Case Presentation
A 15-year-old male was admitted with a five-day history of an acute psychotic state.
Medical History
- A month earlier, the patient had tested positive for SARS-CoV-2 PCR on a nasopharyngeal swab performed for the onset of fever and anosmia.
- About 3 weeks after the COVID-19 diagnosis, a complete resolution of physical symptoms was noticed.
- At the same time, his parents referred to a sudden and progressive change in his behavior characterized by restlessness, insomnia, and prominent paranoid delirium, including feelings of concern and guilt
- During a medical interview, the patient appeared poorly cooperative and showed partial compromission of time and space orientation, incoherent speech, and a tangential thought process with content notable for religious delusions and confabulation.
- He referred to auditory and visual hallucinations and showed poor insight and judgment regarding his condition. His recent memory was impaired, in the absence of gross cognitive decline.
Family History
- Unremarkable
Clinical Exam
- A positive SARS-CoV-2 PCR on a nasopharyngeal swab was detected, although a chest X-ray was negative for SARS-CoV-2 pneumonia
- No significant abnormalities were detected with either blood tests or in a brain CT, EEG, or MRI, except for a slight descent of the right cerebellar tonsil and a thinning corpus callosum.
Treatment
- The patient started a 1week course of lorazepam in two daily doses of 1 mg, with paliperidone progressively titled to 9 mg/day and nightly lithium sulphate added for the persistence of dysphoria and sudden mood changes.
- A significant improvement in religious and paranoid delusions was reported within a week, along with a small improvement in the patient’s insight and judgment
Clinical Outcome
- All positive symptoms disappeared completely, but negative symptoms persisted.
- In particular, abulia, alogia, asthenia, social withdrawal, attention deficit, poor language, and anxiety have been detected at all times, albeit they have been progressively milder.
- EEG, blood count, and ECG were always in the normal range. Lorazepam was discontinued 1 month later upon hospital discharge and lithium after 4 months.
- Patient continued paliperidone and was reported taking Cognitive Behavioral Therapy (CBT)