Pearls & Oy-sters: Bifocal germinoma of the brain

A 17-year-old girl presented to the Pediatric Neurology clinic with new onset headache of 8 weeks duration. She experienced a daily headache described as a pressure-like sensation over both the temporal areas, 4/10 in intensity. This baseline headache was interrupted by a few episodes of pounding bitemporal and occipital headache, 10/10 in severity, worse with activity. The severe headaches were associated with dizziness, photophobia, phonophobia, vomiting, and “zig-zag lights” in front of her eyes and often would occur on awakening. She occasionally described “whooshing sounds” associated with the baseline headache. On review of systems it was noted that she had poor energy level. She had polyuria, nocturia, and polydipsia for 3 years. The polydipsia was attributed to psychogenic cause in the context of ongoing serious personal and familial psychosocial stressors. She had menarche at 13 years of age but for the previous 2 years she had had irregular menstrual cycles, occurring once or twice a year. Her appetite was preserved and her weight was stable within 6 months preceding the diagnosis (54.5–55.7 kg). Her general physical as well as the neurologic examinations were normal. The above features were suspicious …