Ganglioglioma masquerading as childhood depression

Dear Editor, Gangliogliomas are rare central nervous system tumors, accounting for approximately 2–5% of all childhood brain tumors.[1] These tumors, often diagnosed in children and young adults, may present with a variety of symptoms, including seizures, headaches, or behavioral changes, depending on their anatomical location.[2] While traditionally viewed through a neurological lens, increasing evidence supports that psychiatric manifestations may be the initial or sole presentation, particularly in slow-growing tumors like low-grade gliomas or gangliogliomas.[3] There is a growing recognition of the psychiatric–neurological interface in childhood populations. A large-scale retrospective study highlighted that neuropsychiatric symptoms often precede neurological signs, especially in tumors involving frontal and temporal lobes.[4] Guidelines for the management of childhood depression, unlike those for older adults, do not universally recommend early neuroimaging unless clear neurological red flags are present.[5] However, when atypical features such as treatment resistance, cognitive decline, altered consciousness, or focal signs are observed, imaging should be strongly considered to exclude underlying structural pathology.[6] An 11-year-old male was brought to the Psychiatry Outpatient Department by his mother with complaints of decreased social interaction, persistent sadness of mood, frequent headaches, reduced appetite, and loss of interest in previously enjoyable activities for the past six months. The child had been functioning normally until six months ago, Gradually, he became withdrawn, stopped interacting with friends, and preferred staying alone. When questioned, he remained silent and frequently complained of headaches, which increased frequency over the last four months. There was no history of projectile vomiting or loss of consciousness. Simultaneously, teachers reported a significant academic decline. A previously active and attentive student, he became inattentive and underperformed in class. His appetite decreased, and sleep was severely disturbed, dropping from 8 h to only 4 h per night, with both delayed onset and poor maintenance. Family members also noted increased irritability, exaggerated startle response, and vague fears. He began avoiding school, citing discomfort around people. Routine physical examination and laboratory investigations were within normal limits. Psychiatric assessment revealed persistent low mood, anhedonia, and academic decline, consistent with a provisional diagnosis of childhood depression. A provisional diagnosis of childhood depression was made, and escitalopram 5 mg/day was prescribed. Twenty days later, the child returned with concerning new symptoms. He exhibited stereotyped behavior—repeatedly lifting one hand to his mouth, raising it, then covering his mouth again, along with prolonged staring episodes lasting 4–5 min. These occurred 1–2 times daily, with altered awareness but no signs of eye-rolling, tongue biting, or incontinence. Despite regular medication, these episodes increased to 8–10 times daily. His mother also reported two past episodes of brief loss of consciousness, one during play and another at school. Given the unusual symptom pattern and poor response to antidepressants, an organic cause was suspected. Neurological consultation and neuroimaging were advised. A CT scan [Figure 1] revealed a well-defined intra-axial hypodense lesion with calcified walls in the left temporal lobe. Then, MRI with contrast [Figure 2] showed a 6.5 × 4.5 × 4 cm intraparenchymal lesion involving the anterior and middle temporal regions, suggestive of ganglioglioma. The patient underwent successful surgical resection. Postoperative recovery was uneventful. Within weeks, his headaches resolved, stereotyped episodes ceased, and mood and sleep normalized. There was no residual psychiatric or cognitive morbidity postsurgery. The child returned to normal academic and social functioning within 2 months of recovery.Figure 1: Neuroimaging through CT scan of the brain revealed a well-defined intra-axial hypodense lesion (20 Hounsfield unit (HU)) with calcified walls in the left temporal lobe, with the lower part showing extensive calcification [Figure 1]. The imaging findings were suggestive of a ganglioglioma. CT = Computed tomographyFigure 2: MRI brain (P + C) was done which showed a well-defined intraparenchymal space-occupying lesion in the anterior and middle temporal parenchyma measuring 6.5 cm × 4.5 cm × 4 cm, suggestive of ganglioglioma with differential of benign glial neoplasm, pleomorphic xanthoastrocytoma (WHO grade-1) [Figure 2]. MRI = Magnetic resonance imagingIn a case series on childhood CNS germ cell tumors, nearly 30% of patients presented with psychiatric symptoms alone, leading to diagnostic delays exceeding six months.[7] A systematic review also found that over one-third of patients with brain tumors exhibited psychiatric manifestations before any neurological deficits.[5] The absence of uniform imaging guidelines in childhood psychiatry further compounds the challenge in timely diagnosis. While neuroimaging is often recommended for adults with late-onset or treatment-resistant depression, childhood protocols typically reserve imaging for cases showing clear neurological signs.[6] This inconsistency may lead to missed or delayed detection of underlying structural pathologies in children presenting with atypical or evolving psychiatric symptoms. Early diagnosis through neuroimaging and neurological consultation is crucial, as timely surgical intervention can lead to complete resolution of both psychiatric and neurological symptoms. This case highlights the importance of maintaining a high index of suspicion for organic causes in atypical or treatment-resistant psychiatric presentations in children. Although rare, gangliogliomas can mimic primary psychiatric disorders; hence, a multidisciplinary approach is essential. While routine neuroimaging is not feasible in every case of childhood depression, red flags such as persistent headaches, treatment resistance, stereotyped movements, or altered awareness warrant early imaging. Neuroimaging should be considered when red flags such as persistent headaches, cognitive decline, altered awareness, or poor response to treatment are present.[4,6] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.