PSYCHOGERIATRICS 2016; 16: 135–138
doi:10.1111/psyg.12127
CASE REPORT
Secondary mania due to AIDS and cryptococcal meningitis in a 78-year-old patient Po-Han CHOU,1 Wen-Chen OUYANG,2,3,4,5 Tsuo-Hung LAN1 and Chin-Hong CHAN1
1
Department of Psychiatry, Taichung Veterans General Hospital, Taichung, and 2Department of Psychiatry, Changhua Christian Hospital, 3Section of Psychiatry, Lutung Christian Hospital, Changhua, and 4Department of Psychiatry, Kaohsiung Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, and 5College of Medicine and Life Science, Chung Hwa University of Medical Technology, Tainan, Taiwan
Abstract We report a 78-year-old man without past psychiatric history who experienced his first manic episode successfully treated with quetiapine and lorazepam, but was ultimately found to have AIDS and Cryptococcus neoformans meningitis. Our presented case highlights the importance of comprehensive differential diagnoses to rule out secondary causes of psychiatric symptoms presenting for the first time in elderly patients.
Correspondence: Dr Po-Han Chou, MD, Department of Psychiatry, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Section 4, Taichung City 40705, Taiwan. Email: [email protected] Received 17 October 2014; revision received 16 January 2015; accepted 22 February 2015.
Key words: acquired immunodeficiency syndrome (AIDS), Cryptococcus neoformans meningitis (CNM), secondary mania.
INTRODUCTION Late-life onset mania is often a secondary condition resulting from pharmacological, metabolic, or neurologic causes.1 Older adults are especially at risk for secondary mania because of increased medical comorbidities and neurological changes. Here, we present a case of late-life onset mania caused by HIV and cryptococcal meningitis. This case report highlights the importance of a broad differential diagnosis when approaching new-onset manic symptoms in geriatric patients in an outpatient setting.
CASE REPORT Mr Y, a 78-year-old Chinese man who had an elementary school education, was brought to our psychiatric outpatient department because of changes in mood and behaviour over 1 month without any precipitating factors. The symptoms included decreased sleep, elevated mood, increased energy, hyperactivity, racing thoughts, and eccentric behaviour (such as being stark naked at home). His past medical history © 2015 The Authors Psychogeriatrics © 2015 Japanese Psychogeriatric Society
was significant for gouty arthritis, hypertension, and benign prostate hyperplasia. Our patient also had no family or previous history of psychiatric disorder or substance abuse. However, he had unprotected sexual contact once with sex workers 2 years before presenting. During the mental status examination, the patient was oriented and alert with pressured speech and expansive mood. Flight of ideas and delusions of grandeur were also noted, and he had a Young Mania Rating Scale (YMRS) score of 23 (elevated mood = 3, increased motor activity-energy = 4, sexual interest = 1, sleep = 3, irritability = 2, speech = 4, languagethought disorder = 1, content = 2, disruptiveaggressive behaviour = 0, appearance = 0, insight = 3).2 Cognitively, he was without waxing or waning of alertness and had a Mini-Mental Status Examination score of 18 with 5 years of education.3 The results of the three-object test of the Mini-Mental State Examination showed that the patient’s short-term memory was intact, but he lost the last 4 points on attention and concentration in the serial sevens test.
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With regard to self-care, he was able to perform all activities of daily living without assistance, even with manic symptoms. The patient’s medications before this visit included allopurinol 100 mg/day, colchicine 0.5 mg/day, and meloxicam 15 mg/day for gouty arthritis, amlodipine 2.5 mg/day for hypertension, and finasteride 5 mg/ day and tamsulosin HCL 0.4 mg/day for benign prostate hyperplasia. Initial surveys, including serum chemistry, and treponemal haemagluttination test were all normal. Haematology profile revealed leucopenia (white blood cell count: 3500/cumm), microcytic anaemia (haemoglobin: 9.9 g/dL), and thrombocytopenia (platelet count: 88000/cumm). Brain computed tomography revealed senile changes with generalized tissue loss of brain (Fig. 1). Based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, and the most recent episode manic,4 bipolar I disorder was temporarily diagnosed, and the patient was then treated with quetiapine 50 mg (hora somni) and lorazepam 1 mg (hora somni). Two weeks later, the patient’s manic symptoms improved and he had a YMRS score of 5 (elevated mood = 1, increased motor activity-energy = 0, sexual interest = 0, sleep = 0, irritability = 0, speech = 0, language-thought disorder = 0, content = 2, disruptive-aggressive behaviour = 0, appearance = 0, insight = 2). His psychiatric symptoms were stable in the 2 weeks that followed until he developed fever
Figure 1 Brain computed tomography revealed the following: (i) generalized loss of brain, which is why senile changes were considered; (ii) focal brain atrophy with widening of sulci over both frontal regions; and (iii) faint calcification over the right globus pallidus.
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and consciousness disturbances. He was brought to our emergency department, where complete blood count/differential count (DC) revealed pancytopenia (white blood cell count = 3300/cumm, haemoglobin = 10.3 g/dL, and platelet = 76000/cumm). Cerebrospinal fluid analysis including India ink, Latex test, and fungal culture confirmed Cryptococcus neoformans infections. HIV-1 infection was confirmed by HIV-enzymelinked immunosorbent assay and HIV-1 Western blot from blood serum. Based on the diagnosis of AIDS and Cryptococcus neoformans meningitis (CNM), the patient was then transferred to an isolation ward in the Division of Infection for further management. During the patient’s hospitalization in the isolation ward, cryptococcal meningitis was treated with amphotericin-B 50 mg/day, and his HIV infection was treated with highly active antiretroviral therapy, including lopinaivir 800 mg/day, ritonavir 200 mg/day, abacavir 600 mg/day, and lamivudine 300 mg/day. His manic symptoms were relatively stable (YMRS = 2) even without psychotropic medication. Unfortunately, 1 month after his admission to the Infection Unit, he became infected with Pneumocystis carinii and died of pneumonia-related sepsis. The clinical course of Mr Y is delineated in Figure 2.
DISCUSSIONS In the literature, there have been two reports of secondary mania due to AIDS and CNM,5,6 but both cases involved middle-aged men. To the best of our knowledge, this is the first report of late-onset mania due to AIDS and CNM in a geriatric patient. In this report, we highlighted a case of late-onset mania that appeared to be associated with AIDS and CNM in a geriatric patient. In the present case, delirium should have been a differential diagnosis because central nervous system (CNS) infection was revealed. Although the patient was distractible, he was fully oriented and alert without fluctuating consciousness during the interview. In addition, he was able to perform all activities of daily living even with the presence of manic symptoms. Therefore, delirium was not likely in this case. Among HIV-seropositive patients, CNM is the second most common cause of opportunistic infection.6 Both HIV and CNM have been reported to be associated with manic episodes.6–11 Therefore, we could not definitively conclude that that Mr Y’s symptoms were due to CNM, AIDS, or both. Although we © 2015 The Authors Psychogeriatrics © 2015 Japanese Psychogeriatric Society
Mania due to AIDS
Figure 2 Clinical course of Mr Y. ER, emergency room; MMSE, Mini-Mental State Examination; PCP, Pneumocystis Carinii Pneumonia; YMRS, Young Mania Rating Scale.
could not effectively rule out cognitive impairment or dementia secondary to AIDS, the patient displayed no signs or symptoms of HIV-associated dementia, including memory loss, mental slowing, reading and comprehension difficulties, and apathy,6 other than his expansive mood and distractibility on the attention and concentration sections of the Mini-Mental State Examination. Pharmacological treatment for secondary mania is similar to treatment for primary mania but with lower doses of atypical antipsychotics or mood stabilizers.1 With limited evidence base for the treatment of mania due to CNM (or AIDS), our decision to initiate treatment with atypical antipsychotics was based on the limited efficacy of mood stabilizers in HIV-infected patients and our patient’s unique medical conditions.6 As HIV induces neuronal damage at the basal ganglia, treating HIV-infected patients with dopamine receptor-2 antagonists may increase the risk of extrapyramidal symptoms. Risperidone, ziprasidone, and olanzapine have been reported to be efficacious with fewer side-effects in the treatment of either HIV or CNM-related manic symptoms.6,9,11,12 However, for this 78-year-old patient, we prescribed quetiapine 50 mg/day because olanzapine was unavailable in our hospital and the risks of extrapyramidal symptoms with quetiapine when compared with other antipsychotics are relatively low.13 Our patient responded © 2015 The Authors Psychogeriatrics © 2015 Japanese Psychogeriatric Society
well to quetiapine 50 mg/day along with lorazepam 1 mg/day and showed improvements in his YMRS score within 2 weeks. In conclusion, our case highlighted the importance of comprehensive differential diagnosis to rule out secondary causes of psychiatric symptoms presenting for the first time in elderly patients in clinical practice. For clinical practitioners, a thorough medical work-up is warranted when approaching new-onset manic symptoms among geriatric patients.
REFERENCES 1 Brooks JO, 3rd, Hoblyn JC. Secondary mania in older adults. Am J Psychiatry 2005; 162: 2033–2038. 2 Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978; 133: 429–435. 3 Folstein MF, Folstein SE, McHugh PR. ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189–198. 4 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000. 5 Johannessen DJ, Wilson LG. Mania with cryptococcal meningitis in two AIDS patients. J Clin Psychiatry 1988; 49: 200–201. 6 Spiegel DR, Bayne CE, Wilcox L, Somova M. A case of mania due to cryptococcal meningitis, successfully treated with adjunctive olanzapine, in a patient with acquired immunodeficiency syndrome. Gen Hosp Psychiatry 2011; 33: 301.e3– 301.e6. 7 Dube B, Benton T, Cruess DG, Evans DL. Neuropsychiatric manifestations of HIV infection and AIDS. J Psychiatry Neurosci 2005; 30: 237–246.
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P.-H. Chou et al. 8 Ferrando SJ, Nims C. HIV-associated mania treated with electroconvulsive therapy and highly-active antiretroviral therapy. Psychosomatics 2006; 47: 170–174. 9 Prakash O, Bagepally BS. Catatonia and mania in patient with AIDS: treatment with lorazepam and risperidone. Gen Hosp Psychiatry 2012; 34: 321.e5–321.e6. 10 Johnson FY, Naraqi S. Manic episode secondary to cryptococcal meningitis in a previously healthy adult. P N G Med J 1993; 36: 59–62. 11 Tang WK, Hui M, Ungvari GS, Leung CM. Cryptococcal meningitis mimicking primary mania in a young female. Gen Hosp Psychiatry 2005; 27: 301–303.
138
12 Spiegel DR, Weller AL, Pennell K, Turner K. The successful treatment of mania due to acquired immunodeficiency syndrome using ziprasidone: a case series. J Neuropsychiatry Clin Neurosci 2010; 22: 111–114. 13 Scherk H, Pajonk FG, Leucht S. Second-generation antipsychotic agents in the treatment of acute mania: a systematic review and meta-analysis of randomized controlled trials. Arch Gen Psychiatry 2007; 64: 442–455.
© 2015 The Authors Psychogeriatrics © 2015 Japanese Psychogeriatric Society
doi:10.1111/psyg.12127
CASE REPORT
Secondary mania due to AIDS and cryptococcal meningitis in a 78-year-old patient Po-Han CHOU,1 Wen-Chen OUYANG,2,3,4,5 Tsuo-Hung LAN1 and Chin-Hong CHAN1
1
Department of Psychiatry, Taichung Veterans General Hospital, Taichung, and 2Department of Psychiatry, Changhua Christian Hospital, 3Section of Psychiatry, Lutung Christian Hospital, Changhua, and 4Department of Psychiatry, Kaohsiung Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, and 5College of Medicine and Life Science, Chung Hwa University of Medical Technology, Tainan, Taiwan
Abstract We report a 78-year-old man without past psychiatric history who experienced his first manic episode successfully treated with quetiapine and lorazepam, but was ultimately found to have AIDS and Cryptococcus neoformans meningitis. Our presented case highlights the importance of comprehensive differential diagnoses to rule out secondary causes of psychiatric symptoms presenting for the first time in elderly patients.
Correspondence: Dr Po-Han Chou, MD, Department of Psychiatry, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Section 4, Taichung City 40705, Taiwan. Email: [email protected] Received 17 October 2014; revision received 16 January 2015; accepted 22 February 2015.
Key words: acquired immunodeficiency syndrome (AIDS), Cryptococcus neoformans meningitis (CNM), secondary mania.
INTRODUCTION Late-life onset mania is often a secondary condition resulting from pharmacological, metabolic, or neurologic causes.1 Older adults are especially at risk for secondary mania because of increased medical comorbidities and neurological changes. Here, we present a case of late-life onset mania caused by HIV and cryptococcal meningitis. This case report highlights the importance of a broad differential diagnosis when approaching new-onset manic symptoms in geriatric patients in an outpatient setting.
CASE REPORT Mr Y, a 78-year-old Chinese man who had an elementary school education, was brought to our psychiatric outpatient department because of changes in mood and behaviour over 1 month without any precipitating factors. The symptoms included decreased sleep, elevated mood, increased energy, hyperactivity, racing thoughts, and eccentric behaviour (such as being stark naked at home). His past medical history © 2015 The Authors Psychogeriatrics © 2015 Japanese Psychogeriatric Society
was significant for gouty arthritis, hypertension, and benign prostate hyperplasia. Our patient also had no family or previous history of psychiatric disorder or substance abuse. However, he had unprotected sexual contact once with sex workers 2 years before presenting. During the mental status examination, the patient was oriented and alert with pressured speech and expansive mood. Flight of ideas and delusions of grandeur were also noted, and he had a Young Mania Rating Scale (YMRS) score of 23 (elevated mood = 3, increased motor activity-energy = 4, sexual interest = 1, sleep = 3, irritability = 2, speech = 4, languagethought disorder = 1, content = 2, disruptiveaggressive behaviour = 0, appearance = 0, insight = 3).2 Cognitively, he was without waxing or waning of alertness and had a Mini-Mental Status Examination score of 18 with 5 years of education.3 The results of the three-object test of the Mini-Mental State Examination showed that the patient’s short-term memory was intact, but he lost the last 4 points on attention and concentration in the serial sevens test.
135
P.-H. Chou et al.
With regard to self-care, he was able to perform all activities of daily living without assistance, even with manic symptoms. The patient’s medications before this visit included allopurinol 100 mg/day, colchicine 0.5 mg/day, and meloxicam 15 mg/day for gouty arthritis, amlodipine 2.5 mg/day for hypertension, and finasteride 5 mg/ day and tamsulosin HCL 0.4 mg/day for benign prostate hyperplasia. Initial surveys, including serum chemistry, and treponemal haemagluttination test were all normal. Haematology profile revealed leucopenia (white blood cell count: 3500/cumm), microcytic anaemia (haemoglobin: 9.9 g/dL), and thrombocytopenia (platelet count: 88000/cumm). Brain computed tomography revealed senile changes with generalized tissue loss of brain (Fig. 1). Based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, and the most recent episode manic,4 bipolar I disorder was temporarily diagnosed, and the patient was then treated with quetiapine 50 mg (hora somni) and lorazepam 1 mg (hora somni). Two weeks later, the patient’s manic symptoms improved and he had a YMRS score of 5 (elevated mood = 1, increased motor activity-energy = 0, sexual interest = 0, sleep = 0, irritability = 0, speech = 0, language-thought disorder = 0, content = 2, disruptive-aggressive behaviour = 0, appearance = 0, insight = 2). His psychiatric symptoms were stable in the 2 weeks that followed until he developed fever
Figure 1 Brain computed tomography revealed the following: (i) generalized loss of brain, which is why senile changes were considered; (ii) focal brain atrophy with widening of sulci over both frontal regions; and (iii) faint calcification over the right globus pallidus.
136
and consciousness disturbances. He was brought to our emergency department, where complete blood count/differential count (DC) revealed pancytopenia (white blood cell count = 3300/cumm, haemoglobin = 10.3 g/dL, and platelet = 76000/cumm). Cerebrospinal fluid analysis including India ink, Latex test, and fungal culture confirmed Cryptococcus neoformans infections. HIV-1 infection was confirmed by HIV-enzymelinked immunosorbent assay and HIV-1 Western blot from blood serum. Based on the diagnosis of AIDS and Cryptococcus neoformans meningitis (CNM), the patient was then transferred to an isolation ward in the Division of Infection for further management. During the patient’s hospitalization in the isolation ward, cryptococcal meningitis was treated with amphotericin-B 50 mg/day, and his HIV infection was treated with highly active antiretroviral therapy, including lopinaivir 800 mg/day, ritonavir 200 mg/day, abacavir 600 mg/day, and lamivudine 300 mg/day. His manic symptoms were relatively stable (YMRS = 2) even without psychotropic medication. Unfortunately, 1 month after his admission to the Infection Unit, he became infected with Pneumocystis carinii and died of pneumonia-related sepsis. The clinical course of Mr Y is delineated in Figure 2.
DISCUSSIONS In the literature, there have been two reports of secondary mania due to AIDS and CNM,5,6 but both cases involved middle-aged men. To the best of our knowledge, this is the first report of late-onset mania due to AIDS and CNM in a geriatric patient. In this report, we highlighted a case of late-onset mania that appeared to be associated with AIDS and CNM in a geriatric patient. In the present case, delirium should have been a differential diagnosis because central nervous system (CNS) infection was revealed. Although the patient was distractible, he was fully oriented and alert without fluctuating consciousness during the interview. In addition, he was able to perform all activities of daily living even with the presence of manic symptoms. Therefore, delirium was not likely in this case. Among HIV-seropositive patients, CNM is the second most common cause of opportunistic infection.6 Both HIV and CNM have been reported to be associated with manic episodes.6–11 Therefore, we could not definitively conclude that that Mr Y’s symptoms were due to CNM, AIDS, or both. Although we © 2015 The Authors Psychogeriatrics © 2015 Japanese Psychogeriatric Society
Mania due to AIDS
Figure 2 Clinical course of Mr Y. ER, emergency room; MMSE, Mini-Mental State Examination; PCP, Pneumocystis Carinii Pneumonia; YMRS, Young Mania Rating Scale.
could not effectively rule out cognitive impairment or dementia secondary to AIDS, the patient displayed no signs or symptoms of HIV-associated dementia, including memory loss, mental slowing, reading and comprehension difficulties, and apathy,6 other than his expansive mood and distractibility on the attention and concentration sections of the Mini-Mental State Examination. Pharmacological treatment for secondary mania is similar to treatment for primary mania but with lower doses of atypical antipsychotics or mood stabilizers.1 With limited evidence base for the treatment of mania due to CNM (or AIDS), our decision to initiate treatment with atypical antipsychotics was based on the limited efficacy of mood stabilizers in HIV-infected patients and our patient’s unique medical conditions.6 As HIV induces neuronal damage at the basal ganglia, treating HIV-infected patients with dopamine receptor-2 antagonists may increase the risk of extrapyramidal symptoms. Risperidone, ziprasidone, and olanzapine have been reported to be efficacious with fewer side-effects in the treatment of either HIV or CNM-related manic symptoms.6,9,11,12 However, for this 78-year-old patient, we prescribed quetiapine 50 mg/day because olanzapine was unavailable in our hospital and the risks of extrapyramidal symptoms with quetiapine when compared with other antipsychotics are relatively low.13 Our patient responded © 2015 The Authors Psychogeriatrics © 2015 Japanese Psychogeriatric Society
well to quetiapine 50 mg/day along with lorazepam 1 mg/day and showed improvements in his YMRS score within 2 weeks. In conclusion, our case highlighted the importance of comprehensive differential diagnosis to rule out secondary causes of psychiatric symptoms presenting for the first time in elderly patients in clinical practice. For clinical practitioners, a thorough medical work-up is warranted when approaching new-onset manic symptoms among geriatric patients.
REFERENCES 1 Brooks JO, 3rd, Hoblyn JC. Secondary mania in older adults. Am J Psychiatry 2005; 162: 2033–2038. 2 Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978; 133: 429–435. 3 Folstein MF, Folstein SE, McHugh PR. ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189–198. 4 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington, DC: American Psychiatric Association, 2000. 5 Johannessen DJ, Wilson LG. Mania with cryptococcal meningitis in two AIDS patients. J Clin Psychiatry 1988; 49: 200–201. 6 Spiegel DR, Bayne CE, Wilcox L, Somova M. A case of mania due to cryptococcal meningitis, successfully treated with adjunctive olanzapine, in a patient with acquired immunodeficiency syndrome. Gen Hosp Psychiatry 2011; 33: 301.e3– 301.e6. 7 Dube B, Benton T, Cruess DG, Evans DL. Neuropsychiatric manifestations of HIV infection and AIDS. J Psychiatry Neurosci 2005; 30: 237–246.
137
P.-H. Chou et al. 8 Ferrando SJ, Nims C. HIV-associated mania treated with electroconvulsive therapy and highly-active antiretroviral therapy. Psychosomatics 2006; 47: 170–174. 9 Prakash O, Bagepally BS. Catatonia and mania in patient with AIDS: treatment with lorazepam and risperidone. Gen Hosp Psychiatry 2012; 34: 321.e5–321.e6. 10 Johnson FY, Naraqi S. Manic episode secondary to cryptococcal meningitis in a previously healthy adult. P N G Med J 1993; 36: 59–62. 11 Tang WK, Hui M, Ungvari GS, Leung CM. Cryptococcal meningitis mimicking primary mania in a young female. Gen Hosp Psychiatry 2005; 27: 301–303.
138
12 Spiegel DR, Weller AL, Pennell K, Turner K. The successful treatment of mania due to acquired immunodeficiency syndrome using ziprasidone: a case series. J Neuropsychiatry Clin Neurosci 2010; 22: 111–114. 13 Scherk H, Pajonk FG, Leucht S. Second-generation antipsychotic agents in the treatment of acute mania: a systematic review and meta-analysis of randomized controlled trials. Arch Gen Psychiatry 2007; 64: 442–455.
© 2015 The Authors Psychogeriatrics © 2015 Japanese Psychogeriatric Society
