COVID-19 presenting with catatonia.

Infection with SARS-CoV-2 has resulted in a global pandemic, with predominant respiratory symptoms. High rates of anxiety, depression, and Post traumatic stress disorder (PTSD) have been the usual psychiatric presentation in people with COVID-19.[12] Neurologic sequelae has also reported.[34] Catatonia has been associated with various psychiatric disorders and medical conditions, including infections, metabolic, autoimmune, inflammatory, and substances, including antipsychotics, immunosuppressants, antibiotics, and recreational drugs.[5] This case highlights a rare neuropsychiatric presentation of COVID-19.

A 28-year-old COVID-19–positive female with no past or family history of psychiatric illness presented with sudden onset of over talkativeness, muttering to self, disturbed sleep, for the past 3 weeks with reduced speech output, reduced oral intake, and poor self-care for 1 week. The patient was talking excessively, was irritable, and remained awake throughout the night, pacing around. She remained inattentive, barely did any of the chores, and was not looking after her children properly. Her spouse noticed her muttering to self and seemed fearful; on asking, the patient said that she was hearing voices but did not elaborate. Her self-care and appetite were poor. After admission to a private psychiatry hospital, she stopped talking completely and acted exactly opposite of what was being told. The patient kept doing repeated activities, without any apparent reason and refused to accept food or water, so Ryle's tube was inserted. She was diagnosed as a case of acute psychosis and was treated with oral and injectable antipsychotics. The patient showed 10% improvement; however, as she tested positive for COVID-19, she was referred to a dedicated COVID hospital, for both psychiatric and COVID-19 management. There was no history of head injury, convulsion, substance use, fluctuating consciousness, or any known medical comorbidity. On Mental status Examination (MSE), she was unkempt, conscious, uncooperative, and noncommunicative. She had catatonic features in the form of stupor, mutism, stereotypy, negativism, withdrawal, and ambivalence. Her affect was flat and nonreactive. No hallucinatory behavior was noted. Social judgment and insight were lacking. Bush Francis Catatonia Rating Scale score was 16 (suggestive of moderate catatonia). Her physical examination and baseline laboratory investigations, chest X-ray, and computed tomography brain did not reveal any abnormality. With a diagnosis of “catatonia due to another medical condition,” lorazepam challenge test was done, to which her catatonic features responded well. Intravenous (IV) lorazepam was continued, with routine COVID-19 protocol, IV fluids, and Ryle's tube (RT) feeding. Her catatonic features subsided gradually, and the patient was discharged on day 8 with 90% remission, on tablet lorazepam 1 mg BD, and on tablet olanzapine 5 mg HS along with routine COVID management and strict home isolation for 14 days.

COVID-19 presenting in the form of catatonia is not a common finding. However, as quoted by Caan et al., “catatonia can be associated with acute COVID-19. They have also highlighted the importance of considering a diagnosis of catatonia in medically hospitalized patients who display altered mental status and motor abnormalities.”[6] Emerging evidence supports the association between acute COVID-19 infection and neuropsychiatric complications.[7] Exposure to proinflammatory cytokines has been associated with alterations in GABAergic and dopaminergic modulation of the corticobasal ganglia–thalamocortical circuit.[8] An immune response to infection, psychological trauma, and socioeconomic stressors are found to be other contributing factors.[910] COVID-19 is likely to have an effect on other organ systems in the human body, apart from the respiratory system, both in short and long term. Neuropsychiatric aspects of COVID-19 should be considered while treating the patients. Conversely, comorbid diagnosis of COVID-19 should be investigated in patients presenting with acute-onset behavioral disturbances.

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Conflicts of interest

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