A Case of Personality Change With Brain Tumor

This case was href="http://content.nejm.org/cgi/content/full/357/23/2411">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.