Our patient was a 24-year-old, single male, working as an accountant in a bank. He presented initially to a physician with complaints of nonspecific diffuse headaches, which had started one year before. In view of working on computers, an ophthalmologist's evaluation was advised, which was reported as normal. An otorhinolaryngologist's opinion ruled out the possibility of other causes for headache. A neurologist consultation ruled out any intracranial causes for his headache. He was prescribed pain relief medications that provided transient relief, for few minutes only. Subsequently, he was referred to us for psychiatric assessment of the headache. A thorough clinical history revealed the concurrent presence of pervasive sadness, easy fatigability, lack of interest in his daily activities, decreasing appetite associated with poor quality of sleep, poor attention and concentration, pessimism about the future, along with the presenting symptom of headache. There were no life stressors, suicidal ideas, or psychotic symptoms. His birth and developmental history was normal and there was no past history of alcohol or other substance-use disorders, epilepsy, head injury, or any dental problems. He was not a known hypertensive and not on any medications for other medical illnesses, which could adversely produce headache-like symptoms. Hence, a diagnosis of severe depression without psychotic symptoms was made, according to ICD-10. As the headache was the presenting symptom, a magnetic resonance imaging (MRI) brain scan was carried out, to rule out the possibility of any intracranial space-occupying lesion. Surprisingly, the MRI of the brain showed a lobulated hyperintense temporal lobe mass of size 2.7 × 2.2 mm, in the hippocampus region, which the radiologist reported as suggestive of DNET [Figures and ].
The MRI of the brain showing a cortical-based mass lesion at the medial aspect of the right temporal lobe, involving the Amygdala and part of the head of the hippocampus
The MRI of the brain showing a hypointense mass lesion on T1, hyperintense on T2, giving a ‘bubbly’ appearance, and a mixed signal, with a bright rim in the Fluid attenuated inversion recovery images
A repeat neurologist opinion was sought to rule out the possibility of temporal lobe epilepsy as the etiology of the headache. Electroencephalography was obtained and it showed a normal EEG pattern. A neurosurgery consultation recommended no surgical intervention due to the absence of epilepsy and any intracranial compression effects of the brain or ventricles. Further investigations like blood sugar, electrolytes, hemogram, liver function tests, and thyroid profile, were all within normal limits. In this background, we started him on Tablet Escitalopram 10 mg once daily. After four weeks of this treatment, the Hamilton Depression Rating score dropped from 29 at baseline to 12 after treatment, with no adverse effects of medications reported. Subjectively, the patient reported complete relief of headache and improved mood levels. His attention and concentration was better at work. He has been maintained on the same dose of Escitalopram for the past four months, and the initial improvement has not worsened. There is no evidence of epilepsy or evidence of raised intracranial tension now. A repeat MRI brain revealed absolutely no change in the DNET tumor diagnosed initially.