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.