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Anorexia and vomiting in a depressed patient are not always due to depression.
A man aged 65, depressed after the death of his wife four months earlier, had experienced vomiting and anorexia for two months. His medical history included middle-ear surgery for Menière's disease. On investigation elsewhere a month before, upper gastrointestinal endoscopy had revealed only gastritis. Anti-Helicobacter treatment had been given; but, when the vomiting continued, his symptoms were ascribed to bereavement and depression.
On admission direct questioning revealed that he was experiencing occasional headaches and diplopia. The ocular fundi were normal. He had nystagmus which was exaggerated on right horizontal gaze. Ocular movements seemed intact in all directions and no cranial nerve abnormalities were detected. His gait was not ataxic but past-pointing was evident on the right side. In view of the history and examination findings, a posterior fossa space-occupying lesion was suspected. A CT scan revealed a 5-6 cm area of predominantly low attenuation in the right cerebellar hemisphere with a 2-3 cm mass in the lateral aspect of this area (Figure 1). There was compression of the fourth ventricle, with hydrocephalus. The patient was transferred to the regional neurosurgical unit. Findings on cerebral angiography suggested a glomus jugulare tumour. Vertebral artery embolization of the tumour was followed by retromastoid craniectomy and excision of a tumour that proved to be a benign choroid plexus papilloma. The patient recovered without neurological deficit, his vomiting resolved and he remains well.
Choroid plexus papillomas account for less than 1% of all intracranial tumours in adults, though relatively more common in childhood. They are most often located in the lateral ventricle, followed by the fourth and third ventricles and, rarely (as in our case), the cerebellopontine angle1. They are generally benign in nature with a male preponderance2. Derived from the neuroepithelial cells of the choroid plexus these tumours recapitulate the normal choroid plexus, often demonstrating a well preserved papillary architecture3. Magnetic resonance imaging is the diagnostic tool of choice2, and total surgical excision is the optimum treatment. Radiotherapy can be used if the resection is incomplete4.
We think this case is of interest for three reasons. First, it describes a rare tumour in an atypical place at an unusual time of life. Secondly, it illustrates the important principle that the cause of vomiting may lie beyond the gastrointestinal tract. This presentation of posterior fossa mass lesions has been reported previously5, and caution is needed before such physical symptoms are ascribed to psychological disturbance.
The final point concerns the previous diagnosis of Menière's disease. Although we have not been able to obtain information on the neurological findings at that time or the details of the middle-ear surgery, we suspect that these earlier symptoms were due to the lesion in the posterior fossa.
We thank PT van Hille and his team at the regional neurosurgical centre in Leeds for their expert help with this patient.