Musical Hallucination in a Patient With Frontal Lobe Meningioma

Introduction: Many conditions can mimic psychiatric symptoms. Amongst them, intracranial mass and space occupying lesions have a significant importance. Aggression and hallucination are seen in association with a basal frontal lesion, and may mimic psychotic syndromes. Case Presentation: A 37-year-old man with no previous mental illness presented with a month history of headache, blurred vision, diplopia, aggression, loss of interest, fatigue, insomnia, and depressed mood. He was suffering from daily auditory hallucination which described as musical hallucination lasting about an hour per day. The headache was tension-type which appeared swinging, two times per week lasting 30 minutes. After auditory hallucination, the patient disclosed nausea, vomiting, and transient loss of consciousness. He referred from a neurologist, because, conventional therapy for the patient had not response. There were no other neurological symptoms or deficits. The results of neurologic examination including evaluation of the cranial nerves as well as head and neck examination were normal; But, psychiatric symptoms developed. Therefore, he was admitted to the psychiatric ward. The patient was diagnosed with major depressive disorder (MDD) with psychotic feature by Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria and received psychiatric treatment. He started on antipsychotic agent (olanzapine 5 mg tablet/bid), antidepressant (sertraline 50 mg tablet/qhs) and valproate sodium 200 mg tablet/bid for treatment of aggression and headaches. After five days of admission, primary symptoms of headache and auditory hallucination were better but diplopia and blurred vision were still present. Ophthalmology examination revealed. The pupils were round, isochoric, and normoreactive to light and accommodation, and there was no sign of a relative afferent pupillary defect. Ophthalmoscopy showed a papilledema in both eyes. In order to rule out the intracranial pressure and their causes, neuroimaging was requested. An emergent noncontrast-enhanced computed tomography (CT) image of the head revealed a hyperdense mass in midfrontal convexity. Magnetic resonance imaging of the brain and orbits with and without intravenous gadolinium enhancement further delineated the CT findings and highlighted a large avidly enhancing midline mass within the frontal region measuring approximately 48×50×42 mm in axial dimension, consistent with a meningioma. The patient discharged from psychiatric ward with necessary advices and was admitted to the neurosurgery ward for further evaluation. A first psychosis episode is a clinical condition with principal indication for cerebral CT-scan. Discussion: Meningioma is a common intracranial tumor with a variety of histomorphologic growth patterns, which are usually easily recognized. The three most common symptoms are headaches, mental status changes, and paresis. Aggression and hallucination are seen in association with a basal frontal lesion and may mimic psychotic syndromes like hypomania and schizophrenia. A first psychosis episode is a clinical condition with principal indication for cerebral CT-scan.