A 47-year-old woman with past medical history of hypertension and no psychiatric history presented to the psychiatric hospital with altered mental status. She was previously prescribed duloxetine for symptoms of premenstrual syndrome but otherwise denies a history of mood symptoms. Seventeen days before her arrival at the psychiatric hospital, she had developed symptoms suggestive of COVID-19 and began quarantining at the advice of her physician (Fig. 1). She was diagnosed as an outpatient with pneumonia on day seven and had a positive COVID-19 test at that time. She continued self-isolating and was managed conservatively as an outpatient. Symptomatic management included over the counter pain relievers and decongestants as needed, however the patient preferred not to take medications. Steroids were not prescribed. During self-isolation, she developed anxiety related to the pandemic becoming aware of several deaths in her social group secondary to COVID-19 and became anxious for her husband and herself. By day 17, she began exhibiting elevated mood, bizarre behavior, flight of ideas, talkativeness, sleeplessness, and grandiosity. On day 21, her spouse called emergency medical services because she was exhibiting bizarre behavior including infatuation with the number three, magical thinking, and uncharacteristic behaviors. For example, her husband was afraid when she reportedly held a knife and offered to make it disappear as a magic trick. She has slept very little since day 17 when her elevated mood began. She was brought to the emergency department by ambulance and was referred to the psychiatric hospital the following day. She has a family history of bipolar disorder but reports no previous manic or depressive episodes. Her spouse corroborated this, describing her mood historically as “rock solid.” The patient was employed and lived with her spouse.
On admission, the patient was evaluated for organic causes of her presentation. The medical staff determined there was no evidence of encephalopathy or altered mental status from toxic, metabolic, ischemic, infectious, or structural sources. Her vital signs were stable with a temperature of 98.8° F, heart rate of 90, blood pressure of 148/85 mmHg, oxygen saturation of 99% on room air, and respiratory rate of 16 breaths per minute. Laboratory evaluation included a complete metabolic panel and complete blood count which was noncontributory and did not reveal any potential cause for altered mental status. Notably, serology was negative for COVID-19 on arrival to the Emergency Department. Urine drug screening for alcohol and drugs of abuse was negative. The patient denied head trauma and no intracranial abnormalities were observed on imaging.
On arrival to the psychiatric hospital, an assessment was conducted. The patient demonstrated an expansive mood and exhibited flight of ideas, distractibility, increased goal directed behavior, restlessness, talkativeness, and grandiosity. Grandiose delusions were characterized by an elevated sense of self and the perception that she had been chosen to combat the pandemic. There were no obvious perceptual disturbances. There were no appreciable cognitive deficits. Her behavior included carrying papers on which she was planning a party with the intention to invite the entire world. The patient was euphoric, equating her stay to that of a five-star resort.” Despite having not slept in five days, the patient reported feeling energetic and feeling that she was “on top of the world.” She was diagnosed with acute mania and provided with pharmaceutical treatment in addition to group therapy. Delirious mania was considered, however no fluctuations in level of consciousness were observed, and the patient was neither disoriented nor confused. Choice of pharmacologic agent was made according to patient preference. Concerns were discussed regarding potential side effects and stigma regarding the use of lithium as a mood stabilizer. Quetiapine was chosen as an antipsychotic due to the presence of insomnia. A short course of benzodiazepine was also prescribed. The regimen utilized was extended release alprazolam 1 mg, quetiapine 100 mg, and lamotrigine 25 mg for mood. She reported improved sleep attributed to the initiation of these medications. Her quetiapine was titrated upwards by 100 mg each day, eventually reaching a total of 500 mg. Many of her symptoms improved, including her elevated mood, increased activity level, and flight of ideas, though decreased need for sleep returned somewhat as her benzodiazepine was tapered. She tolerated the medicines well and reported only drowsiness as a side effect. She and her partner were agreeable to transitioning to outpatient care after her mood stabilized. The length of stay was ten days from arrival to discharge. At the time of discharge, her mood was euthymic. She was no longer exhibiting flight of ideas, restlessness, or increased goal directed activity. Grandiose and bizarre behaviors had resolved, but overvalued ideas remained. She reported significant improvements in sleep.