Case Presentation: A 53-year-old female with a past medical history of hypertension presented with three days of progressively worsening confusion, aphasia, poor PO intake, and urinary incontinence. Vital signs were within normal limits. Physical exam notable for orientation only to person and place, hyperreflexia, and no other focal neurologic deficits. Initial workup significant for positive HIV antibody, unremarkable non-contrasted CT head, EEG, and cerebrospinal fluid analysis. On day two of hospitalization, the patient became minimally interactive and began exhibiting waxy posturing. Further work-up revealed a negative HIV confirmatory test, a viral load of >10,000,000 and CD4 of 551 suggestive of acute HIV infection. The patient was started on bictegravir/emtricitabine/tenofovir alafenamide for HIV and lorazepam for catatonia. Neurology was consulted, and suspected encephalopathy was secondary to acute HIV CNS infection. Review of MRI by Neurology was significant for “a confluent area of white matter change in the bilateral frontal periventricular white matter,” which can be seen in neuro-invasion of HIV. Overall, cognition improved after initiation of antiretroviral therapy.
Discussion: While the classic presentation of acute HIV infection includes vague symptoms such as fatigue, fever, or lymphadenopathy; over half of patients will experience mild to moderate neurologic manifestations. (1,2). HIV-associated neurocognitive disorder (HAND) is typically seen in patients with high viral load or low CD4 count. The pathophysiology of HAND is not well understood. It is hypothesized HIV enters the CNS via lymphocytes leading to neuron damage, cytokine activation, and auto-immune antibody production (3,4). While previous case reports have described encephalopathy in acute HIV infection, mutism and catatonia are not well documented in current literature (5,6,7). However, regardless of HAND presentation prompt initiation of antiretroviral therapy improves patient outcomes (7).
Conclusions: This case represents an unusual presentation of acute HIV infection; demonstrating the importance of considering HIV infection as a reversible cause of encephalopathy.