SUN-872 - Symptomatic Pineal Cyst Masquerading as Gastrointestinal and Endocrine Pathology: A Case Report

Introduction

Chronic nausea and vomiting are most often attributed to gastrointestinal or endocrine disorders, frequently resulting in prolonged and repetitive evaluations before neurologic causes are considered. Pineal cysts are commonly identified as incidental findings on neuroimaging and are generally presumed asymptomatic. Consequently, symptomatic pineal cysts—particularly in the absence of hydrocephalus or focal neurologic deficits—are rarely included in the differential diagnosis of chronic nausea, vomiting, or headache. This case highlights a significant diagnostic delay in a patient with debilitating gastrointestinal symptoms ultimately attributable to a pineal cyst and underscores the clinical impact of timely surgical intervention
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Clinical Case

A 54-year-old woman with hypothyroidism, chronic headaches, ankylosing spondylitis, Crohn’s disease, depression, and obesity presented with a 4–5-year history of persistent nausea, vomiting, and daily headaches that markedly impaired her quality of life. She underwent extensive gastrointestinal evaluation, including imaging and subspecialty consultation, without identification of a unifying etiology. Although she was hospitalized for Clostridioides difficile colitis in 2023, her symptoms long predated this infection and persisted after its resolution.
Given the chronicity and refractory nature of her symptoms, further evaluation was pursued. Brain MRI revealed a pineal cyst without associated hydrocephalus. After multidisciplinary discussion, neurosurgical resection was recommended due to the severity of symptoms and high suspicion that the cyst was contributory. She subsequently underwent transcranial pineal cyst resection at an outside institution, with near-complete resolution of her longstanding nausea, vomiting, and headaches. Postoperatively, she was admitted for evaluation of generalized weakness, orthostatic dizziness, and low outpatient cortisol levels following glucocorticoid exposure. Serial cortisol measurements improved, and cosyntropin stimulation testing demonstrated an appropriate adrenal response, excluding adrenal insufficiency. Follow-up neuroimaging showed expected postoperative changes without acute intracranial pathology.

Clinical Lessons / Conclusions

This case demonstrates that symptomatic pineal cysts, even in the absence of hydrocephalus or focal neurologic deficits, can present with chronic nausea, vomiting, and headache and may be misattributed to gastrointestinal or endocrine pathology for years. The dramatic symptom resolution following surgical resection highlights the importance of maintaining a broad differential diagnosis in refractory cases. Increased awareness of non-hydrocephalic symptomatic pineal cysts may reduce diagnostic delays, prevent unnecessary testing, and facilitate timely neurosurgical referral

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