Right Temporal Lobe Meningioma presenting as postpartum depression: A case report

Case Report

Right Temporal Lobe Meningioma presenting aspostpartum depression: A case report

Tarun Kumar a,*, Archana Kathpal a, Carrol T. Longshore b

aResident, Department of Psychiatry, Elmhurst Hospital Center (Mount Sinai School of Medicine), 79-01 Broadway,

Elmhurst, NY 11373, United StatesbAttending and Head, Adult Psychiatry Inpatient Unit, Elmhurst Hospital Center (Mount Sinai School of Medicine),

79-01 Broadway, Elmhurst, NY 11373, United States

a r t i c l e i n f o

Article history:

Received 31 August 2012

Accepted 31 January 2013

Available online 20 February 2013

Keywords:

Meningioma

Postpartum depression

Neuroimaging

a b s t r a c t

Meningiomas are tumors which arise from arachnoid cells and can occur both in the brain

and spinal cord. Meningiomas can present with psychiatric symptoms (such as depression,

anxiety disorders, or personality changes) in the absence of any neurologic signs or

symptoms. Literature review also shows few cases of postpartum depression seen in as-

sociation with Frontal Lobe Meningiomas. Authors in this article present a unique case of

Right Temporal Lobe Meningioma in a patient, who presented with chief complaint

of postpartum depression. This presentation has never been reported to date. Routine use

of neuroimaging in the evaluation of new onset psychiatric disorders has always been

controversial but this case clearly underscores the value of a detailed history, careful

physical examination, and consideration of other diagnostic studies in patients presenting

for psychiatric evaluation. This case also provides an opportunity for clinical departments

to improve and redefine its protocols and management strategies.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Meningioma is brain tumors that arise from arachnoid cells

lining brain and spinal cord. These usually occur spontane-

ously, or secondary to radiation exposure. Incident rate of

these tumors is about 7.8% per 100,000 per year.1 Most of these

tumors remain silent and only 25% of them produce symp-

toms based on their location.2e5 These tumors have been

associated with depression, mania, psychosis and personality

changes. These tumors can be easily diagnosed by using

neuroimaging but the use of neuroimaging such as CT scan in

the evaluation of new onset psychiatric disorders has always

been a topic of debate.

Postpartum depression is a form of clinical depression

which begins after child birth. It may last up to severalmonths

or even a year. In the past, a case of postpartum depression

secondary to bifrontal meningioma has been reported but we

recently had a case of right temporal meningioma which

presented as postpartum depression.

2. Case report

Ms Y is a 28-year-old Asian female with no prior psychiatric

treatment who presented to psychiatry walk-in clinic at our

hospital with symptoms of depressed mood, anhedonia,

* Corresponding author.E-mail address: drtarundhingra@gmail.com (T. Kumar).

Available online at www.sciencedirect.com

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0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2013.01.018

fatigue, decreased concentration, and difficulty sleeping of 8

months duration. As per Ms Y, her symptoms started just

2e3 weeks after the birth of her first child. Along with

depressive symptoms, she reported mild headache, occa-

sional dizziness, and nausea. She lost interest in her former

hobbies and also reported lack of motivation to take care of

the baby but she managed to do so. She denied having any

suicidal or homicidal ideations toward self, her baby or any

other individual. The pregnancy was planned.

She did not seek any help for about 5 months but later was

referred to a psychiatrist by her primary physician. She did not

seek help of a psychiatrist and took some herbal medications

for depression which made the symptoms worse. Later at the

request of a friend, she came to our walk-in clinic. Ms Y pre-

sented with depressed mood, anhedonia, psychomotor

retardation with poor sleep and appetite. Her speech was of

normal volume, rate and rhythm. She denied any suicidal or

homicidal ideations along with denying any psychotic symp-

toms. Except for a history of miscarriage at the age of 22, Ms Y

denied having any medical problems. She reported having

headaches (mentioned above) for about 8 months with occa-

sional double vision. She was referred for a regular physical

exam (which includes a brief neurological exam) which was

reported as normal. Routine blood work including toxicology

screen were normal. CT scan was ordered for which she got

appointment in 2 weeks. Ms Y was diagnosed with post-

partumdepression andwas started on paroxetine 20mg daily.

At her follow up visit, she reported feeling better with

improved sleep and appetite though she still did not feel

enthusiastic about caring for her son. She still reported oc-

casional mild headaches and dizziness. A week later, Ms Y

presented to the medical emergency roomwith complaints of

severe dizziness and headache. CT scan of head done in

emergency room showed a 4 � 3 � 3.5 cm, hyperdense, well

marginated extra axial, right sided parasellar mass (later

confirmed histologically as meningioma) with some sur-

rounding vasogenic edema. MRI confirmed the above finding

and reported the tumor to be located on right sphenoid bone

with some compression of right lateral ventricle. She was

admitted to neurosurgery where she underwent right pter-

ional craniotomy and tumor resection.

Ms Y was discharge after a one week hospital stay. Two

weeks after the discharge, she came for her psychiatry

appointment.Shealsoreportedthatherparoxetinewasstopped

while shewas admitted to surgery and shehadnot resumed the

medication. Ms Y reported resolution of her depressive symp-

toms after the resection of tumor. She reported good sleep,

appetite,motivation, and good concentration. She also reported

that shenowenjoys goingout and takingher babyout forwalks.

Ms Y was followed on monthly basis in psychiatry clinic

and over the next 3 month. She showed resolution of all her

symptoms of depression. After discussion with the patient,

she was discharged from psychiatry clinic. Ms Y is still

continuing her regular follow up with neurosurgery.

3. Discussion

PubMed search done for literature review reported only one

case of postpartum depression in a patient with bifrontal

meningioma.6 Temporal lobe meningioma causing post-

partum depression has never been reported so far.

The temporal lobe is involved in memory, emotions and

audition.7 Temporal lobe tumors can present similar to frontal

lobe tumors with depressed mood, apathy and irritability or

euphoria andmania. Personality change and anxiety have also

beennotedwith thesetumorsof temporal lobeorigin.8MsYhad

a meningioma located in the temporal lobe which presented

withpostpartumdepression.Although it isapossibility thather

meningioma and postpartum depression could be unrelated

but it appears unlikely based on her presentation. It is implied

that she had an underlying meningioma which was silent but

during pregnancy this tumor grew and produced psychiatric

symptoms. Many theories have been postulated about accel-

erated growth of meningiomas in pregnant females9 which

include endogenous hormonal exposure, water retention,

vessel engorgement10 and activation of progesterone receptor.9

Patients presenting in psychiatry emergency room and

outpatient clinics often undergo a medical clearance exami-

nation which includes basic lab work including CBC, chem-7,

liver function tests, lipid profile, toxicology screen and a

physical examination. A measurement of weight has also

become routine as many of these patients are prescribed

neuroleptics which are prone to cause metabolic syndrome.

At least 2 studies have suggested that a minimum, basic

screening laboratory studies should be obtained in patients

with no medical complaints presenting for psychiatric eval-

uation11,12; but the use of neuroimaging to evaluate psychi-

atric patients has always been a controversial topic of

debate.13 Rosse et al suggested that CT scan of brain would be

indicated in cases with neurological signs, delirium, demen-

tia, anorexia nervosa, and first presentation psychosis. Rec-

ommendations were also made regarding patients more than

50 years of age showing personality change or first episode of

depression ormania.14 In this case, the patient was young and

had a recent pregnancy, which coincidedwith the onset of her

symptoms - routine imaging is less strongly suggested in

these types of patients. Our case had occasional nausea and

headaches which did warrant emergent CT scan but was un-

fortunately not done. Somatic symptoms like headaches and

nausea can present with depression and thus can be

misleading. Readers are reminded that they should suspect

intracranial pathology as a cause of psychiatric symptoms in

all the patients as the signs and symptoms of an intracranial

mass may be subtle, and a detailed history and physical ex-

amination may not reveal early lesions.

This casehas reemphasizedourneed for constant vigilance.

Symptoms that should definitely make a clinician to suspect a

structural cause of psychiatric symptoms include delirium,

disorientation,headaches, recenthistoryofmalignancy, andor

focal neurologic symptoms or signs.15 This case also provides

anopportunity foradministrationto improveandredefinetheir

departmental protocols and management strategies depend-

ing upon the availability of resources and patient population.

Disclosure

Authors of this paper have contributed significantly in this

case report.

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Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

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