CASE PRESENTATION
A 52-year-old man with a background of longstanding well-controlled epilepsy. He was not known to have a previous history of any mental illness. He tested positive for the novel SARS-COV-2 virus on a nasopharyngeal and throat swab after community exposure to a confirmed case. He was asymptomatic at the time of testing positive but was admitted to a governmental quarantine facility as per the country’s guidelines (Table 1). Eight days following his initial presentation, he was transferred from the quarantine facility to a designated COVID-19 hospital after developing fever, cough and shortness of breath. Clinical imaging confirmed the diagnosis of severe covid-19 pneumonia; he was commenced on antibiotics (Oral azithromycin and intravenous cefuroxime), hydroxychloroquine, dexamethasone and oxygen therapy. Hemoglobin A1c was found to be high and he was diagnosed with diabetes mellitus and started on insulin. One week following hospitalization, he was noted to be confused and complained of severe headache and abdominal pain. He was transferred to the intensive care unit to be investigated and managed for an impression of an acute confusional state. The initial workup revealed hyponatremia for which he was started on hypertonic saline. Computed tomography of the brain did not show any abnormalities.
During his stay in the intensive care unit, he was assessed by the consultation-liaison psychiatry team. The team’s assessment was consistent with an acute confusional state based on disorientation to time, impaired concentration and memory, visual and auditory hallucinations (seeing and hearing Jesus), persecutory beliefs against hospital staff, labile mood, and delinquent behavior requiring sedation with oral quetiapine and injectable haloperidol.
The patient responded well to treatment, he was transferred to a medical ward after spending four days in the intensive care unit and was discharged home two days later. Upon discharge, he was fully oriented, and his mental state examination did not show any abnormalities. He was discharged from the hospital on oral hypoglycemic agents, antiepileptic medications, and quetiapine 50 mg twice daily. His repeated Nasopharyngeal and throat swab was still Positive for SARS-COV2 but was declared to be non-infectious based on an RdRp-gene ct value of 32.3.
Two days after his discharge from the hospital, he presented to the emergency department following an episode of physical aggression in a hotel where he was residing, during the assessment, he justified his behavior by dereliction from the hotel staff. He was threatening to be physically aggressive if his demands were not immediately met. He was noted with a grandiose attitude and claimed to be a Master of Yoga. He demanded to be released from the hospital citing that he does not believe that he has any mental illness based on his medical, educational background. His family members and friends have reported that he was calling and messaging them repeatedly throughout the day.
His mental state examination was remarkable for psychomotor agitation, overfamiliar attitude, pressured speech, “very happy” mood, an expansive effect, persecutory and grandiose delusions and poor insight. Attention and orientation were found to be intact.
Physical and neurological examinations didn’t reveal any abnormalities.
His medical history is significant of epilepsy since childhood, he was well maintained on medications (levetiracetam 1000 mg and sodium valproate 1500 mg), his last seizure was 20 years prior to presentation. He was newly diagnosed with diabetes mellitus and was on two oral hypoglycemic agents. He denied any background of mental illness in himself or his family.
He had maintained a job as a financial consultant for the past 10 years. He is married for 25 years with 3 children. He was living alone, and his family resided in his home country. He is a non-smoker and had no history of alcohol or illicit substance use.