Visual hallucinations as psychiatric onset of a primary central nervous system lymphoma: a case report and a brief revie
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LETTER TO THE EDITOR
Visual hallucinations as psychiatric onset of a primary central nervous system lymphoma: a case report and a brief review of literature on neoplasm-correlated neuropsychiatric disorders Massimo Napolitano 1
&
Angelo Ranieri 1 & Giorgia Teresa Maniscalco 1 & Ferdinando Riccardi 2 & Valentino Manzo 1
Received: 30 January 2020 / Accepted: 30 May 2020 # Fondazione Società Italiana di Neurologia 2020
Dear Sir, Primary central nervous system lymphomas (PCNSLs) are rare brain tumours, although their occurrence has increased in the last decades, especially among the elderly. Since PCNSLs are often localized in deep grey matter structures, neuropsychiatric disorders commonly represent early symptoms with respect to other malignant tumours. Here we describe a patient that had visual hallucinations (lasting about 2 months) and no other neurological complaints, leading to the diagnosis of a perithalamic and mesencephalic PCNSL (Fig. 1). This kind of isolated psychiatric presentation is very rare also for lymphomas. According to literature, the onset with pure psychiatric disturbances like psychosis and hallucinations has been encountered only in 18% of brain tumours [1]. Moreover, pure mood disorders or rapid cognitive decline has been observed in diffuse lymphomas. In elderly, such disturbances can lead to a delayed diagnosis as they can be wrongly attributed to neurodegenerative, vascular or metabolic disorders.
focal signs, confusion and behavioural changes may characterize a subacute clinical onset [4]. Occasionally, mood disorders and rapidly progressive dementia (RPD) have been described as initial clinical predominant signs in diffuse lymphoma, but isolated psychiatric symptoms are very rare [5, 6]. At magnetic resonance imaging (MRI), PCNSLs in immunocompetent patients usually present the aspect of a unique homogenously enhanced lesion (50–80% of cases) localized in deep periventricular white matter or in subcortical lobar regions [7–9]. In HIV-infected young people, they are more often multifocal at the onset, causing a more evident cognitive decline [10]. In rare cases, PCNSLs can present as nonenhancing white matter patches or diffuse hyperintense lesions. As such, in these cases, it can be hard to differentiate them from multifocal leukoencephalopaties of different origin [6, 11, 12].
Case report Introduction Primary central nervous system lymphoma (PCNSL) is an uncommon neoplasm, accounting for approximately 4–5% of all primitive brain tumours. According to epidemiological data, over the last 40 years, the overall occurrence has been increasing in immunocompetent patients, in particular for elderly over 60, also because of the improvement of diagnostics and reporting [2, 3]. Neuropsychiatric symptoms as headache, * Massimo Napolitano [email protected] 1
Department of Neurology, Neuro-Oncology Service, “A Cardarelli” Hospital, Naples, Italy
2
Department of Oncology, “A Cardarelli” Hospital, Naples, Italy
Here we present the case of an 83-year-old male in which visual hallucinations, a
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