Late-onset mania revealed advanced small cell lung cancer

What happened, in summary

A 57-year-old man was brought to the emergency department after three weeks of extreme elation, insomnia, increased energy, spending, anger, and uncharacteristic sexual behavior. During the final four days, he developed grandiose and persecutory delusions. He had no personal or family psychiatric history. A short course of prednisone for tinnitus had recently been tapered, making medication-related mania one possible explanation.

He was admitted under oncology with psychiatric support. Risperidone and bromazepam were started, and within several days he became less irritable and more coherent. A liver biopsy showed high-grade neuroendocrine carcinoma that was considered likely to have spread from the lungs. Further evaluation established an ACTH-producing small cell lung carcinoma. ACTH and cortisol levels were markedly elevated. The final diagnosis was stage IV left-sided small cell lung cancer with spread to the right lung and liver.

He was discharged for outpatient chemotherapy and received cisplatin plus etoposide one week later. His psychiatric symptoms resolved after 11 days of treatment, and the psychotropic medicines were stopped. Dexamethasone given with chemotherapy did not trigger another manic episode.

Three weeks after chemotherapy, he was readmitted with altered consciousness and imaging evidence of multiple strokes. He was discharged but returned three days later with sepsis, complicated pneumonia, and severe hypokalemia. Although his physical condition deteriorated rapidly, the mania and psychosis did not return. He died a few months later from aspiration pneumonia and multiorgan failure.

His family described the abrupt behavioral change as both frightening and stigmatizing. The presentation showed how a sudden first manic episode in later adulthood can accompany an underlying cancer or its hormonal effects, even before typical cancer symptoms become apparent.