A 39-year-old woman presents to the emergency department via a protective order after attempting to make her children drink bleach because she believed they were infected with parasites. The protective order was initiated by her husband and stated the patient had been acting “out of the ordinary” for the past 2 weeks, but this is the first time any potentially harmful behavior had occurred.

On initial presentation, the patient is calm, alert, and oriented to person, place, and time. She is unaware of why she is being evaluated in the emergency department. She has a flat affect. The patient denies suicidal or homicidal ideation, but does admit that she attempted to make her children drink bleach to “clean the parasites out of their bodies.” The patient denies use of prescription or illicit drugs. She also denies use of alcohol and tobacco. The patient states she has not experienced any recent stressors and currently works as a paralegal for a local attorney.

Diagnostic tests for psychiatric evaluation and medical clearance are ordered and include the following: complete blood cell count (CBC), basic metabolic profile (BMP), liver function tests (LFT), acetylsalicylic acid (ASA) level, acetaminophen level, urine toxicology, ethanol alcohol (ETOH) level, urine pregnancy test (UPT), thyrotropin level, electrocardiogram (ECG), and brain computed tomography (CT) without contrast.1,2 Laboratory results are all within normal range and urine pregnancy test is negative. The urine toxicology is negative. The ECG reveals normal sinus rhythm with no ST-segment abnormalities. The CT scan of her head was read by the radiologist as “normal.”


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Significant Medical/Psychiatric History

The patient has no significant medical or psychiatric history. Her last menstrual cycle was 2 weeks ago and normal per patient report. The patient does admit to being diagnosed with COVID-19 approximately 3 weeks ago, but she reports only having mild symptoms, which included headache and nonproductive cough for 3 days.

The patient’s family history is negative for any psychiatric disorders or hospitalizations. The patient’s mother has type 2 diabetes and her father has hypertension.

Physical Examination

The patient is a well-appearing woman with no signs of physical distress. Admission vital signs are as follows: blood pressure 118/68 mm Hg, heart rate 78 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation 99% on room air. Physical examination is benign and neurologic examination reveals no deficits.

The patient is diagnosed with post-COVID-19 psychosis with delusional disorder and admitted to a local psychiatric inpatient unit for treatment and observation. She is started on 1-mg risperidone daily and increased to 2 mg daily after 3 days. After 7 days of inpatient care and pharmacotherapy with risperidone, the patient no longer believes she needed to “clean the parasites” out of her children’s bodies and she is discharged with close outpatient follow-up and continuation of 2-mg risperidone daily.

Discussion

COVID-19 psychosis can occur in both the active (0-13 days) and postinfection (14-90 days) phases of COVID-19.1-4 Patients with no previous diagnosis of a psychiatric disorder have a greater probability of being diagnosed with their first psychiatric disorder 14 to 90 days after being diagnosed with COVID-19.3 It is theorized that microvascular injury secondary to a cytokine-mediated inflammatory response to COVID-19 infection is responsible for new-onset or relapse of neuropsychiatric symptoms.2-4

Neuropsychiatric symptoms have been affiliated with several types of respiratory viruses such as reports of schizophrenia, depression, encephalitis, and acute psychosis with specific strains of influenza and other severe acute respiratory syndromes (SARS) caused by different strains of coronavirus.3,4 Other potential causes contributing to COVID-19 psychosis include social isolation and utilization of glucorticoids.1,4

Diagnosis

COVID-19 psychosis, whether during the acute or postinfection phase, can present with a multitude of neuropsychiatric symptoms such as anxiety, agitation, confusion, delusions, disorganized thinking, visual and auditory hallucinations, insomnia, suicidal or homicidal ideation, and paranoia.2,4 Diagnosis of COVID-19 psychosis can be made when a patient with no history of psychiatric disorder presents with new-onset neuropsychiatric symptoms or when a patient with a well-controlled psychiatric disorder presents with a psychotic relapse; all patients much have recently been diagnosed (14-90 days) with or currently have COVID-19 infection and have no other explanation for the presenting symptoms.1-4

Laboratory Studies

COVID-19 PCR testing should be performed if there is no recent history of a positive COVID-19 test.4 Routine laboratory tests for psychiatric clearance, such as CBC, BMP, LFT, ASA  level, acetaminophen level, ETOH level, urine toxicology, UPT, and thyrotropin levels, should be conducted to rule out other potential causes of psychosis.5 Thyrotropin level assessment is   extremely important because a thyrotoxic patient may present with new-onset psychosis.5

C-Reactive Protein

C-reactive protein (CPR) is made by the liver as a result of inflammation that occurs in an immune response.4 While not measured in the case presentation above, CRP is typically elevated in patients presenting with COVID-19 psychosis.

Computed Tomography

Regardless of COVID-19 status, patients undergoing psychiatric evaluation with altered mental status, trauma, immunodeficiency, or focal neurologic findings should undergo a CT scan of the head to rule out organic brain disorders as an underlying cause of psychosis.5 Even in patients with a normal CT of the head, central nervous system pathology cannot be ruled out.4

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) of the brain is more sensitive than CT and can better detect white matter and inflammatory changes.4

Lumbar Puncture

Presence of cytokines in cerebrospinal fluid (CSF) may indicate immune activation. Further evaluation for presence of COVID-19 RNA in CSF could indicate viral invasion of the central nervous system.2,6

Management and Treatment

Treatment for COVID-19 psychosis is dependent on presenting symptoms and may include supportive care, pharmacotherapy, and management of any underlying complications from COVID-19 infection. Case severity can range from mild, with symptoms such as insomnia and agitation, to severe, with symptoms such as delusions and hallucinations.

If patients are at risk of harming themselves or others, inpatient hospitalization is appropriate until they can be stabilized. In the case of acute psychosis, antipsychotics such as risperidone, quetiapine, olanzapine, or aripiprazole are appropriate.1,4,6 For patients experiencing panic attacks, agitation, or anxiety, benzodiazepines such as lorazepam are appropriate.2,4,6 Other medications may include antidepressants and mood stabilizers depending on symptomology.6

Discussion/Follow-Up

Duration of treatment for COVID-19 psychosis ranges from days to months and is determined based on resolution of neuropsychiatric symptoms and patient’s return to baseline. Once acute psychosis has resolved, close outpatient follow-up is recommended. Discontinuation of antipsychotics should be performed at the discretion of the provider. Of note, some cases may only require a few days of pharmacotherapy while others may require pharmacotherapy indefinitely.6

Christy L. McDonald Lenahan, DNP, FNP-BC, ENP-C, CNE, is an advanced practice registered nurse in family and emergency medicine who works for an emergency medicine and hospitalist staffing agency. She is also an associate professor at the University of Louisiana at Lafayette and teaches in the masters and doctoral programs.

Deedra Harrington, DNP, MSN, APRN, ACNP-BC, is associate professor at the College of Nurse and Allied Health Professions, University of Louisiana at Lafayette. Dr Harrington is an advanced practice registered nurse-acute care who works with an inpatient cardiology intensivist group in Louisiana.

Frances Stueben, DNP, RN, CHSE, is an assistant professor and simulation program coordinator at the University of Louisiana at Lafayette. She teaches in the graduate and undergraduate nursing programs.

The authors have published an 8-part series on complications in patients with COVID-19. Links to other articles in this series:

1. Management of NSTEMI/STEMI in patients with COVID-19, click here
2. Venous thromboembolism management in patients with COVID-19, click 
here
3. Atrial fibrillation and other dysrhythmias in patients with COVID-19, click 
here
4. Acute pericarditis, myopericarditis, and perimyocarditis in patients with COVID-19, click 
here
5. Heart failure in patients with COVID-19, click
here
6. Cardiogenic shock in patients with COVID-19, click
here
7. Takotsubo syndrome in patients with COVID-19, clear here

References

1. Al-Bussaidi S, Huseini S, Al-Shehhi R, Zishan AA, Moghadas M, Al-Adawi S. COVID-19 induced new-onset psychosis: a case report from Oman. Oman Med J. 2021;36(5):e303. doi:10.5001/omj.2022.25

2. Losee S, Hanson H. COVID-19 delirium with psychosis: a case report. S D Med. 2020; 78(8):346-349.

3. Desai S, Sheikh B, Belzie L. New-onset psychosis following COVID-19 infection. Cureus. 2021;3(9):e17904. doi:10.7759/cureus.17904

4. Ferrando SJ, Klepacz L, Lynch S, et al. COVID-19 psychosis: a potential new neuropsychiatric condition triggered by novel coronavirus infection and the inflammatory response. Pychosomatics. 2020;61(5):551-555. doi:10.1016/j.psym.2020.05.012

5. D’Orazio JL. Medical clearance of psychiatric patients: pearls & pitfalls. emDOCs. Updated May 28, 2015. Accessed January 29, 2022. http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/

6. Smith CM, Gilbert EB, Riordan PA, et al. COVID-19-associated psyhosis: a systematic review of case reports. Gen Hosp Pyschiatry. 2021;73:84-100.  doi:10.1016/j.genhosppsych.2021.10.003