Evidence-Based Reviews

5-step psychiatric workup of HIV patients

Current Psychiatry. 2007 December;6(12):61-71

References

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cryptococcus
aseptic meningitis (which may be caused by HIV)
histoplasmosis
coccidioidomycosis.

A stiff neck or positive Kernig’s and Brudzinski’s signs (pain elicited upon passive extension of the knee with the hip flexed, or with flexion of the neck) specifically indicate an infection or other inflammatory process within the meninges that may lead to mental status changes. Motor, sensory, and cranial nerve examinations can detect evidence of intracranial mass lesions resulting from CNS neoplasms or infections to which immunocompromised patients are vulnerable.

CASE CONTINUED

Physical exam reveals that Mr. G has a low-grade fever (100.2° F) and penile erosion consistent with herpes simplex infection. He has no meningeal signs and an otherwise normal neurologic examination.

STEP 2 Evaluate lab results

Use laboratory testing to search for potential medical causes of the patient’s presentation. Include a complete blood cell count, electrolytes, blood urea nitrogen and creatinine, and liver function tests to look for underlying metabolic problems.

CASE CONTINUED

Complete blood count, electrolytes, kidney function, and liver function tests are all within normal limits, and rapid plasma reagin (RPR) for syphilis is negative. Cerebrospinal fluid (CSF) analysis demonstrates normal opening pressures, protein, and glucose. India ink stain is negative for Cryptococcus neoformans, but 1 week later CSF cultures are positive for Cryptococcus. The patient has a CD4 count of 15 and a viral load of approximately 44,000.

Clinical Point

Fever might suggest an infection that could be contributing to psychiatric symptoms

In patients with HIV, CD4 count can reveal the degree of immunocompromise, whereas viral load shows the extent of viral activity. Typically, patients with a CD4 count >500 are not at risk for opportunistic infections. A count

Box

New-onset symptoms: Psychosis or CNS impairment?

The stepwise approach this article describes to evaluate and diagnose psychiatric symptoms in HIV-positive patients can be used in any patient to determine if psychiatric symptoms are the result of a primary psychiatric disorder or CNS impairment. This approach may be particularly helpful when evaluating patients with new-onset or unusual symptoms, as described in the following case.

Ms. K, 34, has a diagnosis of ophthalmic herpes and is hospitalized to control severe pain in her left eye. On the second day, she appears moderately anxious and somewhat restless. Although it is possible to recognize some words and connections between a few ideas, her speech is otherwise incomprehensible. The ophthalmologist requests a psychiatric consultation, concerned that the change in mental status represents emerging psychosis.

Because Ms. K is unable to provide information coherently, the psychiatrist carefully reviews her medical, social, and psychiatric histories and medications. Ms. K’s history includes tonsillectomy at age 2, arthroscopic knee surgery after a skiing accident in college, and the use of oral contraception.

STEP 1 During Ms. K’s mental status exam, she appears alert, attentive, and cooperative, although moderately anxious. Rather than tangentiality or loosening of associations, her speech is notable for pervasive word substitutions and paraphasic errors, such as saying “chair” when asked to identify the nightstand in her room.

Aside from her ocular lesion, Ms. K’s physical exam is normal.

STEP 2 Laboratory testing reveals normal electrolytes, renal functioning, liver function tests, thyroid functioning, and B12 and folate levels. Rapid plasma reagin for syphilis is negative.

STEP 3 The psychiatrist feels that her exam demonstrates aphasic features rather than psychotic thought process abnormalities and orders neuroimaging. Brain CT with contrast reveals that Ms. K has a ring-enhancing lesion in the left temporal-parietal area, consistent with toxoplasmosis or a glioblastoma. Biopsy confirms toxoplasmosis.

STEPS 4/5 Neuropsychological testing was not performed in this case. It would have revealed the aphasia. Putting all of the data together resulted in clarifying that the patient was not psychotic.

Because toxoplasmosis often develops in patients with severely compromised immune systems, the healthcare team advises Ms. K to undergo HIV testing. Her enzyme-linked immunoadsorbent assay is positive for HIV antibodies, and her HIV infection is confirmed with a Western blot test.

Treatment with pyrimethamine and sulfadiazine rapidly resolves her neurologic symptoms. When she is no longer aphasic, Ms. K gives a history of several sexual relationships in the last 4 years. She typically used condoms during sexual activity but recalled instances when the condom had ruptured during intercourse. She denies any other risk factors for contracting HIV. Ms. K fully recovers from toxoplasmosis with no signs of cognitive impairment. She is started on antiretroviral therapy and followed as an outpatient.

Carefully evaluate patients with a CD4 count

Clinical Point

Consider ordering a test for syphilis because syphilis can mimic psychiatric symptoms and worsen the course of HIV infection

Strongly consider ordering the RPR test for syphilis because:

5-step psychiatric workup of HIV patients

References

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