Combination of risperidone and fluoxetine in the treatment of schizophrenia-like disorder in a patient with frontal lobe meningioma and oral cancer

Cian-Cian Lin; Tzu-Yun Wang; Chuan-Chia Chang; Nian-Sheng Tzeng

doi:10.4103/jmedsci.jmedsci_27_19

CASE REPORT

Year : 2021 | Volume : 41 | Issue : 1 | Page : 38-40

Combination of risperidone and fluoxetine in the treatment of schizophrenia-like disorder in a patient with frontal lobe meningioma and oral cancer

Cian-Cian Lin¹, Tzu-Yun Wang², Chuan-Chia Chang¹, Nian-Sheng Tzeng³
¹ Department of Psychiatry, National Defense Medical Center, School of Medicine, Tri-Service General Hospital, Taipei, Taiwan
² Department of Psychiatry, National Defense Medical Center, School of Medicine, Tri-Service General Hospital; Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
³ Department of Psychiatry, National Defense Medical Center, School of Medicine, Tri-Service General Hospital; Student Counseling Center, National Defense Medical Center, Taipei, Taiwan

Date of Submission	27-Feb-2019
Date of Decision	29-May-2019
Date of Acceptance	27-Jun-2019
Date of Web Publication	06-Oct-2020

Correspondence Address:
Dr. Nian-Sheng Tzeng
Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, 325, Chung-Gung Rd, Sec 2, Nei-Hu District 114, Taipei, Taiwan. Student Counseling Center, National Defense Medical Center, Taipei
Taiwan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmedsci.jmedsci_27_19

Abstract

We report a case of a patient with schizophrenia-like disorder related to the right-side frontal lobe meningioma and oral cancer. This 55-year-old female began to show symptoms of talking to herself, insomnia, psychomotor agitation, persecutory delusions, violent behavior, and auditory and visual hallucinations, after the surgery for her oral cancer. The brain imaging studies revealed one right frontal lobe meningioma. The combination of risperidone and fluoxetine has successfully resolved the schizophrenia-like psychotic disorder related to both frontal lobe meningioma and mood disorder related to the body disfigurement due to the oral cancer surgery. This report aims to serve as a reminder for clinicians who are responsible for the treatment of the psychotic disorders in patients with concurrent brain and extracerebral tumors.

Keywords: Fluoxetine, meningioma, risperidone, schizophrenia-like psychotic disorder

How to cite this article:
Lin CC, Wang TY, Chang CC, Tzeng NS. Combination of risperidone and fluoxetine in the treatment of schizophrenia-like disorder in a patient with frontal lobe meningioma and oral cancer. J Med Sci 2021;41:38-40

How to cite this URL:
Lin CC, Wang TY, Chang CC, Tzeng NS. Combination of risperidone and fluoxetine in the treatment of schizophrenia-like disorder in a patient with frontal lobe meningioma and oral cancer. J Med Sci [serial online] 2021 [cited 2021 Mar 2];41:38-40. Available from: https://www.jmedscindmc.com/text.asp?2021/41/1/38/297431

Introduction

The frontal lobe meningioma was associated with the psychotic and depressive symptoms.^[1],[2] Primary cancer could also contribute to the psychiatric manifestations.^[3],[4],[5] However, there were no reports about the psychiatric disorders in patients with both a meningioma and an extracerebral tumor. Here, we report on the combined risperidone and fluoxetine in the treatment of the schizophrenia-like disorder in a patient with both a meningioma and an extracerebral tumor.

Case Report

Ms. D, a housewife, was diagnosed with squamous cell carcinoma of the left buccal mucosa, which was treated with a wide excision and oral reconstruction by the left pectoris major myocutaneous flap coverage in February 2008, at the age of 55. She began to show symptoms of talking to herself, insomnia, psychomotor agitation, persecutory delusions, violent behavior, and auditory and visual hallucinations, after the surgery. She was admitted to the psychiatric ward with the impression of psychotic disorder due to the general medical conditions. She also reported distress and a dysphoric mood toward the disruption of her future social life caused by her facial disfigurement. The symptom severity was 6 by the Clinical Global Impression-Severity (CGI-S). Laboratory work-up was essentially normal. The brain computed tomography revealed a meningioma about 2.6 cm over the right frontal lobe region [Figure 1]. A neurosurgeon recommended conservative management. The patient received risperidone 2 mg/day, lorazepam 0.5 mg/day, and alprazolam 0.5 mg/day for psychotic symptoms. During the entire hospital course, she was alert and oriented. The psychotic symptoms became resolved after 2 days of antipsychotic treatment. The initial diagnostic impression at discharge was brief psychotic disorder with marked psychosocial stressors. We tapered risperidone to 0.5 mg/day 1 week later. Fluoxetine 20 mg/day was added for her depressive mood. Her depressive symptoms acquired partial response within 2 weeks, which was much more efficient than the average effect time general antidepressants take. Another schizophrenia-like episode recurred, while the usage of antipsychotics and antidepressants was stopped, about 2 years later after the first episode. In the last 3 years, paliperidone long-acting depot of 150 mg a month replaced the risperidone for the control of her psychotic symptoms at her own request, since she requested longer intervals of psychiatric visits, with the CGI-S 4.

Figure 1: The meningioma over the right frontal lobe region

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Discussion

There were two contributory factors in the psychotic disorder in this patient: frontal lobe meningioma, which was associated with psychotic and depressive symptoms,^[1],[2] and oral cancer. Psychiatric morbidity among cancer patients ranges from 30% to 47%, although acute psychotic symptoms are relatively rare in cancer patients without a previous history of any psychotic disorders.^[3],[4] One previous study pointed out that the psychotic symptoms might well be related to the primary tumor, brain metastases, leukoencephalopathy, electrolyte imbalance,^[6] and marked psychological stressors.^[6]

One previous study found that the prevalence of brain metastasis of the oral squamous cell carcinoma was lower than 1%.^[7] In this case, the patient's meningioma was found by preoperative brain imaging, and her psychotic symptoms were displayed after the surgery. Therefore, the concurrent brain tumor was a coincidental finding. Nonetheless, we aimed to highlight the combined influence of both the underlying brain tumor and the psychosocial stress from the surgery resulting in disfigurement to precipitate the psychosis.

Previous reports have denoted that different psychiatric symptoms are correlated with the locations of the meningiomas, such as depression in the frontal convexity meningioma, mania and depression in the basal frontal and sphenoid wing meningiomas, and delusional disorders in the suprasellar and temporal convexity meningiomas.^[8],[9],[10] In addition, depression increased in the meningioma on the anterior location of the brain.^[11] In this case, her depressive and psychotic symptoms were compatible with the location of the meningioma at the right frontal lobe region.

Several previous studies have found that the resections of the meningiomas resections were related to the reduced depression and other psychiatric symptoms.^{[11],[12],[13]} However, in the present case, the consultation opinions from a neurosurgeon were conservative treatment.

Risperidone is an antipsychotic used for psychotic disorders and the adjuvant treatment for depression.^[14] Paliperidone long-acting injection is indicated for patients with schizophrenia,^[15],[16] even though several case reports have stated the effects in patients of psychotic disorder due to traumatic brain injury^[17] and Huntington's disease.^[18] The patient exhibited intermittent auditory hallucinations after a fair response after the treatment for the oral cancer years later without obvious mood symptoms, and thus, psychotic disorder due to meningioma^[19] was highly suspected after our long-term outpatient department observation. In addition, schizophrenia was also considered; the shifting from the oral risperidone to the long-acting injection, paliperidone, or 9-hydroxyrisperidone, a derivate of risperidone, seems to be a reasonable choice for her doubtful drug compliance. Fluoxetine, a selective serotonin reuptake inhibitor, is the first-line pharmacological treatment for depression and body dysmorphic symptoms.^{[14],[20],[21]} To the best of our knowledge, this is the first case that combined risperidone and fluoxetine in the treatment of schizophrenia-like psychotic disorder related to both the frontal lobe meningioma and the mood disorder related to the body disfigurement due to the oral cancer surgery. This therapeutic experience could be a reminder for clinicians who are responsible for the treatment of the psychotic disorders in patients with concurrent brain and extracerebral tumors.

Ethical approval

The institutional review board of the Tri-Service General Hospital, Taipei, Taiwan as TSGH-IRB No.: C202005108.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that her names and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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