Case history

A 58 year old man, diagnosed HIV-1 antibody positive 3 years previously, presented with a 24 hour history of hyperactivity. This culminated in the development of suicidal and homicidal ideation. For fear of injury to himself and others he was admitted to hospital.

He had commenced a course of clarithromycin by mouth 500 mg twice daily 10 days previously, for a bacterial chest infection. Two months before this, HAART had been commenced with zidovudine by mouth 250 mg twice daily, didanosine by mouth 200 mg twice daily, and nevirapine by mouth 200 mg twice daily. This was in addition to long term treatment with simvastatin by mouth 20 mg once daily for hypercholesterolaemia. There was no other medical history of note. He also had no previous history of mental ill health, alcohol, or drug misuse.

On physical examination, he was afebrile with oxygen saturations of 100% on air. His pulse was regular at 80 beats/minute and blood pressure 110/60 mm Hg. Examination of his respiratory and …