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<p class="ltrs-br-ltr-br-title"><span class="bold">A Case of Glioblastoma Masquerading as an Affective Disorder</span></p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> Brain tumors can produce psychiatric symptoms, particularly if malignant<span class="htm-cite"><a href="#ref1">1</a></span> and fast growing.<span class="htm-cite"><a href="#ref2">2</a></span> Among gliomas, growth rate seems to be particularly relevant for the occurrence of mental disturbance, with symptoms in up to 80% of glioblastomas and only 25%–35% of lower-grade astrocytomas.<span class="htm-cite"><a href="#ref1">1</a></span> We report a case of glioblastoma multiforme, a very fast-growing brain tumor, initially presenting as acute mania.</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Case report.</span> Mr A, a 76-year-old white man, was admitted to our psychiatric inpatient ward with euphoric mood, increased sexual activity, excessive money spending, and overvalued ideas of grandiose capacity starting 2 months prior. Results of physical and neurologic examination and cognitive evaluation (Mini-Mental State Examination<span class="htm-cite"><a href="#ref3">3</a>,<a href="#ref4">4</a></span> [MMSE] score: 30/30) were normal, as were brain computed tomography (CT) scan (<span class="callout"><a href="#" onclick="createFigure('f1'); return false;">Figure 1A</a></span>), electrocardiogram, and chest radiograph results. Blood and urine analyses, including toxicology screening, revealed only mild leucocytosis. Mr A had a 12-year history of treatment-resistant depression (<span class="italic">DSM-IV-TR </span>criteria). During the last depressive episode, a neurologist considered the possibility of Parkinson’s disease and dementia and started Mr A on selegiline (5 mg/d), donepezil (10 mg/d), amitriptyline (25 mg/d), and perphenazine (2 mg/d). Depression symptoms remitted 1 year prior to the current episode, leading to discontinuation of amitriptyline and perphenazine. In addition, Mr A had a history of hypertension, benign prostatic hypertrophy, glaucoma, gastric ulcer, and degenerative lumbar disc disease, and, at the onset of the current episode, was also taking telmisartan (40 mg/d) and tamsulosin (0.4 mg/d).</p>
<div id="figure-2"> <a href="#" onclick="createFigure('f1'); return false;"><img src="14l01682f1.jpg" alt="Figure 1" id="f1" border="0" /></a>
<p class="click-to-enlarge">Click figure to enlarge</p>
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<p class="ltrs-br-ltr-br-body-text">On the basis of a working diagnosis of acute mania (<span class="italic">DSM-IV-TR </span>criteria), Mr A was started on valproic acid (1,000 mg/d), risperidone (2 mg/d), and flurazepam (15 mg if needed). Selegiline and donepezil were discontinued, with no adverse consequences. There was a gradual improvement, leading to full symptomatic remission, with no significant side effects, and he was discharged after 1 month with a diagnosis of bipolar disorder (<span class="italic">DSM-IV-TR </span>criteria). At his first follow-up consultation 1 month later, Mr A showed marked sedation and significant cognitive deficits (Montreal Cognitive Assessment<span class="htm-cite"><a href="#ref5">5</a>,<a href="#ref6">6</a> </span><span class="htm-cite">score:</span> 18/30; MMSE score: 23/30), prompting reduction of risperidone to 1 mg/d and replacement of flurazepam with lorazepam. At subsequent evaluations, Mr A remained sedated, and his cognitive function further deteriorated, leading to requests for an electroencephalogram, which was normal, and brain magnetic resonance imaging (MRI). Four months after being discharged, Mr A developed left-side hemiparesis and was referred to our emergency department, where a repeat brain CT scan (<span class="callout"><a href="#" onclick="createFigure('f1'); return false;">Figure 1B</a></span>) revealed a large right frontal lobe tumor, confirmed by the MRI scan and later diagnosed “postoperatively” as glioblastoma.</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text">In late-onset bipolar disorder, there is a higher likelihood of underlying organic causes meriting, as exemplified here, extensive diagnostic testing.<span class="htm-cite"><a href="#ref7">7</a>,<a href="#ref8">8</a></span> In this patient, while an iatrogenic cause could be considered on initial presentation,<span class="htm-cite"><a href="#ref9">9</a>,<a href="#ref10">10</a></span> the subsequent follow-up highlights the need for careful longitudinal investigation. We note that a brain CT, concomitant with an inaugural presentation of mania, was normal, and the same examination performed 5 months later revealed a large tumor in the right frontal lobe. Frontal brain tumors can present symptomatically as mood disorders,<span class="htm-cite"><a href="#ref11">11–13</a></span> with right hemisphere tumors more frequently associated with mania-like syndromes and left hemisphere tumors with depression-like syndromes.<span class="htm-cite"><a href="#ref11">11</a>,<a href="#ref14">14</a></span> Similar laterality trends have been described for cerebrovascular lesions.<span class="htm-cite"><a href="#ref15">15</a></span> In Mr A, the use of brain MRI at presentation could possibly have allowed for an earlier diagnosis of the lesion.<span class="htm-cite"><a href="#ref7">7</a></span> Nevertheless, it is tempting to speculate that the inaugural manic episode was the first expression of a tumor developing in the right frontal lobe, even prior to structural evidence of the lesion, raising interesting possibilities regarding the mechanisms mediating this association.<span class="htm-cite"><a href="#ref14">14</a></span></p>
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<p class="ltrs-br-ltr-br-author"><span class="bold">Albino J. Oliveira-Maia, MD, MPH, PhD</span></p>
<p class="ltrs-br-ltr-br-author"><a href="
mailto:albino.maia@neuro.fchampalimaud.org">
albino.maia@neuro.fchampalimaud.org</a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Joana Ruivo, MD</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">J. Bernardo Barahona-Corrêa, MD, PhD</span></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Author affiliations:</span> Department of Psychiatry and Mental Health (Drs Oliveira-Maia and Barahona-Corrêa) and Department of Neuroradiology (Dr Ruivo), Centro Hospitalar de Lisboa Ocidental; Neuropsychiatry Unit (Drs Oliveira-Maia and Barahona-Corrêa) and Department of Radiology (Dr Ruivo), Champalimaud Clinical Centre, Fundação Champalimaud; Champalimaud Neuroscience Programme, Fundação Champalimaud (Dr Oliveira-Maia); and Department of Psychiatry and Mental Health, Nova Medical School, Universidade Nova de Lisboa (Dr Barahona-Corrêa), Lisbon, Portugal.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Potential conflicts of interest:</span> None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Funding/support:</span> None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Published online:</span> December 25, 2014.</p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">Prim Care Companion CNS Disord 2014;16(6):</span><span class="doi">doi:10.4088/PCC.14l01682</span></p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">© Copyright 2014 Physicians Postgraduate Press, Inc.</span></p>
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