A 39-year-old Japanese man with HIV presented to our hospital with delusions, hallucinations, and cognitive dysfunction. He was diagnosed with HIV infection 6 years ago and continued to work while being treated with antiretroviral drugs (dolutegravir 50 mg, abacavir 600 mg, and lamivudine 300 mg). Five years ago, his activity and speech decreased, and on August 3 of the same year, he stopped moving when he was out. The patient underwent further examination and treatment. The patient experienced visual and auditory hallucinations with critical patient content. Blood tests did not detect HIV-ribonucleic acids. Ribonucleic acid (RNA) and his cluster of differentiation (CD) 4 T-lymphocyte count was 996 cells/μL, indicating that treatment for HIV infection was controlled. Electroencephalography revealed sporadic slow waves at approximately 6 Hz. Head magnetic resonance imaging (MRI) showed age-inappropriate mild cerebral atrophy but no other abnormal intracranial signals, including white matter signals. Head single-photon emission computed tomography (SPECT) showed decreased blood flow in the bilateral parietal lobes, precuneus, and cerebellum. However, these findings were nonspecific, and secondary brain diseases, such as opportunistic infections secondary to HIV infection and neurodegenerative diseases, were ruled out. Finally, the patient was diagnosed with HIV-associated neurocognitive disorder. The patient was prescribed risperidone (4 mg); his symptoms resolved, and he was discharged. After discharge, he was able to work and lead a normal life. However, around March two years ago, he became reluctant to take risperidone because of somnolence and began taking it irregularly. Risperidone was discontinued upon request in May of the same year. The patient continued to receive antiretroviral medications. Subsequently, his facial expressions became increasingly difficult, and his irritability increased. In June of the same year, he stopped working. In November of the previous year, he began to have attention and short-term memory deficits, such as losing his wallet and forgetting where he had left his medications. HE discontinued the antiretroviral medications around the same time. In September of the same year, he started experiencing hallucinations and delusions, like seeing his sister’s hair floating towards his face and delusions that his brother was responsible for his father’s death and the closure of the family’s restaurant. He also developed autistic tendencies and anhedonia. Since October of the same year, his ability to respond to his family’s attempts at communication has become limited. On October 5, year, when the patient went shopping with his brother, he became completely immobile and was admitted to our hospital.
When we examined him, he was lying on his bed with closed eyes and did not respond to our calls. After some time, he could open his eyes and assume a sitting posture. However, he loudly sighed when asked questions and took a long time to respond. He ignored our calls and stared at the faces and names of medical personnel. Antiretroviral medication was restarted on the first day of hospitalization. Aripiprazole 12 mg was initiated on the third day of hospitalization. He misidentified the medical personnel as relatives. He also admitted to delusions that the world had broken and a big fight was happening outside the hospital. He took a long time to respond, often only sighing and not responding. He was also seen making challenging comments to medical personnel. On the fifth day of admission, he showed abnormal behavior, such as unlocking the lock in another patient’s protection room. A total of 24/30 points on the Mini-Mental State Examination (MMSE) showed decreased disorientation of place and time. The score on the Japanese version of the MoCA was 27/30, with deficits in trial-making, sentence recitation, and word recall. Laboratory tests showed no abnormalities in electrolytes, liver, kidney, or thyroid function, and HIV-RNA quantification was 20 copies/mL with a CD4+ count of 771 cells/μL, indicating that treatment for HIV infection was serologically successful. Electroencephalography revealed slow waves scattered at approximately 6 Hz. Head MRI showed slight cerebral atrophy. However, no abnormalities were observed, such as HIV-associated leukoencephalopathy or vascular lesions (Figure 1). Head SPECT showed nonspecific mild hypoperfusion in the left cerebral hemisphere and mildly increased blood flow in the right frontotemporal and left temporal lobes (Figure 2). After the aripiprazole dose was increased to 30 mg, his delusional complaints ceased, his challenging attitude disappeared, and he could spend time in the ward peacefully. However, he continued to have an attention disorder, slowness of movement, and sluggish reactions, such as being distracted by the attending physician’s nameplate, window, or television during the examination and unable to carry on a conversation. On the 17th day after admission, abnormal behaviors were observed, such as attempting to climb the patio fence and removing the wall clock from the wards. Detailed cognitive testing was deemed necessary, and the Brief Assessment of Cognitive Scale for Schizophrenia was version (BACS-J). The results showed that motor function, attention, and information-processing ability were impaired by a -2 standard deviation or more (Table 1). On day 22 of hospitalization, he was treated with 400 mg aripiprazole long-acting injections, with no apparent psychiatric exacerbations or adverse events. The patient was discharged on day 36 of hospitalization.
After being discharged, the patient maintained regular visits to our hospital and received a 400 mg aripiprazole long-acting injection. One year later, in January, his response slowness noticeably improved. His activity level also increased, and by March of that same year, he had even started working part-time. We administered the BACS-J test to assess his cognitive function during an outpatient visit on March 16 of the same year. The results showed improved motor function and attention processing speed (Table 1). He continued to work part-time and received treatment at our hospital without hallucinations, delusions, abnormal behavior, or irritability. The MMSE score on August 31 of the same year was 30. Head SPECT showed no change in the nonspecific mild hypoperfusion in the left cerebral hemisphere and improvement in increased blood flow in the right frontotemporal and left temporal lobes. (Figure 3).