Brain Tumor-induced Mania in Schizophrenia

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1 236 Taiwanese Journal of Psychiatry Vol. 23 No Case Report Brain Tumor-induced Mania in Schizophrenia Po-Han Chou, M.D., Lieh-Yung Ping, M.D., M.P.H. 2,3, Hong-Shiow Yeh, M.D., M.P.H. 2,4, Chin-Hong Chan, M.D., M.S. Objective: We report on a chronic schizophrenic patient with mania induced by a temporal lobe tumor and we also review the related literature. Case report: A schizophrenic patient with negative symptoms was found to have a tumor in the right temporal lobe following a seizure. Albeit being diagnosed, the patient started to have pressure of speech, expansive mood, racing thoughts and violence, and he was transferred to the acute psychiatry ward. After having received valproate and lithium, his condition became stabilized. Conclusion: Temporal lobe tumor may induce secondary mania. Treatment with mood stabilizers can help control symptoms. Key words: temporal lobe tumor, negative symptoms, mania, mood stabilizer (Taiwanese Journal of Psychiatry 2009;23:236-40) Introduction Secondary mania is a rare clinical manifestation of brain tumors of the temporal lobe. Few studies have been reported that developing psychiatric symptoms such as mania, panic attacks and memory loss, is related to brain tumors affecting the temporal regions. [-6]. Although symptomatic treatment of both primary and secondary mania may be similar, the etiology of mania is important because appropriate treatment of secondary mania includes addressing the underlying cause [6]. We present here a case of chronic schizophrenia who had had negative symptoms of schizophrenia for over 5 years before having a seizure and subsequent classic presentations of mania. The result in further evaluation revealed a tumor in the right temporal lobe. Case Report A 5-year-old married male veteran patient with a history of schizophrenia has been receiving treatment in our chronic psychiatry ward for more than 5 years with main presentations of negative symptoms including flattening of affect, poverty of speech, social withdrawal, and decreased spontaneous movements. In his history, the patient did not have any depressive or manic episode during his whole course of illness. He also had occasional self-laughing. He was transferred to the acute psychiatry ward because of progressive changes in mood and behaviors for several months. Department of Psychiatry, Taichung Veterans General Hospital 2 Department of Psychiatry, Yu-Li Veterans Hospital, Taiwan 3 Institute of Public Health, Tzu Chi University, Taiwan 4 Institute of Public Health, Auckland University, New Zealand Received: September, 2008; revised: March 3, 2009; accepted: April, 2009 Address correspondence to: Dr. Po-Han Chou, Department of Psychiatry, Taichung Veterans General Hospital, No. 60, Sec. 3, Chung-Kang Road, Taichung 407, Taiwan.

2 Chou PH, Ping LY, Yeh HS, et al. 237 About six months before he was admitted to the acute psychiatry ward, the patient started to have elated mood, aggravated self-talking, and increased social activities. Then, on August 20, 2007, he suffered from a seizure. The results of the initial laboratory tests including serum chemistry and hematology profile were unremarkable. The brain CT scan finding showed a punctuated and calcified 2.x2.x2.3-cm mass in the right temporal lobe, suspecting to have an oligodendroglioma (Figure ). The patient was then transferred to the Buddhist Tzu Chi General Hospital for surgical resection of the mass. But he refused to receive the operation after being well-informed of the possible benefits and complications. He was then sent back to our chronic psychiatry ward on August 27, 2007 for supportive managements. The patient started to show aggravated self-talking and manic symptoms including hypertalkativeness, argumentativeness, hyperactivity, expansive and irritable mood, poor impulse control, and violence toward other patients. He was transferred to the acute psychiatry ward on February 3, On admission, the patient did not have any remarkable physical or neurological findings. In the mental status examination, he was found to be unkempt and excited, and he had poor attention and concentration, and over-politeness. His speech was moderately pressured and tangential, requiring repeated redirections to guide him back to the question. He showed expansive and labile mood and his affect was mood-congruent. He also had flight of ideas and illogical thinking, but he denied having auditory hallucinations or paranoid delusions. On the Mini-Mental State Examination, he was scored 7 out of 30 with main errors in the areas of calculation and short-term memory. The initial surveys including serum chemistry and chest X-ray examination did not reveal Figure. Brain CT scan showing a mass in the right temporal lobe, about 2.x 2.x2.3 cm in size, suspected oligodendroglioma Figure 2. Follow-up brain CT scan with contrast enhencement any remarkable findings. The hematology profile showed normocytic anemia with a Hgb of 9.2 g/ dl. As shown in Figure 2, contrast-enhanced brain CT scan in a routine follow-up revealed no obvious progressions of the brain tumor.

3 238 Brain Tumor-induced Mania in Schizophrenia The patient s usual medications included amisulpride 800 mg/day, phenytoin 400 mg/day, estazolam (2 mg h.s.), metformin (500 mg b.i.d.), and nateglinide (20 mg t.i.d). He received valproate 2,00 mg/day initially. The symptoms of poor attention and concentration, expansive mood, pressure of speech, and racing thoughts gradually became remitted when his valproate serum levels reached between μg/ml after about one month. But he had irritability and occasional poor impulse control with violence toward other patients. Thus, he received low dose lithium (300 mg b.i.d.) during the second month of admission (serum level: meq/l). After receiving mood stabilizers with valproate and lithium for about two months, his condition was gradually stabilized and he was then transferred back to the chronic psychiatry ward for further rehabilitation. Discussion The temporal lobes are mainly concerned with the functions of hearing, language (left lobe), sensory prosody (right lobe), memory and emotions. Damage in these parts of the brain, the patient may have impairments in related functions. Neuropsychiatric presentations, such as mania, auditory and visual hallucinations, panic attacks and amnesia, have been shown to be associated with temporal lobe tumors [5,6]. The mood symptoms are especially associated with brain tumors of the right side. The underlying mechanism of mania induced by right temporal lobe lesions may involve the interrupted frontotemporal pathways [7]. Although bipolar disorder can have a late onset in persons over the age of 50 years without a previous psychiatric history or a family history of bipolar disorder [6], most new onset mania in older adults is secondary in cause. In addition, older adults with new onset mania are twice more likely to have an underlying neurological disorder compared to older bipolar patients who have had history of many manic episodes [6]. Therefore, to rule out other contributing factors is important when the patient has atypical psychiatric presentations. Our case showed that the patient had similar neuropsychiatric presentations to those described in the literature [,5,6], in which mania was the main symptom in patients with right temporal lobe tumor. But there are some differences. First, our patient has a history of chronic schizophrenia, whereas the patient described by Mazure et al. [] and Brooks et al. [6] had no past psychiatric history, and the patient reported by Filley et al. [5] had a history of intermittent depression. Second, unlike Brooks et al. s patients who received surgical removal of the primary tumor and then were on perphenazine 28 mg b.i.d., or olanzapine 20 mg/ day plus valproate 500 mg b.i.d., our patient did not receive surgery although his condition was also stabilized with the regimen of both valproate 2,00 mg/day and lithium 600 mg/day. The symptomatic treatment of secondary mania is similar to that of primary mania, [6] but obviously treating the underlying cause is of prime importance. In our case, the initial treatment policy was surgical removal of the mass. But the patient refused to undergo surgery, therefore, supportive treatment was given instead. He was under regular evaluations by a neurologist. For controlling acute agitation, benzodiazepines and antipsychotics are preferable choices, but benzodiazepines should be used with caution in the elderly and those with hepatic dysfunctions. Being less likely to have the extrapyramidal symptoms, risk of neuroleptic malignant syndrome, and incidence of dystonia, second generation antipsychotic drugs are preferred. They include olanzapine, risperidone, quetiapine, aripiprazole, ziprasi-

4 Chou PH, Ping LY, Yeh HS, et al. 239 done, and in some studies, amisulpride [8,9]. The major factors influencing selection are the presence of medical conditions like diabetes, metabolic syndrome, etc. In our patient, we chose amisulpride out of concern for his relatively poorly controlled blood sugar. Mood stabilizers, like valproate or lithium, are frequently used, but lithium should be used with caution in the elderly and those with impairments of thyroid or renal functions. Mania associated with structural central nervous system disease may respond better to valproate or carbamazepine [0]. Our patient received valproate 2,00 mg/day and lithium 600 mg/day and showed significant improvements in his manic conditions. Our experience with this case indicates a combination of valproate and lithium may be a safe and effective choice for treating secondary mania caused by temporal lobe tumor. References. Mazure CM, Leibowitz K, Bowers MB Jr.: Drug- Responsive Mania in a man with a brain tumor. J Neuropsychiatry Clin Neurosci 999;: Starkstein SE, Boston JD, Robinson RG: Mechanisms of mania after brain injury: 2 case reports and review of the literature. J Nerv Ment Dis 988;76: Cummings JL: Neuropsychiatric manifestations of right hemisphere lesions. Brain Lang 997;57: Sokolski KN, Denson TF: Exacerbation of mania secondary to right temporal lobe astrocytoma in a bipolar patient previously stabilized on valproate. Cog Behav Neurol 2003;6: Filley CM, Kleinschmidt-DeMasters BK: Neurobehavioral presentations of brain neoplasms. West J Med 995;63: Brooks JO 3rd, Hoblyn JC: Secondary mania in older adults. Am J Psychiatry 2005;62: Gafoor R, O'Keane V: Three case reports of secondary mania: evidence supporting a right frontotemporal locus. Eur Psychiatry 2003;8: Vieta E, Ros S, Goikolea JM,et al: An open-label study of amisulpride in the treatment of mania. J Clin Psychiatry 2005;66: Yatham LN, Kennedy SH, O Donovan C, et al.: Guidelines update: Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: update 2007, Bipolar Disord 2006;8: Evans DL: Bipolar disorder: diagnostic challenges and treatment considerations. J Clin Psychiatry 2000;6(suppl 3):26-3.

5 240 台灣精神醫學第 23 卷第 3 期,2009 個案報告摘要 慢性精神分裂症病人疑因腦瘤引起的躁症 周伯翰 2,3 平烈勇 2,4 葉紅秀 陳展航 本文報告一位慢性精神分裂症患者, 因顳葉腫瘤導致的躁症發作, 並且回顧相關文獻探討治療方式 一位長期表現負性症狀的慢性精神分裂症患者, 因為癲癇發作而發現右顳葉腫瘤, 並因出現話多 情 緒高昂 意念飛躍 暴力而轉入急性病房, 使用 valproate 和 lithium 之後症狀獲得控制 顳葉腫瘤會引起病人的躁症發作, 使用情緒穩定劑有助於控制症狀 關鍵詞 : 顳葉腫瘤, 負性症狀, 躁症, 情緒穩定劑 ( 台灣精神醫學 2009;23:236-40) 台中榮民總醫院精神部 2 玉里榮民醫院精神部 3 慈濟大學公共衛生研究所 4 紐西蘭奧克蘭大學公共衛生研究所受理日期 :2008 年 9 月 日 ; 修正日期 :2009 年 3 月 3 日 ; 接受日期 :2009 年 4 月 日通信作者地址 : 周伯翰,407 台中市西屯區台中港路三段 60 號台中榮民總醫院精神部