53-year-old female with recent diagnosis of Wegener’s granulomatosis (Granulomatosiswith polyangiitis (GPA), formerly known as Wegener’s granulomatosis(WG) presented with subacute headache, nausea, vomiting and blood pressure of 220/106 [1]. She was diagnosed with GPA 3 months prior after developing kidney failure, upper respiratory tract infection and arthritis. Brain MRI (Figure 1-3). The patient was started on high dose steroids and her symptoms improved. She refused brain biopsy and was discharged home with neurology follow up. Lesions of the pineal gland may be subdivided into two categories: Lesions arising from the pineal cells (cyst, pineoblastoma, pineocytoma, and pineal parenchymal tumor of intermediate differentiation); Lesions arising from the germ cells (germinoma, teratoma, choricarcinoma and retinoblastoma) and lesions arising from the adjacent structures (papillary tumors of pineal region, metastases, direct tumor extension from the brainstem, meningioma [2].

Our main two differentials were GPA/other autoimmune disease versus of the pineal gland versus meningioma. GPAGPA causes mononeuritis multiplex, symmetric distal neuropathy, cranial neuropathies, diffuses meningeal enhancement, cerebral infarction, and seizures [3]. Sarcoid involvement of the pineal gland has been reported in the literature which responded well to high dose steroids as in our patient.

Figure 1: Description: brain MRI shows a T2 hyper intense and contrast enhancing lesion in the pineal region, measuring 1.7 x 1.3 cm

1. Fauci AS, Haynes BF, Katz P, Wolff SM.Wegener’s granulomatosis:prospective clinical and therapeutic experience with 85 patientsfor 21 years. Ann InternMed. 1983 Jan;98(1):76-85.
2. Chatterjee D et al: Papillary tumor of the pineal region-report ofthree cases with literature review. Neurol India. 2015;63(4):567-570.
3. Casanova A, Pérez Amor E, Girón RM, Zamora E, VélezMD. Polyradiculitis and Wegener’s granulomatosis. ArchBronconeumol. 2004 Jan;40(1):41-44.