Case Presentation: A 32-year-old man with no known medical history presented with altered mental status and fever. The patient was unable to give any history but his partner noted a gradual worsening of symptoms over a week with decreased interactions with his environment and he eventually stopped talking the day prior to presentation. She denied that he had any underlying psychiatric issues or exhibited any signs or symptoms of a mood disorder. He took no medications. On physical exam, his eyes were open with a fixed gaze with no interaction with the external world. His speech was absent and he did not have any spontaneous movements. There was no rigidity or waxy flexibility. A broad work-up was initiated which showed a mild normocytic anemia on CBC, normal BMP and hepatic function panel, a slightly elevated ammonia at 46, and normal B12, thiamine, RPR, and TSH. An MRI brain was done and revealed chronic atrophy and cerebral volume loss and an EEG showed diffuse slowing. Psychiatry was consulted for concern for catatonia. He became more responsive after a trial of IV midazolam which supported the diagnosis but the underlying cause remained unknown. His MRI findings were unusual for his age and HIV testing was considered as part of this work up. This was initially delayed while his catatonia symptoms were uncontrolled due to the institution’s opt-in screening strategy and inability to inform him of the testing. There was hesitancy to select a surrogate decision maker given the sensitive nature of the test. Once catatonia symptoms improved and allowed for informed consent, labs revealed advanced HIV/AIDS with a viral load of 2,250,000 copies/ml and CD4 count < 35. After a broad work up, it was determined that his HIV was the underlying cause of his catatonia. He had a very complicated hospital course which included disseminated Mycobacterium avium complex which resulted in immune reconstitution syndrome (IRIS) after he started antiretroviral therapy. He was discharged close to his previous functional status after two months.
Discussion: Patients presenting with catatonia often end up on the hospital medicine service during their diagnostic work up for altered mental status. Catatonia can be a manifestation of many underlying pathologies including primary psychiatric processes, toxin exposure, metabolic derangements, and CNS infections which makes diagnosis complex. Although a rare cause of catatonia, HIV should be considered when evaluating catatonia as early identification and intervention is critical. There was a delay in diagnosis of this patient’s HIV due to the opt-in screening strategy, the lack of ability to obtain consent due to his catatonic state, and unclear ethics around using a surrogate decision maker.
Conclusions: It is important to view catatonia as a symptom of an underlying cause rather than a primary disease. Hospitalists should be aware that catatonia can develop as a neuropsychiatric symptom of HIV. Obtaining consent for testing may be especially difficult in catatonic patients depending on institution-specific protocols for HIV testing but should be considered once symptoms improve.