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LETTERS TO EDITOR  
Year : 2018  |  Volume : 60  |  Issue : 4  |  Page : 511-512
Understanding the correlates of manic episode in a woman with insular glioma


1 Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

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Date of Web Publication28-Nov-2018
 

How to cite this article:
Kar SK, Ahmad J, Das KK. Understanding the correlates of manic episode in a woman with insular glioma. Indian J Psychiatry 2018;60:511-2

How to cite this URL:
Kar SK, Ahmad J, Das KK. Understanding the correlates of manic episode in a woman with insular glioma. Indian J Psychiatry [serial online] 2018 [cited 2018 Dec 17];60:511-2. Available from: http://www.indianjpsychiatry.org/text.asp?2018/60/4/511/246192




Sir,

Psychiatric manifestations are common in patients with brain tumors and sometimes psychiatric symptoms are the only manifestation in these patients.[1] The common psychiatric manifestations are psychosis, mood symptoms, cognitive symptoms, changes in personality, and changes in eating or sexual behavior.[1] It is often difficult to ascertain the development of psychiatric manifestations with the course of the brain tumor. The interventions done for the treatment of brain tumor may also attribute to development of psychiatric manifestations. We highlight here a case (after obtaining informed consent) of insular glioma, who developed manic symptoms after neurosurgical and radiotherapy intervention. The management issues are also discussed.

A 36-year-old female of rural background presented in the outpatient services of psychiatry with the complaints of increased irritability, increased talkativeness, grandiose talks, increased physical activity, increased religiosity and reduced sleep for the past 1 month. The symptoms would persist for most part of the day and due to which she would not be able to perform the daily chores. It was the first episode of psychiatric illness. History revealed that there was 3 episodes of generalized tonic clonic type of seizure around 1 year back. She had consulted in a neurosurgery unit and investigated for seizure. Her magnetic resonance imaging of the brain revealed left insular high-grade glioma. She had undergone left frontotemporal craniotomy for the same around 8 months back and tumor was removed [Figure 1]. Her postoperative period was uneventful. She was started on phenytoin 300 mg/day after surgery and also completed the course of radiotherapy over a period of 4 months. Neuropsychological assessment (on NIMHANS battery) in the post-operative period revealed mild deficits in sustained attention, delayed recall and verbal fluency. However, her recent and remote memory, visual retention and recognition and performance abilities were intact. There was no history of any other medical illness. Her family history was also uneventful. Premorbidly, she was well adjusted to life. There was no history of any psychoactive substance abuse.
Figure 1: Postoperative magnetic resonance imaging showing near total excision of left insular glioma (a-c). At the depth of the surgical cavity, the internal capsule is visualized (a and c) which was carefully protected during surgery. Hyperintensity around the surgical cavity may indicate small infiltrating tumor residue or postoperative gliosis (c)

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Her general physical examination and systemic examination did not reveal any abnormality except gum hypertrophy (adverse effect of phenytoin therapy). Her routine hemogram, liver function test, and kidney function test were within normal limits. She was diagnosed with Mania without psychotic symptoms as per the International Statistical Classification of Diseases and Related Health Problems-10 diagnostic criteria for research diagnostic criteria. She was started sodium valproate 750 mg/day, and phenytoin was tapered off and gradually stopped. Her seizure was controlled, and manic symptoms were significantly improved over 3 weeks' time. At the end of 3 months, her symptoms were completely resolved.

Among the mood symptoms associated with glioma, depressive features are more common.[2] The presence of brain lesions in an individual cannot be always to the psychiatric manifestations present in the person.[3] In our patient, there are many potential causes (tumor in the left temporal lobe, temporal lobectomy, brain tissue damage due to radiotherapy as well seizure episodes) that might have attributed to the development of psychiatric symptoms. However, none of the events temporally correlated with the onset of psychiatric manifestations. Stress response to all these major medical issues might be attributed to the psychopathology. Evidence suggest that a significant number of patients with glioma experience stress during their hospitalization and thereafter.[4] Stress can have a potential role in the development of psychiatric disorder and seems to be of relevance in our case. A mood episode independent of glioma seems to be a sound explanation in this case.

Patient's manic symptoms resolved completely with sodium valproate, which is a potent antiepileptic agent as well as a mood stabilizer. Other antiepileptic agents like– phenytoin, phenobarbitone, topiramate, levetiracetam, lacosamide, zonisamide, and benzodiazepines lack the mood stabilizing the property. Choosing valproate as a medication for seizure prophylaxis, will not only ensure a seizure-free recovery; its mood stabilizing property will also take care of manic symptoms as well as aggression. The clinician needs to be cautious enough in considering the psychiatric diagnosis as well as selection of appropriate medication for its treatment. A multidisciplinary collaborative approach might be more useful in this regards.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Madhusoodanan S, Ting MB, Farah T, Ugur U. Psychiatric aspects of brain tumors: A review. World J Psychiatry 2015;5:273-85.  Back to cited text no. 1
    
2.
Boele FW, Rooney AG, Grant R, Klein M. Psychiatric symptoms in glioma patients: From diagnosis to management. Neuropsychiatr Dis Treat 2015;11:1413-20.  Back to cited text no. 2
    
3.
Gupta B, Patel A, Kar SK, Alam Z. Delusional disorder in brain abscess: Searching the missing link. Asian J Psychiatr 2018;34:62-3.  Back to cited text no. 3
    
4.
Singer S, Roick J, Danker H, Kortmann RD, Papsdorf K, Taubenheim S, et al. Psychiatric co-morbidity, distress, and use of psycho-social services in adult glioma patients-a prospective study. Acta Neurochir (Wien) 2018;160:1187-94.  Back to cited text no. 4
    

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Correspondence Address:
Dr. Sujita Kumar Kar
Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_245_18

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