Paget's disease of bone presented as normal pressure hydrocephalus: A case report and review of literature
A 66-year-old woman was admitted to Imam Khomeini Hospital with the chief complaint of gait difficulty since 6 years ago. She described the gait difficulty as a falling tendency while walking. She also complained of urinary incontinence. Furthermore, she expressed annoying memory problems. She had diabetes type II, hypertension, dyslipidemia, and hypothyroidism in past medical history. Moreover, she had ischemic heart disease and a previous angiography had revealed stenosis, which was treated by percutaneous coronary intervention. The drug history comprised the following medications: amlodipine, losartan, atenolol, nitrocontin, glibenclamide, atorvastatin, metformin, and levothyroxine. Her pulse rate was 90 per minute with blood pressure of 140/90. Her recent memory was disrupted. A slight facial paresis was detectable as asymmetric nasolabial fissure pattern. She also utilized hearing aids due to hearing problems. Assessing the cerebellar function, the finger to nose and heel to shin tests were normal, while the tandem gait was disrupted. Her gait was slow but normal for her age.\nCell blood count showed lymphocytosis of 42.1% with the white blood cell (WBC) count of 5500/µl. The brain CT scan revealed thickened calvaria (). Furthermore, hydrocephaly was detectable in all supratentorial ventricles, but the forth ventricle remained intact (),. Besides, emphysema was observable in all subcutaneous areas around the skull and outside calvaria (). MRI showed periventricular leukoencephalopathy and increased marrow signal (). In order to assess the thickened calvaria, whole body scan was performed and the serum levels of calcium, phosphorous, and alkaline phosphatase were assessed.\nIn order to investigate the problem, cerebral spinal fluid (CSF) sample was collected after lumbar puncture. After the lumbar puncture the patient's problems including recent memory deficits diminished for one day. Venereal disease research laboratory test (VDRL) and Wright test of CSF were negative. Other indicators of the CSF sample were normal. To investigate multiple myeloma, serum and urine proteins electrophoresis failed to show any specific abnormality. The serum B12 level was normal. Serum calcium and phosphorous levels were within normal limits. Serum alkaline phosphatase was 4723IU/L. The symptoms relieved dramatically after lumbar puncture.