Discussion
The onset of delusion of infestation several years after the diagnosis
may pose a challenge in causal linkage within the natural cause of
HIV/AIDS because of the multifactorial nature of Ekbom syndrome.
Nevertheless, the diagnosis of a psychotic disorder (Ekbom syndrome) due
to another medical condition is met as per DSM-V criteria. Ekbom
Syndrome may develop following dementia or other organic diseases(8),
and the presence of HIV significantly increase the risk(9).
The ritualistic skin picking and subsequent lesions may suggest skin
excoriation disorder. However, the presence of an unshakable conviction
of being infected by living things supports the diagnosis of delusion of
infestations, specifically Ekbom syndrome(9)and no other variant known
as Morgellons disease of which an individual believes to be infested
with inanimate objects like hairs, strands or fibers(10)
Although there was no overt CNS opportunistic infection, the objective
assessment suggested CNS involvement manifesting as HIV-associated
neurocognitive disorders. While cognitive assessment with MoCA showed no
significant decline, the assessment with IHDS showed significant
deficit, particularly in motor and psychomotor functioning, attributable
to slow information processing speed as one of the most common cognitive
impairments in HIV Associated Neurocognitive Disorder(HAND)(11). This
suggests the specificity and strength of IHDS in screening for
subcortical cognitive deficits, which are typical in HIV(12). Cognitive
impairment (CI) in patients living with HIV is commonly reported. As the
population ages, the problem becomes more significant; even with
sufficient antiviral medication, milder forms of CI still exist(13). Low
CD4 counts (200 cells/mm3), prolonged HIV infection, and advanced age
are risk factors for HIV Associated Dementia (HAD)(14). Generally, using
ARTs improves the overall clinical outcome; however, the association
with neuropsychiatric manifestation has also been observed.
Antiretroviral medications such as Efavirenz used for our patient are
linked to neurocognitive impairment (15) and also psychotic symptoms,
including Ekbom syndrome(16).
Perhaps the most intriguing observation is the onset of depressive
symptoms soon after the resolution of psychotic symptoms as a condition
that may be referred to as post psychotic depression(17). Albeit having
a five-year history of psychosis, a first-episode psychosis(FEP) has a
notably higher incidence rate (50%) of post-psychotic depression
compared to non-first-episode psychotic patients(18). Also, treatment
for FEP within the first year is linked to increased risk, with
approximately half of the patients experiencing depression at the
beginning of their treatment, and more than a third continues to have it
at the one-year follow-up(19).
Until recently, pimozide, a first-generation antipsychotic, was
considered the treatment of choice for delusional infestation. Because
of newer-generation antipsychotics with better safety profiles and equal
efficacy, pimozide has lost relevance(4). The patient used haloperidol,
which is readily available and has a relatively safer cardio-metabolic
profile than the newer generation antipsychotics(20).
The prognosis of this patient is somewhat guarded by her cardiovascular
and HIV/AIDS intermediate outcome. Her advanced age significantly risks
cardiovascular complications in addition to her HIV status. Prevention
of the progression of HIV/AIDS and cerebrovascular event is crucial for
favorable medical and psychiatric outcomes. Her strong family support is
essential for close to follow-up and treatment adherence.