Pancytopenia and Bizzare Behavior: Admit to Psychiatry or Medicine?

Sophia Paraschos, MD* and Dr. Richard M. Wardrop III, MD, PhD, University of North Carolina, Chapel Hill, NC

Meeting: Hospital Medicine 2016, March 6-9, San Diego, Calif.

Abstract number: 724

Categories: Adult, Clinical Vignettes Abstracts

Keywords: ,

Case Presentation:

A 46 year-old caucasian man presented with one week of altered mental status and bizarre behavior. He had no personal or familial psychiatric history. His past medical history included documented asthma, thalassemia, and celiac disease, both recently diagnosed. His bizarre behaviors included quitting his job, entertaining fixed delusions regarding his identity, and mania with features of relentless energy, total sleeplessness and anorexia. He described a new facial rash, as well as diarrhea and weight loss, which had been diagnosed as Celiac disease. He denied fever or other signs of infection. He had an erythematous, scaly rash over his nasolabial folds, beard, and eyebrows, oral thrush, pressured speech, flight of ideas, fixed delusions, and absence of insight.  His labs revealed pancytopenia with WBC 2.8, hemoglobin 9.2, hematocrit 31, and platelets 114.  Drug and alcohol screens were negative.  Head CT and MRI were normal. HIV serology was positive, RNA viral load was 95,900, and CD4 count was 6. He was initially unable to provide a sexual history, but eventually disclosed that he had been sexually active with one male partner who had known HIV. He was started on olanzapine and HAART with minimal improvement in his mania 2 weeks later at the time of transfer to a psychiatric facility.

Discussion:

New-onset mania in a middle-aged individual with no personal or family psychiatric history should prompt investigation for potential medical etiologies. The patient also had several characteristic findings of late-stage HIV, including weight loss, seborrheic dermatitis, oral candidiasis, diarrhea, and pancytopenia. His recently diagnosed thalassemia and celiac disease were therefore suspect. His secondary mania, or “AIDS mania,” is an uncommon, but well described complication of late-stage HIV.

Early studies of HIV patients found that AIDS mania has an incidence of 4-8% and could be differentiated from bipolar-associated mania by its manifestation late in the course of HIV (CD4 count <200), its association with irritability, psychomotor slowing, progressive dementia, and patients’ lack of prior personal or familial psychiatric history. AIDS mania may also manifest as increased cycling in a patient with known bipolar disorder. These cognitive and behavioral symptoms are thought to be a direct effect of HIV in the CNS.

Treatment for this condition includes anti-psychotics and HAART.  Typical and atypical neuroleptics have shown similar success rates. Electroconvulsive therapy has also been effective in refractory cases. Compared to primary bipolar disorder, AIDS-mania has a more chronic and severe course, including association with HIV-associated dementia.

Conclusions:

New onset mania in a middle-aged patient with no psychiatric history should raise suspicion for medical etiologies.  AIDS mania is an uncommon but well described complication of late-stage HIV, which has a poor prognosis. Treatment includes HAART and anti-psychotics.

To cite this abstract:

Paraschos S, Wardrop RM III. Pancytopenia and Bizzare Behavior: Admit to Psychiatry or Medicine?. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 724. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/pancytopenia-and-bizzare-behavior-admit-to-psychiatry-or-medicine/. Accessed November 19, 2019.

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