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Vol 16, No 6
Table of Contents

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<p class="frontmatter-fieldnotes disclaimernew" style="margin-bottom:15px;">This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s <a href="/pages/termsofuse.aspx" target="_blank">Terms & Conditions</a>.</p> <div id="_idContainer000">
  <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">&nbsp;</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>
  </div>
  <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">&nbsp;</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>
  <p class="ltrs-br-ltr-br-references-head"><span class="smallcaps">REFERENCES</span></p>
  <p class="references-references-text-1-9"><span class="htm-ref"> </span>1.&#9;Busch E. Physical symptoms in neurosurgical disease. <span class="italic">Acta Psychiatr Neurol Scand.</span> 1940;15(3-4):257–290. <a href="http://dx.doi.org/10.1111/j.1600-0447.1940.tb06757.x"><span class="pubmed-crossref">doi:10.1111/j.1600-0447.1940.tb06757.x</span></a></p>
  <p class="references-references-text-1-9"><span class="htm-ref"> 2.&#9;</span>Keschner M, Bender MB, Strauss I. Mental symptoms associated with brain tumor: a study of 530 verified cases. <span class="italic">JAMA.</span> 1938;110(10):714–718. <a href="http://dx.doi.org/10.1001/jama.1938.02790100012004"><span class="pubmed-crossref">doi:10.1001/jama.1938.02790100012004</span></a></p>
  <p class="references-references-text-1-9"><span class="htm-ref"> 3.&#9;</span>Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. <span class="italic">J&#160;Psychiatr Res</span>. 1975;12(3):189–198.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=1202204&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.1016/0022-3956(75)90026-6"><span class="pubmed-crossref">doi:10.1016/0022-3956(75)90026-6</span></a></p>
  <p class="references-references-text-1-9"><span class="htm-ref"> 4.&#9;</span>Morgado J, Rocha CS, Maruta C, et al. Cut-off scores in MMSE: a moving target? <span class="italic">Eur J Neurol</span>. 2010;17(5):692–695.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=20050900&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.1111/j.1468-1331.2009.02907.x"><span class="pubmed-crossref">doi:10.1111/j.1468-1331.2009.02907.x</span></a></p>
  <p class="references-references-text-1-9"><a name="ref5"></a>5.<span class="htm-ref">&#9;</span>Freitas S, Simões MR, Alves L, et al. Montreal Cognitive Assessment (MoCA): normative study for the Portuguese population. <span class="italic">J&#160;Clin Exp Neuropsychol</span>. 2011;33(9):989–996.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=22082082&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.1080/13803395.2011.589374"><span class="pubmed-crossref">doi:10.1080/13803395.2011.589374</span></a></p>
  <p class="references-references-text-1-9"><span class="htm-ref"> 6.&#9;</span>Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. <span class="italic">J&#160;Am Geriatr Soc</span>. 2005;53(4):695–699.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=15817019&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.1111/j.1532-5415.2005.53221.x"><span class="pubmed-crossref">doi:10.1111/j.1532-5415.2005.53221.x</span></a></p>
  <p class="references-references-text-1-9"><span class="htm-ref"> 7.&#9;</span>Arciniegas DB. New-onset bipolar disorder in late life: a case of mistaken identity. <span class="italic">Am J Psychiatry</span>. 2006;163(2):198–203.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=16449470&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.1176/appi.ajp.163.2.198"><span class="pubmed-crossref">doi:10.1176/appi.ajp.163.2.198</span></a></p>
  <p class="references-references-text-1-9"><span class="htm-ref"> 8.&#9;</span>Depp CA, Jeste DV. Bipolar disorder in older adults: a critical review. <span class="italic">Bipolar Disord</span>. 2004;6(5):343–367.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=15383127&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.1111/j.1399-5618.2004.00139.x"><span class="pubmed-crossref">doi:10.1111/j.1399-5618.2004.00139.x</span></a></p>
  <p class="references-references-text-1-9"><span class="htm-ref"> 9.&#9;</span>Benazzi F. Mania associated with donepezil. <span class="italic">J&#160;Psychiatry Neurosci</span>. 1999;24(5):468–469.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=10586539&amp;dopt=Abstract"><span class="pubmed-crossref"> PubMed</span></a></p>
  <p class="references-references-text-10-99"><a name="ref10"></a>10.&#9;Boyson SJ. Psychiatric effects of selegiline. <span class="italic">Arch Neurol</span>. 1991;48(9):902.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=1953411&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.1001/archneur.1991.00530210028017"><span class="pubmed-crossref">doi:10.1001/archneur.1991.00530210028017</span></a></p>
  <p class="references-references-text-10-99"><a name="ref11"></a>11.&#9;Belyi BI. Mental impairment in unilateral frontal tumours: role of the laterality of the lesion. <span class="italic">Int J Neurosci</span>. 1987;32(3–4):799–810.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=3596923&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.3109/00207458709043334"><span class="pubmed-crossref">doi:10.3109/00207458709043334</span></a></p>
  <p class="references-references-text-10-99"><a name="ref12"></a>12.&#9;Direkze M, Bayliss SG, Cutting JC. Primary tumours of the frontal lobe. <span class="italic">Br J Clin Pract</span>. 1971;25(5):207–213.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=5580691&amp;dopt=Abstract"><span class="pubmed-crossref"> PubMed</span></a></p>
  <p class="references-references-text-10-99"><a name="ref13"></a>13.&#9;Strauss I, Keschner M. Mental symptoms in cases of tumor of the frontal lobe. <span class="italic">Arch Neurol Psychiatry</span>. 1935;33(5):986–1005. <a href="http://dx.doi.org/10.1001/archneurpsyc.1935.02250170072006"><span class="pubmed-crossref">doi:10.1001/archneurpsyc.1935.02250170072006</span></a></p>
  <p class="references-references-text-10-99"><a name="ref14"></a>14.&#9;Starkstein SE, Boston JD, Robinson RG. Mechanisms of mania after brain injury. 12 case reports and review of the literature. <span class="italic">J&#160;Nerv Ment Dis</span>. 1988;176(2):87–100.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=3276815&amp;dopt=Abstract"><span class="pubmed-crossref">PubMed</span></a> <a href="http://dx.doi.org/10.1097/00005053-198802000-00004"><span class="pubmed-crossref">doi:10.1097/00005053-198802000-00004</span></a></p>
  <p class="references-references-text-10-99"><a name="ref15"></a>15.&#9;Cummings JL, Mendez MF. Secondary mania with focal cerebrovascular lesions. <span class="italic">Am J Psychiatry</span>. 1984;141(9):1084–1087.<a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&amp;db=PubMed&amp;list_uids=6465386&amp;dopt=Abstract"><span class="pubmed-crossref"> PubMed</span></a></p>
  <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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