Case Studies of Mental Health in General Practice(28)
——HIV and Mood Disturbance

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This case demonstrates the complex issues which need to be considered in the diagnostic assessment of an individual with a known medical illness presenting with psychiatric disturbance.It also demonstrates the importance of the general practitioner using specialist consultation and advice to work through this complexity,and the importance of understanding one′s own diagnostic and therapeutic limitations in such situations.

1 Background

Jim C and his family have been patients of your clinic for many years,but you have not seen Jim,now aged 22 years,for 4 years as he has been away in X city of China at University studying.You have heard little about Jim over this time,in part as he has had little contact with his parents after telling them he was in a same-sex relationship.However,you are aware he has had some health problems,and was hospitalised for a period for the treatment of depression 12 months ago.

Jim′s father has asked if you will see him as he is concerned that Jim is ′not himself′ after coming home to visit unexpectedly to tell his parents he thinks he has found the cure for cancer.His father wonders whether Jim is developing the same kind of mental health problem he has seen his wife deal with over the past 20 years.

2 Further history

Jim reluctantly comes to your clinic,protesting that there is no reason for him to see a doctor.However,once settled in your office,with little encouragement he tells you he has been very busy at university,has been ′experimenting day and night′ and has found the cure for cancer.As you probe for more detail he tells you his partner of 2 years died 14 months ago,and since that time he′s been trying to focus on his studies and research.He acknowledges that at times he′s had troubles concentrating on his work,and attributes this to fatigue and the side effects of his medications.He states he stopped his medications because of these problems around 9 months ago.

Jim reports to you that he,and his partner were both found to be HIV positive when they went to be tested before starting their relationship.Jim has been ′pretty good′ physically and when he last had his viral load tested 12 months ago it was undetectable.He states he has not been attending regularly for review as he did not see the point if he was off his medications.

3 Examination

Jim is casually dressed,but a little dishevelled,he has obviously not shaved for a couple of days and you notice he is wearing bright orange socks and red jeans.He is quite agitated,getting up and down in his chair.He has mild pressure of speech,but can be interrupted,but does become a bit irritable in response to your questions.

His BP is 120/75 mm Hg(1 mm Hg=0.133 kPa),pulse 76 and regular,he is afebrile.Examination of the chest and abdomen reveals no abnormality.He has no enlarged lymph nodes,skin lesions,mouth or dental abnormalities.His eye examination is also unremarkable.

In addition to the features described above,key findings on mental state examination include his self- report of feeling ′great′,quite a lot of jocularity as well as his irritability as you talk with him and a range of grandiose ideas in addition to his claim he has found the cure for cancer.These include his prediction he will win the top science prize at University this year.There is no disorder of form of thought and no perceptual disturbance.

4 Investigations

In view of Jim′s disclosure of his HIV diagnosis,you tell him you need to seek details from his usual treating doctor.He is dismissive of this,saying he knows more than those doctors do,but he does consent to you contacting them.You order a series of tests including FBE,U&E,LFT,thyroid function,CD4 count,viral load (to assess the status of his HIV),and CT scan brain (to see if he has any HIV related brain disease).

You contact the psychiatrist who looked after Jim when he was hospitalised for depression for 12 months ago.He tells you that Jim was devastated when his partner died and just could not cope.He defined the episode as one of intense grief rather than a depressive episode.

The doctors in X city confirm they have been treating Jim for HIV infection,and when they last saw him he was taking three HIV medications;AZT,3TC and Efavirenz.His most recent CD4 count was 250.Results of the blood tests you have ordered show his CD4 count is 30 (which is indicative of significant immunosuppression) and his viral load is 430 (which is very high).The CT scan is unremarkable.

5 Questions

5.1 What is the likely diagnosis?

5.2 What are the differential diagnoses?

5.3 What further information do you require?

5.4 What treatment will you offer Jim?

5.5 What is Jim′s prognosis?

6 Answers

6.1 What is the likely diagnosis? The likely diagnosis is a hypomanic episode.Jim has a number of the features of this including elevated mood,irritable and elevated affect,agitation,pressure of speech,decreased need for sleep,grandiose thinking.

6.2 What are the differential diagnoses? The differential diagnoses fall to 2 groups.

6.2.1 Hypomanic episode occurring as part of bipolar disorder- and in this case the diagnosis would be bipolar type 11 disorder.Hypomania,as the word sounds,is literally "less than mania".People experiencing this are often overconfident,over talkative and take uncharacteristic risks.Lack of need for sleep and heightened sexual behaviour are common features.It can go on to become full blown mania.

6.2.2 Secondary hypomania i.e.a hypomanic episode with an identified organic cause[1],this includes:(1)Substance use disorders such as amphetamines and other stimulants,so its important to check with the patient if they are taking these.(2)Prescribed drug induced mood disturbance e.g.corticosteroids.(3)Cerebral lesions such as tumour or infection.When frontal lobes are involved,behavioural change and disinhibited or uncharacteristic behaviours and grandiose ideas may be prominent.Opportunistic infections that occur in HIV such as cerebral toxoplasmosis,may present in this way.(4)In a patient such as Jim,who has marked immunosuppression and active disease (as indicated by his high viral load) a further consideration is HIV-related brain disease i.e.widespread cerebral involvement by the virus rather than a focal lesion such as a tumour or localised infection[2].

6.3 Further information First,Jim′s father has raised the question of a relationship to the illness Jim′s mother has.You are aware she has suffered from bipolar disorder and that her aunt also has this problem,which certainly raises the question as to whether Jim′s presentation reflects his first presentation of this familial disorder.

Whilst Jim obviously has a strong genetic loading,and he has had depression previously (although importantly his treating psychiatrist regarded this as a grief reaction).Given Jim′s HIV diagnosis,and his high risk of an underlying organic cause for this presentation,this cannot be assumed to be the case.

You seek further information from the doctors in X city and find that when Jim first presented for HIV testing he had a low CD4 count and high viral load,suggesting he had already been positive for some time when first tested.You also discover that he has used IV drugs in the past and that he is also Hepatitis C positive.His advanced disease certainly increases his risk of HIV-related brain disease.

You order an MRI as this will be more sensitive in detecting any HIV related brain changes than a CT scan.The MRI shows mild atrophy and bilateral periventricular high T2 signal intensities,which suggests the HIV is active in the brain.

You also arrange for neuropsychiatric testing (a detailed set of specific psychological and cognitive tests usually performed by a specially trained psychologist) to determine whether Jim has any evidence of HIV associated neurocognitive disorder (HAND).This is an umbrella term which refers to a range of HIV related neurological problems- patients with HAND usually experience problems of mental slowing,loss of memory and poor concentration.Given Jim′s current mental state you will delay the timing of this testing until his mood is settled.

Finally,you seek a secondary consultation from the psychiatrist involved in the HIV treatment team in X city who have been managing Jim′s illness until recently.He suggests that although Jim does have a family history of bipolar disorder the presentation of psychiatric problems accompanying the course of Jim′s HIV are consistent with a secondary mania (in other words,the hypomanic episode is likely to be due to the HIV),and he recommends management should be based on this assumption.

6.4 What treatment will you offer Jim? You are aware that it is essential to treat Jim′s mood disorder symptomatically,and in doing so hopefully prevent any worsening of the elevated mood and progression to mania.You are also aware,that people with elevated mood often behave in a disinhibited and/or risky manner,including unprotected sex and IV drug use and either could present a great risk to others,so needs to be addressed with Jim.

You talk with Jim and ask if his parents are aware he is HIV positive.He indicates they are not,although they were aware his partner died from AIDS,but agrees they will need to know and agrees for you to discuss this with them.You speak to Jim′s parents and explain your diagnosis,and your concerns about possible worsening,and about the need for Jim to receive specialist care for both his HIV and his mood disturbance as soon as possible.

Although Jim is reluctant to accept your assessment and treatment recommendations,he does eventually agree to start a medication as he can see that his life is spinning out of control.The psychiatrist recommends that you start an atypical antipsychotic,olanzapine,initially 5 mg/day.The psychiatrist explains that he was reluctant to use a mood stabiliser because patients with physical illness are more prone to medication toxicity and problematic drug interactions when taking mood stabilisers such as lithium or sodium valproate.

The psychiatrist in X city also explains that it is important Jim restart his antiretroviral (HIV) medications as soon as possible as suppression of systemic viral load may result in reduction of viral replication in the brain.However,since you have no experience in the use of these medications you defer any prescribing of these agents until Jim can be seen by the clinic in X city.

6.5 Prognosis Prognosis is dependant on a number of factors.These include Jim′s compliance with and response to antiretroviral therapies,and whether Jim does in fact have any evidence of HIV neurocognitive associated disorder (HAND) - it is known that the poor prognostic features for HAND include poor viral control,comorbid drug abuse and co-infection with hepatitis C.Importantly,whilst cognitive deterioration accompanies HIV related mania in some cases it does not occur in all.

Finally,as Jim has a familial risk for bipolar disorder this may still become manifest at some stage irrespective of his HIV infection.

1 Ellen SR,Judd FK,Mijch AM,et al.Secondary mania in patients with HIV infection[J].Aust NZ J Psych,1999,33:353-360.

2 Jeffries K,Agrawal N.Early onset dementia.Advances in psychiatric treatment[Z].2009.