(113) A Case of Lesional Mania from Multiple Myeloma

Abstract:

Introduction:

Lesional mania, mania induced by focal damage to neuroanatomy, is well-documented and should be considered in patients presenting with first manic episodes after 40 years old (Satzer & Bond, 2016). Invasion of the central nervous system is exceedingly rare in multiple myeloma (MM), documented only in case reports (Schluterman et al., 2004).



Case:

A 64-year-old man with a history of MM and generalized anxiety disorder (GAD) presented with acute manic symptoms following new osseous frontal metastasis visualized on brain MRI.



Patient was initially diagnosed with MM in 04/2020 after finding lytic lesions in his left frontal bone. After radiation, treatment with lenalidomide, bortezomib, dexamethasone, and stem-cell transplant, he no longer had tumor activity, confirmed with PET.



Patient presented to psychiatry in 08/2021 for GAD and started on sertraline titrated to 150 mg, trazodone 50 mg, and lorazepam 0.5 mg prn, which eventually resolved his symptoms over six months. He had no prior personal or family psychiatric history, including manic or psychotic episodes.



However, in 03/2022, his sister contacted psychiatry, concerned due to one-week of acute behavioral changes, including inappropriate text messages, grandiose delusions, nonsensical rambling, decreased need for sleep, and increased goal-directed activity. He then experienced a seizure and was hospitalized, which confirmed new bilateral frontal bone osseous lesions on brain MRI.



Post-discharge, he was started on dexamethasone for cerebral edema caused by the osseous lesions, after which his manic symptoms resolved and he returned to baseline. He continued his psychiatric regimen and oncology took over further care of the metastasis.



Discussion:

Metastatic brain tumors are more likely to cause neuropsychiatric symptoms via mass effect over primary brain tumors (Madhusoodanan et al., 2015). Systematic review defines right-sided and frontal lobe lesions to be among the most common presentations of lesional mania (Madhusoodanan et al., 2015). Though there are reports of bortezomib and dexamethasone-induced mania, this patient did not exhibit symptoms while receiving this treatment (Geniş & Coşar, 2018).



Conclusion:

This patient’s acute mania was likely due to mass effect from bilateral frontal bone osseous lesions, as demonstrated by symptom resolution with dexamethasone. To date there is no literature of lesional mania with MM as the primary cancer.



References:

1. Geniş B, Coşar B. Bortezomib ve Deksametazon Kullanımına Bağlı Gelişen Mani Olgusu [Mania Associated with the Use of Bortezomib and Dexamethasone]. Turk Psikiyatri Derg. 2018;29(3):209-215.


2. Madhusoodanan S, Ting MB, Farah T, Ugur U. Psychiatric aspects of brain tumors: A review. World J Psychiatry. 2015;5(3):273-285. doi:10.5498/wjp.v5.i3.273


3. Satzer D, Bond DJ. Mania secondary to focal brain lesions: implications for understanding the functional neuroanatomy of bipolar disorder. Bipolar Disord. 2016;18(3):205-220. doi:10.1111/bdi.12387


4. Schluterman KO, Fassas AB, Van Hemert RL, Harik SI. Multiple Myeloma Invasion of the Central Nervous System. Arch Neurol. 2004;61(9):1423–1429. doi:10.1001/archneur.61.9.1423