Severe Corticosteroid-Induced Mania With Psychotic Features in an HIV-Positive Patient: A Case Report

Corticosteroids are widely used to treat numerous inflammatory conditions but are associated with a significant risk of psychiatric adverse effects, including mood disturbances, psychosis, and mania. These reactions may be challenging to recognize in medically complex patients. We report the case of a 40-year-old woman who developed an acute manic episode with mood-congruent psychotic features three days after initiation of intravenous methylprednisolone (80 mg/day) for hypoxemic respiratory failure, later diagnosed as probable <i>Pneumocystis jirovecii</i> pneumonia in the context of newly diagnosed HIV infection. The clinical picture was marked by euphoric mood, behavioral disinhibition, pressured speech, increased goal-directed activity, reduced need for sleep, and mood-congruent delusions and hallucinations. The differential diagnosis included steroid-induced psychosis versus an organic psychiatric disorder secondary to HIV encephalopathy or a CNS opportunistic infection. Brain MRI revealed no acute intracranial abnormalities, and additional investigations were unremarkable. Haloperidol was introduced to manage the acute phase, while corticosteroids were rapidly tapered and then discontinued. A rapid and complete resolution of manic and psychotic symptoms was observed following steroid withdrawal, with sustained remission despite subsequent tapering and cessation of antipsychotic treatment. This case illustrates a typical presentation of corticosteroid-induced bipolar and related disorder and underscores the need to consider this iatrogenic etiology even in the presence of significant medical confounders such as a new HIV diagnosis. It also highlights the diagnostic value of symptom resolution after drug discontinuation in supporting causality.