A 58-year-old man is brought to the office by his sister due to behavioral symptoms. For the last several months, he has had changes in personality associated with increasingly bizarre behaviors. His mood has been very labile and he often says things that are nonsensical. The patient was diagnosed with HIV 25 years ago and is on antiretroviral therapy but frequently skips doses. He also has a history of hepatitis A and 2 episodes of gonorrhea. Temperature is 36.7 C (98.1 F), blood pressure is 138/86 mm Hg, and pulse is 90/min. Oral examination shows thrush. Cranial nerve examination, motor strength, and deep tendon reflexes are normal. The patient is alert and oriented to person, place, and time. Three-item recall is normal, but the patient is unable to count backwards from 100 by 7 or to spell "world" backward. When asked to explain the meaning of "don't count your chickens before they hatch," he laughs and says, "I guess you just shouldn't count too many chickens." Laboratory results are as follows: MRI of the brain reveals ventricular enlargement and an increase in intensity in the white matter diffusely. Which of the following is the most likely cause of this patient's symptoms?

Question

A 58-year-old man is brought to the office by his sister due to behavioral symptoms.  For the last several months, he has had changes in personality associated with increasingly bizarre behaviors.  His mood has been very labile and he often says things that are nonsensical.  The patient was diagnosed with HIV 25 years ago and is on antiretroviral therapy but frequently skips doses.  He also has a history of hepatitis A and 2 episodes of gonorrhea.  Temperature is 36.7 C (98.1 F), blood pressure is 138/86 mm Hg, and pulse is 90/min.  Oral examination shows thrush.  Cranial nerve examination, motor strength, and deep tendon reflexes are normal.  The patient is alert and oriented to person, place, and time.  Three-item recall is normal, but the patient is unable to count backwards from 100 by 7 or to spell "world" backward.  When asked to explain the meaning of "don't count your chickens before they hatch," he laughs and says, "I guess you just shouldn't count too many chickens."  Laboratory results are as follows:  MRI of the brain reveals ventricular enlargement and an increase in intensity in the white matter diffusely.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec25c8_d499_0e05_bc81_812c321b86e9_MD0003_00 This patient with long-standing HIV has personality changes, signs of impaired neurocognitive function, and MRI evidence of ventricular enlargement and diffuse white matter changes, consistent with HIV-associated neurocognitive disorder (HAND). HAND is characterized by a progressive decline in multiple cognitive domains (eg, memory, attention, calculation, executive function), as in this patient who is unable to count backward or to explain a proverb. Mood and behavior disturbances are common and reflect subcortical dysfunction (eg, impaired attention/concentration, depression, psychomotor slowness and imprecision). Diagnosis is based primarily on clinical features and neuropsychological testing, but MRI may also be helpful and usually reveals diffuse brain atrophy, ventricular enlargement, and increased white matter intensity. HAND is due to replication of HIV in the CNS and has been associated with a broad range of deficits, from asymptomatic impairments to severe dementia. Incidence of HIV dementia has declined with widespread use of highly active antiretroviral therapy, but less severe syndromes are common and may affect up to 69% of patients with chronic HIV (even with adequate viral suppression). Risk is greatest in those with long-standing infection, age >50, and CD4 count <200/mm³. (Choice A) HIV is not associated with increased incidence of Alzheimer disease (AD), and early-onset AD (age <65) is rare. In addition, early symptoms of AD primarily affect memory; personality changes as well as deficits in calculation, executive function, and abstract thinking are later findings. MRI changes are nonspecific; reduced hippocampal volume and medial temporal lobe atrophy are characteristic. (Choice B) Frontotemporal dementia is characterized by early changes in personality and behavior. However, MRI would show atrophy in the frontal and anterior temporal cortices rather than increased white matter intensity. (Choice D) Progressive multifocal leukoencephalopathy is caused by reactivation of the JC virus and has an increased incidence in patients with poorly controlled HIV. Symptoms are subacute. Altered mental status is common, but manifestations generally reflect focal cortical involvement, including motor deficits (eg, focal arm/leg weakness or hemiparesis), ataxia, and vision abnormalities, with MRI classically revealing well-delineated, asymmetric (rather than diffuse) white matter lesions. (Choice E) The incidence of tertiary syphilis is increased in patients with HIV, especially those with a history of sexually transmitted infections. However, in addition to dementia, typical neurological manifestations include headache, meningitis, hearing and visual problems, and ataxia. Educational objective: HIV-associated neurocognitive disorder is due to replication of HIV in the CNS and is characterized by a chronic decline in multiple cognitive domains. Mood and behavior disturbances are common. The risk increases with duration of HIV infection and is greatest in patients age >50 and those with CD4 counts <200/mm³. References: HIV-associated complications: a systems-based approach. (http://www.ncbi.nlm.nih.gov/pubmed/28762691) HIV-associated neurocognitive disorders (HAND). (http://www.ncbi.nlm.nih.gov/pubmed/25739180)

A 58-Year-Old Man Is Brought to the Office by His