Altered Mental Status in Patients Hospitalized with COVID-19: Perspectives from Neurologic and Psychiatric Consultants.

Abstract

History of Present Illness A 62-year-old man with a past medical history of asthma and opioid use disorder on methadone developed respiratory symptoms in mid-March, which progressed to subacute respiratory failure by early April. He was diagnosed with COVID-19 by nasopharyngeal RT-PCR and admitted to an academic New York City hospital. The patient was intubated for hypoxemia, sedated with propofol and fentanyl, and admitted to themedical intensive care unit (MICU). Laboratory testing revealed elevated serum levels of D-dimer at 1143 ng/mL (reference level <500 ng/mL), C-reactive protein at 73.70 mg/L (reference level <8 mg/L), and ferritin at 554 ng/mL, together reflecting a pattern of elevated inflammatory markers associated with severe COVID-19 infection. The patient’s prolonged hospital course was complicated by numerous infections, including methicillin-resistant Staphylococcus aureus bacteremia (hospital day 8), vancomycinresistant Enterococus bacteremia (hospital day 13), multidrugresistant Enterobacter pneumonia (hospital day 14), and a Pseudomonas-positive urinary tract infection (hospital day 17), all of which were treated with multiple courses of antibiotics. Attempts to wean sedation and ventilatory support were complicated by the above infections and,when sedationwasweaned, by ventilator dyssynchrony and agitation, resulting in the uptitration of propofol and maintenance on mechanical ventilation. Because of a need for prolonged respiratory support, the patient required tracheostomy on hospital day 10. By hospital day 14, the patient had developed acute kidney injury with creatinine elevated to 2.1 mg/dL, from a baseline 0.8 mg/dL at time of admission.