- Email: [email protected]
A horse in zebra stripes: a peculiar case of undetected end-stage AIDS
General Hospital Psychiatry xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
A horse in zebra stripes: a peculiar case of undetected end-stage AIDS☆,☆☆ Kei Yoshimatsu, M.D. 1, J. Michael Bostwick, M.D. ⁎ Mayo Clinic, Rochester, MN 55905
a r t i c l e
i n f o
Article history: Received 7 May 2014 Revised 12 June 2015 Accepted 12 June 2015 Available online xxxx Keywords: HIV AIDS HIV-associated dementia Depression Mood disorder
a b s t r a c t Objective: Late HIV diagnosis occurs in up to 45% of new HIV cases in the developed world and is linked to worse health outcomes, including more hospitalizations, higher health care resource utilization and less robust responses to highly active antiretroviral therapy. Method: Case report Results: A 70-year-old woman with an obscure constellation of medical and psychiatric complaints ultimately proved to have end-stage acquired immunodeficiency syndrome discovered much too late. Curiously, she had no obvious risk factors for HIV infection. Conclusion: This tragic case underscores the importance of keeping HIV infection in the differential for a patient with diverse vague complaints. Let this story caution its readers: when you hear hoof beats, do not look for zebras — even when you are least expecting a horse. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Late HIV diagnosis, typically defined as a CD4+ T-cell count b200 cells/mm 3 at the time of discovery, occurs in up to 45% of new HIV cases in the developed world [1] and is linked to worse health outcomes, including more hospitalizations [2], higher health care resource utilization [3] and less robust responses to highly active antiretroviral therapy (HAART) [4]. This is of particular concern in the psychiatric population, which has both increased HIV infection risk [5,6] and high prevalence of undetected HIV positivity [7,8]. We report a patient who gradually accrued a mysterious constellation of hematologic, psychiatric and neurologic symptoms whose commonality did not become overt until in a late-stage AIDS diagnosis was made.
2. Case report Mrs. N, a previously healthy 70-year-old Caucasian married grandmother from rural Minnesota, was referred to our tertiary academic center for nausea, poor appetite, profound fatigue and 35-lb weight ☆ Conflicts of interest: none. ☆☆ Financial support: none. ⁎ Corresponding author at: Department of Psychiatry & Psychology, Rochester, MN 55905. Tel.:+1 507 255 9187; fax: +1 507 255 9416. E-mail addresses: [email protected] (K. Yoshimatsu), [email protected] (J.M. Bostwick). 1 Present address: Department of Psychiatry, University of California, San Francisco, CA 94117.
loss over 10 months. Her past medical, surgical, family and social histories were noncontributory. An initial comprehensive outpatient gastrointestinal workup was unremarkable. Hematological investigations revealed mild leukopenia and a diagnosis of chronic indolent leukemia likely unrelated to her presenting symptoms. Seen by Psychiatry for depressive symptoms with a Beck Depression Inventory Score of 10, Ms. N was diagnosed with major depressive disorder and started on citalopram 10 mg. Over the next few months, she continued to follow with outpatient Hematology for leukopenia surveillance and Psychiatry for ongoing depression management. On citalopram 20 mg, she experienced less fatigue, better sleep and weight stabilization. She continued, however, to complain of diminished motivation and concentration. Several months later, her daughter noted the patient becoming excessively sleepy, confused and dehydrated. After emergency department evaluation identified a urinary tract infection (ITU), she was admitted to the medical/geriatric psychiatric unit for treatment of the infection and associated delirium. During a week-long hospitalization, her mental status returned to baseline. Methylphenidate 20 mg was added to treat her now-chronic complaints of diminished concentration, poor motivation and overall apathy. Eight months later, Mrs. N was hospitalized after episodes of transient neurologic symptoms, including hemiparesis, expressive aphasia, gait disturbance and confusion. An extensive workup ruled out stroke, transient ischemic attack, seizures, migraines, infections and more obscure neurologic disorders. A diagnosis of psychogenic spells was briefly entertained. After weeks of unrevealing investigations, a single screen came up positive — her HIV test. When she proved to have an HIV
http://dx.doi.org/10.1016/j.genhosppsych.2015.06.013 0163-8343/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Yoshimatsu K., Bostwick JM, A horse in zebra stripes: a peculiar case of undetected end-stage AIDS, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.06.013
2
K. Yoshimatsu, J.M. Bostwick / General Hospital Psychiatry xxx (2015) xxx–xxx
viral load of over 100,000 copies/ml and a CD4 count of 1/μl, advanced AIDS was diagnosed. Suddenly, her disparate medical findings made sense: the persistent leukopenia stemmed from chronic HIV infection; AIDS subacute encephalitis explained her susceptibility to delirium as well as intermittent neurologic symptoms; her treatment-resistant depressive symptoms were manifestations of HIV-associated dementia. Despite immediate initiation of HAART and infection prophylaxis, her neuropsychiatric status continued to worsen. Discharged to a nursing home, Mrs. N expired months later from complications of a fall. 3. Discussion 3.1. Why was her HIV undetected? How did Mrs. N’s HIV infection remain undetected for nearly a year despite involvement of multiple specialized teams? First, she had no obvious HIV risk factors. A seemingly straitlaced 70-year-old rural wife, she denied illicit drug use or sex outside her marriage, both currently and remotely. Aside from minor dental surgeries and a dilatation-andcurettage procedure, she had had no major surgeries or other plausible exposures to HIV through foreign travel, blood transfusions or health care employment. Second, her signs and symptoms were nonspecific. Throughout the months of investigation, she never exhibited lymphadenopathy, dermatological changes or other suggestive findings. Aside from oral thrush during ITU treatment, she experienced no opportunistic infections. Upon repeated questioning, her husband did reveal that the couple had engaged in a brief episode of spouse-swapping decades earlier, though he proved to be HIV-negative. Mrs. N also did not meet the current universal HIV screening guideline by the Centers for Disease Control and Prevention: “in all health-care settings, screening for HIV infection should be performed routinely for all patients aged 13–64 years” [9]. 3.2. Can HIV/AIDS explain her psychiatric symptoms? The AIDS diagnosis made sense of disparate elements of her presentation. First, anorexia and involuntary weight loss are common initial presenting symptoms of AIDS [10], and over 80% of HIV patients experience fatigue [11,12]. Furthermore, Mrs. N’s diminished concentration and motivation could have been signs of early HIV-associated dementia [13,14]. Cognitive impairment, including altered mental status, memory loss and language deficits, occurs in up to 50% of patients [15,16]. HIV also leads to a “lack of mental reserve” and an increased risk for delirium [17]. Psychosis, delusions and other psychiatric manifestations are also common in these patients [18]. 3.3. What is known about depression and HIV? Up to 30% of HIV-positive individuals receiving medical care experience depression [19,20]. Studies have shown that the severity of depression correlates with the HIV disease progression [21,22]. Furthermore, depression was associated with lower medication adherence and higher mortality [23–25]. Another study correlated depression in HIVpositive patients with a rapid decline in CD4 counts compared to those without affective symptoms [26]. Complicating the picture even more is the depression that HAART treatment itself can induce [27]. 4. Conclusion We report the case of a 70-year-old female without obvious HIV risk factors who presented with a piecemeal collection of medical and psychiatric symptoms that lacked coherence until occult end-stage AIDS was exposed. More than 30 years after the emergence of the AIDS epidemic, this tragic case underscores the importance of keeping HIV
infection in the differential for a patient with diverse vague complaints, even when the diagnosis seems implausible based on the demure and conventional demeanor of the patient before you. Ultimately, Mrs. N’s herd of symptoms proved to be not a zebra but a horse of a different color. References [1] Fisher M. Late diagnosis of HIV infection: major consequences and missed opportunities. Curr Opin Infect Dis 2008;21:1–3. [2] Shrosbree J, Campbell LJ, Ibrahim F, Hopkins P, Vizcaychipi M, Strachan S, et al. Late HIV diagnosis is a major risk factor for intensive care unit admission in HIV-positive patients: a single centre observational cohort study. BMC Infect Dis 2013;13:23. [3] Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 b200 cells/microl) with HIV infection. HIV Med 2004;5:93–8. [4] May M, Sterne JA, Sabin C, Costagliola D, Justice AC, Thiebaut R, et al. Prognosis of HIV-1-infected patients up to 5 years after initiation of HAART: collaborative analysis of prospective studies. AIDS 2007;21:1185–97. [5] Cournos F, Empfield M, Horwath E, McKinnon K, Meyer I, Schrage H, et al. HIV seroprevalence among patients admitted to two psychiatric hospitals. Am J Psychiatry 1991;148: 1225–30. [6] Beyer JL, Taylor L, Gersing KR, Krishnan KR. Prevalence of HIV infection in a general psychiatric outpatient population. Psychosomatics 2007;48:31–7. [7] Sacks M, Dermatis H, Looser-Ott S, Burton W, Perry S. Undetected HIV infection among acutely ill psychiatric inpatients. Am J Psychiatry 1992;149:544–5. [8] Mahler J, Yi D, Sacks M, Dermatis H, Stebinger A, Card C, et al. Undetected HIV infection among patients admitted to an alcohol rehabilitation unit. Am J Psychiatry 1994;151:439–40. [9] Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morbidity and mortality weekly report: recommendations and reports. Washington, DC: Centers for Disease Control and Prevention, Department of Health and Human Services, U.S. Government Printing Office; 2006. p. 1–17. [10] Kotler DP. Nutritional alterations associated with HIV infection. J Acquir Immune Defic Syndr 2000;25(Suppl. 1):S81–7. [11] Leserman J, Barroso J, Pence BW, Salahuddin N, Harmon JL. Trauma, stressful life events and depression predict HIV-related fatigue. AIDS Care 2008;20: 1258–65. [12] Schifitto G, Deng L, Yeh TM, Evans SR, Ernst T, Zhong J, et al. Clinical, laboratory, and neuroimaging characteristics of fatigue in HIV-infected individuals. J Neurovirol 2011;17:17–25. [13] Singh D. What's in a name? AIDS dementia complex, HIV-associated dementia, HIVassociated neurocognitive disorder or HIV encephalopathy. Afr J Psychiatry (Johannesbg) 2012;15:172–5. [14] Boisse L, Gill MJ, Power C. HIV infection of the central nervous system: clinical features and neuropathogenesis. Neurol Clin 2008;26:799–819. [15] Schouten J, Cinque P, Gisslen M, Reiss P, Portegies P. HIV-1 infection and cognitive impairment in the cART era: a review. AIDS 2011;25:561–75. [16] Treisman GJ, Kaplin AI. Neurologic and psychiatric complications of antiretroviral agents. AIDS 2002;16:1201–15. [17] Angelino AF, Treisman GJ. Issues in co-morbid severe mental illnesses in HIV infected individuals. Int Rev Psychiatry 2008;20:95–101. [18] Alciati A, Fusi A, D'Arminio Monforte A, Coen M, Ferri A, Mellado C, et al. New-onset delusions and hallucinations in patients infected with HIV. J Psychiatry Neurosci 2001;26:229–34. [19] Atkinson Jr JH, Grant I, Kennedy CJ, Richman DD, Spector SA, McCutchan JA. Prevalence of psychiatric disorders among men infected with human immunodeficiency virus. A controlled study. Arch Gen Psychiatry 1988;45:859–64. [20] Pence BW, O'Donnell JK, Gaynes BN. Falling through the cracks: the gaps between depression prevalence, diagnosis, treatment, and response in HIV care. AIDS 2012; 26:656–8. [21] Lyketsos CG, Hoover DR, Guccione M, Dew MA, Wesch JE, Bing EG, et al. Changes in depressive symptoms as aids develops. The multicenter aids cohort study. Am J Psychiatry 1996;153:1430–7. [22] Lyketsos CG, Hoover DR, Guccione M, Dew MA, Wesch JE, Bing EG, et al. Depressive symptoms over the course of HIV infection before aids. Soc Psychiatry Psychiatr Epidemiol 1996;31:212–9. [23] Bouhnik AD, Preau M, Vincent E, Carrieri MP, Gallais H, Lepeu G, et al. Depression and clinical progression in HIV-infected drug users treated with highly active antiretroviral therapy. Antivir Ther 2005;10:53–61. [24] Lima VD, Geller J, Bangsberg DR, Patterson TL, Daniel M, Kerr T, et al. The effect of adherence on the association between depressive symptoms and mortality among HIV-infected individuals first initiating HAART. AIDS 2007;21:1175–83. [25] Tegger MK, Crane HM, Tapia KA, Uldall KK, Holte SE, Kitahata MM. The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals. AIDS Patient Care STDS 2008;22:233–43. [26] Burack JH, Barrett DC, Stall RD, Chesney MA, Ekstrand ML, Coates TJ. Depressive symptoms and CD4 lymphocyte decline among HIV-infected men. JAMA 1993; 270:2568–73. [27] Raines C, Radcliffe O, Treisman GJ. Neurologic and psychiatric complications of antiretroviral agents. J Assoc Nurses AIDS Care 2005;16:35–48.
Please cite this article as: Yoshimatsu K., Bostwick JM, A horse in zebra stripes: a peculiar case of undetected end-stage AIDS, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.06.013
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
A horse in zebra stripes: a peculiar case of undetected end-stage AIDS☆,☆☆ Kei Yoshimatsu, M.D. 1, J. Michael Bostwick, M.D. ⁎ Mayo Clinic, Rochester, MN 55905
a r t i c l e
i n f o
Article history: Received 7 May 2014 Revised 12 June 2015 Accepted 12 June 2015 Available online xxxx Keywords: HIV AIDS HIV-associated dementia Depression Mood disorder
a b s t r a c t Objective: Late HIV diagnosis occurs in up to 45% of new HIV cases in the developed world and is linked to worse health outcomes, including more hospitalizations, higher health care resource utilization and less robust responses to highly active antiretroviral therapy. Method: Case report Results: A 70-year-old woman with an obscure constellation of medical and psychiatric complaints ultimately proved to have end-stage acquired immunodeficiency syndrome discovered much too late. Curiously, she had no obvious risk factors for HIV infection. Conclusion: This tragic case underscores the importance of keeping HIV infection in the differential for a patient with diverse vague complaints. Let this story caution its readers: when you hear hoof beats, do not look for zebras — even when you are least expecting a horse. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Late HIV diagnosis, typically defined as a CD4+ T-cell count b200 cells/mm 3 at the time of discovery, occurs in up to 45% of new HIV cases in the developed world [1] and is linked to worse health outcomes, including more hospitalizations [2], higher health care resource utilization [3] and less robust responses to highly active antiretroviral therapy (HAART) [4]. This is of particular concern in the psychiatric population, which has both increased HIV infection risk [5,6] and high prevalence of undetected HIV positivity [7,8]. We report a patient who gradually accrued a mysterious constellation of hematologic, psychiatric and neurologic symptoms whose commonality did not become overt until in a late-stage AIDS diagnosis was made.
2. Case report Mrs. N, a previously healthy 70-year-old Caucasian married grandmother from rural Minnesota, was referred to our tertiary academic center for nausea, poor appetite, profound fatigue and 35-lb weight ☆ Conflicts of interest: none. ☆☆ Financial support: none. ⁎ Corresponding author at: Department of Psychiatry & Psychology, Rochester, MN 55905. Tel.:+1 507 255 9187; fax: +1 507 255 9416. E-mail addresses: [email protected] (K. Yoshimatsu), [email protected] (J.M. Bostwick). 1 Present address: Department of Psychiatry, University of California, San Francisco, CA 94117.
loss over 10 months. Her past medical, surgical, family and social histories were noncontributory. An initial comprehensive outpatient gastrointestinal workup was unremarkable. Hematological investigations revealed mild leukopenia and a diagnosis of chronic indolent leukemia likely unrelated to her presenting symptoms. Seen by Psychiatry for depressive symptoms with a Beck Depression Inventory Score of 10, Ms. N was diagnosed with major depressive disorder and started on citalopram 10 mg. Over the next few months, she continued to follow with outpatient Hematology for leukopenia surveillance and Psychiatry for ongoing depression management. On citalopram 20 mg, she experienced less fatigue, better sleep and weight stabilization. She continued, however, to complain of diminished motivation and concentration. Several months later, her daughter noted the patient becoming excessively sleepy, confused and dehydrated. After emergency department evaluation identified a urinary tract infection (ITU), she was admitted to the medical/geriatric psychiatric unit for treatment of the infection and associated delirium. During a week-long hospitalization, her mental status returned to baseline. Methylphenidate 20 mg was added to treat her now-chronic complaints of diminished concentration, poor motivation and overall apathy. Eight months later, Mrs. N was hospitalized after episodes of transient neurologic symptoms, including hemiparesis, expressive aphasia, gait disturbance and confusion. An extensive workup ruled out stroke, transient ischemic attack, seizures, migraines, infections and more obscure neurologic disorders. A diagnosis of psychogenic spells was briefly entertained. After weeks of unrevealing investigations, a single screen came up positive — her HIV test. When she proved to have an HIV
http://dx.doi.org/10.1016/j.genhosppsych.2015.06.013 0163-8343/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Yoshimatsu K., Bostwick JM, A horse in zebra stripes: a peculiar case of undetected end-stage AIDS, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.06.013
2
K. Yoshimatsu, J.M. Bostwick / General Hospital Psychiatry xxx (2015) xxx–xxx
viral load of over 100,000 copies/ml and a CD4 count of 1/μl, advanced AIDS was diagnosed. Suddenly, her disparate medical findings made sense: the persistent leukopenia stemmed from chronic HIV infection; AIDS subacute encephalitis explained her susceptibility to delirium as well as intermittent neurologic symptoms; her treatment-resistant depressive symptoms were manifestations of HIV-associated dementia. Despite immediate initiation of HAART and infection prophylaxis, her neuropsychiatric status continued to worsen. Discharged to a nursing home, Mrs. N expired months later from complications of a fall. 3. Discussion 3.1. Why was her HIV undetected? How did Mrs. N’s HIV infection remain undetected for nearly a year despite involvement of multiple specialized teams? First, she had no obvious HIV risk factors. A seemingly straitlaced 70-year-old rural wife, she denied illicit drug use or sex outside her marriage, both currently and remotely. Aside from minor dental surgeries and a dilatation-andcurettage procedure, she had had no major surgeries or other plausible exposures to HIV through foreign travel, blood transfusions or health care employment. Second, her signs and symptoms were nonspecific. Throughout the months of investigation, she never exhibited lymphadenopathy, dermatological changes or other suggestive findings. Aside from oral thrush during ITU treatment, she experienced no opportunistic infections. Upon repeated questioning, her husband did reveal that the couple had engaged in a brief episode of spouse-swapping decades earlier, though he proved to be HIV-negative. Mrs. N also did not meet the current universal HIV screening guideline by the Centers for Disease Control and Prevention: “in all health-care settings, screening for HIV infection should be performed routinely for all patients aged 13–64 years” [9]. 3.2. Can HIV/AIDS explain her psychiatric symptoms? The AIDS diagnosis made sense of disparate elements of her presentation. First, anorexia and involuntary weight loss are common initial presenting symptoms of AIDS [10], and over 80% of HIV patients experience fatigue [11,12]. Furthermore, Mrs. N’s diminished concentration and motivation could have been signs of early HIV-associated dementia [13,14]. Cognitive impairment, including altered mental status, memory loss and language deficits, occurs in up to 50% of patients [15,16]. HIV also leads to a “lack of mental reserve” and an increased risk for delirium [17]. Psychosis, delusions and other psychiatric manifestations are also common in these patients [18]. 3.3. What is known about depression and HIV? Up to 30% of HIV-positive individuals receiving medical care experience depression [19,20]. Studies have shown that the severity of depression correlates with the HIV disease progression [21,22]. Furthermore, depression was associated with lower medication adherence and higher mortality [23–25]. Another study correlated depression in HIVpositive patients with a rapid decline in CD4 counts compared to those without affective symptoms [26]. Complicating the picture even more is the depression that HAART treatment itself can induce [27]. 4. Conclusion We report the case of a 70-year-old female without obvious HIV risk factors who presented with a piecemeal collection of medical and psychiatric symptoms that lacked coherence until occult end-stage AIDS was exposed. More than 30 years after the emergence of the AIDS epidemic, this tragic case underscores the importance of keeping HIV
infection in the differential for a patient with diverse vague complaints, even when the diagnosis seems implausible based on the demure and conventional demeanor of the patient before you. Ultimately, Mrs. N’s herd of symptoms proved to be not a zebra but a horse of a different color. References [1] Fisher M. Late diagnosis of HIV infection: major consequences and missed opportunities. Curr Opin Infect Dis 2008;21:1–3. [2] Shrosbree J, Campbell LJ, Ibrahim F, Hopkins P, Vizcaychipi M, Strachan S, et al. Late HIV diagnosis is a major risk factor for intensive care unit admission in HIV-positive patients: a single centre observational cohort study. BMC Infect Dis 2013;13:23. [3] Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 b200 cells/microl) with HIV infection. HIV Med 2004;5:93–8. [4] May M, Sterne JA, Sabin C, Costagliola D, Justice AC, Thiebaut R, et al. Prognosis of HIV-1-infected patients up to 5 years after initiation of HAART: collaborative analysis of prospective studies. AIDS 2007;21:1185–97. [5] Cournos F, Empfield M, Horwath E, McKinnon K, Meyer I, Schrage H, et al. HIV seroprevalence among patients admitted to two psychiatric hospitals. Am J Psychiatry 1991;148: 1225–30. [6] Beyer JL, Taylor L, Gersing KR, Krishnan KR. Prevalence of HIV infection in a general psychiatric outpatient population. Psychosomatics 2007;48:31–7. [7] Sacks M, Dermatis H, Looser-Ott S, Burton W, Perry S. Undetected HIV infection among acutely ill psychiatric inpatients. Am J Psychiatry 1992;149:544–5. [8] Mahler J, Yi D, Sacks M, Dermatis H, Stebinger A, Card C, et al. Undetected HIV infection among patients admitted to an alcohol rehabilitation unit. Am J Psychiatry 1994;151:439–40. [9] Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morbidity and mortality weekly report: recommendations and reports. Washington, DC: Centers for Disease Control and Prevention, Department of Health and Human Services, U.S. Government Printing Office; 2006. p. 1–17. [10] Kotler DP. Nutritional alterations associated with HIV infection. J Acquir Immune Defic Syndr 2000;25(Suppl. 1):S81–7. [11] Leserman J, Barroso J, Pence BW, Salahuddin N, Harmon JL. Trauma, stressful life events and depression predict HIV-related fatigue. AIDS Care 2008;20: 1258–65. [12] Schifitto G, Deng L, Yeh TM, Evans SR, Ernst T, Zhong J, et al. Clinical, laboratory, and neuroimaging characteristics of fatigue in HIV-infected individuals. J Neurovirol 2011;17:17–25. [13] Singh D. What's in a name? AIDS dementia complex, HIV-associated dementia, HIVassociated neurocognitive disorder or HIV encephalopathy. Afr J Psychiatry (Johannesbg) 2012;15:172–5. [14] Boisse L, Gill MJ, Power C. HIV infection of the central nervous system: clinical features and neuropathogenesis. Neurol Clin 2008;26:799–819. [15] Schouten J, Cinque P, Gisslen M, Reiss P, Portegies P. HIV-1 infection and cognitive impairment in the cART era: a review. AIDS 2011;25:561–75. [16] Treisman GJ, Kaplin AI. Neurologic and psychiatric complications of antiretroviral agents. AIDS 2002;16:1201–15. [17] Angelino AF, Treisman GJ. Issues in co-morbid severe mental illnesses in HIV infected individuals. Int Rev Psychiatry 2008;20:95–101. [18] Alciati A, Fusi A, D'Arminio Monforte A, Coen M, Ferri A, Mellado C, et al. New-onset delusions and hallucinations in patients infected with HIV. J Psychiatry Neurosci 2001;26:229–34. [19] Atkinson Jr JH, Grant I, Kennedy CJ, Richman DD, Spector SA, McCutchan JA. Prevalence of psychiatric disorders among men infected with human immunodeficiency virus. A controlled study. Arch Gen Psychiatry 1988;45:859–64. [20] Pence BW, O'Donnell JK, Gaynes BN. Falling through the cracks: the gaps between depression prevalence, diagnosis, treatment, and response in HIV care. AIDS 2012; 26:656–8. [21] Lyketsos CG, Hoover DR, Guccione M, Dew MA, Wesch JE, Bing EG, et al. Changes in depressive symptoms as aids develops. The multicenter aids cohort study. Am J Psychiatry 1996;153:1430–7. [22] Lyketsos CG, Hoover DR, Guccione M, Dew MA, Wesch JE, Bing EG, et al. Depressive symptoms over the course of HIV infection before aids. Soc Psychiatry Psychiatr Epidemiol 1996;31:212–9. [23] Bouhnik AD, Preau M, Vincent E, Carrieri MP, Gallais H, Lepeu G, et al. Depression and clinical progression in HIV-infected drug users treated with highly active antiretroviral therapy. Antivir Ther 2005;10:53–61. [24] Lima VD, Geller J, Bangsberg DR, Patterson TL, Daniel M, Kerr T, et al. The effect of adherence on the association between depressive symptoms and mortality among HIV-infected individuals first initiating HAART. AIDS 2007;21:1175–83. [25] Tegger MK, Crane HM, Tapia KA, Uldall KK, Holte SE, Kitahata MM. The effect of mental illness, substance use, and treatment for depression on the initiation of highly active antiretroviral therapy among HIV-infected individuals. AIDS Patient Care STDS 2008;22:233–43. [26] Burack JH, Barrett DC, Stall RD, Chesney MA, Ekstrand ML, Coates TJ. Depressive symptoms and CD4 lymphocyte decline among HIV-infected men. JAMA 1993; 270:2568–73. [27] Raines C, Radcliffe O, Treisman GJ. Neurologic and psychiatric complications of antiretroviral agents. J Assoc Nurses AIDS Care 2005;16:35–48.
Please cite this article as: Yoshimatsu K., Bostwick JM, A horse in zebra stripes: a peculiar case of undetected end-stage AIDS, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.06.013