Craniopharyngioma mimicking bipolar disorder with rapidly progressive functional decline.

Sir,

Craniopharyngioma is a rare, benign, and slow-growing brain tumor. It is typically located over the sellar and suprasellar region, constituting 1%–5% of primary brain tumors with low incidence rate of one per million person-years approximately.[1] Headache, increased intracranial pressure, and hydrocephalus are common problems related to mass effect. Some patients manifest visual field defect and endocrine disturbance due to the anatomical proximity to the optic chiasma and hypothalamic–pituitary axis, respectively.[2] To date, only a few cases of psychopathological symptoms related to craniopharyngioma have been reported. Herein, we present the case of a patient who experienced behavioral changes and mood swings. Our findings indicate that slow-growing brain tumors might mimic bipolar disorder.

A 51-year-old man was first time admitted 2 years ago with the presentation of poor attention, irritability, expansive mood, pressure of speech, grandiose delusion, and aggressive behaviors, diagnosed as having bipolar disorder, and placed on a regimen of quetiapine (500 mg/day) and valproic acid (1000 mg/day). Over the past year, he discontinued outpatient visits and developed decreased motivation with poor workplace performance, lack of interest, poor self-care, and recent memory impairment. The patient was admitted again approximately 2 years after his last admission because of incoherent speech, hyperactivity, and function deterioration.

On examination, impairment in recent memory, disorganized speech, and a derailed thought process were revealed without neurological significant findings. However, during the hospital course, neurological soft signs developed, such as disorientation to time and place and suspected hallucinatory behaviors. Furthermore, a wide-based gait and urinary/fecal incontinence was noted. Thus, a brain computed tomography was arranged because of suspected organicity, the results of which indicated a space-occupied lesion and hydrocephalus. Further, magnetic resonance imaging revealed a 4.1 cm × 3.9 cm × 4.4 cm cystic lesion over the sellar and suprasellar regions [Figure 1]. A neurosurgeon performed a right craniotomy for tumor removal and inserted an external ventricular drain. Pathological reports indicated adamantinomatous craniopharyngioma. Three months after the surgery, the patient's cognitive abilities and mood symptoms were considerably improved.

Figure 1

(a and b) Preoperative brain magnetic resonance imaging: The sagittal/coronal T1-weighted images

Our patient had a typical manic episode 2 years previously, which could not be differentiated from the tumor's effect. Figure 1 illustrates the tumor invasion area. Consequently, the patient's initial core symptoms were attention deficit, irritability, and memory impairment, which may be explained by dysfunction of the hippocampus.[3] The lack of motivation and behavioral change, which developed later, may be related to hypothalamus involvement.[4] These symptoms could be characterized as manic and depressive episodes, respectively. In addition, mood stabilizers also ameliorated his manic symptoms. Therefore, we did not consider further evaluation until clear signs of delirium and hydrocephalus. However, depression-like symptoms persisted with atypical presentation, such as onset age, poor response to medication and rapid functional decline without significant depressed mood. Had the patient continued his outpatient treatment, we might have been able to offer appropriate interventions earlier. Thus, clinicians should remember that slow-growing brain tumors, such as craniopharyngiomas, might mimic major psychiatric diseases. Laboratory tests, neurological assessment, and imaging should be performed as early as possible.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. The study has been reviewed and approved by Ethics Committee of the Taoyuan Psychiatric Center on (IRB No: R20200515 2), and it is conformed to the provisions of the Declaration of Helsinki.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.