First-episode psychosis revealing a low-grade astrocytoma in an adolescent with refractory focal epilepsy: A case report

Abstract

Background: Brain tumours may present first with psychiatric symptoms; in a review of 165 published cases, 10.3% had psychiatric symptoms alone. Recognition is harder in adolescents, in whom first-episode psychosis is usually attributed to primary psychiatric illness. Neuroimaging is recommended when red flags such as seizures or functional decline are present. Case description and management: A 17-year-old girl presented with six days of persecutory delusions, disorganised speech and insomnia, preceded by two to three months of irritability, fatigue and academic decline. She had focal epilepsy since the age of 10, with two to three brief seizures monthly in the preceding year despite good adherence; the last was four days before psychosis onset. No neuroimaging had ever been performed, reflecting limited access in peripheral settings. Examination, blood tests, electrocardiogram and cerebrospinal fluid parameters, including an autoimmune encephalitis panel, were normal. Contrast magnetic resonance imaging showed a 5.0 x 3.7 x 3.5 cm left temporo-parietal and capsuloganglionic lesion. Risperidone 2 mg/day, increased to 4 mg/day, was given with sodium valproate 1000 mg/day and clobazam 10 mg/day. Maximal safe resection with intraoperative language mapping followed two weeks later; integrated histopathological and molecular assessment confirmed isocitrate dehydrogenase mutant astrocytoma, WHO Classification of CNS Tumours, 5th edition grade 2, Ki-67 approximately 2%. Seizures ceased immediately after surgery and psychosis remitted gradually; she remained well at two months. Conclusion: Adolescent first-episode psychosis  with refractory epilepsy and functional decline warrants urgent neuroimaging, as it may reveal an occult astrocytoma. Recovery followed the combination of resection, antiseizure optimisation and antipsychotic treatment.