Brain germinoma presenting as a first psychotic episode in an adolescent male

Sir, The association between brain lesions and psychiatric disorders has long been known. A wide variety of these syndromes have been reported since Dr. John Harlow’s description of his patient Phineas Gage more than 150 years ago [4]. These syndromes have included personality changes, psychosis, obsessive–compulsive symptoms, depression, anxiety disorders, mania, cognitive deterioration, and anorexia nervosa [1, 5, 6]. Most reports describe tumors of the frontal or temporal lobes, and very few discuss the psychiatric sequelae of tumors primarily affecting subcortical structures [7, 13]. Moreover, there have been few reports in the pediatric literature concerning this phenomenon [2, 3, 9]. We report on a well-adjusted 17-year-old adolescent with no prior psychiatric history who was brought by his parents to our psychiatric emergency room. He presented with a 3-month history of progressive social withdrawal, apathy, lack of drive, and deterioration of academic achievement. During the month prior to consultation, he also showed neglect in personal cleanliness and daytime somnolence. There was no significant medical or developmental history, and he was receiving no medication. No family history of mental illness was reported. At clinical admission, the patient was conscious, attentive, and well-oriented in terms of place and person, but with respect to time he could only identify the year. He had short-term memory loss, was perplexed, exhibited psychomotor inhibition, and maintained poor eye contact. His affect was flattened and incongruent in quality, with unprovoked smiles. He was apathic and presented loss of drive. He showed poverty of content of speech, and spoke in an unfluent, low, and unexpressive tone. Thought processes were retarded and overly concrete. He was not delusional, but described hearing noises and voices calling his name and sporadic visual sensations on the edge of his visual field which he described as ‘‘wing flutters’’. There were no suicidal thoughts or plans. He had daytime hypersomnolence. He demonstrated little insight into his condition, but accepted hospitalization with indifference. The Positive and Negative Syndrome Scale (PANSS) was administered, and the scores were 13 on PANSS positive, 36 on PANSS negative, 33 on PANSS general, and 82 on PANSS total. Physical and neurological examination revealed a limitation in supraversion of the eyes, with no other significant abnormalities. Serum chemistry and complete blood count was normal. A brain magnetic resonance image (MRI) revealed a heterogeneous cerebral mass, with necrotic and hemorrhagic areas, infiltrating the thalamus, mesencephalon, right mammillary tubercle, interventricular septum, and corpus callosum with mild perilesional edema extending to both internal capsules. Secondary ventricular dilatation was also observed. The patient was transferred to the neurosurgery unit where a cerebral biopsy and ventriculo-peritoneal derivation was performed. The biopsy revealed an intracranial J. Undurraga (&) M. Valenti Department of Psychiatry, Institute of Neuroscience, Hospital Clinic de Barcelona, Servicio de Psiquiatria (Escalera 9, Planta 6), Calle Villarroel, 170, 08036 Barcelona, Spain e-mail: jundurra@clinic.ub.es