A 27-year-old male presents with progressively worsening headaches for the past three months. For the past two weeks, he has felt that he is losing his balance. He denies any motor weakness or sensory symptoms. He does not have any history suggestive of cranial nerve paralysis. On physical examination, his pupils do not react to light bilaterally. He has an impaired upward gaze and loss of optokinetic nystagmus. The rest of his eye movements are within normal limits. On tandem walking, he tends to fall on both sides. The rest of the physical examination is unremarkable. What is the most likely diagnosis of this patient?

Question

A 27-year-old male presents with progressively worsening headaches for the past three months.  For the past two weeks, he has felt that he is losing his balance.  He denies any motor weakness or sensory symptoms.  He does not have any history suggestive of cranial nerve paralysis.  On physical examination, his pupils do not react to light bilaterally.  He has an impaired upward gaze and loss of optokinetic nystagmus.  The rest of his eye movements are within normal limits.  On tandem walking, he tends to fall on both sides.  The rest of the physical examination is unremarkable.  What is the most likely diagnosis of this patient?

Quizplus · Accepted Answer

Explanation: A tumor of the pineal gland characteristically causes Parinaud's syndrome, which is characterized by the loss of pupillary reaction, vertical gaze paralysis, the loss of optokinetic nystagmus, and ataxia. The headache is a prominent feature, and is due to obstructive hydrocephalus. Some pineal tumors are germinomas and secrete HCG, which can cause precocious puberty in prepubertal males. (Choice A) Although craniopharyngioma can cause a headache, it cannot explain the other signs and symptoms of the patient. Craniopharyngiomas are classically associated with diabetes insipidus and a deficiency of one or more anterior pituitary hormones. (Choice B) Frontal lobe tumors can be silent. When symptomatic, these tumors present with headaches, focal neurological deficits, or seizures. Loss of inhibition from the frontal lobe can cause the release of primitive reflexes such as glabellar tap, grasp and palmomental reflexes. Frontal lobe tumors can be associated with Foster Kennedy syndrome (optic atrophy on the side of the tumor and papilledema on the contralateral side). (Choice C) A pituitary tumor with suprasellar extension can cause bitemporal hemianopsia. Patients with pituitary tumors can present with hormonal dysfunction, depending on the secretory state and size of the tumor. (Choice E) Eye findings in multiple sclerosis are due to involvement of the medial longitudinal fasciculus, which leads to internuclear ophthalmoplegia. Bilateral or unilateral optic neuritis can also occur. Educational Objective: Pineal tumor classically presents with Parinaud's syndrome, which is characterized by the loss of pupillary reaction, vertical gaze paralysis, the loss of optokinetic nystagmus, and ataxia. Some pineal tumors are germinomas that can secrete HCG.

A 27-Year-Old Male Presents with Progressively Worsening Headaches for the Past