• Users Online: 70
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Contacts Login 

 Table of Contents  
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


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 Submission27-Feb-2019
Date of Decision29-May-2019
Date of Acceptance27-Jun-2019
Date of Web Publication06-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
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmedsci.jmedsci_27_19

Rights and Permissions
  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 1];41:38-40. Available from: https://www.jmedscindmc.com/text.asp?2021/41/1/38/297431




  Introduction Top


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 Top


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

Click here to view



  Discussion Top


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.



 
  References Top

1.
Madhusoodanan S, Patel S, Reinharth J, Hines A, Serper M. Meningioma and psychiatric symptoms: A case report and brief review. Ann Clin Psychiatry 2015;27:126-33.  Back to cited text no. 1
    
2.
Cabello-Rangel H, Díaz-Castro L. Frontal lobe syndrome with psychotic symptoms secondary to a giant meningioma in a 38 year old man. Actas Esp Psiquiatr 2016;44:244-52.  Back to cited text no. 2
    
3.
Derogatis LR, Morrow GR, Fetting J, Penman D, Piasetsky S, Schmale AM, et al. The prevalence of psychiatric disorders among cancer patients. JAMA 1983;249:751-7.  Back to cited text no. 3
    
4.
Onishi H, Onose M, Yamada T, Mizuno Y, Ito M, Sugiura K, et al. Brief psychotic disorder associated with bereavement in a patient with terminal-stage uterine cervical cancer: A case report and review of the literature. Support Care Cancer 2003;11:491-3.  Back to cited text no. 4
    
5.
Mitchell AJ, Chan M, Bhatti H, Halton M, Grassi L, Johansen C, et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: A meta-analysis of 94 interview-based studies. Lancet Oncol 2011;12:160-74.  Back to cited text no. 5
    
6.
Keshavan MS, Kaneko Y. Secondary psychoses: An update. World Psychiatry 2013;12:4-15.  Back to cited text no. 6
    
7.
Barrett TF, Gill CM, Miles BA, Iloreta AM, Bakst RL, Fowkes M, et al. Brain metastasis from squamous cell carcinoma of the head and neck: A review of the literature in the genomic era. Neurosurg Focus 2018;44:E11.  Back to cited text no. 7
    
8.
Lampl Y, Barak Y, Achiron A, Sarova-Pinchas I. Intracranial meningiomas: Correlation of peritumoral edema and psychiatric disturbances. Psychiatry Res 1995;58:177-80.  Back to cited text no. 8
    
9.
Bommakanti K, Gaddamanugu P, Alladi S, Purohit AK, Chadalawadi SK, Mekala S, et al. Pre-operative and post-operative psychiatric manifestations in patients with supratentorial meningiomas. Clin Neurol Neurosurg 2016;147:24-9.  Back to cited text no. 9
    
10.
Hussin S, Yusoff SS, Zin FM, Ghani AR. Frontal meningioma with psychiatric symptoms. J Family Med Prim Care 2018;7:252-4.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Kessler RA, Loewenstern J, Kohli K, Shrivastava RK. Is psychiatric depression a presenting neurologic sign of meningioma? A critical review of the literature with causative etiology. World Neurosurg 2018;112:64-72.  Back to cited text no. 11
    
12.
Sim SK, Khairul Aizad A, Lim SS, Wong A. Large falcine meningioma presented as treatment-resistant depression: A case report. Med J Malaysia 2019;74:87-9.  Back to cited text no. 12
    
13.
Zivković N, Marković M, Spaić M. Convexity meningioma associated with depression: A case report. Srp Arh Celok Lek 2014;142:586-8.  Back to cited text no. 13
    
14.
Wen XJ, Wang LM, Liu ZL, Huang A, Liu YY, Hu JY. Meta-analysis on the efficacy and tolerability of the augmentation of antidepressants with atypical antipsychotics in patients with major depressive disorder. Braz J Med Biol Res 2014;47:605-16.  Back to cited text no. 14
    
15.
Newton R, Hustig H, Lakshmana R, Lee J, Motamarri B, Norrie P, et al. Practical guidelines on the use of paliperidone palmitate in schizophrenia. Curr Med Res Opin 2012;28:559-67.  Back to cited text no. 15
    
16.
Rauch AS, Fleischhacker WW. Long-acting injectable formulations of new-generation antipsychotics: A review from a clinical perspective. CNS Drugs 2013;27:637-52.  Back to cited text no. 16
    
17.
Douglass AR, Smyth U. A case report of guardian-consent forced paliperidone palmitate for behavioral disturbance due to traumatic brain injury. Ment Health Clin 2018;8:155-8.  Back to cited text no. 17
    
18.
van Oosterom N, Theodoros T. Paliperidone long-acting injections in huntington's disease for motor and behavioural disturbances. Clin Drug Investig 2019;39:407-10.  Back to cited text no. 18
    
19.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Washington, DC: American Psychiatric Publishing; 2013.  Back to cited text no. 19
    
20.
Krebs G, Fernández de la Cruz L, Mataix-Cols D. Recent advances in understanding and managing body dysmorphic disorder. Evid Based Ment Health 2017;20:71-5.  Back to cited text no. 20
    
21.
Siegfried E, Ayrolles A, Rahioui H. Body dysmorphic disorder: Future prospects of medical care. Encephale 2018;44:288-90.  Back to cited text no. 21
    


    Figures

  [Figure 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed388    
    Printed19    
    Emailed0    
    PDF Downloaded45    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]