511998 2013
ANP48510.1177/0004867413511998ANZJP CorrespondenceANZJP Correspondence
Letters Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(5) 486–489
Letters
Frontal meningioma mimicking relapse of schizophrenia Dennis Velakoulis1,2, Andrew Gleason1, Brad Hayhow1,2, Peter McNeil3 and Frank Gaillard4
© The Royal Australian and New Zealand College of Psychiatrists 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Figure 1.
1Neuropsychiatry
Unit, Royal Melbourne Hospital, Parkville, Australia 2Melbourne Neuropsychiatry Centre, University of Melbourne and Melbourne Health, Parkville, Australia 3Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Australia 4Department of Radiology, Royal Melbourne Hospital, Parkville, Australia Corresponding author: Dennis Velakoulis, Neuropsychiatry Unit, Level 2, John Cade Building, Royal Melbourne Hospital, Parkville, VIC 3050, Australia. Email: [email protected] DOI: 10.1177/0004867413511998
To the Editor A 68-year-old woman with a 25-year history of schizophrenia presented with a 3-month history of persecutory delusions, amotivation, personality change and forgetfulness. She complained of headaches she believed were caused by her neighbours, whose voices she could hear abusing her. Prior to this, she had been on antipsychotic medication and free of psychotic symptoms for over 10 years. She exhibited impairments in attention, orientation, memory, drawing reproduction, calculation, left–right orientation, and praxis. The patient’s presentation was considered atypical for a relapse of schizophrenia.
Magnetic resonance imaging (MRI) of the brain obtained with contrast (Figure 1) demonstrated a 3 cm mass located anteriorly in the interhemispheric fissure, between the frontal lobes and above the corpus callosum which it distorts (C). The mass demonstrated a low signal centrally on all sequences, in keeping with calcification, and a rim of enhancing tissue around the periphery (B). Extensive vasogenic oedema involving both frontal lobes was seen as a high T2 signal on the axial
fluid attenuation inversion recovery (FLAIR) image (A). There was no appreciable diffusion restriction (D) and the remainder of the brain was unremarkable. The imaging was consistent with a frontal falx meningioma, and the patient proceeded to complete surgical removal. Her presenting symptoms subsequently resolved and she returned to her premorbid level of function. Meningiomas are treatable, slowgrowing and mostly histologically
Australian & New Zealand Journal of Psychiatry, 48(5) Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on May 30, 2015
487
ANZJP Correspondence benign tumours of the central nervous system with a pathologically confirmed prevalence of around 1/1000 (Dolecek, 2012). The clinical manifestations of frontal meningioma are often non-specific and late to present, but in patients with mental illness they may mimic past symptoms and delay diagnosis.
Funding
Mirtazapine associated tender pitting pedal oedema Sahoo Saddichha
disease (STDs). A general physical and neurological examination was unremarkable as were the results of comprehensive urine and blood tests. Mirtazapine 15mg/day was added to her existing medications of venlafaxine, and increased a week later to 30mg/day. She started complaining of swelling and tender feet. On examination, she was noted to have bilateral tender pitting pedal oedema, which was circumscribed up to ankle level; otherwise the physical examination was unremarkable. Mirtazapine dosage was reduced to 15mg/day, which improved oedema but did not resolve it. Finally, mirtazapine was ceased and within 48 hours, the tender pitting oedema resolved completely. All tests (blood and urine) repeated at this time were unremarkable. She was diagnosed to have mirtazapine associated bilateral, tender, pitting pedal oedema, with a Naranjo ADR score of 7, which makes it highly probable that mirtazapine was the offending agent. Various physiologic processes can produce pedal oedema, including medical conditions, allergic reactions and drugs. The patient was concurrently taking venlafaxine which has independently been associated with peripheral oedema (Mitkov et al., 2013; Degner et al., 2004). However, she had been taking venlafaxine for the past two years without any adverse effect making a direct association unlikely.The development of pedal oedema may be attributed to a variety of non– immune-mediated mechanisms as
NWMH, Melbourne Health, Preston, Australia Corresponding author: Sahoo Saddichha, NWMH, Melbourne Health, 83 Hotham Street, Preston, VIC 3072, Australia. Email: [email protected] DOI: 10.1177/0004867413514495
To the Editor Although relatively uncommon, dermatological reactions to psychotropic medications may hinder treatment and reduce compliance. Among psychotropic medications, antidepressants can cause dermatological side effects at an incidence of 0.05%, the most common culprit being Bupropion (Mitkov et al., 2013). Mirtazapine, has been reported to rarely cause dermatitis, alopecia, acneiform eruptions (Degner et al., 2004) and very rarely, peripheral oedema (non-pitting and non-tender) (Lin and Chen, 2010). We report the first case of a mirtazapine associated pitting tender pedal oedema. Ms. GA was a 48-year-old female admitted due to recurrence of her major depressive episode with suicidal ideation. She denied history of surgery or any significant medical problems, as well as insect bite, drug rash, allergy to medication or food, and exposure to sexually transmitted
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of interest FG is founder, CEO and Editor of Radiopaedia.org, a collaborative online radiology resource. The other authors
report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Reference Dolecek TA, Propp JM, Stroup NE, et al. (2012) CBTRUS Statistical Report: Primary brain and central nervous system tumors diagnosed in the United States in 2005–2009. NeuroOncology 14(suppl 5): v1–v49.
well as the direct release of mediators from mast cells, production and accumulation of toxic metabolites, and phototoxicity (Mitkov et al., 2013). It is also possible that addition of mirtazapine possibly produced the pharmacodynamic or pharmacokinetic interaction detailed above. However, it is not possible to either confirm or deny this effect. Such side effects can carry significant morbidity and affect compliance, it is important for clinicians to recognize it so that proper management of the presenting patient can be achieved. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of interest The author reports no conflicts of interest.The author alone is responsible for the content and writing of the paper.
References Degner D, Grohmann R, Kropp S, et al. (2004) Severe adverse drug reactions of antidepressants: results of the German multicenter drug surveillance program AMSP. Pharmcopsychiatry 37: S39–S45. Lin CE and Chen CL (2010) Repeated angioedema following administration of venlafaxine and mirtazapine. General Hospital Psychiatry 32: e1–e2. Mitkov MV, Trowbridge RM, Lockshin BN, et al. (2013) Dermatologic side effects of psychotropic medications. Psychosomatics. Epub ahead pf print, 4 October 2013. pii: S0033-3182(13)00138-2. doi: 10.1016/j.psym.2013.07.003.
Australian & New Zealand Journal of Psychiatry, 48(5)
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on May 30, 2015
ANP48510.1177/0004867413511998ANZJP CorrespondenceANZJP Correspondence
Letters Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(5) 486–489
Letters
Frontal meningioma mimicking relapse of schizophrenia Dennis Velakoulis1,2, Andrew Gleason1, Brad Hayhow1,2, Peter McNeil3 and Frank Gaillard4
© The Royal Australian and New Zealand College of Psychiatrists 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Figure 1.
1Neuropsychiatry
Unit, Royal Melbourne Hospital, Parkville, Australia 2Melbourne Neuropsychiatry Centre, University of Melbourne and Melbourne Health, Parkville, Australia 3Department of Neurosurgery, St Vincent’s Hospital Melbourne, Fitzroy, Australia 4Department of Radiology, Royal Melbourne Hospital, Parkville, Australia Corresponding author: Dennis Velakoulis, Neuropsychiatry Unit, Level 2, John Cade Building, Royal Melbourne Hospital, Parkville, VIC 3050, Australia. Email: [email protected] DOI: 10.1177/0004867413511998
To the Editor A 68-year-old woman with a 25-year history of schizophrenia presented with a 3-month history of persecutory delusions, amotivation, personality change and forgetfulness. She complained of headaches she believed were caused by her neighbours, whose voices she could hear abusing her. Prior to this, she had been on antipsychotic medication and free of psychotic symptoms for over 10 years. She exhibited impairments in attention, orientation, memory, drawing reproduction, calculation, left–right orientation, and praxis. The patient’s presentation was considered atypical for a relapse of schizophrenia.
Magnetic resonance imaging (MRI) of the brain obtained with contrast (Figure 1) demonstrated a 3 cm mass located anteriorly in the interhemispheric fissure, between the frontal lobes and above the corpus callosum which it distorts (C). The mass demonstrated a low signal centrally on all sequences, in keeping with calcification, and a rim of enhancing tissue around the periphery (B). Extensive vasogenic oedema involving both frontal lobes was seen as a high T2 signal on the axial
fluid attenuation inversion recovery (FLAIR) image (A). There was no appreciable diffusion restriction (D) and the remainder of the brain was unremarkable. The imaging was consistent with a frontal falx meningioma, and the patient proceeded to complete surgical removal. Her presenting symptoms subsequently resolved and she returned to her premorbid level of function. Meningiomas are treatable, slowgrowing and mostly histologically
Australian & New Zealand Journal of Psychiatry, 48(5) Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on May 30, 2015
487
ANZJP Correspondence benign tumours of the central nervous system with a pathologically confirmed prevalence of around 1/1000 (Dolecek, 2012). The clinical manifestations of frontal meningioma are often non-specific and late to present, but in patients with mental illness they may mimic past symptoms and delay diagnosis.
Funding
Mirtazapine associated tender pitting pedal oedema Sahoo Saddichha
disease (STDs). A general physical and neurological examination was unremarkable as were the results of comprehensive urine and blood tests. Mirtazapine 15mg/day was added to her existing medications of venlafaxine, and increased a week later to 30mg/day. She started complaining of swelling and tender feet. On examination, she was noted to have bilateral tender pitting pedal oedema, which was circumscribed up to ankle level; otherwise the physical examination was unremarkable. Mirtazapine dosage was reduced to 15mg/day, which improved oedema but did not resolve it. Finally, mirtazapine was ceased and within 48 hours, the tender pitting oedema resolved completely. All tests (blood and urine) repeated at this time were unremarkable. She was diagnosed to have mirtazapine associated bilateral, tender, pitting pedal oedema, with a Naranjo ADR score of 7, which makes it highly probable that mirtazapine was the offending agent. Various physiologic processes can produce pedal oedema, including medical conditions, allergic reactions and drugs. The patient was concurrently taking venlafaxine which has independently been associated with peripheral oedema (Mitkov et al., 2013; Degner et al., 2004). However, she had been taking venlafaxine for the past two years without any adverse effect making a direct association unlikely.The development of pedal oedema may be attributed to a variety of non– immune-mediated mechanisms as
NWMH, Melbourne Health, Preston, Australia Corresponding author: Sahoo Saddichha, NWMH, Melbourne Health, 83 Hotham Street, Preston, VIC 3072, Australia. Email: [email protected] DOI: 10.1177/0004867413514495
To the Editor Although relatively uncommon, dermatological reactions to psychotropic medications may hinder treatment and reduce compliance. Among psychotropic medications, antidepressants can cause dermatological side effects at an incidence of 0.05%, the most common culprit being Bupropion (Mitkov et al., 2013). Mirtazapine, has been reported to rarely cause dermatitis, alopecia, acneiform eruptions (Degner et al., 2004) and very rarely, peripheral oedema (non-pitting and non-tender) (Lin and Chen, 2010). We report the first case of a mirtazapine associated pitting tender pedal oedema. Ms. GA was a 48-year-old female admitted due to recurrence of her major depressive episode with suicidal ideation. She denied history of surgery or any significant medical problems, as well as insect bite, drug rash, allergy to medication or food, and exposure to sexually transmitted
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of interest FG is founder, CEO and Editor of Radiopaedia.org, a collaborative online radiology resource. The other authors
report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Reference Dolecek TA, Propp JM, Stroup NE, et al. (2012) CBTRUS Statistical Report: Primary brain and central nervous system tumors diagnosed in the United States in 2005–2009. NeuroOncology 14(suppl 5): v1–v49.
well as the direct release of mediators from mast cells, production and accumulation of toxic metabolites, and phototoxicity (Mitkov et al., 2013). It is also possible that addition of mirtazapine possibly produced the pharmacodynamic or pharmacokinetic interaction detailed above. However, it is not possible to either confirm or deny this effect. Such side effects can carry significant morbidity and affect compliance, it is important for clinicians to recognize it so that proper management of the presenting patient can be achieved. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of interest The author reports no conflicts of interest.The author alone is responsible for the content and writing of the paper.
References Degner D, Grohmann R, Kropp S, et al. (2004) Severe adverse drug reactions of antidepressants: results of the German multicenter drug surveillance program AMSP. Pharmcopsychiatry 37: S39–S45. Lin CE and Chen CL (2010) Repeated angioedema following administration of venlafaxine and mirtazapine. General Hospital Psychiatry 32: e1–e2. Mitkov MV, Trowbridge RM, Lockshin BN, et al. (2013) Dermatologic side effects of psychotropic medications. Psychosomatics. Epub ahead pf print, 4 October 2013. pii: S0033-3182(13)00138-2. doi: 10.1016/j.psym.2013.07.003.
Australian & New Zealand Journal of Psychiatry, 48(5)
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on May 30, 2015
