Background
Patients struggling with COVID-19 are at increased risk for delirium due to factors such as central nervous system invasion, inflammatory mediators, organ failure, sedation, and prolonged ventilation (1.) Symptoms of COVID-19 delirium range between agitation and catatonia (1).
Methods
We present two cases of COVID-19 delirium that had concurrent symptoms of catatonia. Interestingly, these cases presented initially with catatonia before they had a positive COVID-19 test. Case One is a 72 year old man with a past medical history of hypertension, Myasthenia Gravis, major depressive disorder, and mild cognitive impairment who was admitted for rectal bleeding. Initially he presented with symptoms of agitation and excitation that progressed into mutism, posturing, negativism, and gengehalten. Our second case is a 61 year old male with a past medical history of paranoid schizophrenia, HIV, hypertension, and Diabetes Mellitus II who initially presented with altered mental status including agitation as well as intermittent episodes of posturing, thrashing ,and holding his breath.
Results
Interestingly, both patients were given COVID-19 rapid polymerase chain reaction (PCR) tests upon admission, however, they did not test positive until several days into admission. In case one, the initial COVID-19 nasal swab was negative, but 3 days later, his COVID PCR test was positive. Case One struggled with confusion, disorientation (at most was alert and oriented x2) and posturing through admission and was eventually discharged to a nursing facility. Case Two tested positive for COVID-19 four days into admission and continued to struggle with catatonic features through hospitalization, but his agitation appeared improved with valproic acid. He developed acute hypoxic failure during his course of treatment and eventually passed away.
Conclusion
Catatonia has been associated, in the literature, with multiple medical and psychiatric conditions (2). Recent reports indicate a relationship between COVID-19 and catatonia, currently hypothesized to be related to dysregulation in dopamine transmission (2). In the cases described, catatonic symptoms appear to be a “herald” for an active COVID-19 infection, even when viral load is too low to be picked up by PCR test. These cases argue for repeated and frequent testing of patients with catatonic symptoms at risk for COVID-19 infection as symptoms could be a harbinger of infection.
References
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1
Kotfis K, Williams Roberson S, Wilson JE, Dabrowski W, Pun BT, Ely EW. COVID-19: ICU delirium management during SARS-CoV-2 pandemic. Crit Care. 2020 Apr 28;24(1):176.
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2
Rasmussen, S. A., Mazurek, M. F., & Rosebush, P. I. (2016). Catatonia: our current understanding of its diagnosis, treatment and pathophysiology. World journal of psychiatry, 6(4), 391.
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3
Baller EB, Hogan CS, Fusunyan MA, Ivkovic A, Luccarelli JW, Madva E, Nisavic M, Praschan N, Quijije NV, Beach SR, Smith FA. Neurocovid: Pharmacological Recommendations for Delirium Associated With COVID-19. Psychosomatics. 2020 Nov-Dec;61(6):585-596.