Neuropsychiatric sequelae in an efavirenz treated patient with hepatitis B

Abstract

We report the case of a 34-year-old man of African origin, positive for both HIV and hepatitis B virus, who developed symptoms of mania and psychosis while being treated with efavirenz (a non-nucleoside reverse transcriptase inhibitor used in HIV therapy) that required inpatient psychiatric admission and treatment with antipsychotic medication. Our case illustrates multiple predisposing and precipitating factors occurring simultaneously that have been previously implicated individually in the development of neuropsychiatric complications with efavirenz (and other HIV treatments in general). We suggest that patient's commenced on antiretroviral medication should have a screening process for pre-existing mental and medical health problems as well as psychosocial risk factors that might put a patient at risk. In addition with advances in pharmacogenomics we advocate future cytochrome P450 gene variant testing coupled with routine efavirenz plasma concentration monitoring to help ensure maximum treatment benefit and minimal risk of side effects.

Neuronal toxicity of efavirenz: a systematic review

“…One study reported that mild neuropsychiatric symptoms persisted for up to 3 years in many patients [8]. Early severe neuropsychiatric symptoms usually resolve on discontinuation of efavirenz [9][10][11][12][13][14]. A recent case report of vacuolar axonopathy leading to a depressed level of consciousness, aspiration pneumonia and death was thought to be efavirenz induced, suggesting that efavirenz neurotoxicity may on occasion be more severe than transient neuropsychiatric effects [15].…”

Antiretroviral Therapy Outcomes in Patients with Severe Mental Illness

“…[22][23][24] There have been a number of reports of psychosis or mania (after an overdose) developing in patients without SMI in a temporal relationship to starting ART with EFV. 22,[25][26][27][28][29][30][31][32][33] High serum levels of EFV related to genetic factors have been implicated in the development of psychosis, 27,29,30 but this has not been borne out in longitudinal studies. [22][23][24]34 Other antiretroviral drugs, including ZDV, abacavir (ABC), and NVP, have also been implicated in the development of psychosis by temporal association.…”

RE: Severe mental illness at ART initiation is associated with worse retention in care among HIV‐infected Ugandan adults by JM Nachega et al. (2013), TMIH 18, pp 53–57

“…Efavirenz-induced psychosis has been reported in patients as young as 12 years of age. The general consensus is that efavirenz may alter cytokine levels that may contribute to the development of these psychiatric symptoms (Salter & Patel 2009). The CD4 lymphocyte counts as well as the 'viral load' have a significant influence on the severity of these psychiatric effects.…”