Category: Pituitary Disorders/Neuroendocrinology

Monitor: 4

4 - MULTIPLE GERMINOMAS OF THE BRAIN: CLINICAL AND ENDOCRINE CHALLENGES

Thursday, Apr 25
12:30 PM – 1:00 PM

Objective :

To describe clinical and endocrine challenges due to uncommon presentation of intracranial Germinomas leading to delay in diagnosis and multispecialty consultations.


Methods :

22 year female.
Physician: Severe nausea, vomiting, weight loss 6 kg in 8 months. Medical work up, Endoscopy, H pylori treatment, PPI, B12 inj, Vit D
Gastroenterologists 2: Colonoscopy, CT abdomen/chest, malabsorption studies; “Anorexia Nervosa” and depression; "Drink Ensure"!!
Psychiatrists 2: Somatiform disorder/psychosis; Olanzapine.
Endocrinologists 2: ? Addison’s disease, surprisingly “high" cortisol levels; “Eat more and improve your nutrition”.
Patient had also developed amenorrhea and polyuria in the meantime.
Gynecologist: OCP

Endocrinologist 3: MRI pituitary: Multiple germinomas; confirmed by biopsy; treated with chemotherapy and radiation. 2 months post radiation developed severe generalized weakness; diagnosed as panhypopituitarism; treated with levothyroxine and prednisolone.


Results :

Endocrinology= S Cortisol ‘0’ min= 31 and 22 mcg/dl (5-22 mcg/dl), ACTH= < 5 (7-63 pg/ml), Overnight dexamethasone suppression= 2.3, T4= 9.4 (4.5-11 mcg/dl), TSH=1.07 (0.4-4.2mcIU/ml), FSH= 7 (2-10 mIU/ml), LH=2 (2-13 mIU/ml), Prolactin= 92 (3-29 ng/ml).


MRI Pituitary= 3: Pineal gland region(1.3x1.0x0.8 cm); Floor of 4th ventricle(1.4x1.4x1.9 cm); Suprasellar cistern infundibulum(0.8x0.7x0.7 cm); pituitary gland(3.6 mm craniocaudal), posterior pituitary bright spot not seen. Impression: Pineal gland germinoma with fourth ventricular and infundibular seeding/synchronous germinomas.


CSF analysis= AFP and beta-HCG: normal; Visual Field Testing= Normal.

Surgery= Midline suboccipital craniotomy; biopsy/partial decompression 4th ventricle mass.


Histopathology= Primordial cells, hyperchromatic nuclei, brisk mitosis, consistent with germinoma.


Chemotherapy= 4 cycles carboetoposide; alternative ifosfamide and etoposide.


Proton beam radiation= 40 CGE over 35 days.


Endocrinology= 2 months post radiation: TSH= 0.03, FT4= 0.79 (0.8-1.7 ng/dl), Testosterone 5.5 (15-70 ng/dl), GH 0.2 (upto 8 ng/ml), Cortisol ‘0’ min= 3.4, S ACE 80 (12-68 U/L).


Discussion :

Germinomas [synchronous or metachronous] can have varied methods of presentation, like in this case, posing clinical challenges, leading to multiple speciality consultations before being referred to  endocrine department.


Conclusion :

Diagnosis of pituitary and related intracranial tumours [and associated hypopituitarism] merits very high level of suspicion in primary care, along with early endocrine testing and imaging, for prompt diagnosis and multidisciplinary management and follow up.  

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Kavitha Muniraj

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty; Director Medical ; Director Research; Trustee
Specialties: Endocrinology Diabetes; Clinical Research
Clinical Interests: Pituitary Adrenal disorders; Bone health; Cardiovascular Health; Thyroid dysfunction; Diabetes Pharmacotherapy; Clinical Pharmacology; Pharmacovigilance; Clinical research Safety and Audits

Muralidhara Krishna

Consultant Faculty Endocrinology Diabetes Biochemistry
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty: Endocrinology Diabetes Metabolism; Associate Professor: Clinical Biochemistry and Laboratory Medicine
Specialties: Endocrinology Diabetes Metabolism; Clinical Biochemistry
Clinical Interests: Diabetes mellitus; Thyroid Disorders; Obesity; Dyslipidemia.

Vasanthi Nath

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology, Diabetes, Internal Medicine, Geriatrics
Clinical Interests: Neuroendocrinology and Neurometabolism, Metabolic Myopathies; Thyroid tumors, Geriatric Endocrinology, Inpatient Diabetes Care and Endocrine Emergencies; Type 1 diabetes across ages

Chandraprabha S

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology Diabetes Metabolism
Clinical Interests: Pregnancy Diabetes, Pregnancy Thyroid Dysfunction, Women Health, Geriatric Endocrinology, Diabetes mellitus and Mental Health, Spiritual Medicine

Babitha D. T

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology, Diabetes
Clinical Interests: Endocrine disorders of pregnancy, Pregnancy Diabetes, Cardiovascular Health, Thyroid, Inpatient diabetes care and endocrine metabolic emergencies

Jayalakshmi T

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty

Specialties: Endocrinology, Diabetes, Internal Medicine,
Clinical Interests: Diabetes mellitus, Cardiovascular Health, Thyroid, In Patient Diabetes Care, Endocrinology Metabolic emergencies and critical care

Nidhi Garg

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
bangalore, Karnataka, India

Designation: Senior Consultant and Faculty
Specialties: Diabetes and Metabolism
Clinical Interests: Comprehensive diabetes care, In-patient diabetes and metabolic care, Perioperative diabetes management, Diabetes and endocrine emergencies – Metabolic Intensive Care, Obesity management, Lipids and preventive cardiology, Gestational diabetes, Thyroid disorders, Type 1 diabetes across ages

Apoorva Govind

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
bangalore, Karnataka, India

Designation: Resident
Specialties: Endocrinology, Diabetes, Internal Medicine, Pediatrics
Clinical Interests: Diabetes mellitus, Cardiovascular Health, Thyroid, Pediatric Diabetes Endocrinology

Reshma B. Vijay

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology Diabetes and Metabolism
Clinical Interests: Pediatric Endocrinology; Diabetes mellitus; Insulin Pumps, Continuous Glucose Monitoring and Artificial Pancreas; Growth and Puberty; Thyroid; Pituitary Adrenal disorders

MD Chitra

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center

Designation: Consultant and Faculty; Trustee
Specialties: Endocrinology Diabetes; Clinical Research
Clinical Interests: Diabetes, Obesity, Dyslipidemia, Osteoporosis, Pituitary Adrenal disorders; Bone health; Cardiovascular Health; Thyroid dysfunction;

Sri Srikanta

Thummala Kamala

Vasudha Srikanth


India

Nalini Rayas

Siddartha Dinesha

Resident, Medicine Diabetes Endocrinology
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center

Designation: Resident: Medicine; Endocrinology Diabetes, Samatvam Endocrinology Diabetes Centre and Jnana Sanjeevini Medical Centre and Diabetes Hospital
Specialties: Endocrinology, Diabetes, Internal Medicine

Madhumati S Vaishnav

Scientist Faculty
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center; CENSE Indian Institute of Science, India

B.Sc (Microbiology), University of Pune, India.
M.Sc (Microbiology), University of Pune, India.
Post Graduate Diploma in Clinical Research and Clinical Data Management, University of Pune, India
CDE (Certified Diabetes Educator - Counselor), Samatvam Institute of Medical Sciences, India

Monica Narayanaswamy

Resident doctor
Samatvam jnana sanjeevini diabetes hospital and medical centre
Chintamani, India

Keerthana Haridas