A case of neuro-psychiatric manifestations (Catatonic syndrome) in a 16 years old sero-positive girl who improved on withholding anti-retrovirals, continued to have fluctuating psychotic course.

1. Neuropsychiatric manifestations in 16 years old Seropositive:
Primary manifestations or Antiretroviral treatment induced ?
Authors: Dr. Nikhil Gupta, Dr. Jyoti Shetty
DEPARTMENT OF PSYCHIATRY
BHARATI VIDYAPEETH DEEMED UNIVERSITY
MEDICAL COLLEGE AND RESEARCH HOSPITAL
PUNE-411043

2. INTRODUCTION
• In India more than 2.40 million people are
living with HIV with an adult prevalence of
0.31% (2009).
• Children below 15 years account for 3.5% of
all infections whereas 83% are in the age
group 15–49 years.
• HIV infection has been associated with
psychiatric illness in both adults and children.

3. • Potential causes include biological predisposition
for primary disease, psychosocial stress factors,
HIV related pathologic characteristics and
adverse effects of medication.
• Antiretroviral treatment along with co-morbid
medical conditions are associated with new onset
psychosis whose prevalence among patients with
HIV infection is reported to range from 0.23%
to15.2%.
• Highly Active Antiretroviral Treatment (HAART)
can result in neuropsychiatric adverse events.

4. CASE REPORT
• A 16 years-old girl who was on Antiretroviral
therapy for a period of 2 years referred initially
from Pediatric OPD to Child Development and
Guidance Clinic, as mother reported changes
in her behaviour over a couple of months.
• She has been sleeping less than usual, denying
food, feeling low, noted to be irritable and
fearful at times, decreased interaction with
school friends, lack of interest in school,
eventually stopped going to school without any
apparent reason.

5. • She was prescribed Tb.Escitalopram 5mg and
Tb. Clonazepam 0.25mg which she took for
next couple of days and stopped on her own.
• Over next few weeks, her mother noted her
staring in one direction, muttering and smiling
to self.
• All the symptoms increased in intensity over
next few days, later she had difficulty in
walking, was seen to be posturing, had
increased sweating and salivation.
• She stopped talking completely and was
brought to OPD and diagnosed to have
Catatonic syndrome.

6. • She was on Tb. Zidovudine 300mg OD, Tb.
Nevirapine 200mg OD and Tb. Lamivudine 150mg
OD for a period of 2 years from Integrated
Counseling and Treatment Centre (ICTC).
• Her mother was also seropositive on Antiretroviral
therapy.
• She had a history of Pulmonary Koch for which she
was treated 2 and half years back as per Revised
National Tuberculosis Control Programme (RNTCP).
• Her seropositive father died of Pulmonary Koch
when she was 7 years old.

7. • No Past history of any psychiatric illness.
• No Family history of any neurodegenerative
disorder, epilepsy or any psychiatric illness.
• Developmental History-
She was a pre-term baby (28 weeks) and her
birth weight was1.3 Kg for which she was
admitted in NICU for 2 months.
She was breastfed and weaned normally.
She had history of delayed neonatal, infancy
and childhood milestones.
• Immunization was apparently complete till 10
years of age.

8. • She is studying in 9th standard, she is not very good
academically but regular to school.
• Her younger sister is sero-negative and functioning
well.
• Examination revealed-
Mask like facies, tremors, rigid posture and
loss of balance
There was psychomotor retardation and difficulty
in articulation
Constricted affect,
with impaired judgement and absent insight.

9. ASSESSMENTS
• Simpson Angus scale (SAS) score of 12 for Extra
pyramidal side effects.
• Abnormal Involuntary movement Scale (AIMS)
her score was 0.
• Barnes Akathisia Rating Scale (BARS) score was 0
for akathisia.
• Laboratory investigations showed raised MCV,
MCH, MCHC and SGPT levels. She maintained
good CD4 count.

10. • MRI brain showed tiny non-specific, non enhancing
sub cortical white matter hyper intensities in left
frontal region.

11. • Antiretroviral treatment was withheld immediately after
admission.
• Lorazepam (3mg) in divided doses was administered.
• All the presenting complaints completely resolved
within 3 days of withholding Antiretrovirals and giving
Lorazepam.
• She continued to report fearfulness, was suspicious and
was then started on Olanzapine 2.5 mg B.D.
• She responded well and was discharged after one week.

12. • The suspected adverse reaction of Antiretroviral
drugs were reported to pharmaco-vigilance team of
hospital working with Central Drugs Standard
Control Organization (CDSCO).
• She maintained well and again started on
Antiretroviral therapy after 6 weeks.
• Her subsequent course has been fluctuating with
regard to the psychiatric/ behavioural problems but
has not shown significant extrapyramidal or catatonic
symptoms.
• She continues to be on Antiretroviral treatment and
Olanzapine.

13. DISCUSSION
• HIV is a neuropsychiatric disease with systemic
manifestations and psychosocial sequelae.
• Although effective against CNS infections,
Antiretrovirals are themselves increasingly recognized
as a source of neuropsychiatric disorders.
• Combination of at least three antiretroviral drugs (also
known as HAART) has created a large potential for
drug interactions and subsequent toxicity.

14. • It is important to determine whether such presentation
is due to neurotoxic effects of Antiretroviral drugs or
it may be the primary manifestations of HIV
Encephalopathy.
• This case highlights the presentation of
neuropsychiatric symptoms in a seropositive
adolescent on HAART and need for management and
close follow-up of the same.
Contact:
1. Dr. Nikhil Gupta (drnikhilsgupta@yahoo.com)
2. Dr. Jyoti Shetty (shettyjyoti19@gmail.com)