Brain Tumor

Introduction
Brain tumors are inherently serious because of the risk of compression of cerebral structures and alteration of brain function. They are usually detected only when diagnostic test are specifically directed to the brain after the tumor had produced unexplained signs and symptoms. These presenting signs are variable depending on the location, size and the growth rate of the mass.They usually include focal neurological deficits and/or signs of elevated intracranial pressure. Tumors in the suprasellar area, including those in the third ventricle, can impair the function of the hypothalamus-pituitary-adrenal axis by compressing the hypothalamus.
We present a case of a 58 year old male who presented with a solitary complaint of fever for two months. After infectious workupwas inconclusive, he had a sudden severe headache and deterioration in his mental status. A third ventricular mass was found on head CT scan. The patient was hospitalized in critical condition with signs of central hypopituarism. Resection of the mass was aborted after the patient suffered a cardiac arrest on the operating table. The tumor has not been categorized histologically at the time ofwriting.

Case Description
A 58 year old male native of Pakistan began experiencing fever about 2 months prior to hospital admission. The fever was intermittent and daily with a maximum of 1020 F. He went to his primary care provider and had a fever work up which included blood cultures, chest x-ray, complete blood count with differential and urinalysis. They were unable to find any problems.He was treated with amoxicillin with subjective remission of his temperature.
He stopped taking amoxicillin before completing the full course. His temperature became elevated again and he returned to the primary care clinic. He had a new negative fever workup. This time, he took a complete course of amoxicillin with no improvement on his temperature. He did not have any respiratory, urinarysymptoms, wounds or any known source of infection at that time. Per patient's son he had on year history of depression and fatigue but he had not sought medical help. He was noted to be depressed and duloxetine was prescribed. This coincided with him becoming somnolent and duloxetine was stopped. The patient continued to be progressively more tired and somnolent. There were no reports of visiondisturbances, weight changes, dizziness, diaphoresis, tremors, heat or cold intolerance, diarrhea constipation prior to hospitalization. Patient’s son reports that the patient had noted frequency prior to hospitalization. The patient did not complain of urinary flow problems or increased voiding amount. One week after discontinuation of duloxetine, he developed acute severe headache and became hislevel of consciousness decreased, being disoriented and slow to respond. He was taken to Olive View Medical Center where a non-contrast CT of his head showed a 20x22x26 mm third ventricle mass without evidence of hydrocephalus. It was suspected the intracranial lesions were either a tuberculoma or malignancy. He was transferred to the neurosurgery intensive care unit of a tertiary hospital forhigher level of care. MRI confirmed a uniformly enhancing mass, which was isodense in T1 and T2. MRA was negative for aneurysm. Among the radiologic differential diagnosis were lymphoma, metastasis and ependymoma.
Regardless of etiology, the mass appeared to have an impact on the Hypothalamus Pituitary Adrenal (HPA) axis with laboratory values suggesting pan-hypopituarism. Thyroid Function Testswere abnormal with low TSH, and FT4, as well as low FSH, LH and testosterone. Levothyroxine 250mcg IV loading dose was started and then followed with 100mcg IV daily.
The cortisol level was also low, although this could have been appropriate for the time of day the cortisol was drawn. Dexamethasone I.V. 10 mg stat followed by 4 mg I.V every 6 hours was initiated for brain edema shortly thereafter....