|Year : 2014 | Volume
| Issue : 3 | Page : 283-285
Antiretroviral treatment induced catatonia in 16-year-old boy
Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Kalitheerthalkuppam, Puducherry, Tamil Nadu, India
|Date of Web Publication||23-Dec-2014|
Department of Psychiatry, Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Kalitheerthalkuppam, Puducherry - 605 009, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
We present a 16-year-old boy, who had presented to us with catatonic features of mutism, withdrawal, passive negativism, grimacing, gesturing, echopraxia, and excitement of 5 days duration while taking antiretroviral therapy (ART) for a period of 2 years. He had history of birth asphyxia and acquired HIV infection from his father when the same syringe and needle was used on both of them in a medical setting where the father and son had consulted for treatment of pyrexia of unknown origin. He was the eldest of a three children family in which the biologic father had acquired HIV through extramarital sexual contact with HIV-infected sex workers but was unaware of his HIV positive status till our patient, the 16-year-old was admitted and treated for pulmonary tuberculosis at 14 years of age. The boy's mother had only acquired HIV after having three children with the HIV-positive husband, thus leaving the other two children HIV negative. The catatonia completely resolved within 2 days after the ART was withheld, and risperidone 1 mg twice a day was prescribed. This case highlights the risks of ART and breach of universal precautions.
Keywords: Antiretroviral therapy, catatonia, HIV, olanzapine
|How to cite this article:|
Lingeswaran A. Antiretroviral treatment induced catatonia in 16-year-old boy. J Pediatr Neurosci 2014;9:283-5
| Introduction|| |
Globally an estimated 2.5 million children are living with HIV/AIDS, 10,000 becoming infected daily and 2,60,000 deaths of children under 15 occur due to AIDS-related illnesses.  The government of India estimates that about 2.40 million Indians are living with HIV (1.93 -3.04 million) with an adult prevalence of 0.31% (2009). Children (<15 years) account for 3.5% of all infections whereas 83% are the in age group 15-49 years. India's highly heterogeneous epidemic is largely concentrated in only a few states - in the industrialized south and west, and in the north-east. The four high prevalence states of South India (Andhra Pradesh - 500,000, Maharashtra - 420,000, Karnataka - 250,000, Tamil Nadu - 150,000) account for 55% of all HIV infections in the country. 
Although efficacious, (antiretroviral therapy [ART]) highly active antiretroviral treatment (HAART) is not available to more than half with HIV in India and those who receive it develop neuropsychiatric side-effects. ART, along with comorbid medical conditions and substance abuse are associated with new-onset psychosis whose prevalence among patients with HIV infection is reported to range from 0.23% to 15.2%.  Side-effects have been described in patients without psychiatric antecedents, but those with a previous psychiatric history are more vulnerable and should be monitored closely.  These problems are very debilitating when they occur in children who acquire HIV, unfortunately, from infected mothers.
Although World Health Organization guidelines on ART prophylaxis reduces HIV transmission from mother to fetus, the United Nations guidelines on primary prevention in health care settings on universal precautions in needle use practices are equally important and together helps to reduce childhood HIV. Safe needle practices only reduce the risk of mother-to-child HIV transmission to 2%.  Sadly, not surprisingly breaches in safe needle practices during childhood or adolescence might sometimes lead to new onset HIV.
In this background, we report a case where there was initially a breach of safe needle practice in a health care setting that had led a 16-year-old boy to accidently acquire HIV infection from his HIV-positive father. He subsequently presented to psychiatric services with ART induced catatonic symptoms.
| Case Report|| |
A 16-year-old boy was brought to our psychiatric outpatient setting by his parents with 5 days history of mutism, grimacing, excitement, echopraxia and withdrawal symptoms in addition to poor sleep. He was admitted into the child and adolescent inpatient psychiatric unit of our hospital for further management with the consent of the parents.
Detailed history and mental state examination provided a definitive diagnosis of catatonia with Bush Francis rating scale score of 12. There was no past psychiatric history. Both his parents were illiterates, and there was no family history of any neurodegenerative disorders, mental illness, and epilepsy except for the father who had a history of alcohol abuse. Antenatal history was uneventful but perinatal period was complicated with birth asphyxia and forceps delivery in a hospital with birth weight of 2.7 kg and he was breastfed and weaned normally. Immunization history was adequate, and there was no developmental delay. He had an elder sister and younger brother who were functioning well.
Physical examination showed normal head circumference and absent Kayser-Fleischer ring More Details. Although clinically relevant differential diagnosis such as Wilson's disease, thyroid disorders, mental retardation were considered, only IQ assessment could be done which was in the average range. Blood and biochemical parameters were all normal. HIV serology was positive and negative for hepatitis B and syphilis. A plain computed tomography scan of the brain revealed gliotic changes in the left temporal lobe, which the radiologist reported as a possible consequence of birth asphyxia.
Past medical history showed that HIV seropositivity was diagnosed in 2011 when the boy was admitted for pulmonary tuberculosis (PTB) at Government General Hospital, Vizhupuram and had received intensive 6 months treatment for PTB as per Revised National PTB Programme (RNTCP). Both his parents also tested positive for HIV but the other two children showed HIV negative results. Subsequently, the boy and his parents have been taking ART which consisted of tablet zidovudine (ZDV) 250 mg 2 times a day, tablet abacavir (ABC) 300 mg one in the morning and two at night with tablet efavirenz (EFV) 300 mg at night from the Integrated Counseling and Treatment Centre (ICTC), Vizhupuram. Further, it was evident from the old hospital records that the daily dosage of ZDV, ABC and EFV were increased 2 months before the onset of catatonic symptoms. In consultation with the ICTC, all the ART medications were stopped, tablet risperidone 1 mg twice daily was started, and the boy was monitored for resolution of symptoms. Within 5 days, all the catatonic symptoms resolved completely, and he was communicating relevantly and taking his feeds and sleeping well. He was referred back to the ICTC where the dosage of ART was reduced. The patient returned for review after 3 weeks and there was no evidence of any psychiatric symptomatology. He was still asymptomatic after 6 weeks follow-up on ART.
During the inpatient admission, repeat serology of other family members showed that our patient's elder sister and younger brother tested negative for HIV as before while both his parents tested positive. This gap in seropositivity among the children was explored further, and it was found that the father had acquired HIV through unsafe extramarital sexual contact, but after having three children with his wife and remained ignorant of it. Antenatally, the boy's mother was always seronegative in all three pregnancies. Further exploration revealed a history that our patient had acquired HIV infection in 2009, when he and his father had attended a rural health care centre, for treatment of loose stools and that is when the same needle was allegedly used on both the father and the son. This history was strongly corroborated by the boy's mother who had accompanied them.
| Discussion|| |
Our case highlights two important factors in childhood acquired HIV infection - firstly the mandatory need for safe needle use practices always which could have prevented HIV infection in our patient and secondly the neurotoxic side-effects of ART in children.
World Health Organization's new guidelines (2010), reports that early ART for a larger group of HIV-positive pregnant women, longer provision of ART prophylaxis for HIV-positive pregnant women with relatively strong immune systems to benefit both the health of the mother and provision of ARV prophylaxis to the mother or child can prevent HIV transmission to her child during pregnancy and breastfeeding.  Illiteracy, low socioeconomic status, rural population, unsafe sex practices and nonavailability of ART still remain risk factors for HIV transmission in children in developing countries like India and Sub-Saharan Africa. Inadequate precautions in rural health care settings in developing countries sometimes become a matter of medical negligence and unacceptable reason for HIV transmission in children. Safer use of the same needle in a health care setting is definitely an easily preventable primary prevention method of HIV across all ages.
Although effective against central nervous system (CNS) infection, antiretrovirals are themselves increasingly recognized as a source of neuropsychiatric disorders and the combination of at least three antiretroviral drugs also known as HAART has created a large potential for drug interactions and subsequent toxicity. The mechanisms underlying the development of neuropsychiatric symptoms in HIV are complex. Several factors interact, including the direct effect of the virus, immune mediators and medications.  Among the ART's, ZDV, lamivudine, didanosine cause dose-related psychiatric disturbances. ABC does not cause prominent psychiatric side-effects, although when used in combination, it may induce psychosis and catatonia.  EFV notably has been reported to induce a variety of CNS side-effects in up to 50% of patients that may be severe and sudden in onset. Symptoms include twilight states, personality changes, with increased hostility, and cognitive disturbances.  The treatment of antiretroviral-induced psychiatric disturbance varies according to its severity. Mild symptoms should be monitored, and psychotropics may be added if required. Severe cases may require switching or discontinuing the HAART regimen, which could be reinstated (often with different medication) once the patient improves. Our patient was receiving a combination of ABC, didanosine and EFV at therapeutic dosages, and the catatonic symptoms noted possibly due to a recent dose increase and the neurological effects of HIV infection.
This case stresses the need for imparting better knowledge to the vulnerable population about unsafe sex practices, stricter adherence to universal precautions of safe needle usage and to all medical professionals about neurotoxic side-effects of ART.
| Acknowledgment|| |
I am grateful to the parents and children who agreed to participate in this report. I acknowledge the support of the Department of Microbiology for providing lab support.
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