P019 - Intracranial Germinoma: Very rare mimicker of multiple sclerosis

Abstract

Background Multiple sclerosis (MS) mimickers are neurological conditions that may share clinical, biologic and radiologic features similar to MS. Standard MS treatments often fail. Objectives To report a very rare case of intracranial Germinoma with clinical, biological and radiological features similar to MS. Methods We report 26 year old Emirati male patient who presented with history of recurrent attacks of neurological dysfunction and recurrent brain stem lesions since 2010. Results MRIs of the brain revealed recurrent brain stem T2 hyperintense lesions changing in size and location but remained localized in the brain stem. Initially CSF was positive for OCB so he was diagnosed as clinically isolated syndrome and was started on Rebif injections. In 2011 he developed another relapse and new lesion appeared in the left side of the brain stem like mirror image of the old right side lesion which has disappeared. The symptoms included episodic diplopia, facial paresthesias with subsequent brainstem symptoms that improve with a high dose of corticosteroids. He developed oral ulceration in 2011. Diagnostic work up excluded all other possibilities and Neuro Behcet's disease (NBD) was considered, he responded well to Azathioprine and steroid. He remained well but in 2013 he developed relapse and MRI revealed that left sided midbrain has expanded. CSF revealed lymphocytic pleocytosis without OCB. Patient refused brain biopsy. He received three cycles of Infliximab but he deteriorated clinically and radiologically. The behavior of the disease and the lesion was suggestive of MS in the first year and suggestive of NBD in the second and third year, but in the fourth year it was not typical of MS or NBD. Brain biopsy was performed at John Hopkins hospital in USA in April 2014 and the lesion was reported Germinoma responsive to radiotherapy. The tumor disappeared after radiotherapy. Conclusion Intracranial Germinoma is very rare intracranial tumor that occurs at 0.7 per million, it is even more rare to be a mimicker for MS. This patient was treated successfully with radiotherapy. Multiple sclerosis (MS) mimickers are neurological conditions that may share clinical, biologic and radiologic features similar to MS. Standard MS treatments often fail. To report a very rare case of intracranial Germinoma with clinical, biological and radiological features similar to MS. We report 26 year old Emirati male patient who presented with history of recurrent attacks of neurological dysfunction and recurrent brain stem lesions since 2010. MRIs of the brain revealed recurrent brain stem T2 hyperintense lesions changing in size and location but remained localized in the brain stem. Initially CSF was positive for OCB so he was diagnosed as clinically isolated syndrome and was started on Rebif injections. In 2011 he developed another relapse and new lesion appeared in the left side of the brain stem like mirror image of the old right side lesion which has disappeared. The symptoms included episodic diplopia, facial paresthesias with subsequent brainstem symptoms that improve with a high dose of corticosteroids. He developed oral ulceration in 2011. Diagnostic work up excluded all other possibilities and Neuro Behcet's disease (NBD) was considered, he responded well to Azathioprine and steroid. He remained well but in 2013 he developed relapse and MRI revealed that left sided midbrain has expanded. CSF revealed lymphocytic pleocytosis without OCB. Patient refused brain biopsy. He received three cycles of Infliximab but he deteriorated clinically and radiologically. The behavior of the disease and the lesion was suggestive of MS in the first year and suggestive of NBD in the second and third year, but in the fourth year it was not typical of MS or NBD. Brain biopsy was performed at John Hopkins hospital in USA in April 2014 and the lesion was reported Germinoma responsive to radiotherapy. The tumor disappeared after radiotherapy. Intracranial Germinoma is very rare intracranial tumor that occurs at 0.7 per million, it is even more rare to be a mimicker for MS. This patient was treated successfully with radiotherapy.