- Email: [email protected]
AIDS encephalitis mimicking alcohol dementia and depression
394
BlOL
PSYCHIATR’r
19X6:21:294-397
CASE REPORT
AIDS Encephalitis Depression
Mimicking Alcohol Dementia and
Thomas P. Beresford. Frederic C. Blow, and Richard C. W. Hall
introduction Despite the notoriety ofaqnred immune deficiency syndrome (AIDS) both in the popular press and in medical news magazines. only three cases of ADS have been reported 111 the psychiatric literature to our knowledge. Numberg and associates (Nurnberg et al. 1984) described a patient hospitalized with depression, anxiety, and delusions of making other people ill. This homosexual man, with no history of iv drug abuse. evidenced both command hallucinations and impaired cognition. His white cell count was low (3500 cells/cm’) and his cerebrospinal fluid (CSF) protein was high ( 100 mg/ml). A computerized tomography (CT) scan of the brain was negative. He had been hospitalized for Ptwrcttwcysti.\ curitzii pneumonia 4 months earlier. He died from this opportunistic infection on day 36 of his second hospitalization. never emerging from delirium. Hoffman reported two cases: a 36-year-old homosexual man admitted to a psychiatrrc service with apparent depression. and a 3 I -year-old homosexual man seen in psychiatric consultation service because of acute psychosis, confusion. and lethargy while hospitalized for Ptzerrmoc~~stis pneumonia (Hoffman 1984). The first case presented a leukopenia (4000 cells/cm’), whereas the second showed a normal white cell count. Cranial CT scan\ showed moderate diffuse cortical atrophy in both cases. Initial lumbar punctures in both cases revealed no abnormalities. The first patient expired 6 months later, after gradual worsening of his dementiform illness. The second patient improved with supportive medical therapy and low-dose haloperidol to control his psychotic symptoms. Both cases
AIDS Encephalitis, Dementia, and Depression
BIOL PSYCHIATRY 1986:21:394-397
395
suffered opportunistic infections. Gross and microscopic examinations of the brain at the first patient’s autopsy were normal, with no encephalitic changes. We report a fourth case.
Case Report
This 29-year-old black man was admitted to psychiatry after threatening his father with a knife. The history included iv drug abuse and homosexual
and heterosexual contacts. The present illness had begun within the 12 months prior to admission, causing his parents to go to another city to bring him home. He had been admitted to the same psychiatry service two months earlier, after threatening his family with violence. At that time, the history included heavy drinking, at least one episode of delirium tremens, and a diagnosis of pseudogranulomatous hepatitis. His mental status showed an uncooperative man who avoided eye contact and tried to evade the interview questions. Mood and affect were both subdued, and speech was slow and monotonous. Motor activity was slow. His thought processes, however, were normal, and there were no hallucinations, delusions, or thoughts of suicide or homicide. The patient would not cooperate with the cognitive examination other than to say that he was too tired. On physical examination, he appeared older than his stated age. He had a midline scar, allegedly from a cholecystectomy done 4 months earlier, with an abscess that was actively draining. His liver was enlarged, and he had a diffuse papular rash, diagnosed during his second admission as molluscum contagiousurn. His laboratory studies, including hepatitis B antigen and antibody tests, were within normal limits, save a marked leukopenia: 3600 cells/cm’. The patient was diagnosed as suffering from alcoholism, with a possible sociopathic character disorder. He refused admission to a rehabilitation program and left against medical advice after 3 days in the hospital. Two months later, at his final admission, the patient’s mental state had significantly worsened: he appeared very lethargic, lay in a fetal position, and stated he was too tired to respond to questions. The patient appeared thin, but not cachectic. His weight was 59 kg and had not varied appreciably since his earlier admission; his height was 170 cm. Admission temperature was 35.8”C. He had a draining scalp abscess, 3 x 4 cm, over his left occiput. His abdominal would had healed. He had diffuse lymphadenopathy prominent in inguinal, cervical, and axial areas. He was able to orient himself to person, place, and time but appeared to have difficulty with recent memory. He refused to cooperate with formal mental status testing, again saying that he was too tired. Laboratory studies again showed a leukopenia (2100 cells/cm’). Over the next 9 days, he became unable to orient himself with respect to time and only intermittently to place. His short-term memory markedly worsened, as did his abilities to attend and to concentrate. He did not develop delusions, hallucinations, or a thought disorder, but remained very lethargic and withdrawn. On the tenth day he became somnolent and was transferred to the medical service. The patient’s temperature was 34.4”C. His chest was clear, both on examination and roentgenogram. Lumbar puncture revealed four lymphocytes in the CSF and a protein of 250 mg/ml. His leukocyte count had risen slightly to 3400 cells/cm”. His serum triiodothyronine was mildly raised. Repeat hepatitis B antigen and antibody levels remained negative. Blood cultures of the patient’s serum were negative throughout. On the 1 lth
396
BIOL PSYCHIATRY 1986;21:394-397
T.P.
Beresford et al.
day, he expired from cardiac and respiratory arrest, brought on by an apparent pneumonia. An anti-HTLV III test drawn before the patient expired was reported positive. (The HTLV-III virus has been found in the brains of some AIDS patients suffering from dementia and encephalopathy; Shaw et al. 198.5.) Final anatomic diagnoses included ( 1J acute encephalitis and cerebral vasculitis with giant epithelioid cells of unknown etiology, (2) molluscum contagiosum involving face. thigh, and penis. and (31 acute pulmonary congestion and edema. Microscopic examination revealed tubuloreticular inclusions in lymphocytes in the brain. (These have been reported in numerous tissues of 85%) of AIDS patients; Sidhu et al. 1985.) Additionally, perivascular cellular infiltrates with focal necrosis and demyelination. as well as vasculitis of small vessels. were widespread throughout the brain; these involved brain stem, cerebellum, hippocampus. cerebral cortex. and deep white matter. Gram, acid-fast, and methanamine stains and electron microscopy of the brain revealed no infectious agents. Skin lesions of the lip and thigh examined by both light and electron microscopes showed changes typical of molluscum contagiosum. with pox-type viruses filling the cytoplasm of involved cells.
Discussion The patient’s history, presentation, and pathological findings, including opportunistic infection with molluscum contagiosum, are consistent with the diagnosis of AIDS (Downing et al. 1984; Fauci et al. 1985.) This patient’s lethargy and depressed appearance. along with eventual cognitive impairment, were typical of patients suffering from AIDS with concurrent “subacute encephalitis.” This term was used by Snider and colleagues (1983). Fourteen of I8 patients in their series were described as “demented” or “confused.” Ten of their cases of subacute encephalitis were also described as “depressed’ or “lethargic.” whereas only three cases in this group complained of hallucinations or hallucinatory-like phenomena. This smoldering, nonacute encephalitis may be easily mistaken as depression, as the delirium OI dementia complicating polydrug or alcohol abuse, or, as in this case, a worsening character disorder. Psychiatrists often see cases of depression and are frequently the first-line medical practitioners for persons suffering from intravenous substance abuse. Given the seriousness of AIDS and its potential for spread, as might have been possible in this case from the patient’s open wounds, psychiatrists must be alert to this illness and its clinical manifestations. AIDS-related disease must be considered in the differential diagnosis ot patients with depression and cognitive loss. The clinician must search for a history ot homosexual contact, intravenous drug abuse. blood transfusion, or other exposure to the AIDS virus. Evaluation should include a CT scan of the brain, lumbar puncture and anti-HTLV III test, in addition to standard blood counts, urinalysis, and blood chemistries. The white cell count and the CSF protein appear to be especially useful. Suspected cases should be referred to infectious disease or other medical specialists for further evaluation and supportive medical therapy. _ ‘The authors wish to thank Betty C. Uzman. M.D.. CITCHS, for her kmd asslslance in this report.
Pathology Service. VAMC.
and Department of Pathdog.
AIDS Encephalitis,
Dementia,
BIOL PSYCHIATRY 1986;21:394397
and Depression
397
References Downing RG, Eglin RP, Bayley AC (1984): African Kaposi’s sarcoma and AIDS. Lancer i:478-480. Fauci AS, Masur H, Gelman EP, et al (1985): The acquired immunodeficiency update. Ann Intern Med 102:800-813. Hoffman RS (1984): Neuropsychiatric
complications
of AIDS. Psychosomarics
Numberg HG, Prudic J, Fiori M, Freedman EP (1984): Psychopathology immune deficiency syndrome (AIDS). Am J Psychiatry 141:95-96.
syndrome:
An
25:393-400.
complicating
acquired
Shaw GM, Harper ME, Hahn BH, et al (198.5): HTLV-III infection in brains of children and adults with AIDS encephalopathy Science 227: 177- 182. Sidhu GS, Stahl RE, El-Sadr W, et al (1985): The acquired immunodeficiency ultrastructural study. Human Pathol 16:377-386.
syndrome:
An
Snider WD, Simpson DM, Nielsen S, Gold JWM. Metroka CE, Posner JB (1983): Neurological complications of acquired immune deficiency syndrome: Analysis of 50 patients. Ann Neural 14:403418.
BlOL
PSYCHIATR’r
19X6:21:294-397
CASE REPORT
AIDS Encephalitis Depression
Mimicking Alcohol Dementia and
Thomas P. Beresford. Frederic C. Blow, and Richard C. W. Hall
introduction Despite the notoriety ofaqnred immune deficiency syndrome (AIDS) both in the popular press and in medical news magazines. only three cases of ADS have been reported 111 the psychiatric literature to our knowledge. Numberg and associates (Nurnberg et al. 1984) described a patient hospitalized with depression, anxiety, and delusions of making other people ill. This homosexual man, with no history of iv drug abuse. evidenced both command hallucinations and impaired cognition. His white cell count was low (3500 cells/cm’) and his cerebrospinal fluid (CSF) protein was high ( 100 mg/ml). A computerized tomography (CT) scan of the brain was negative. He had been hospitalized for Ptwrcttwcysti.\ curitzii pneumonia 4 months earlier. He died from this opportunistic infection on day 36 of his second hospitalization. never emerging from delirium. Hoffman reported two cases: a 36-year-old homosexual man admitted to a psychiatrrc service with apparent depression. and a 3 I -year-old homosexual man seen in psychiatric consultation service because of acute psychosis, confusion. and lethargy while hospitalized for Ptzerrmoc~~stis pneumonia (Hoffman 1984). The first case presented a leukopenia (4000 cells/cm’), whereas the second showed a normal white cell count. Cranial CT scan\ showed moderate diffuse cortical atrophy in both cases. Initial lumbar punctures in both cases revealed no abnormalities. The first patient expired 6 months later, after gradual worsening of his dementiform illness. The second patient improved with supportive medical therapy and low-dose haloperidol to control his psychotic symptoms. Both cases
AIDS Encephalitis, Dementia, and Depression
BIOL PSYCHIATRY 1986:21:394-397
395
suffered opportunistic infections. Gross and microscopic examinations of the brain at the first patient’s autopsy were normal, with no encephalitic changes. We report a fourth case.
Case Report
This 29-year-old black man was admitted to psychiatry after threatening his father with a knife. The history included iv drug abuse and homosexual
and heterosexual contacts. The present illness had begun within the 12 months prior to admission, causing his parents to go to another city to bring him home. He had been admitted to the same psychiatry service two months earlier, after threatening his family with violence. At that time, the history included heavy drinking, at least one episode of delirium tremens, and a diagnosis of pseudogranulomatous hepatitis. His mental status showed an uncooperative man who avoided eye contact and tried to evade the interview questions. Mood and affect were both subdued, and speech was slow and monotonous. Motor activity was slow. His thought processes, however, were normal, and there were no hallucinations, delusions, or thoughts of suicide or homicide. The patient would not cooperate with the cognitive examination other than to say that he was too tired. On physical examination, he appeared older than his stated age. He had a midline scar, allegedly from a cholecystectomy done 4 months earlier, with an abscess that was actively draining. His liver was enlarged, and he had a diffuse papular rash, diagnosed during his second admission as molluscum contagiousurn. His laboratory studies, including hepatitis B antigen and antibody tests, were within normal limits, save a marked leukopenia: 3600 cells/cm’. The patient was diagnosed as suffering from alcoholism, with a possible sociopathic character disorder. He refused admission to a rehabilitation program and left against medical advice after 3 days in the hospital. Two months later, at his final admission, the patient’s mental state had significantly worsened: he appeared very lethargic, lay in a fetal position, and stated he was too tired to respond to questions. The patient appeared thin, but not cachectic. His weight was 59 kg and had not varied appreciably since his earlier admission; his height was 170 cm. Admission temperature was 35.8”C. He had a draining scalp abscess, 3 x 4 cm, over his left occiput. His abdominal would had healed. He had diffuse lymphadenopathy prominent in inguinal, cervical, and axial areas. He was able to orient himself to person, place, and time but appeared to have difficulty with recent memory. He refused to cooperate with formal mental status testing, again saying that he was too tired. Laboratory studies again showed a leukopenia (2100 cells/cm’). Over the next 9 days, he became unable to orient himself with respect to time and only intermittently to place. His short-term memory markedly worsened, as did his abilities to attend and to concentrate. He did not develop delusions, hallucinations, or a thought disorder, but remained very lethargic and withdrawn. On the tenth day he became somnolent and was transferred to the medical service. The patient’s temperature was 34.4”C. His chest was clear, both on examination and roentgenogram. Lumbar puncture revealed four lymphocytes in the CSF and a protein of 250 mg/ml. His leukocyte count had risen slightly to 3400 cells/cm”. His serum triiodothyronine was mildly raised. Repeat hepatitis B antigen and antibody levels remained negative. Blood cultures of the patient’s serum were negative throughout. On the 1 lth
396
BIOL PSYCHIATRY 1986;21:394-397
T.P.
Beresford et al.
day, he expired from cardiac and respiratory arrest, brought on by an apparent pneumonia. An anti-HTLV III test drawn before the patient expired was reported positive. (The HTLV-III virus has been found in the brains of some AIDS patients suffering from dementia and encephalopathy; Shaw et al. 198.5.) Final anatomic diagnoses included ( 1J acute encephalitis and cerebral vasculitis with giant epithelioid cells of unknown etiology, (2) molluscum contagiosum involving face. thigh, and penis. and (31 acute pulmonary congestion and edema. Microscopic examination revealed tubuloreticular inclusions in lymphocytes in the brain. (These have been reported in numerous tissues of 85%) of AIDS patients; Sidhu et al. 1985.) Additionally, perivascular cellular infiltrates with focal necrosis and demyelination. as well as vasculitis of small vessels. were widespread throughout the brain; these involved brain stem, cerebellum, hippocampus. cerebral cortex. and deep white matter. Gram, acid-fast, and methanamine stains and electron microscopy of the brain revealed no infectious agents. Skin lesions of the lip and thigh examined by both light and electron microscopes showed changes typical of molluscum contagiosum. with pox-type viruses filling the cytoplasm of involved cells.
Discussion The patient’s history, presentation, and pathological findings, including opportunistic infection with molluscum contagiosum, are consistent with the diagnosis of AIDS (Downing et al. 1984; Fauci et al. 1985.) This patient’s lethargy and depressed appearance. along with eventual cognitive impairment, were typical of patients suffering from AIDS with concurrent “subacute encephalitis.” This term was used by Snider and colleagues (1983). Fourteen of I8 patients in their series were described as “demented” or “confused.” Ten of their cases of subacute encephalitis were also described as “depressed’ or “lethargic.” whereas only three cases in this group complained of hallucinations or hallucinatory-like phenomena. This smoldering, nonacute encephalitis may be easily mistaken as depression, as the delirium OI dementia complicating polydrug or alcohol abuse, or, as in this case, a worsening character disorder. Psychiatrists often see cases of depression and are frequently the first-line medical practitioners for persons suffering from intravenous substance abuse. Given the seriousness of AIDS and its potential for spread, as might have been possible in this case from the patient’s open wounds, psychiatrists must be alert to this illness and its clinical manifestations. AIDS-related disease must be considered in the differential diagnosis ot patients with depression and cognitive loss. The clinician must search for a history ot homosexual contact, intravenous drug abuse. blood transfusion, or other exposure to the AIDS virus. Evaluation should include a CT scan of the brain, lumbar puncture and anti-HTLV III test, in addition to standard blood counts, urinalysis, and blood chemistries. The white cell count and the CSF protein appear to be especially useful. Suspected cases should be referred to infectious disease or other medical specialists for further evaluation and supportive medical therapy. _ ‘The authors wish to thank Betty C. Uzman. M.D.. CITCHS, for her kmd asslslance in this report.
Pathology Service. VAMC.
and Department of Pathdog.
AIDS Encephalitis,
Dementia,
BIOL PSYCHIATRY 1986;21:394397
and Depression
397
References Downing RG, Eglin RP, Bayley AC (1984): African Kaposi’s sarcoma and AIDS. Lancer i:478-480. Fauci AS, Masur H, Gelman EP, et al (1985): The acquired immunodeficiency update. Ann Intern Med 102:800-813. Hoffman RS (1984): Neuropsychiatric
complications
of AIDS. Psychosomarics
Numberg HG, Prudic J, Fiori M, Freedman EP (1984): Psychopathology immune deficiency syndrome (AIDS). Am J Psychiatry 141:95-96.
syndrome:
An
25:393-400.
complicating
acquired
Shaw GM, Harper ME, Hahn BH, et al (198.5): HTLV-III infection in brains of children and adults with AIDS encephalopathy Science 227: 177- 182. Sidhu GS, Stahl RE, El-Sadr W, et al (1985): The acquired immunodeficiency ultrastructural study. Human Pathol 16:377-386.
syndrome:
An
Snider WD, Simpson DM, Nielsen S, Gold JWM. Metroka CE, Posner JB (1983): Neurological complications of acquired immune deficiency syndrome: Analysis of 50 patients. Ann Neural 14:403418.