Exacerbation of psychosis accompanied by seizure and catatonia in a patient with COVID‐19: A case report

Since the start of the COVID-19 pandemic, there have been numerous reports of neurological and neuropsychiatric manifestations in patients with COVID-19. The complexities associated with the neuropsychiatric manifestations of COVID-19 have led to estimates of the potential prevalence of related disorders, with the goal of treatment and care planning related to them. Here we introduce a patient who, despite the relative control of psychiatric symptoms in the months before hospitalization, was admitted to the psychiatric ward with worsening psychiatric symptoms. The patient was a 61-year-old man who had had schizophrenia for many years and who had been referred to our psychiatric center due to the sudden exacerbation of psychotic symptoms. He had auditory hallucinations in such a way that he heard people telling him that his neighbors were going to take over his house. He experienced the Capgras delusion and deeply believed that the woman who was with him was not his real wife, but only looked like her; and he also had persecutory delusion, and stated that his enemies were attempting to obtain his property. He was admitted to the psychiatric ward due to the exacerbation of psychotic symptoms in the form of auditory hallucinations, and persecutory and Capgras delusions. At the time of admission, he was treated with 10 mg haloperidol with 3 mg biperiden daily. According to the history, he had not had any respiratory symptoms or fever recently. He also had no history of any other physical problems. On the first night of hospitalization, he gradually became lethargic and suffered from nausea and sweating and lost contact with others. During diagnostic evaluations, he had a sudden onset of seizure that was controlled with lorazepam administration (total, 6 mg). Brain computed tomography (CT) scan, electroencephalography (EEG), and lumbar puncture were normal. In his lab tests, he had sodium at 120 mg/L and white blood cells at 15 700/mL. Other laboratory tests were normal. The patient was screened for COVID-19 due to a number of atypical symptoms, such as weakness and sweating (while probable cardiac causes were also ruled out). The result of real-time polymerase chain reaction test based on nasal and pharyngeal swab sampling for the 2019 novel coronavirus (2019-nCoV) was positive. Also, chest CT scan had bilateral opacities in the base of both lungs. During this time, the patient’s antidopaminergic medication had been put on hold based on psychiatric consultation. He was then treated with normal saline infusion and the necessary controls for the gradual treatment of hyponatremia; however, after a while, he lost contact with others, putting his hands in a fixed position and resisting their movement to a normal position. He stared at one point, did not respond to environmental stimuli, refused to consume water or food, and finally became completely mute. In the psychiatric evaluation, according to the patient’s condition, the diagnosis of catatonia was made, and he was treated with lorazepam 2 mg 3 times a day. Gradually, within 24 h, his catatonic symptoms resolved. After 36 h, his lethargy decreased, and he started consuming water and food. With correction of hyponatremia, the patient’s seizures did not recur. After a while, he was discharged from the hospital with a marked reduction in psychotic symptoms and in good general condition. At the time of discharge, he was being treated with the same antipsychotic drugs as before. According to some reports, COVID-19 may cause hyponatremia in some patients, which can be a cause of their psychosis. On the other hand, according to some reports, we may see the Capgras delusion due to central nervous system trauma associated with the effects of hyponatremia. One report on COVID-19 and hyponatremia considers the possible association between COVID-19 and the syndrome of inappropriate antidiuretic hormone secretion in relation to a series of patients, and the possible related mechanisms are discussed. Seizures due to cerebral edema seem likely in such conditions. In our patient, manifestations such as mutism, stupor, positioning, negativism, and rigidity, which meet the criteria of catatonia, occurred following the initial recovery of the patient. Also, delirium and neuroleptic malignant syndrome were not considered for this patient due to his condition of stable vital signs, laboratory results, and normal EEG results. Catatonia has been reported in some patients with COVID-19. In our patient, symptoms improved shortly after he received lorazepam. The role of COVID-19 in catatonic formation still needs to be investigated, especially in terms of its possible mechanisms. In fact, while correcting hyponatremia and controlling the patient’s seizures, catatonia was also controlled at the same time as treatment with lorazepam. The gradual improvement of hyponatremia was accompanied by the improvement of psychosis in the patient, and the patient’s delusions (Capgras and persecutory) gradually became shakable before antipsychotic treatment was started. According to our knowledge, the patient referred to here is the first with COVID-19 who has presented with a series of manifestations in the form of electrolyte abnormality, exacerbation of underlying psychosis, seizure, and catatonia. Seizure in this patient occurred for the first time without a previous history. Hyponatremia was the only finding that could justify this clinical condition after all diagnostic evaluations. Given the importance of the issue, it seems that the effects of COVID-19 on the development of symptoms such as catatonia, exacerbation of underlying psychosis, and seizure should be considered with more focus. The co-occurrence of such manifestations in association with hyponatremia, as one of the possible electrolyte disturbances associated with COVID-19, in the form of seizure, Capgras and persecutory delusions, and catatonia, may be considered in the clinical evaluation of other similar COVID-19-related cases. One of the limitations of our study was the status of the patient as a psychiatric patient admitted to the psychiatric ward and the need for constant communication with other specialists in other fields for the patient’s diagnostic and therapeutic management. In this situation, after requesting the desired counseling and explaining the patient’s condition, the cooperation of other related specialists was obtained.