CLINICAL CASE

ORGANIC PSYCHOTIC DISORDER OR

COMORBIDITY?

1 2 2Cristina Daniela Cojocaru , Paul Sorin Pletea , Ciprian Roºu

151

Abstract: We describe the case of a man 27 years old at its second psychiatric hospitalization for acute psychotic symptoms and no neurological symptoms which, after investigations, proved to be secondary to multiple brain tumors disseminated in both hemispheres of the brain. Patient's psychiatric condition has improved substantially after etiologic treatment (neurosurgical, chemotherapy and radiotherapy). Clinical examination and paraclinical investigation of psychiatric patients should be made accurately to reveal any organic cause of mental distress or comorbidity.Key words: psychosis, brain tumor, brain parasytosis.

Rezumat:Descriem cazul unui bãrbat de 27 de ani aflat la a doua internare psihiatricã pentru o simptomatologie psihoticã acutã care în urma investigaþiilor paraclinice s-a dovedit a fi secundarã unor tumori cerebrale multiple diseminate în ambele emisfere cerebrale. Starea psihiatricã a pacientului s-a îmbunãtãþit substanþial în urma tratamentului etiologic (neurochirurgical, chimioterapie ºi radioterapie). Examinarea clinicã ºi investigarea paraclinicã a pacienþilor psihiatrici trebuie fãcute cu acurateþe pentru a evidenþia o eventualã cauzã organicã a suferinþei psihice sau o comorbiditate.Cuvinte cheie: psihozã, tumorã cerebralã, parazitozã cerebralã .

Received August 31, 2010; revised September 30, 2010; accepted October 1, 20101 Psychiatrist Senior at the Clinical Hospital of Psychiatry „Prof. Dr. Al. Obregia”, Berceni Road No. 10-12, Bucharest, Romania 2 Resident in Psychiatry at the Clinical Hospital of Psychiatry „Prof. Dr. Al. Obregia”, Berceni Road No. 10-12, Bucharest, Romania. Contact - email: sorin.paul.pletea@gmail.com

A psychiatric diagnosis is basically a clinical one. Laboratory investigations have less importance in comparison with other disciplines. However psychiatric patients should be properly investigated to exclude an organic cause of mental suffering or to highlight any comorbidity.

Some of the most common neurological causes of mental diseases are brain tumors. They are associated with a wide range of psychiatric symptoms according to their location. In 18% of the cases the brain tumors begins with psychiatric symptoms (1). The frontal tumors have the highest degree (90%) of association with psychiatric symptoms while the parietal tumors have the lowest association. The temporal, occipital and pituitary tumors are associated with psychiatric symptoms at a rate of 25-60%. The association of psychiatric disorders with brain tumors is an important issue in terms of tumor incidence and 5-years survival rate. In the U.S., in 2000, the incidence of primary brain tumors was 130.8 to 100,000 people (ie 375,000 people with neuropsychiatric problems secondary to the brain tumors). The fact that the 5-year survival rate, according to early diagnosis and appropriate treatment, increased from 22% to 32% since the 1980's covinced psychiatric practitioners to take into account the possibility of a neurological disease and in particular the brain tumor, especially at the beginning of a psychiatric pathology. (1)

We report the case of a 27-year-old man who was admitted to the emergency unit in April 2010 for a schizophrenia-like psychotic symptoms (with acute onset of about 5 days), which later turned out to be secondary to a brain tumor. This was the patient's second hospitalization. 14 months ago he had a first hospitalization for an acute psychotic picture with delusional paranoid ideation, anxiety and marked phenomena of mental automatism. He was treated initially with Haloperidol oral solution, which

was changed to olanzapine 10 mg/day because of an acute dystonia. The pacients status improved and he was discharged with the same treatment, but after 2-3 months he interrupted the treatment of his own will.

The data obtained from the patient and the family members revealed that he has 2 brothers and 1 sister (he is the youngest). The psychiatric family history was irrelevant. The patient had an appropriate psychosomatic development (in the secondary school and high school had average results). After compulsory military service has worked in a military unit where he was promoted and well integrated. At the age of 24 he exhibit some behavioral changes: he began to consume alcohol in increasingly larger quantities and he was easier engaged in conflicts, which was the reasons why he was discharged from service. After this the patient was admitted to the Faculty of the Animal Sciences and during the first year occurred the first psychiatric hospitalization. About two months before the current admission the patient had been expelled from college because he had assaulted a teacher. At that time the patient has resumed the abuse of alcohol, he behave inappropriately in social and family relations, with verbal and sexual disinhibition, verbal and gesture aggressivness.

Psychiatric examination revealed a conscious patient with proper hygiene, partly cooperating, hidden, suspicious, with broad gestures and mimicry hypermobility, psychomotor agitated with sexual disinhibition, coprolalic, oriented in time, place and person, with voluntary hypoprosexia and spontaneous hyperprosexia, short-term memory loss and paramnesia.

The patient had comentative auditory pseudohallucination and hallucinatory-delusional modified behavior. We observed disturbances in the form and content of thought: the speech was spontaneous, fluent with slight acceleration of the rhythm and flow of

thoughts, alternating with long latency in response and thought blocking. The thought content was mood-incongruent paranoyd type - delusions of persecution, tracking, damage, grandeur, reference, associated with delusion of control. We have detected dificulty in abstract thinking. Thought disorders were incongruous with affection, the patient showing indifference. He was slightly dysphoric, irritable, with the father affective ambivalence. The patient had interrupted sleep. He also has an impaired insight and indecisive. His personality was altered, for about two years, with explosive-impulsive and dissocial traits, alternating with periods of apathy.Objective clinical examination, including neurological, was within normal limits, except for some facial bruising which were assigned to the patient as a consequence of conflict he had two days earlier. Laboratory tests (including HIV serology) were unmodified. We initiated the treatment with Risperidone (oral solution 1mg/ml) with doses increasing gradually from 4 to 6 mg/day, Sodium Valproate (extended release capsules) 1500 mg/day, Clonazepam 2 mg/day and Tryhexifenydil 2cp/day. Under this treatment there has been favorable but slow wave partial remission of symptoms. Because of the relatively sudden onset, symptoms polymorphism and the lasting personality changes (moriatic-type) was raised a differential diagnosis with organic pathology. Thus, EEG examination revealed pathological changes - spontaneous and during hyperpnea - isolated left frontotemporal theta waves (2) (Figure 1).

Figure 1: Isolated left frontotemporal theta waves

Figure 2: Native CT image-left frontal tumor

Native brain CT revealed an almost round tumor size about 2/2 cm., in left frontal area (Figure 2). At the native and contrast MRI were observed five round tumors with different sizes (from 3 to 22 mm), in different stages of evolution, disseminated in both hemispheres of the brain (Figures 3 ,4 and 5)

Figure 3: Tumors disseminated in the right hemisphere of the brain.

Figure 4: Transverse IRM section: Left temporal tumor

Figure 5: Frontal IRM section: Left frontal and frontal and right temporal tumors

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The largest was located on the left frontal lobe, has a liquidian content and discreet perilesional edema (Figures 6 and 7). After the contrast substance administration an intense gadolinium enhancement at the solid lesions and slight perilesional enhancement at the liquidian-content tumor was found. One of the images was suggestive for a cerebral parasitosis (Figure 8).

Figure 6: Sagital IRM section: Left frontal tumor with peritumoral edema

Figure 7: Transverse IRM section: Left frontal tumor with peritumotal edema

Figure 8: Transverse IRM section: Left frontal lesion suggestive for cerebral parasitosis

Parasitological consult recommended IgE and IgG for Tenia solium and Toxoplasma gondii serum dosage(3,4), which were negative. WesternBlot analysis of CSF to confirm parasitic infection could not be done because the patient refused lumbar puncture. We run a chest X-ray and an abdomynal ultrasound to detect other sites of parasytosis but both was in normal limits. In these circumstances the patient was discharged with psychiatric symptoms partially remitted with outpatient treatment (Risperidone oral solution 6 ml/day and sodium valproate 1000 mg/day). The patient's adherence to the psychiatric treatment improved steadily and there has been a favorable evolution. Thus, the pacient accepted an admission into a neurosurgical facility. The surgery took place in July when the larger (left frontal) tumor was removed. The postoperative course was favorable without neurological defici ts . Histopathological and immunohistochemical examinations revealed a diffuse glioma with possible association with oligodendroglioma. Subsequently, the patient was admitted in an oncology clinic (at the present time, the patient is still commited in the Oncology Clinic).Under specific treatment (neurosurgical and oncology) the patient's mental condition has improved allowig to decrease the risperidone dose from 6 to 2 mg per day.

DISCUSSION

The association of mental disorders with organic pathology is relatively common as it is revealed from a study (5) of 5,733,781 discharges of psychiatric patients (aged between 15 and 64) made in the USA between 1979-2003. It was found that more than 50% of patients had at least one psychiatric or organic comorbidity. The association grew with age. The most common associated diseases were hypothyroidism, dermatitis and eczema, obesity, epilepsy, hepatitis, diabetes mellitus, hypertension and obstructive pulmonary disease. A high frequency of occurrence of organic pathology in psychiatric patients has also been highlighted by a study (6) conducted in Finland on 11017 subjects.

The combination of psychiatric symptoms is uncommon in brain tumor pathology (7), but clinicians must remain alert for the differential diagnosis of psychiatric suffering especially with acute onset and unusual evolution.The peculiarity of the case presented is that the rich and polymorphic psychiatric symptomatology is consecutive to intracranial expansive processes. Symptoms started with behavioral and personality changes long before the emergence of psychotic symptoms (8). Correct diagnosis and etiological therapeutic intervention were delayed by the inability of the patient's decision as a result of its psychotic manifestations. However the patient's mental condition has improved enough under psychiatric treatment so that he may be able to accept the specific oncological treatment– neurosurgery, chemotherapy and radiotherapy (9).

Initial symptoms of intracranial expansive processes (IEP) may be subtle and because the clinical expression can be psychiatric and not neurological (10) a complete and accurate medical history can greatly help in diagnosing a potential IEP.Given the type of onset (pseudopsychopatic), the changes of the psychiatric symptoms with treatment (before and

Romanian Journal of Psychiatry, vol. XII, No.4, 2010

after the establishing of the specific oncologicaltreatment) we are faced with a psychiatric pathology secondary to an organic disease and not with a comorbidity.

REFERENCES

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10. Ropper AH, Brown RH. Adam's and Victor's Principles of Neurology. New York: McGraw-Hill, 2005, 552.

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