Psychiatric Manifestations in a Patient with HIV-Associated Neurocognitive Symptoms and Cryptococcal Meningitis.

We report here a case that presented as mania followed by depression and mild cognitive impairment, which was misinterpreted and treated as a depressive episode of bipolar disorder and planned for electroconvulsive therapy, but was ultimately found to have cryptococcal meningitis and HIV-associated neurocognitive symptoms.

INTRODUCTION

Mania secondary to acquired immunodeficiency syndrome (AIDS) is linked to the pathophysiology of HIV brain infection.[1] Clinically, HIV-positive patients with first-episode secondary mania have more severe manic symptoms, higher rates of psychotic symptoms, more cognitive impairment, and more immune suppression.[2] Around 20 – 37% of HIV-infected individuals may have diagnosable depression, which is correlated to the stressors associated with HIV diagnosis.[3]

CASE REPORT

A 28-year-old married graduate male, attended the Neurology Clinic for symptoms like increase in activity, excessive happiness, and flashes of lights in front of his eyes. The symptoms were present for around two months; which began without any precipitating factor/ stress. The neurological examination was normal and the case was referred for a psychiatric evaluation. He did not have a history of mania, nor did any of his family members. He had multiple unprotected sexual contacts with sex workers for the previous three to four years. He was diagnosed with having mania. He was prescribed divalproex (500 mg) and trifluoperazine (2.5 mg).

The symptoms of mania improved within one month. The patient rejoined his work in two months and was working satisfactorily; and reached his pre-morbid level of functioning. However, about a month after joining work, he complained of weakness, sadness of mood, decreased interest in work, irritability, and difficulty in concentration. He was prescribed an antidepressant (escitapram 10 mg) along with a mood stabilizer. It was planned that if there was further deterioration in the severity of symptoms, ECT would be considered.

The patient's forgetfulness became more prominent; he was unable to remember simple instructions at work and at home. He also had difficulty in writing. He was finding it difficult to complete his work properly; there were frequent complaints regarding mistakes in his work. His sadness increased; he began to remain aloof. He started suspecting his wife's character. Family members tried to help him to take psychotropic medicines, however, he did not follow the medical advice with regard to the medications. He rather engaged in faith healing rituals suspecting the situations as a curse of God.

In another two months, the symptoms worsened, and the patient became quite suspicious. The mental state examination revealed suicidal thoughts, nihilistic delusion, and delusion of infidelity. He had insomnia. The patient became suspicious and hostile toward the treating doctor. The patient was admitted to the Psychiatric Department. Investigation results suggested that the patient was reactive to HIV type 1. Other investigations on complete blood count, urine, renal function tests, liver function tests, thyroid function tests, blood sugar, ultrasonography of the abdomen, urine porphobilinogen, HIV, HBs Ag, HCV, rapid plasma regain test, and EEG were within normal limits. A computed tomography (CT) scan of the brain showed diffuse cerebral cortical atrophy – mild but significant for age. His Mini Mental State Examination (MMSE) score was 19/30. He was at that time prescribed venlafaxine 37.5 mg, quetiapine 25 mg, and divalproex 500 mg.

Later, he complained of severe headache, blurring of vision, and had fever. Further investigation found that the cerebrospinal fluid (CSF) Indian Ink preparation was positive for Cryptococcus Neoformans, CD4% was 7.1 (24–48) and absolute CD4 was 127 (387–1256). The remaining investigation was normal. Magnetic resonance imaging (MRI) of the brain suggested mild cortical atrophy and no other obvious abnormality. He was diagnosed as having Cryptococcus Neoformans meningitis.

After three days of starting injection amphoterocin B and one therapeutic lumbar puncture, the symptoms of headache, blurring of vision, suspiciousness, nihilistic delusion, and depressive symptoms dramatically improved. He began to interact, his MMSE improved to 27/30. The patient remained well for the next four days; after which he had a relapse of all the symptoms. In addition he became suspicious about other patients and their relatives. He believed that other patients and their relatives were talking about him and laughing at him. He accused doctors and nurses of giving him false medication and making money out of it. He mentioned hearing voices of unknown people teasing and threatening him. Quetiapine was increased to 100 mg. After 15 doses of injection amphoterocin B, the patient was discharged. At the time of discharge there was no suspiciousness; however, there were occasional auditory hallucinations and irrelevant talk. His MMSE was 19/30.

DISCUSSION

Early symptoms of impaired neurocognitive function could be misinterpreted as depressive symptoms especially when followed by manic symptoms, as in our case. Neurocongnitive impairment in HIV / AIDS can range from mild cognitive and motor difficulties to AIDS dementia complex (ADC), with evidence of psychomotor slowing, impairment in attention, information processing, language, abstraction of executive skills, complex perceptual motor skills, memory including learning and recall, simple motor skills or sensory perception abilities.[4] The index patient was not responding to the adequate dose of antidepressants. It was stated that apathy may reflect HIV-associated neurological dysfunction, which was not amenable to treatment with antidepressant medications.[5] Along with primary HAND (HIV- associated neurocognitive disorders), impaired cognition in HIV patients had also been reported secondary to opportunistic infections.[6] Our patient was positive for CSF India Ink preparation, for Cryptococcus neoformans.

This case exemplifies the psychiatric presentation of cryptococcal meningitis and HIV-associated neurocognitive symptom (HANS) and the need to consider organic and infective causes in atypical symptomatic presentations.