Right Temporal Lobe Meningioma presenting as postpartum depression: A case report

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Meningiomas are tumors which arise from arachnoid cells and can occur both in the brain and spinal cord. Meningiomas can present with psychiatric symptoms (such as depression, anxiety disorders, or personality changes) in the absence of any neurologic signs or symptoms.

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Right Temporal Lobe Meningioma presenting as postpartum depression: A case report

  1. 1. Right Temporal Lobe Meningioma presenting as postpartum depression: A case report
  2. 2. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 9 9 e3 0 1 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/apme Case Report Right Temporal Lobe Meningioma presenting as postpartum depression: A case report Tarun Kumar a,*, Archana Kathpal a, Carrol T. Longshore b a Resident, Department of Psychiatry, Elmhurst Hospital Center (Mount Sinai School of Medicine), 79-01 Broadway, Elmhurst, NY 11373, United States b Attending and Head, Adult Psychiatry Inpatient Unit, Elmhurst Hospital Center (Mount Sinai School of Medicine), 79-01 Broadway, Elmhurst, NY 11373, United States article info abstract Article history: Meningiomas are tumors which arise from arachnoid cells and can occur both in the brain Received 31 August 2012 and spinal cord. Meningiomas can present with psychiatric symptoms (such as depression, Accepted 31 January 2013 anxiety disorders, or personality changes) in the absence of any neurologic signs or Available online 20 February 2013 symptoms. Literature review also shows few cases of postpartum depression seen in association with Frontal Lobe Meningiomas. Authors in this article present a unique case of Keywords: Right Temporal Lobe Meningioma in a patient, who presented with chief complaint Meningioma of postpartum depression. This presentation has never been reported to date. Routine use Postpartum depression of neuroimaging in the evaluation of new onset psychiatric disorders has always been Neuroimaging controversial but this case clearly underscores the value of a detailed history, careful physical examination, and consideration of other diagnostic studies in patients presenting for psychiatric evaluation. This case also provides an opportunity for clinical departments to improve and redefine its protocols and management strategies. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Meningioma is brain tumors that arise from arachnoid cells lining brain and spinal cord. These usually occur spontaneously, or secondary to radiation exposure. Incident rate of these tumors is about 7.8% per 100,000 per year.1 Most of these tumors remain silent and only 25% of them produce symptoms based on their location.2e5 These tumors have been associated with depression, mania, psychosis and personality changes. These tumors can be easily diagnosed by using neuroimaging but the use of neuroimaging such as CT scan in the evaluation of new onset psychiatric disorders has always been a topic of debate. Postpartum depression is a form of clinical depression which begins after child birth. It may last up to several months or even a year. In the past, a case of postpartum depression secondary to bifrontal meningioma has been reported but we recently had a case of right temporal meningioma which presented as postpartum depression. 2. Case report Ms Y is a 28-year-old Asian female with no prior psychiatric treatment who presented to psychiatry walk-in clinic at our hospital with symptoms of depressed mood, anhedonia, * Corresponding author. E-mail address: drtarundhingra@gmail.com (T. Kumar). 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.01.018
  3. 3. 300 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 9 9 e3 0 1 fatigue, decreased concentration, and difficulty sleeping of 8 months duration. As per Ms Y, her symptoms started just 2e3 weeks after the birth of her first child. Along with depressive symptoms, she reported mild headache, occasional dizziness, and nausea. She lost interest in her former hobbies and also reported lack of motivation to take care of the baby but she managed to do so. She denied having any suicidal or homicidal ideations toward self, her baby or any other individual. The pregnancy was planned. She did not seek any help for about 5 months but later was referred to a psychiatrist by her primary physician. She did not seek help of a psychiatrist and took some herbal medications for depression which made the symptoms worse. Later at the request of a friend, she came to our walk-in clinic. Ms Y presented with depressed mood, anhedonia, psychomotor retardation with poor sleep and appetite. Her speech was of normal volume, rate and rhythm. She denied any suicidal or homicidal ideations along with denying any psychotic symptoms. Except for a history of miscarriage at the age of 22, Ms Y denied having any medical problems. She reported having headaches (mentioned above) for about 8 months with occasional double vision. She was referred for a regular physical exam (which includes a brief neurological exam) which was reported as normal. Routine blood work including toxicology screen were normal. CT scan was ordered for which she got appointment in 2 weeks. Ms Y was diagnosed with postpartum depression and was started on paroxetine 20 mg daily. At her follow up visit, she reported feeling better with improved sleep and appetite though she still did not feel enthusiastic about caring for her son. She still reported occasional mild headaches and dizziness. A week later, Ms Y presented to the medical emergency room with complaints of severe dizziness and headache. CT scan of head done in emergency room showed a 4 Â 3 Â 3.5 cm, hyperdense, well marginated extra axial, right sided parasellar mass (later confirmed histologically as meningioma) with some surrounding vasogenic edema. MRI confirmed the above finding and reported the tumor to be located on right sphenoid bone with some compression of right lateral ventricle. She was admitted to neurosurgery where she underwent right pterional craniotomy and tumor resection. Ms Y was discharge after a one week hospital stay. Two weeks after the discharge, she came for her psychiatry appointment. She also reported that her paroxetine was stopped while she was admitted to surgery and she had not resumed the medication. Ms Y reported resolution of her depressive symptoms after the resection of tumor. She reported good sleep, appetite, motivation, and good concentration. She also reported that she now enjoys going out and taking her baby out for walks. Ms Y was followed on monthly basis in psychiatry clinic and over the next 3 month. She showed resolution of all her symptoms of depression. After discussion with the patient, she was discharged from psychiatry clinic. Ms Y is still continuing her regular follow up with neurosurgery. meningioma.6 Temporal lobe meningioma causing postpartum depression has never been reported so far. The temporal lobe is involved in memory, emotions and audition.7 Temporal lobe tumors can present similar to frontal lobe tumors with depressed mood, apathy and irritability or euphoria and mania. Personality change and anxiety have also been noted with these tumors of temporal lobe origin.8 Ms Y had a meningioma located in the temporal lobe which presented with postpartum depression. Although it is a possibility that her meningioma and postpartum depression could be unrelated but it appears unlikely based on her presentation. It is implied that she had an underlying meningioma which was silent but during pregnancy this tumor grew and produced psychiatric symptoms. Many theories have been postulated about accelerated growth of meningiomas in pregnant females9 which include endogenous hormonal exposure, water retention, vessel engorgement10 and activation of progesterone receptor.9 Patients presenting in psychiatry emergency room and outpatient clinics often undergo a medical clearance examination which includes basic lab work including CBC, chem-7, liver function tests, lipid profile, toxicology screen and a physical examination. A measurement of weight has also become routine as many of these patients are prescribed neuroleptics which are prone to cause metabolic syndrome. At least 2 studies have suggested that a minimum, basic screening laboratory studies should be obtained in patients with no medical complaints presenting for psychiatric evaluation11,12; but the use of neuroimaging to evaluate psychiatric patients has always been a controversial topic of debate.13 Rosse et al suggested that CT scan of brain would be indicated in cases with neurological signs, delirium, dementia, anorexia nervosa, and first presentation psychosis. Recommendations were also made regarding patients more than 50 years of age showing personality change or first episode of depression or mania.14 In this case, the patient was young and had a recent pregnancy, which coincided with the onset of her symptoms - routine imaging is less strongly suggested in these types of patients. Our case had occasional nausea and headaches which did warrant emergent CT scan but was unfortunately not done. Somatic symptoms like headaches and nausea can present with depression and thus can be misleading. Readers are reminded that they should suspect intracranial pathology as a cause of psychiatric symptoms in all the patients as the signs and symptoms of an intracranial mass may be subtle, and a detailed history and physical examination may not reveal early lesions. This case has reemphasized our need for constant vigilance. Symptoms that should definitely make a clinician to suspect a structural cause of psychiatric symptoms include delirium, disorientation, headaches, recent history of malignancy, and or focal neurologic symptoms or signs.15 This case also provides an opportunity for administration to improve and redefine their departmental protocols and management strategies depending upon the availability of resources and patient population. 3. Disclosure Discussion PubMed search done for literature review reported only one case of postpartum depression in a patient with bifrontal Authors of this paper have contributed significantly in this case report.
  4. 4. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 9 9 e3 0 1 Conflicts of interest All authors have none to declare. references 1. Radhakrishnan K, Mokri B, Parisi JE, O’Fallon WM, Sunku J, Kurland LT. The trends in incidence of primary brain tumors in the population of Rochester Minnesota. Ann Neurol. 1995 Jan;37(1):67e73. 2. Kaplan HI, Sadock BJ. Mental disorders due to general medical condition. MD. In: Kaplan HI, ed. Synopsis of Psychiatry. USA: Williams and Wilkins; 1998:350e364. 3. Bunevicius A, Deltuva VP, Deltuviene D, Tamasauskas A, Bunevicius R. Brain lesions manifesting as psychiatric disorders: eight cases. CNS Spectr. 2008 Nov;13(11):950e958. 4. Madhusoodanan S, Danan D, Moise D. Psychiatric manifestations of brain tumors: diagnostic implications. Expert Rev Neurother. 2007 Apr;7(4):343e349. 5. Lisanby SH, Kohler C, Swanson CL, Gur RE. Psychosis secondary to brain tumor. Semin Clin Neuropsychiatry. 1998 Jan;3(1):12e22. 6. Schwartz AC, Afejuku A, Garlow SJ. Bifrontal meningioma presenting as postpartum depression with psychotic features. Psychosomatics; 2012 Apr 26. 301 7. Martin J. Neuroanatomy: Text and Atlas. 2nd ed. Stamford, USA: Appleton, Lange; 1996. 8. Price TRP GK, Lovell MR. Neuropsychiatric aspects of brain tumors. In: Yudofsky SC, Hales RE, eds. Neuropsychiatry and Clinical Neurosciences. 4th ed. Washington, DC, USA: American Psychiatric Publishing, Inc.; 2002. 9. Wolfsberger S, Doostkam S, Boecher-Schwarz HG, et al. Progesterone-receptor index in meningiomas: correlation with clinico-pathological parameters and review of the literature. Neurosurg Rev. 2004 Oct;27(4):238e245. 10. Jhawar BS, Fuchs CS, Colditz GA, Stampfer MJ. Sex steroid hormone exposures and risk for meningioma. J Neurosurg. 2003 Nov;99(5):848e853. 11. Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am. 2000 May;18(2):185e198 [vii]. 12. Henneman PL, Mendoza R, Lewis RJ. Prospective evaluation of emergency department medical clearance. Ann Emerg Med. 1994 Oct;24(4):672e677. 13. Korn CS, Currier GW, Henderson SO. "Medical clearance" of psychiatric patients without medical complaints in the emergency department. J Emerg Med. 2000 Feb;18(2):173e176. 14. Rosse RB, Deutsch LH, Deutsch SI. In: Sadock BJ, Sadock VA, eds. Medical Assessment and Laboratory Testing in Psychiatry. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2000. 15. Ananth J, Gamal R, Miller M, Wohl M, Vandewater S. Is the routine CT head scan justified for psychiatric patients? A prospective study. J Psychiatry Neurosci. 1993 Mar;18(2):69e73.
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