Psychosis and catatonia with recent COVID-19 infection: A case report

Abstract

The connection between COVID-19 infection and psychosis is an evolving topic of discussion. Physicians are still trying to understand how COVID-19 can lead to, influence, and impact a diagnosis of psychosis—an inherently complicated diagnosis with various etiologies. This case report describes the clinical course of a 25-year-old male who presented to the emergency department with an acute onset of paranoia, visual hallucinations, and delusions of unknown durations after testing positive for COVID-19 2 weeks prior to admission. He was admitted to the neurology critical care unit, neurological causes of his psychosis were ruled out, and psychiatry was consulted. Initial risperidone administration resulted in symptoms of hyperactive catatonia which was then treated with a lorazepam challenge showing moderate improvement of irregular motor activity but continued agitation and hallucinations. Despite the diagnosis of catatonia, delirium precautions were still taken, such as maintaining day/night cycles, frequent reorientation, minimizing restraints, and verbal redirection. First haloperidol, then switched to chlorpromazine, improved his disposition and communication, but hallucinations and delusions persisted throughout the duration of his stay. Of note, a nucleic acid amplification test was positive for active COVID-19 infection on hospital day 5, and negative on subsequent testing. Psychiatry's final impression was “schizophreniform including possible contributing residual delirium from COVID-19 or other causes” due to symptoms persisting for more than a month, positive hallucinations and delusions, a catatonic state, and negative symptoms. This case report captures the difficulty of determining the etiology of psychosis when complicated by concurrent COVID-19 infection. It is unclear how COVID-19 impacted the diagnosis and disease course. Delirium has not been shown to be a common feature of COVID-19 infection, but acute stressors have been shown to lead to the onset of schizophrenic psychosis in genetically susceptible individuals. Further research is needed to further understand the relationship between COVID-19, delirium, and schizophrenia, and any case of altered mental status, especially when complicated by COVID-19, merits a comprehensive history and workup to fully appreciate the interaction between various disease states.