PEDIATRIC ASTHMA, ALLERGY & IMMUNOLOGYVolume 15, Number 3, 2002© Mary Ann Liebert, Inc.

Case Report

Intracranial Tumor Masquerading as Allergic Rhinitis

KIRK H. WAIBEL, M.D., and ROHIT K. KATIAL, M.D.

ABSTRACT

Seasonal allergic rhinitis and perennial allergic rhinitis can present with rhinorrhea, con-gestion, and headache. Although headache is often attributed to allergic disease, it can beoverlooked as a manifestation of other underlying processes. We present a case of intracra-nial calcifications that incidentally were found on sinus imaging. Subsequently the patientwas diagnosed with a craniopharyngioma. Health care providers should be cautious aboutattributing prominent headache complaints to “hay fever” or “sinus-related disease” andconsider other etiologies. (Pediatr Asthma Allergy Immunol 2002; 15[3]:163–166.)

INTRODUCTION

A13-YEAR-OLD MALE presented with a 6-year history of seasonal ocular pruritis, sneezing, bilateral rhi-norrhea, perennial congestion, and a 1-year history of progressive headache. Seasonal symptoms oc-

curred from March to September. Headache occurred intermittently until 4 months prior to presentationwhen it increased in severity and frequency. The patient’s headache was throbbing, aching, and localizedin the temporal region bilaterally. Headache occurred multiple times per day, lasted 1 to 2 hours, and wasminimally relieved after nonsteroidal anti-inflammatory drugs or rest. Antihistamines improved nasal andocular symptoms but did not improve headache. There was no history of recent viral infections; tick expo-sure; fever; vomiting; weight loss; visual disturbances; tooth pain; anosmia; trauma; sensory or motor com-plaints; migraines; or caffeine, alcohol, or illicit drug use. The patient had resided in the eastern UnitedStates for the past 9 years.

PAST MEDICAL HISTORY

The patient had a normal birth and childhood history without hospitalizations. He had one sinus infec-tion treated with oral antibiotics 1 year prior to presentation; no imaging studies were obtained.

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Department of Allergy and Immunology, Walter Reed Army Medical Center, Washington, D.C.The opinions or assertations contained herein are the private views of the authors and are not to be construed as of-

ficial or as reflecting the views of the Department of the Army or the Department of Defense.

MEDICATIONS

Tylenol® (McNeil Consumer Healthcare, Fort Washington, PA) 650 mg one to two times a day forheadache. No other medications, over-the-counter drugs, or herbal supplements.

FAMILY MEDICAL HISTORY

The patient’s mother had a history of migraine headache and allergic rhinitis. There was no family his-tory of asthma or malignancies.

PHYSICAL EXAMINATION

The patient did not appear ill. Temperature was 37.0°C; pulse, 73 beats per minute; respiratory rate, 20breaths per minute; blood pressure 108/61 mm Hg; weight, 54 kg (50–75th percentile); and height, 145 cm(3rd percentile). Examination was remarkable for bilateral conjunctival injection, bilateral swollen turbinates,and cobblestoning of the posterior pharynx. No sinus tenderness, nasal polyps, or tempomandibular joint(TMJ) pain. Heart, lungs, abdomen, genital, and neurologic examinations were unremarkable.

INITIAL LABORATORY DATA

A nasal smear demonstrated more than 30% eosinophils. Skin-prick testing (SPT) was positive for mul-tiple allergens including maple, bluegrass, rye, timothy, ragweed, alternaria, and dust mite.

CLINICAL COURSE

A coronal sinus computed tomography (CT) scan did not reveal mucosal thickening, opacifications, oranatomic abnormalities; however, intracranial calcifications in the sella tursica were seen (Fig. 1). A neu-rology evaluation revealed a normal neurologic findings with no visual field deficits. Head magnetic reso-nance imaging (MRI) was suggestive for craniopharyngioma.

Endocrine evaluation for pituitary function including free thyroxine, thyroid stimulating hormone, corti-sol, and somatomedin C was significant for a low somatomedin C of 184.0 ng/mL (normal limit, 202–957ng/mL). However, linear growth was 5 cm/year or more, repeat bone age x-ray, pubertal development, andmidparental height were appropriate.

Subtotal tumor resection was performed and biopsy confirmed the diagnosis of craniopharyngioma.Headache markedly decreased after surgery and remained minimal without progression 6 months later.

DISCUSSION

The patient’s history of ocular and nasal symptoms, physical examination, nasal smear, and skin testswere consistent with seasonal and perennial allergic rhinitis. However, the prominent symptom of chronicand progressive headache was of concern. Headache can be a presenting feature of allergic rhinitis and si-nusitis, but can be overlooked as a manifestation of other underlying processes to include primary headachesand intracranial lesions.1,2

Allergic rhinitis affects approximately 5%–20% of children under 18 years old.3 Although headache isoften attributed to “hay fever,” the data do not support this contention.4–6 A retrospective review by Westet al.4 suggests there is not an increased prevalence of headache in patients with allergic rhinitis. The pa-tient’s lack of headache improvement after appropriate oral antihistamine and nasal steroid therapy sug-gested another underlying etiology.

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Interpretation of “sinus-related” headache is also a reason for frequent allergy referral, but the associa-tion of headache and sinusitis is debated.7–13 Studies supporting headache as a symptom of sinusitis havereported headache improvement after sinus surgery, removal of obstructive concha bullosa, steroid therapy,and antibiotics.8,14 On the other hand, Nguyen et al.12 found no correlation between headache symptomsand CT evidence of sinusitis in 91 children 2–17 years of age.12 McNally et al.14 reported headache in only10% of children with chronic sinusitis. Although the relationship of headache and sinusitis is debated, al-lergists are often obligated to evaluate the sinuses in patients complaining of chronic headaches.1,2

Primary headache in adolescents ranges from 20%–54%.5,15,16 Asyun et al.5 evaluated children 11–15years old with the complaint of headache; migraine and tension headache were the most common diag-noses. The patient’s absence of unilateral symptoms, lack of improvement with sleep, and lack of nausea,photophobia, or phonophobia made migraine unlikely.

Headache is a complaint in 60%–80% of patients with an intracranial tumor; however, only 1 in 872 pa-tients presenting to the emergency department with the chief complaint of headache was diagnosed with anintracranial neoplasm.17 The quality of headache associated with intracranial neoplasms can mimic primaryheadache, but progressive symptoms are highly suggestive of increased intracranial pressure.18,19 This issupported by a retrospective review of children 11–16 years old that found intracranial pathology in chil-dren with chronic, progressive headache.6

In this case, a craniopharyngioma was identified as the cause of the chronic headache. Craniopharyngiomasare persistent embryonic squamous cells of Rathke’s cleft and account for 5%–10% of brain tumors in children5–15 years old.20 Craniopharyngiomas present with endocrine abnormalities to include decreased growth rate,visual field abnormalities, and pubertal delay in 80%, 90%, and 90–100% of patients, respectively.21 This pa-tient in this report was unique because his tumor was found incidentally on sinus CT scan and his presentationlacked all of the objective neuroendocrine findings usually seen in patients with craniopharyngioma.

CONCLUSION

Headache can be a presenting symptom of allergic rhinitis but is rarely a prominent complaint. In thiscase, the history, nasal cytology, and skin tests were consistent with allergic rhinitis, whereas the progres-sive headache was the only neuroendocrine sign or symptom of craniopharyngioma. Thus, this lesion couldhave easily been missed if it had not been incidentally detected on sinus imaging. In conclusion, health careproviders should be cautious in attributing prominent headache complaints to “hay fever” or “sinus-relateddisease” and consider other etiologies.

INTRACRANIAL TUMOR

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FIG. 1. Coronal computed tomography (CT) of the sinuses. A. Normal maxillary and ethmoid sinuses. Patent os-teomeatal complexes bilaterally. B: Calcifications (arrow) in the region of the sella turcica.

A B

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Address reprint requests to:Kirk H. Waibel, M.D.

Department of Allergy and ImmunologyClinic 1J

6900 Georgia Avenue, N.W.Walter Reed Army Medical Center

Washington, D.C. 20307

E-mail: kirk.waibel@na.amedd.army.mil

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