'Beyond the blues': A case report on depression as initial presentation of lung cancer with brain metastasis

Lung cancer usually presents with pulmonary symptoms such as cough, dyspnoea, and extrapulmonary symptoms with metastatic involvement of the brain may present as delirium or neurological deficits. However, in rare cases, psychiatric symptoms such as depression may be the only initial manifestation of lung cancer with brain metastasis, which may mislead the clinical picture. We describe a case of a middle-aged female with no past or family history of medical and psychiatric illness who was brought with low mood, decreased social interaction, fatigue, and decreased appetite in the past 2 weeks. She also had poor concentration and memory disturbances with difficulty in performing household chores. Interpersonal relationship issues in the family were attributed as precipitating factors. She was diagnosed with major depressive disorder and initiated on antidepressants but with no improvement. Later course of the illness, she developed a bilateral diffuse headache associated with vomiting. On mental status examination, she had decreased psychomotor activity. Her speech was minimal with decreased response rate and little variability in the tone. She was not able to describe her mood and her affect was restricted. No abnormal beliefs or psychotic symptoms were elicited. On general physical examination, mild deviation of the angle of mouth was noted. Because of the suspicion of organic etiology, a magnetic resonance imaging brain scan with contrast was suggested and an intracranial space-occupying lesion involving the left frontal lobe with significant perilesional edema causing mass effect was noted. Further, a positron emission tomography scan revealed hypermetabolic soft tissue mass over the supra-hilar region of the right lung likely indicating the primary site with brain metastasis. Here in this case, the initial presentation of psychiatric symptoms in lung cancer with brain metastasis obscured the underlying central nervous system pathology. This case illustrates the need for a holistic approach with prompt and detailed assessment including neuroimaging in patients with a high index of suspicion of organicity.