New-onset psychiatric symptoms following intracranial meningioma in a patient with schizophrenia: a case study

Intracranial tumors affect the central nervous system (CNS) by different mechanisms, including pressure and edema.¹ Despite adaptive mechanisms, when this compensatory system is exhausted, CNS deterioration can occur rapidly with a host of manifestations, including neuropsychiatric symptoms.² These may include new-onset psychiatric symptoms and treatment resistance.¹ Herein, we describe the case of a patient diagnosed with schizophrenia who developed reactivation of psychiatric symptoms secondary to a meningioma.

A 52-year-old woman with a 20-year history of schizophrenia, with 15 years’ remission of positive symptoms under adequate pharmacotherapy (olanzapine 20 mg daily), presented with new onset of persecutory delusions, anhedonia, disorganized speech, decreased appetite, and suicidal ideation over a 2-week period. Clozapine 50 mg/day was initiated; however, within 5 days of this medication change, the patient experienced dizziness and a convulsive episode, followed by expressive aphasia. Computed tomography (CT) of the head showed a 7-cm tumor in the left frontoparietal transition (Figure 1). The patient underwent neurosurgery for tumor removal and recovered uneventfully, with no neurological deficit and progressive amelioration of psychiatric symptoms. Histopathological examination was consistent with a meningothelial meningioma. Throughout a 3-year follow-up period, the patient remained stable with a new medication regimen: sertraline 150 mg/day, valproate 1,000 mg/day, lithium carbonate 300 mg/day, and aripiprazole 60 mg/day.

Figure 1
A) Preoperative computed tomography (CT) scan showing a tumor over the left frontotemporal convexity with mass effect; B) follow-up magnetic resonance imaging (MRI) scan showing surgical removal of brain meningioma.

Meningiomas may present initially with psychiatric symptoms. In a study conducted by Gupta and Kumar, 21% of meningioma cases presented with psychiatric symptoms in the absence of neurological manifestations. Affective disorders were the most common presentation, and no correlation between brain laterality and psychiatric comorbidity was reported.³ In another study, psychiatric disorders were diagnosed in 44% of convexity meningiomas, with a significant correlation between edema volume and the presence of coexisting psychiatric disorders, but not between tumor mass volume and psychiatric symptoms.⁴ It has also been reported that meningiomas compressing the frontal lobes may cause progressive behavioral and intellectual changes with no other symptoms or signs until the mass effect becomes too great.

A recent meta-analysis of published cases reports that the associations between brain tumor location and specific psychiatric symptoms are not precise, except for anorexia symptoms without body dysmorphic symptoms and hypothalamic tumor.⁵ Hence, the correct diagnosis is often delayed, since health professionals usually refer patients with these conditions first to a psychiatrist, with no suspicion of malignant etiology.

Although brain tumors usually present clinical manifestations with neurological localizing signs, psychiatric symptoms may be the only clue, and, as noted above, these symptoms usually offer no localizing value.¹ Therefore, the present case study highlights the importance of performing a thorough medical workup, with a detailed physical and psychiatric examination, to exclude organic and toxic causes of psychosis in patients with new-onset psychotic symptoms (or new-onset treatment resistance in those with a psychiatric history).

References

• ¹
  Madhusoodanan S, Ting MB, Farah T, Ugur U. Psychiatric aspects of brain tumors: a review. World J Psychiatry. 2015;5:273-85.
• ²
  Maurice-Williams RS, Dunwoody G. Late diagnosis of frontal meningiomas presenting with psychiatric symptoms. Br Med J (Clin Res Ed). 1988;296:1785-6.
• ³
  Gupta RK, Kumar R. Benign brain tumours and psychiatric morbidity: a 5-years retrospective data analysis. Aust N Z J Psychiatry. 2004;38:316-9.
• ⁴
  Lampl Y, Barak Y, Achiron A, Sarova-Pinchas I. Intracranial meningiomas: correlation of peritumoral edema and psychiatric disturbances. Psychiatry Res. 1995;58:177-80.
• ⁵
  Madhusoodanan S, Opler MG, Moise D, Gordon J, Danan DM, Sinha A, et al. Brain tumor location and psychiatric symptoms: is there any association? A meta-analysis of published case studies. Expert Rev Neurother. 2010;10:1529-36.

Publication Dates

• Publication in this collection
  Jan-Feb 2019

History

• Received
  13 Feb 2018
• Accepted
  4 July 2018