Psychotic symptoms as the presenting feature of advanced human immunodeficiency virus infection in a low-prevalence European setting: a case report

Introduction

Psychiatric symptoms can be the initial manifestation of advanced human immunodeficiency virus (HIV) infection, leading to diagnostic delay and life-threatening progression. In sub-Saharan Africa, up to 39.6% of patients presenting with first-episode psychosis have been found to be HIV-positive [1]. In contrast, adult HIV prevalence in Western and Central Europe and North America is approximately 0.2% [2]. Türkiye sits within this lower-prevalence region but has one of the steepest rises in new HIV diagnoses in Europe, with 51,469 cumulative HIV-positive individuals and 2,577 AIDS cases registered by August 2025 [3]. This shifting epidemiology lowers the threshold of suspicion when atypical psychiatric presentations are accompanied by systemic features such as fever and cachexia.

Aims

To present a case in which psychotic symptoms were the initial manifestation of advanced HIV infection, with medical deterioration during inpatient psychiatric care leading to the underlying diagnosis.

Methods

A 43-year-old man was brought to the emergency department by his family with cough, sputum and nausea, on a background of 1.5 years of food refusal, persecutory delusions, auditory hallucinations and severe self-care neglect. The family had twice tried to obtain care at other hospitals in preceding months; each time he refused admission and left, believing physicians intended to harm him. In the emergency department, vital signs were reported as stable apart from low-grade fever responsive to intravenous paracetamol, and he was referred to emergency psychiatry. He was cachectic (body mass index 15.2) and admitted to the university psychiatry unit with a preliminary diagnosis of psychotic depression; olanzapine 7.5 mg/day was started and written consent was obtained from his mother. Within hours of admission he developed hypotension, tachycardia and severe hypoxaemia. Contrast-enhanced thoracic computed tomography raised suspicion of opportunistic infection and triggered infectious workup. On day 3, progressive respiratory failure required intensive care transfer. Antiretroviral therapy was initiated after transfer under infectious diseases follow-up.

Results

Serology confirmed HIV (Western blot positive, viral load 226,000 copies/mL) with profound lymphopenia (absolute lymphocyte count 0.42×10⁹/L). Pneumocystis jirovecii was confirmed by polymerase chain reaction. Toxoplasmosis, syphilis and connective tissue disease were excluded. Cranial magnetic resonance imaging demonstrated cortical atrophy disproportionate to age, without focal lesions. Formal neuropsychological assessment was not feasible acutely, and HIV-associated neurocognitive disorder could not be diagnosed under Frascati criteria. Following intensive care stabilisation and antiretroviral therapy alongside olanzapine 7.5 mg/day, psychotic symptoms remitted within approximately three weeks. During subsequent follow-up the patient reported no further mental complaints and showed no apparent residual cognitive impairment. After discharge he did not attend the outpatient clinic.

Conclusions

This case illustrates that advanced HIV can present with psychotic symptoms even in low-prevalence settings such as Türkiye. Two messages emerge. First, organic workup should be prioritised in first-episode psychosis accompanied by systemic features such as fever and cachexia, regardless of background HIV prevalence. Second, low-dose olanzapine alongside antiretroviral therapy was associated with sustained remission of psychotic symptoms and was well tolerated despite severe medical fragility. Limitations include the single-case design, absence of formal neuropsychological testing, and loss to outpatient follow-up.

References

1. . Laher AE, et al. HIV prevalence among first-presentation psychotic patients. HIV Med. 2018;19(4):271–9.
2. . UNAIDS. 2024 Global AIDS Update: Western and Central Europe and North America regional profile. Geneva: UNAIDS; 2024.
3. . T.C. Sağlık Bakanlığı Halk Sağlığı Genel Müdürlüğü. HIV/AIDS İstatistikleri (15 Ağustos 2025). Ankara; 2025.