Central JSM Clinical Case Reports Cite this article: Kahraman S, Gumusay O, Hızel K, Ertunc O, Yılmaz G, et al. (2015) An Interesting Case of Pineoblastoma Mimicking Acute Meningitis: A Case Report. JSM Clin Case Rep 3(4): 1089. *Corresponding author Se d a Ka hra ma n, De p a rtme nt o f Inte rna l Me d ic ine ,G a zi Unive rsity Fa c ulty o f Me d ic ine , Be se vle r, Ankara 06500, Turkey,Tel- 90-312-202-4238; Fax: 90-312- Submitte d: 27 April 2015 Accepted: 26 O c to b e r 2015 Publishe d: 29 O c to b e r 2015 Copyright © 2015 Ka hra ma n e t a l. OPEN ACCESS Ke ywo rds • Pine o b la sto ma • Me ning itis • Tub e rc ulo sis Case Report An Interesting Case of Pineoblastoma Mimicking Acute Meningitis: A Case Report Seda Kahraman 1 *, Ozge Gumusay 1 , Kenan Hızel 2 , Onur Ertunc 3 , Guldal Yılmaz 4 and Ahmet Ozet 1 1 Department of Internal Medicine, Gazi University Faculty of Medicine, Turkey 2 Department of Infectious Disease, Gazi University Faculty of Medicine, Turkey 3 Department of Pathology, Gazi University Faculty of Medicine, Turkey Abstract Pineoblastoma are rare malignant embryonal tumors that arise from the pineal parenchyma. We report the case of an adult patient with pineoblastoma who presented with signs and symptoms of central nervous system infection. She was admitted to the emergency room with fever; headache; diplopia and a feeling of numbness in the legs and hands. There were no microorganisms on Gram staining and acido-resistant staining. CSF cytology was also negative for malignancy. On the basis of the patient’s history and CSF laboratory fndings; a central nervous system infection was not ruled out; and meropenem was started empirically. No acid-fast bacilli were seen through microscopic examination and Tuberculin skin test was negative; but quantiferon blood test was positive. Anti-tuberculosis therapy with isoniazid; rifampicin; pyrazinamide and ethambutol was started. But the patient did not respond to antibiotic and anti- tuberculosis treatment. Repeated lumbar punctures revealed malignant cells consistent with primitive embryonal tumor. In conclusion; PBL is an aggressive tumor that has a tendency to metastasize along neuraxis and also recur locally. Months after tumor resection; the patient may present with the symptoms of meningeal irritation and indiscernible clinical presentation of other causes of meningeal infammation. INTRODUCTION Pineoblastoma are rare malignant embryonal tumors that arise from the pineal parenchyma. These tumors are considered primary neuroectodermal tumors (PNETs) of the pineal region and exhibit aggressive clinical behavior with frequent metastases throughout the craniospinal axis [1,2]. Patients often present with findings of elevated intracranial pressure and focal neurological deficits. However; these findings are also seen in many intracranial pathologies and one of the most important is central nervous system infection. We report the case of an adult patient with pineoblastoma who presented with signs and symptoms of central nervous system infection. CASE REPORT A 29-year-old woman without any significant past medical history was admitted to an outside hospital with a 3-month history of headache; gait and balance disorders in September 2010. On magnetic resonance imaging; there was a 30x30x32 mm lobulated lesion with solid and cystic components. The patient was transferred to our institution. The patient underwent subtotal excision of the pineal tumor.The tumor was composed of highly cellular primitive appearing cells with narrow cytoplasm and hyperchromotic nuclei. Focal rosette formation of tumor cells was observed (Figure1,2,3). Immunohistochemically; the tumor cells showed diffuse positive staining for neuron specific enolaseand synaptophysin; and high proliferative labeling with Ki67 (Figure 4,5,6). The patient yielded a diagnosis of a pineoblastoma. Postoperatively; the patient received craniospinal external beam radiotherapy (3420 cGy) that was delivered in 11 fractions. Outpatient follow-up with laboratory and radiologic studies was performed at regular intervals. There had been no evidence of tumor recurrence for 27 months. In February 2013; she was admitted to the emergency room with fever; headache; diplopia and a feeling of numbness in the legs and hands. On her physical examination; stiff neck; severe headache and high fever (39 0 C) were revealed. Kernig’s and Brudzinski’s signs were positive. On her blood biochemistry; liver and kidney function tests were normal. White blood cell was 12000/mm 3 ; and C-reactive protein was 26 IU/mL. No pathological finding was observed on her cranial computed tomography scan. A lumbar puncture was performed to diagnose acute meningitis; thus rapid diagnosis of bacterial meningitis is essential because early antibiotic therapy may reverse the patient’s severe clinical course. Protein level was found to be high (127mg/dl); and chlorine level was normal