No abstract

AimsFirst episode manic illness presenting over the age of 50, is an uncommon presentation, traditionally believed to have an organic basis. However to date there has been little systematic compilation of case reports.MethodsWe undertook a literature search on MEDLINE, PsychInfo and EMBASE to identify case reports of first of mania or hypomania presenting over the age of 50.Results35 cases were identified. 29/35 (82%) had a suspected underlying organic cause. Organic causes included: vascular disease (including CADASIL), iatrogenic drug use, dementia, thyroid disease and meningitis. Vascular risk factors were present in 17/35 cases (48%). Focal imaging abnormalities were identified in 17/30 (57%) cases including basal ganglia, frontal lobe and thalamic lesions. In 10/35 (28%) of cases organic treatment contributed to successful remission of the manic episode.ConclusionsThis review of case reports appears to add evidence of late onset mania having an organic basis. Whether this is a separate organic syndrome remains to be established. Our provisional findings suggest that such patient have a thorough medical screening in identifying an underlying cause.

CRION is a rare cause of optic neuritis. It is usually bilateral, painful and associated with profound visual loss. Significant response to corticosteroid treatment is typical but relapse is common when treatment is withdrawn. We present 2 cases of possible CRION and discuss the diagnostic and management considerations.Case 1: 50-year-old woman presented with right optic neuritis which spontaneous recovered. A year later she had left painful visual loss which improved with a short course of corticosteroids. MRI neuroaxis revealed left optic nerve enhancement. Non-specific, faint unmatched OCBs were detected. AQP4-IgG was negative. Nine months later she had further visual loss in her left eye. Prednisolone and azathioprine were commenced.Case 2: 55-year-old woman with bilateral, painless visual acuity deterioration over two weeks. Investigations revealed negative anti-aquaporin 4 antibodies (AQP4-IgG), normal MRI of the neuroaxis, negative oligoclonal bands (OCBs) and visual evoked potentials showed bilateral delay. Serum ACE was slightly elevated. She was started on a tapering course of steroids and had significant visual acuity improvement.The diagnosis of CRION involves the exclusion of other causes of optic neuritis, particularly multiple sclerosis (MS), Neuromyelitis Optica (NMO) and sarcoidosis. Correct diagnosis is important as aggressive and long-term immunosuppression is required.

A 29 year old male presented with headache and no neurological signs. MRI brain strongly suggested an aggressive primary brain tumour in the right frontal lobe but histopathology revealed a pleomorphic lymphoid infiltrate, necrosis and vague granulomata and vasculitis was diagnosed. There was aggressive clinico-radiological progression despite two debunking surgeries, corticosteroids and cyclophosphamide.On review the following were noted: areas of necrosis and focal diffuse lymphoid infiltrate showing perivascular cuffing; the presence of granuloma formation and vascular necrosis was less certain; overwhelming predominance of T-cells within the parenchyma; high T-cell mitotic activity and the mild nuclear atypia of the T-cells. PCR demonstrated no clonal immunoglobulin gene but showed a T-cell receptor gene rearrangements.The diagnosis was revised to primary T-cell CNS Lymphoma. Arabinoside & methotrexate were administered.Cerebral vasculitis may present with the imaging appearances of a malignancy. In the current case, a mass lesion was misdiagnosed as vasculitis due to atypical histopathology.