Background

The novel coronavirus (severe acute respiratory syndrome coronavirus 2; SARS-CoV-2), the causative agent of the COVID-19, is rapidly emerging. From 29 December 2019, when the first cases of COVID-19 were documented in Wuhan, China, COVID-19 has resulted in more than 3.9 million infections in the USA, representing nearly 30% of cases worldwide.1 2

Typical symptoms of COVID-19 are dyspnoea, cough, fever, myalgia and sore throat, though nervous system involvement, resulting in cerebrovascular diseases, encephalopathy, encephalitis and new-onset anosmia and dysgeusia, has been documented.3–5

Recent cases of reactive psychosis in the context of the COVID-19 pandemic have emerged in the literature, but less attention has been given to incident psychosis affecting patients with COVID-19.6 Although a recent report documented cases of COVID-19-related psychosis in Madrid, this did not include a clinical description of affected patients.7 Ferrando et al8 described three cases of new-onset psychosis in patients with asymptomatic COVID-19, though two of these patients had a pre-existing psychiatric illness, and there were concerns for concurrent delirium.

Here, we report a case of symptomatic COVID-19-related psychosis in a patient with no personal or family history of mental illness and briefly discuss the relevant literature on coronavirus-associated psychosis.

Case presentation

A 36-year-old African–American woman employed at a skilled nursing facility with a remote history of erythema multiforme, and no psychiatric history, was diagnosed with COVID-19 by nasopharyngeal swab after a known exposure at work. Symptoms at the time of diagnosis with COVID-19 were notable for rhinorrhoea and nasal congestion without any concomitant dyspnoea or documentation of anosmia or dysgeusia. Approximately 4 days following onset of upper respiratory symptoms, she was noted to have an acute, rapidly progressive change in her behaviour characterised by prominent persecutory delusions and decreased sleep. Her delusions were primarily directed at her partner and focused on the safety of her children and personal finances. She believed her partner was attempting to kidnap her children and steal her COVID-19 stimulus money. Collateral information from the patient’s family revealed that she had been engaging in ruminative, persecutory thought patterns centring around being ‘tracked by cell phones’ in the days preceding hospitalisation. This began after a domestic dispute with her partner. Her symptoms culminated in the patient attempting to pass her children through a local fast-food restaurant drive-through in an effort to prevent their kidnapping, at which time first responders were notified and she was transported to the hospital.

Due to the acute onset of psychosis of unclear aetiology and her positive COVID-19 status, the patient was initially admitted to the general medicine service, whereupon psychiatry was consulted for further evaluation and management. At the time of her initial psychiatric interview, she was avoiding eye contact, but had no psychomotor agitation or retardation. She did not appear to be responding to internal stimuli. Her speech was noted to be increased in rate, though interruptible with repeated prompts. She described her mood as ‘worried’, and her affect was congruent to mood. She exhibited a tangential thought process with content notable for persecutory delusions. At the time of initial assessment she denied any suicidality or homicidality. Attention, concentration and orientation were intact on bedside testing.

Investigations

Vital signs on admission were: temperature 36.8°C, heart rate 79 beats per minute, respiratory rate 19 breaths per minute and blood pressure 114/85 mm Hg. Laboratory testing revealed positive SARS-CoV-2 nasopharyngeal swab, mild leucocytosis (white cell count 11.5×10⁹/L, 86.4% neutrophils), elevated C-reactive protein (2.37 mg/dL), elevated D-dimer (2274 ng/mL fibrinogen equivalent units), but otherwise normal electrolytes, ferritin, renal function, urine analysis and toxicology. Interleukin levels were not measured as it was not part of the standard of care at our institution. CT scan and MRI of the head were normal. A lumbar puncture revealed: cerebrospinal fluid colour was colourless, hazy, red cell count 187×10¹²/L, and nucleated cell count 1/μL in tube 1, glucose 69 mg/dL and protein 20 mg/dL. Extended meningitis PCR panel was negative.

Differential diagnosis

Given the paucity of alternative aetiologies for her development of acute psychosis, it was felt that the patient’s symptoms were either representative of a first-episode psychosis, triggered by psychosocial stressors secondary to her recent COVID-19 diagnosis, a brief psychotic disorder in the setting of an obvious stressor, or a direct sequela of COVID-19 infection and representative of a brief psychotic disorder. Delirium was also considered, but she lacked alterations in attention or awareness on bedside evaluation and did not screen positive using our institution’s nursing delirium observation scale.

Treatment

Due to the severity of the patient’s psychiatric symptoms, inability to engage in reality testing and perceived elevated risk of both harm to self and others (as her acute illness limited her ability to engage in and appreciate the need for social isolation as an active carrier of COVID-19), the patient was initially involuntarily committed, and pharmacotherapy was initiated. She was initially treated with two daily doses of olanzapine 2.5 and 5 mg in an effort to target both her underlying psychotic symptoms and aid in sedation to promote restoration of the patient’s sleep-wake cycle. Despite initiation of olanzapine, the patient remained paranoid with prominent delusional thinking and minimal insight, leading to an episode of acute agitation. Given the severity of her ongoing symptoms, clonazepam 0.5 mg twice daily was added for acute anxiolysis and reduced to once daily. Considering the possibility that she would need to be on antipsychotics at discharge, and that olanzapine is not recommended as first-line therapy in psychosis (due to metabolic side effects) she was transitioned to risperidone. With titration to 3 mg of risperidone daily, the patient had significant improvement in her persecutory delusions and subsequently exhibited improvement in her insight and judgement. Clonazepam was discontinued and she was discharged on hospital day 7 on risperidone 3 mg nightly with a plan for close outpatient follow-up with psychiatry. Of note, she did not require any therapy for her COVID-19 infection as she remained on room air after hospitalisation with resolution of her respiratory symptoms.

Outcome and follow-up

Follow-up documentation from her outpatient provider 1 week after discharge noted that she had not attended her psychiatry intake appointment, though she had noted near resolution of her psychiatric symptoms and had self-discontinued the risperidone without return of her persecutory delusions.