examination was normal.

Magnetic resonance imaging (MRI) of the brain (Figs. 1 and 2) demonstrated hydrocephalus involving the lateral and third ventricles, a very small aqueduct, and a normal fourth ventricle. Uniform, linear T2-weighted hyperintensities surrounding the lateral ventricular margins were present, indicating the presence of transependymal cerebrospinal fluid (CSF) resorption. These findings were highly suggestive of obstructive hydrocephalus. The patient underwent a lumbar puncture and the opening CSF pressure was 182 mm H20. Analysis of the CSF revealed no abnormality. Subsequent videotaping demonstrated some improvement in gait following withdrawal of 30 mL of fluid. The patient was referred to neurosurgery for further evaluation. A ventriculoperitoneal (VP) shunt was inserted and a scan on postoperative day 15 confirmed a right-sided posterior parietal shunt, as well as a newly-decompressed ventricular system. The patient's neurological symptoms improved considerably in the month following shunt placement, particularly with respect to memory and gait. The cough also resolved immediately, eliminating the need for cough medication.

Figure 1.

Magnetic resonance imaging (MRI) in sagittal view, demonstrating hydrocephalus involving the lateral and third ventricles, a very small aqueduct and a normal fourth ventricle.

Figure 2.

Magnetic resonance imaging (MRI) in axial view, demonstrating hydrocephalus involving the lateral and third ventricles, a very small aqueduct and a normal fourth ventricle.

The majority of the follow up was performed by the patient's local providers. Over the 11 months following shunt implantation, the patient required multiple shunt adjustments. The Codman-Hakim programmable shunt was adjusted multiple times from between 120 mm H20 to 200 mm H20. This was done due to development of a right-sided subdural hygroma initially documented at 7 mm thickness one month after implantation and reaching 13 mm thickness at two months after implantation. Eventually, at nine months after shunt placement, the patient was stabilized at a shunt setting of 120 mm H20. During follow up, the patient was documented to have intermittent recurrence of the cough at two and seven months after shunt implantation.

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