After contracting Covid, a woman develops disturbing mental symptoms, including the belief that she is already dead. While the doctors are still undecided, the situation suddenly comes to a head.
A 57-year-old woman desperately calls the emergency doctor. She reports that she has been isolating for a week because of Covid disease, but her symptoms are not going away. In the meantime, her condition is so bad that she can no longer look after her father, whom she cares for at home – he has now also SARS-CoV-2 captured.
The emergency doctor takes both of them to the nearest clinic, where they are hospitalized and treated for their Covid pneumonia. There the woman receives additional oxygen, Remdesivir and dexamethasone. During her stay, the doctors noticed that the patient repeatedly suffered from anxiety attacks – especially when the subject of her father’s dismissal was discussed. She and her brother refuse to release their father to a rehabilitation center, instead planning for him to return home to the patient once he is well.
patient with mental health problems
A look at the medical record reveals that the patient had often struggled with psychological problems in the past – she had a severe one in her mid-20s Depression diagnosed and treated with electroconvulsive therapy. Since then, she has been hospitalized two more times for psychiatric symptoms: once for a major depressive disorder and once for a bipolar episode attributed to insomnia and anxiety.
After six days in the clinic, the time has come: the woman is released, before her father. But the next day she is back in the emergency room. Her brother worried about her when she looked confused on the phone. The condition of the woman also seems strange to the doctors: During the examination, the patient is no longer so sure why she is actually here and would rather go home again – at the same time she says she is afraid of being alone at home. She seems awake and oriented, but scared. She paces back and forth in the examination room, constantly talking about her father. She feels overwhelmed at the thought of being able to take care of her father again when he is released.
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Further examination is normal. Doctors note that the cough and shortness of breath that developed as a result of the Covid illness have subsided. She has no fever, no visual or auditory hallucinations, and no other noticeable symptoms. Her temperature is 37.2°C, pulse is 97 beats per minute, blood pressure is 153/95 mmHg, respiratory rate is 20 breaths per minute and oxygen saturation is 93%. The doctors nevertheless decide to re-admit the patient to facilitate discharge to a rehabilitation center for further care.
She stares at the ceiling with her eyes wide open
In the clinic, the patient withdraws more and more. On the third day of her stay, she begins to answer questions with only a single word or silence. The situation is getting worse and worse. She just lies motionless in bed and stares at the ceiling with her eyes open. A manic-depressive episode?
There is no evidence of hallucinations or suicidal thoughts. Because of her mood disorder, the patient takes a mix of antidepressants, including Bupropion, fluoxetine and Olanzapine. Doctors suspect that the antidepressants may have triggered a secondary manic episode in this patient with suspected bipolar disorder. However, her condition is not typical of drug-induced mania, which would present with classic symptoms such as insomnia, euphoria or irritability, extreme hyperactivity, and constrained speech. The doctors also tend to rule out a side effect of the high-dose steroid therapy (the patient received dexamethasone) – also known as steroid-induced psychosis – because she stopped taking the drug a few days ago.
“I’m dead”
Is there an organic cause? A CT scan of the head gives no indication of an infarction or a tumor. However, changes in the white matter can be seen. While the patient waits for a vacancy in the clinic’s psychiatric ward, the doctors continue to puzzle over the woman’s condition. Meanwhile, the nursing staff is presented with an eerie picture – but together with the head CT, a hot lead finally emerges: When they encourage the patient to talk more about her condition, she tells about her father and suddenly says: “He is dead. I’m dead.”
She also believes her brother and nurses are dead, as well as the doctors. She says she can no longer urinate because her bladder is gone, and she can no longer eat. She also makes serious allegations because she is convinced that she is solely responsible for the corona pandemic. Doctors suspect that their patient may be suffering from neuroinflammation associated with COVID-19, depression, Katatonie and the Cotard-Syndrom has developed. Cotard syndrome is the painful one delusional Belief of being dead, decomposing, or non-existent.
The doctors give her Clonazepam and increase the dose of olanzapine. In the psychiatric ward, she eventually suffers an epileptic seizure, which is why she Levetiracetam receives and stays in the clinic for another four weeks. After her discharge, however, the patient was admitted to the psychiatric inpatient three more times because of a major depressive disorder with psychotic features – mainly paranoia.
The case report is in NEJM appeared.
Image source: Ian dooley, unsplash