Juniper Publishers-Open Access Journal of Case Studies
Is there a Link between Depression and Morgagni-Stewart-Morel Syndrome? About a Clinical Case
Authored by Smaoui Najeh
Abstract
Morgagni Stewart Morel (MSM) syndrome is an association of clinical features with radiological findings. It is defined as the presence of hyperostosis frontalis interna, variably associated with metabolic, endocrine, and neuropsychiatric disorders. In the literature, the majority of reported cases presented with depression, without any studies focusing on researching the nature of the link between the two types of disorders. In fact, depression raises the question of whether it is related to the Disease or to the elderly since the prevalence of the MSM syndrome increases with age. There is considerable debate in the scientific community as whether to the depression is a comorbidity or a clinical manifestation of this syndrome. In this work, we report a clinical case to discuss the relationship between MSM syndrome and depression in a 67-year-old woman who presented with depression and Imaging consistent with MSM syndrome.
Keywords: Morgagni-stewart-morel syndrome; Depression; Comorbidity; Co-occurrence; Relationship
Introduction
Morgagni Stewart Morel (MSM) syndrome was first described by Morgagni, during autopsy, in an obese female patient who had hirsutism and thickening of inner table of her skull. Stewart, in 1928, and Morel, in 1930, added neuropsychiatric symptoms [1]. Due to the frequency of endocrinal dysfunctions, it was also called metabolic craniopathy. The symptoms are generally non specific and benign, but they may cluster together in some cases, giving rise to various syndromes. This disease is usually misdiagnosed.
In the literature [2], the majority of reported cases presented with psychiatric disorders, in particular depression, without any studies focusing on researching the nature of the link between the two types of disorders. In fact, depression raises the question of whether it is related to the disease or to the elderly since the prevalence of the MSM syndrome increases with age. We report a clinical case to discuss the relationship between MSM syndrome and depression.
Case Report
A 67-year-old woman was referred to our outpatient psychiatry department for persistent affective symptoms during three years, which had gradually worsened in the latest month. She also was suffering from diabetes and high blood pressure, well-balanced under treatment. There was no family history of psychiatric or neurological disorders.
In fact, she suffered from depressed mood, loss of initiative, decreased appetite, anxiety, difficulty staying asleep, and lack of energy and motivation. Over the years, she had gradually withdrawn from social activities.
She was overweighted (body mass index 31kg/m2) with blood pressure: 140/80mm Hg. She looked tired with under-eye dark circles and reduced facial expression. She reported being sad, with anhedonia and panic attacks. There was neither suicidal ideations nor psychotic symptoms. She was vigilant and cooperative. There were no focal neurological symptoms. Her Mini Mental State Exam (MMSE) and Geriatric Depression Scale (GDS) scores were 26/30 and 13/15 respectively.
Routine blood chemistry showed hyperglycemia at 1.46g/l. A brain computed tomography showed bilateral and symmetrical frontal bone hyperostosis centered on the inner table (Figure 1). No parenchymatous or vascular lesions were objectivized. Possible secondary causes were excluded by investigating acromegaly, malignity, Paget’s disease, neuroendocrine tumours, and hyperparathyroidism. The diagnosis of MSM syndrome was retained.
We prescribed selective serotonin reuptake inhibitor (SSRI) antidepressant (Sertraline 50mg/day) for depressive symptoms. A therapeutic adjustment with hygiene and dietetic rules was made. A neurosurgical opinion was sought and concluded that no immediate surgical intervention was indicated.
After three months, there was a noticeable improvement in mood and sleep disorders with resumption of certain activities. Her GDS score became 8/15.
Discussion
MSM syndrome is an association of clinical features with radiological findings. It is defined as the presence of hyperostosis frontalis interna (HFI), variably associated with metabolic, endocrine, neurological and psychiatric disorders [3,4]. The common clinical features are virilism, diabetes, abdominal adiposity, high blood pressure, pituitary disorders (polyphagia, polydypsia, visual disturbances, asthenia) and neurological disorders (headache, migraine, comitial seizures, cognitive impairments, parkinsonism) [5,6]. In the literature [2], psychiatric symptoms have had various manifestations; behavioral disturbances, psychotic symptoms, character change, aggression, suicide attempts, and mainly depression. Our patient presented with a partial expression of MSM symptoms, with depressive disorder in the foreground, metabolic and endocrine disorders (high blood pressure, obesity, diabetes) and HFI on imaging.
Its prevalence in autopsy series is 12%, affecting mainly women, and increasing with age [4], which is the case of our patient. Also like in our clinical case, its discovery is often incidental, either in isolation or associated with disease states. The diagnosis relying on imagery. The characteristic X-ray finding is thickening of inner table of skull [1]. The exact etiology of HFI and MSM syndrome remains unclear. The most interesting theories relate to sex hormones dysregulation, obesity and leptin dysfunction that promoted osteoformation [7,8]. Genetic basis was hypothesized in a case report of monozygotic twins both suffering from MSM syndrome [8]. However, the symptoms were non uniform between them, suggesting phenotypic variability probably due to environmental factors. In practice, doctors are confronted primarily with the “fragments” of the disease, because this syndrome develops its symptoms for many years and at different speeds [9]. But in some cases, they may cluster together, giving rise to delay in diagnosis and treatment.
There is considerable debate in the scientific community as whether to the psychiatric syndrome is a comorbidity or a clinical manifestation of this syndrome. Some authors classify the psychiatric symptoms as ancillary signs because they are heterogeneous, inconstant and almost always present in elderly due to senility [4]. Other authors [9] think there is a clear association between HFI and psychiatric disorders. Future studies aiming to clarify their relationship are necessary to determine if the psychiatric symptom is a primary or secondary manifestation of MSM syndrome. Mental disorders, especially depression may be secondary to the endostosis and its mechanical effects on the one hand. On the other hand, the prevalence of depression in the general population is high, and HFI is quite a common finding nowadays [10]. Therefore, the combination of these two conditions is not unusual. Nevertheless, studies revealed an increased incidence of HFI in mental hospital patients regardless of age [11]. Indeed, the infundibulo-pituitary region is the center of endocrine regulation. It is also involved in psychiatric disorders. Moreover, among the etiopathogenic hypotheses of depression, the endocrine disturbance play a key role, notably sex hormone and leptin dysfunctions which involved in MSM syndrome [12]. All of this could justify depression as a primary manifestation in MSM syndrome.
So, we presume that there was a relationship between our patient’s depressive disorder and her HFI. However, the cause-effect relationship of these association remains unclear. Pathological changes in the brain and cranial box, as well as endocrine imbalance, can contribute to neuropsychiatric disorders, especially depression [2,9]. Anyway, as well as in our case-report, the psychiatric disorder may be improved by specific treatment.
Conclusion
MSM syndrome is one of the less understood syndromes. The patient may present with varied symptoms and thus lead to difficulty in diagnosis. Whatever, depression should be interpreted not only as component of MSM syndrome, but also as a comorbidity of this syndrome. The psychiatric comorbidities, including depression, whether or not related to the disease, are likely to be improved by appropriate treatment.
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