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| CASE REPORT |
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| Year : 2019 | Volume
: 6
| Issue : 2 | Page : 104-105 |
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Hyposmia in geriatric depression can be a meningioma
Muruganandam Partheeban1, Sundararajan Mathivanan2
1 Department of Psychiatry, Aarupadai Veedu Medical College and Hospital, Puducherry, India
2 Department of Surgery, Aarupadai Veedu Medical College and Hospital, Puducherry, India
| Date of Submission | 17-Jun-2019 |
| Date of Decision | 14-Sep-2019 |
| Date of Acceptance | 13-Oct-2019 |
| Date of Web Publication | 20-Feb-2020 |
Correspondence Address:
Dr. Muruganandam Partheeban
Department of Psychiatry, Aarupadai Veedu Medical College and Hospital, Puducherry
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jgmh.jgmh_25_19
Depression in the elderly population can be a manifestation of underlying neurological and systemic disorder. It can be harbinger in many neurological illnesses such as Parkinson's disease and Alzheimer's dementia. It can present as early as 10 years before the onset of clinical neurological signs in dementia. Brain tumors can present with varying psychiatric symptoms such as depression, anxiety, cognitive or personality changes, or schizophrenia. Olfactory groove meningioma is uncommon benign brain tumor which accounts for <10% of all intracranial meningiomas. Olfactory meningioma, which occurs in the anterior cranial fossa, can compress the frontal lobe, thereby rarely present only as depressive symptoms in the absence of neurological symptoms. The present case report illustrates depression with hyposmia in elderly women, which unmasked the giant olfactory groove meningioma and significant improvement in depressive symptoms following surgical resection.
Keywords: Geriatric depression, hyposmia, meningioma
How to cite this article:
Partheeban M, Mathivanan S. Hyposmia in geriatric depression can be a meningioma. J Geriatr Ment Health 2019;6:104-5 |
| Introduction | |  |
Depression in the elderly population can be harbinger in many neurological illnesses such as Parkinson's disease and Alzheimer's dementia.[1] It can present as early as 10 years before the onset of clinical neurological signs in dementia.[2] Brain tumors can present with varying psychiatric symptoms such as depression, anxiety, cognitive or personality changes, or schizophrenia.[3] Olfactory groove meningioma an uncommon benign brain tumor which accounts for <10% of all intracranial meningiomas. Olfactory meningioma, which occurs in the anterior cranial fossa, can compress the frontal lobe and can rarely be present only as depressive symptoms in the absence of neurological symptoms.[4] The present case report illustrates depression with hyposmia in elderly women which unmasked the giant olfactory groove meningioma and its reversibility following surgical resection.
| Case Report | | |
A 57-year-old woman presented with 6 months history of pervasive low mood, decreased interest in daily activities, frequent crying spells, decreased energy level, anhedonia, loss of confidence, decreased appetite, diminished ability to concentrate, and ideas of worthlessness. Patient reported that she had daytime sleepiness for about 1 h in the past 6 months, which was unusual from her routine sleep pattern. No subjective history of cognitive impairment was reported. The patient was functioning well without disturbance in her daily routine in spite of the above complaints. Premorbidly, she was well adjusted. She had a history of type 2 diabetes mellitus and hypertension for the past 10 years, which is under control with medications. There is no past or family history of mental illness.
Although the patient did not report any complaints related to olfactory disturbance, while on systemic examination, the patient had hyposmia without any other neurological signs. On further evaluation, her geriatric depression rating scale (GDRS) – 12/15, Hindi mental state examination (HMSE) score was 27/31, AddenBrooke's cognitive examination (ACE) – ACE-R-score was 78/100 (impairment in attention, delayed recall, verbal fluency, and language noted). As the patient had hyposmia with subtle cognitive deficits, organic basis for her late-onset depression was suspected. The Ear, nose, and throat opinion ruled out local pathology for hyposmia. Blood investigation showed microcytic hypochromic anemia. Other investigations for reversible causes for cognitive deficits such as thyroid profile, serum Vitamin B12, and folate level were within the normal limits, serology for HIV and venereal disease research laboratory were negative. Computed tomography and magnetic resonance imaging brain without contrast were suggestive of large tumor measuring 6 cm (anteroposterior) × 4 cm (craniocaudal) × 5.8 cm (mediolateral) with severe compression of the bilateral frontal lobe with peritumor edema without extension in the optic nerve and fronto limbic cortex [Figure 1]. | Figure 1: Magnetic resonance imaging with gadolinium showing large meningioma with severe compression of the bilateral frontal lobe
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The patient was not initiated on any psychotropic drugs. She underwent bifrontal craniotomy and excision of tumor. Tumor was found to be arising from the olfactory groove and planum sphenoidale intraoperatively. Histological examination was suggestive of meningothelial meningioma, WHO Grade-1 olfactory groove. Postoperative period was uneventful. The patient was assessed 5 months following surgery. There was a significant improvement in her depressive symptoms (GDRS – 2/15) and cognitive deficits (HMSE – 29/30: ACE-R-score – 84/100) with minimal improvement in hyposmia.
| Discussion | | |
Meningioma being a common primary benign brain tumor is often asymptomatic.[5] Previous studies reported 21% prevalence of psychiatric symptoms, particularly of depressive and anxiety symptoms in patients with meningioma.[6] Brain tumor in the frontal region often presents with personality changes and depressive symptoms, possibly due to disruption of frontolimbic cortex.[7] Suspicion of organic brain injury should be considered in a patient with late-onset depressive symptoms, with prominent cognitive deficits, atypical depressive features, poor response to antidepressants, personality changes apathy, and anorexia without body dysmorphic symptoms.[8]
In our case, subtle neurological deficits like impaired olfaction in the presence of depressive symptoms were the key features leading us to suspect organic etiology for her depression, which was completely reversible after surgical resection of tumor. Often depression secondary to frontal tumor remits following surgical resection of the tumor during the postoperative period[9] Nevertheless, the possibility of naturalistic remission of depression cannot be ruled out in our case during follow-up. Olfactory meningioma commonly presents with severe headache combined with personality changes, visual impairment, and anosmia.[10] In our case, hypersomnia and hyposmia were not clinically significant to cause functional impairment. Although olfactory disturbances are noted in early Parkinson's disease, our patient presented only with depressive symptoms in the absence of neurological deficits, particularly in regard to extrapyramidal signs. The structured assessment revealed the presence of hyposmia and subtle cognitive deficits.
This case illustrates the importance of clinical examination when a patient presents with psychiatric symptoms at the late age of onset, atypical clinical presentation, with subtle cognitive deficits. Neuroimaging should be considered in all such cases. The presence of atypical depressive symptoms unmasked the brain tumor early in this patient, which helped the patient to undergo complete resection of brain tumor, thereby improved the quality of life of the individual without significant neurological deficits.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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