Case with psychotic disorder as a clinical presentation of COVID‐19

During the COVID‐19 pandemic, reactive psychiatric symptoms and exacerbation of pre‐existing psychiatric conditions have been widely described as secondary effects of social isolation, consequences of the obliged quarantine, fear of the infection, or a complicated grief for the unexpected loss of beloved people. ¹ , ² Nevertheless, the scientific community working directly with COVID‐19 patients is facing complex neuropsychiatric syndromes, including first onset of psychosis, that seem to be directly related to brain damage in the context of COVID‐19. ³

This is the first report, to the best of our knowledge, describing a non‐reactive psychosis break directly related to COVID‐19 in a naive psychiatric patient. A 63‐year‐old man with no previous psychiatric history was first admitted to hospital presenting with bilateral pneumonia and positive polymerase chain reaction (PCR) COVID‐19 test (30 March 2020), being diagnosed with COVID‐19. He also presented with a delirium during the hospitalization (Table 1) that improved in parallel with the respiratory disorder, leading to the patient's discharge (8 April 2020). Ambulatory treatment with risperidone 2 mg per day was maintained, but bizarre delusions and incoherent thought and speech did not disappear even after antipsychotic treatment adjustment, so the patient was referred to hospital again (15 April 2020).

Table 1.

Treatments prescribed in the patient's first hospitalization

Condition	Treatment
COVID‐19	Oxygen, lopinavir, ritonavir, tozilizumab, hydrochloroquine, and a 3‐day corticoid bolus
Delirium	Risperidone 2.5 mg per day

At this second in‐hospital admission, a new PCR COVID‐19 test was performed with positive result. Respiratory evaluation was normal. An elevation of D‐dimer level was detected in the blood test and a computed tomography pulmonary angiography showed a low‐risk pulmonary thromboembolism, which was determined to be related to COVID‐19 and treated with anticoagulants. In the first psychiatric evaluation, the patient referred to thoughts about changes occurring in his body, including the absence of an anus, so he had decided not to eat anything to avoid exploding. At first, fluctuant attention and orientation to time and place were observed, but no other common features of delirium were present. Cranial magnetic resonance imaging with contrast enhancement showed no significant findings. Finally, a diagnosis of psychotic disorder due to another medical condition (COVID‐19) was made following DSM‐5 criteria. During the case follow‐up by the liaison psychiatry department, the delusions' content changed – the patient related that most of his relatives had died – and auditory verbal hallucinations appeared. Risperidone was titrated in the following days from 2.5 mg per day up to 6 mg per day. On 30 April 2020, the patient was mostly recovered, with absence of delusions and hallucinations and critical thought about the psychotic symptoms presented, so he was discharged and referred to his outpatient mental health unit for further follow‐up.

This case report shows the possibility of a first psychosis break as a direct (non‐reactive) COVID‐19‐related syndrome. The hypothesis of a link between this and an increased immunologic response of the body to the virus affecting the brain may be extrapolated from previous reports linking other respiratory virus infections and the occurrence of psychosis. ⁴ Psychosis post‐NIH1‐virus infection in children was associated with viral‐induced brain‐reactive autoantibodies production. ⁵ Severance et al. ⁶ found a higher level of immunoglobulin G against four different human coronavirus strains in adults diagnosed with psychosis versus controls. An interesting aspect of the case reported is the concomitant occurrence of the psychotic episode and the pulmonary thromboembolism, as both thrombotic phenomena and neuropsychiatric symptoms have been recently described as potential sequelae of the inflammatory storm and the immunoreactivity associated with COVID‐19. ⁷ , ⁸

The hypothesis of the occurrence of psychosis as an adverse reaction to some of the treatments used for COVID‐19, such as hydroxychloroquine or corticosteroids, was also considered but found improbable, as no temporary correlation existed between these treatments' administration and the onset of psychosis, with more than a 2‐week period between the two events. In fact, in a review of adverse reactions reported in chloroquine‐treated patients between 2012 and 2019, ⁹ no statistically significant reporting of psychosis was found.

Overall, the current case report illustrates the possibility of a psychosis break as a COVID‐19 clinical presentation. Though its underlying mechanisms are still unknown, the existing evidence from scientific literature suggests a potential participation of inflammatory and auto‐immunologic phenomena triggered as a response to the coronavirus infection. More investigation on the basis of neuropsychiatric complications of COVID‐19, such as onset of psychosis, is needed to ratify this hypothesis.

The patient provided informed consent and his anonymity has been preserved. This report confirms the new clinical and management challenges for professionals and the Mental Health Network. ¹⁰

Disclosure statement

Dr Susana Majadas, Dr Javier Pérez, Dr Nerea Casado‐Espada, Dr Zambrana, and Dr Alberto Bullón have no conflicts of interest to declare. Dr Carlos Roncero has received fees to give lectures for Janssen‐Cilag, Indivior, Lundbeck, Otsuka, Servier, GSK, Astra, Gilead, MSD, Sanofi, Exceltis, Abbvie, Takeda Rubio, and Casein. He has received financial compensation for his participation as consultant or a board member of Lundbeck, Gilead, MSD, Mundipharm, INDIVIOR, Exceltis, Martindale, Camurus, Gebro, and Abbive Board. He has carried out the PROTEUS project, which was funded by a grant from Reckitt‐Benckisert/Indivior, and the COSTEDOPIA project, which was funded by INDIVIOR. He has received two medical education grants from Gilead. No funding was received for this work.