Case of the Month

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Lloyd A. Taylor, PhD; Reamer L. Bushardt, PharmD, PA-C; Tanya M. Jones, MD

Lloyd Taylor is a faculty member and clinical psychologist at The Citadel and adjunct faculty member with the Medical University of South Carolina (MUSC) PA program in Charleston. Reamer Bushardt is a faculty member and director of the MUSC PA program and a member of the JAAPA editorial advisory board. Tanya Jones is a neurosurgical resident at MUSC. The authors have indicated no relationships to disclose relating to the content of this article.

CASE

A 17-year-old white female who had previously undergone resection for a brain tumor presented to her primary care PA for evaluation of school performance issues. She complained of difficulties with attention and concentration, low frustration tolerance, and symptoms of depression including anhedonia, tearfulness, and sleep problems. A clinical psychologist was asked to assist with the evaluation.

History At age 15 years, the patient had experienced 1 week of progressively worsening headache with associated nausea and vomiting. Initial imaging revealed a left lateral ventricular lesion that was surgically removed and found to be a pilocytic astrocytoma (see Figure 1). Postoperative imaging revealed a small amount of residual tumor in the area of the foramen of Monroe. Secondary to the benign nature of these lesions, no further treatment was recommended, and yearly imaging showed no signs of progression.

Physical examination and diagnostic studies At the current evaluation, physical examination findings, laboratory results, and brain imaging studies were within normal limits. A neurocognitive evaluation was performed by a clinical psychologist in order to document the presence of attention and concentration difficulties, and to rule out competing diagnoses that could account for the symptoms. Before tumor resection, this patient reported no problems with attention and concentration. She reported increased school problems since resection and had failed English three times. The patient reported a stable home environment, quality social interactions, and limited psychosocial difficulties. She denied ongoing or past substance use and/or abuse.

To evaluate attention, concentration, and learning, a battery of standardized neurocognitive tests was administered, including assessments of intellectual abilities, academic achievement, and behavior. Results indicated that this patient’s lifelong intellectual abilities fell in the low average range. Estimates of her academic achievement were generally commensurate with IQ estimates and were not suggestive of learning disability. Assessment of memory problems suggested that she was functioning in the average range. Behavior ratings across settings suggested problems with attention, concentration, and hyperactivity. Assessment for mood disorders was unremarkable. Results of this evaluation suggested problems with planning, attention, and concentration.

WHAT IS YOUR DIAGNOSIS?

Attention-deficit/hyperactivity disorder (ADHD)
Major depression, single episode
Adjustment disorder with depressed mood
Late effect of intracranial injury without mention of skull fracture

DISCUSSION

The results of the evaluation suggest ongoing clinically significant problems with attention and concentration that are not accounted for by premorbid conditions, mood disorders, or common medical disorders. While a diagnosis of ADHD is warranted, the origin of this condition is questionable. In fact, it is difficult to causally attribute the patient’s condition to one factor, and it may be best conceptualized as resulting from the patient’s general experience with diagnosis and treatment of this CNS tumor.

Treatment The patient was given a trial with the stimulant methylphenidate, which has been reported to offer modest improvements in attention and concentration in a variety of medical populations. The psychologist recommended that her symptoms of depression and anxiety be closely monitored and that cognitive behavior therapy be provided should they increase. A meeting between this patient and school administrators was suggested in order to discuss realistic expectations regarding academic performance and to implement accommodations under a formal planning process as indicated.

Comment Brain tumors remain the leading cause of cancer deaths in pediatric oncology patients. Advances in treatment, which is frequently rigorous, have significantly improved 5-year survival rates. Despite this improvement, however, numerous pediatric brain tumor survivors have suffered various disease- and/or treatment-associated neuropsychological problems. Many of these problems are often not apparent in the immediate posttreatment period.

PAs who treat survivors of pediatric brain tumors should ask about school performance problems. If problems exist, the differential diagnosis should include tumor or treatment-related cognitive late effects. Collaboration with a licensed clinical psychologist for evaluation and treatment is appropriate. JAAPA

Erich Fogg, PA-C, MMSc, department editor