A Common Neurologic Symptom Leads To A More Serious Oncologic Diagnosis!

Case presentation: A 5 years old previously healthy boy presented due to a new onset intermittent generalized headache. Neurologic examination was unremarkable. Several weeks later, the headache became a little more severe accompanied by occasional vomiting. Intermittent nonparalytic bilateral esotropia without papilledema was detected at the examination. Brain MRI, EEG, and all laboratory workups were normal. After 2 months, he was admitted due to continuous generalized headache complicated with unilateral facial weakness. Normal Brain Imaging and bilateral mild papilledema resulted in a CSF puncture that showed a high pressure with increased WBCs slightly. Given that headaches disappeared dramatically after lumbar puncture, idiopathic intracranial hypertension is considered a diagnosis. Several accelerated headache episodes with significant symptom relief followed by lumbar puncture accompanied by high CSF pressures were reported. Laboratory evaluations, as well as CSF cytology, protein, and glucose amounts, were normal. Both brain venography and arteriography were insignificant. Serial brain MRI showed increased intracranial pressure features. Three months after the headache onset, blast cells were detected in the CSF sample while bone marrow biopsy and aspiration, whole body radioisotope scan, bone scan, and other investigations to find the blast’s source were failed. Enabling to differentiate primary CNS leukemia from lymphoma, he received mixed chemotherapy protocols that led to a significant remission of clinical and CSF features. Conclusion: Serious insidious underlying etiology could mimic a more benign situation such as idiopathic intracranial hypertension. Differential diagnosis should be considered in atypical and resistant cases.