Case 34-2022: 57-year-old girl with Covid-19 and delirium
Dr. Gregory L. Fricione: This 57-year-old girl with metabolic syndrome and blended affective dysfunction suggestive of bipolar dysfunction developed neuropsychiatric signs 2 weeks after the onset of Covid-19. The affected person had psychomotor agitation, flat have an effect on, anxious persistence, centered on her father’s care. Three days later, she was famous to develop into motionless and hypophonic, with staring, delayed speech, and speech obstinacy. Cognition was intact, however discernment and judgment have been impaired. In an try to clarify her neuropsychiatric signs, I’ll contemplate the potential results of the medicines she was taking, her underlying psychiatric sickness, and her latest an infection.
This affected person was receiving a number of medicines for blended affective dysfunction, together with bupropion, fluoxetine, and olanzapine. Antidepressants could precipitate a secondary manic episode, significantly on this affected person with suspected bipolar dysfunction. Nevertheless, her signs weren’t typical of drug-related mania, which has the traditional signs of insomnia, euphoria or irritability, excessive hyperactivity, and slurred speech. Though she was receiving psychotropic medicines which were related to serotonin syndrome, there have been no findings suggestive of this analysis, corresponding to clonus, tremors, ataxia, hyperreflexia, or fever.1
This affected person has not too long ago began taking dexamethasone to deal with Covid-19. Glucocorticoids, particularly when administered in excessive doses, are potential triggers of a manic response, generally known as “steroid-induced psychosis.” Glucocorticoid use could cause quite a lot of neuropsychiatric affective, cognitive, and behavioral signs.2 The persistence of psychotic signs on this affected person after discontinuation of dexamethasone argues towards a analysis of glucocorticoid-associated psychosis, though it’s potential that dexamethasone precipitated the underlying psychotic dysfunction.
It was famous that the affected person appeared withdrawn, and at occasions she lay immobile and didn’t reply to questions. These episodes point out the potential for complicated partial seizures. Standing epilepticus, together with nonconvulsive standing epilepticus, has been reported in sufferers with Covid-19.3 As well as, the affected person was taking bupropion, a drugs that has been related to reducing the seizure threshold. Nevertheless, if her hyporesponsiveness was on account of nonconvulsive standing epilepticus, I’d count on her to have phases of extra profound unresponsiveness alternating with temporary phases of alertness with confusion. As a result of a fancy partial seizure is commonly troublesome to diagnose, I wish to do a long-term electroencephalographic (EEG) follow-up whereas contemplating different diagnoses.
May this affected person have autoimmune limbic encephalitis? Neuropsychiatric signs appeared to have a subacute onset adopted by fast development, suggesting involvement of the limbic system. As well as, white matter adjustments noticed on head CT point out bilateral mind abnormalities. Nevertheless, if the affected person had autoimmune limbic encephalitis, I’d count on the white matter adjustments to be restricted to the medial temporal lobes and the EEG to indicate focal temporal slowing.4 I’d have a magnetic resonance imaging (MRI) scan of the top and a lumbar puncture for cerebrospinal fluid (CSF) evaluation to assist rule out the analysis of autoimmune encephalitis, particularly given the potential hyperlink of this illness to Covid-19.5,6 Encephalitis related to anti-N-marked-dAntibodies to aspartate (NMDA) receptors can result in neuropsychiatric issues, typically together with catatonic withdrawal syndrome, and this has been related to viral ailments.7 A hyperlink between NMDA receptor antibody-associated encephalitis and SARS-CoV-2 has not but been established, however a possible hyperlink has been advised.8
Neuropsychiatric signs related to Covid-19
May this affected person’s neuropsychiatric signs be associated to her latest analysis of Covid-19? Early research confirmed that greater than a 3rd of sufferers with Covid-19 had a neuropsychiatric syndrome.9
Some circumstances of Covid-19 result in persistent signs or long-term problems that transcend the acute sickness (a situation generally known as post-acute Covid-19 syndrome or “lengthy Covid”).10 In such circumstances, neuropsychiatric signs could embody fatigue, myalgia, headache, nervousness, despair, dysautonomia, and cognitive impairment (often known as “mind fog”).
In a single examine of greater than 60,000 sufferers with Covid-19, 18% of sufferers acquired a psychiatric analysis between 14 and 90 days after an infection.11 Neuroinflammation is believed to play a task within the neuropsychiatric issues related to Covid-19,12,13 and protracted autoantibodies have been detected within the CSF of sufferers with these ailments.13-15
Psychosis has been reported in sufferers with Covid-19. In a single report describing 10 sufferers, psychotic signs developed no less than 2 weeks after the onset of Covid-19 signs, and structured delirium was frequent.16 A latest systematic overview of circumstances of psychosis related to Covid-19 confirmed that delirium was the commonest psychotic symptom.17 Of notice, most sufferers with Covid-19-related psychosis had solely gentle acute signs of Covid-19.
A CT scan of the top carried out on this affected person revealed a subcortical white matter lesion. The most typical neuroimaging abnormalities seen in sufferers with Covid-19 embody white matter adjustments.18 Covid-19 has been linked to a number of white matter ailments, together with Covid-19-associated disseminated leukoencephalopathy and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL).19,20 Nevertheless, this affected person had no reported options that may counsel these diagnoses, corresponding to clinically important decreased degree of consciousness, complications, cranial nerve signs, sensorimotor deficits, gait defects, or adjustments in deep tendon reflexes. As well as, there have been no different CT findings corresponding to microhemorrhages or lacunar infarcts. A head MRI would be the subsequent step to rule out neuropsychological problems of Covid-19.
This affected person had a number of indicators suggestive of catatonia. If the Bush-Francis Catatonia Ranking Scale had been used, this affected person would have scored roughly 13 (on a scale of 0 to 23, with larger , which point out extra extreme catatonia).21 Primarily based on these take a look at outcomes, the affected person will meet the standards Diagnostic and Statistical Guide of Psychological Issuesfifth version (DSM-5), for catatonia related to main temper disturbance and normal sickness (Desk 1).22
Catatonia is a disruption of the cortico-striatal-thalamo-cortical belt circuits that leads to a disruption of motivation and motion, and has a number of neuromedical and psychiatric causes.23,24 Catatonia has been present in a number of sufferers with Covid-19.25 In a small examine evaluating positron emission tomography and head CT scans in sufferers with Covid-19 encephalopathy, there was proof of persistent hypometabolism within the prefrontal cortex, anterior cingulate cortex, insula, and caudate-striate cortex. thalamocortical community.26
This affected person could have had Covid-19-related adjustments within the blood-brain barrier and vascular plexus that disrupted cortico-striatal-thalamo-cortical twine circuits and elevated the chance of catatonia. One other chance is antipsychotic-induced catatonia related to olanzapine use. As well as, the affected person had a historical past of hospitalization for possible bipolar affective psychosis and catatonia, and bipolar dysfunction is the commonest reason behind psychogenic catatonia. There was no historical past of catatonia brought on by conversion dysfunction.
The affected person’s catatonia signs subsided after remedy with benzodiazepines, that are the first-line remedy for catatonia. Nevertheless, one of the crucial hanging options of her presentation stays to be defined: her insistence that she is lifeless.
This affected person expressed self-deprecation and guilt about not with the ability to look after her father, and she or he had a mood-congruent delusion that she and others have been lifeless, in addition to a delusion that her bladder had disappeared. Her presentation is in line with Kotor syndrome, a syndrome included within the DSM-5 class of delusional misidentification syndromes.27,28 Sufferers with Kotor syndrome have nihilistic delusions, corresponding to the idea that they’re lifeless, soulless, or rotting inside, with no functioning organs or limbs. Three subtypes of Kotor syndrome have been described: psychotic despair (a dysfunction related to melancholia and nihilistic delusions), sort 1 (nondepressive delusions), and sort 2 (a dysfunction related to blended signs, together with nervousness, despair, and auditory hallucinations).29 Cotter syndrome has been reported in no less than one affected person with Covid-19,30 catatonia and Cotter syndrome could happen concurrently.31,32
Help and reassurance are key in treating sufferers with Cotter syndrome, however making an attempt to speak sufferers out of their delusions is futile. Profitable remedy of the underlying situation typically helps the delusions resolve, though the delusions could wax and wane in sufferers with persistent despair and will develop into continual in sufferers with schizophrenia. A number of antipsychotic medication have been reported to scale back the signs of Kotor syndrome. If medicines don’t work, electroconvulsive remedy is a vital therapeutic choice. This affected person has acquired electroconvulsive remedy previously for the remedy of catatonia, and such remedy has a variety of results for the remedy of many delusional situations, together with Cotter syndrome.27 Transcranial magnetic stimulation has proven promising results in sufferers with catatonia.33
I think that this affected person had neuroinflammation related to Covid-19, which contributed to the despair, catatonia, and Cotter syndrome.
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