This case was written up in the NEJM, and made freely accessible. The image on the top left shows a brain scan taken three years earlier than the one on the top right. The other images show the cells in the tumor.
It is a meningothelial meningioma, World Health Organization grade I.
You may ask, how is it that we happen to have available before-and-after views of the same brain. That is not usually the case. But this was an unusual case: the patient had undergone sex-change treatment, and was receiving high-dose estrogen.
Three years before the tumor was found, the patient had
developed a
high prolactin level. This occasionally occurs with estrogen
therapy. Sometimes, a high prolactin level is a sign of a
pituitary tumor. That was the reason for the first MRI of the
brain in this patient. That MRI showed no tumor.
Four months before the tumor was discovered, the patient developed euphoria and confusion. This was mistakenly attributed to the sex change. It was not until the patient developed a severe headache, along with partial loss of vision, that the tumor was found.
As it happens, I was in training around the time that brain scans (CT) were coming into widespread use. I recall two cases of persons who were referred to the psychiatric service with a variety of complaints, including confusion and personality changes. In both, we ended up getting CT scans. Both had brain tumors.
In both cases, there was no question about the fact that the patients had developed behavioral, emotional, and cognitive symptoms. However, they did not match any of the classic presentations for common psychiatric illnesses.
This is not common, by the way. However, it points out the importance of the ability to do a good mental status exam. It still astonishes me how often confusion is missed. Often, it is misinterpreted as willful uncooperativeness. This is especially likely when the patient exhibits emotional changes such as depression, or labile affect.
I once saw a person who had had a stroke, and was depressed. I noticed that there was a striking disproportion in the degree of energy loss, compared to the severity of depression. Plus, her capacity to experience positive feelings (hedonic capacity) was intact. She turned out to have endocarditis. The fatigue had nothing to do with depression. In fact, the depression was a red herring.
For various reasons, it is not wise to go around getting brain scans on everyone who has any psychiatric symptoms. Certainly, most would not get blood cultures done. It can be tricky to figure out which patients should get the more vigorous workups.
In order to select patients for more vigorous workups, it is important to have a conceptual basis for doing so. The way I look at it is this: patients with psychiatric symptoms comprise an atypical population. Within that atypical population, however, there are typical presentations: the typical atypicals. There are also some who are atypically atypical. (I know that sounds like a Rumsfeldism, but bear with me.)
Within the atypical atypical population, there are certain warning signs that shout out for an aggressive workup. Confusion or cognitive decline are both worrisome, particularly if the course is acute or subacute. Sometimes it is necessary to get historical perspective from a family member in order to get a sense of the course over time that the decline has followed.
Another worrisome sign is a clear diminution of level of function. Most people who are developing an episode of psychiatric illness will struggle mightily to continue to function. If, in the course of weeks or several months, they get to the point that they simply cannot work any longer, then it is time to be aggressive looking for the reason.
Sometimes you end up wasting a few thousand dollars dong all kinds of tests. But sometimes you end up saving their career, their marriage, or their life.
One final point. Often, I read these medical case histories, and find that the description of mental status changes is relegated to a single sentence. There is hardly any detail at all. I'd like to suggest to my colleagues that they try to include a little more detail. For example, I'd a description of the observations that led to the labels of "euphoria" and "confusion" in the meningioma case in the NEMJ article. Sometimes those things are the keys to an earlier diagnosis.
Four months before the tumor was discovered, the patient developed euphoria and confusion. This was mistakenly attributed to the sex change. It was not until the patient developed a severe headache, along with partial loss of vision, that the tumor was found.
As it happens, I was in training around the time that brain scans (CT) were coming into widespread use. I recall two cases of persons who were referred to the psychiatric service with a variety of complaints, including confusion and personality changes. In both, we ended up getting CT scans. Both had brain tumors.
In both cases, there was no question about the fact that the patients had developed behavioral, emotional, and cognitive symptoms. However, they did not match any of the classic presentations for common psychiatric illnesses.
This is not common, by the way. However, it points out the importance of the ability to do a good mental status exam. It still astonishes me how often confusion is missed. Often, it is misinterpreted as willful uncooperativeness. This is especially likely when the patient exhibits emotional changes such as depression, or labile affect.
I once saw a person who had had a stroke, and was depressed. I noticed that there was a striking disproportion in the degree of energy loss, compared to the severity of depression. Plus, her capacity to experience positive feelings (hedonic capacity) was intact. She turned out to have endocarditis. The fatigue had nothing to do with depression. In fact, the depression was a red herring.
For various reasons, it is not wise to go around getting brain scans on everyone who has any psychiatric symptoms. Certainly, most would not get blood cultures done. It can be tricky to figure out which patients should get the more vigorous workups.
In order to select patients for more vigorous workups, it is important to have a conceptual basis for doing so. The way I look at it is this: patients with psychiatric symptoms comprise an atypical population. Within that atypical population, however, there are typical presentations: the typical atypicals. There are also some who are atypically atypical. (I know that sounds like a Rumsfeldism, but bear with me.)
Within the atypical atypical population, there are certain warning signs that shout out for an aggressive workup. Confusion or cognitive decline are both worrisome, particularly if the course is acute or subacute. Sometimes it is necessary to get historical perspective from a family member in order to get a sense of the course over time that the decline has followed.
Another worrisome sign is a clear diminution of level of function. Most people who are developing an episode of psychiatric illness will struggle mightily to continue to function. If, in the course of weeks or several months, they get to the point that they simply cannot work any longer, then it is time to be aggressive looking for the reason.
Sometimes you end up wasting a few thousand dollars dong all kinds of tests. But sometimes you end up saving their career, their marriage, or their life.
One final point. Often, I read these medical case histories, and find that the description of mental status changes is relegated to a single sentence. There is hardly any detail at all. I'd like to suggest to my colleagues that they try to include a little more detail. For example, I'd a description of the observations that led to the labels of "euphoria" and "confusion" in the meningioma case in the NEMJ article. Sometimes those things are the keys to an earlier diagnosis.
Brain & Behavior
Medicine & Health
Comments
hi, my name is rocio hortal, im from argentina. my father has a corpus callosum tumor, that was found by chance after he was hospitalice because of a vascular accident in the brain. Do you know any treatment at all?? anything please writte me. my email is rociobhortal@hotmail.com
thanks!!!
Posted by: hortal rocio | December 23, 2007 5:35 PM