HIV seems to increase the risk of manic episodes, and mania is a frequent reason for psychiatric hospitalization among people with the virus. (I1,) In some cases illicit drug use or iatrogenic causes are implicated, for example the chance association of HIV infection and bipolar affective disorders, but generally no obvious aetiological factors can be identified. Mania has been found to be a side-effect of medication frequently used for HIV/AIDS, including didanosine (ddI), ganciclovir, procarbazine, estavudine (d4T), steroids, and zidovudine (AZT). Most cases of new-onset mania occur in advanced HIV disease and they are often associated with the presence of substantial cognitive impairment. New-onset mania in severe symptomatic disease is predictive of reduced survival. (12)

Standard pharmacotherapy with neuroleptics and lithium are effective, but the usefulness of these drugs may be restricted by the development of severe adverse effects. Immunosuppressed HIV-infected patients tolerate neuroleptics and lithium poorly. Anticonvulsant medication (carbamazepine, sodium valproate) can adequately control the acute symptoms of a manic episode when standard agents are not tolerated. The administration of carbamazepine should include strict control of these patients' haemopoietic function, above all because they are frequently taking other medications, such as AZT, which can also trigger toxic effects in the bone marrow.

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