key: cord-0730454-pk8siq3o authors: Lim, Lucas J.H.; Ghosh, Arnab Kumar; Tammy Tsang, Yun Ying title: Psychosis: A Presentation of COVID-19? date: 2020-06-12 journal: Psychosomatics DOI: 10.1016/j.psym.2020.06.004 sha: 2a351b4ccb2b0cf6b27089428951c19d7182645a doc_id: 730454 cord_uid: pk8siq3o This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal. Introduction Since the first cluster of 41 patients with mysterious pneumonia in Wuhan was reported by the Chinese Heath Officials in December 2019, Coronavirus disease (COVID-19) has evolved into a full-blown pandemic. Typically, the infected would exhibit symptoms such as fever, dyspnea, myalgia, cough and sputum production, anosmia and ageusia (Huang et al. 2020 , Centers for Disease Control and Prevention, 2020) On average, patients develop dyspnea 8 days after first developing symptoms, and Computer Tomography of the Chest will reveal multi-lobar and subsegmental areas of consolidation. (Huang et al. 2020) There is some evidence suggesting that COVID-19 may cause neuropsychiatric manifestations as well. (Steardo L et al., 2020) . We describe a case presenting with psychosis to a tertiary psychiatric institution in Singapore subsequently found to be positive for COVID-19. Case Details Ms. A is a 28 year old domestic helper from Myanmar with no past psychiatric history. She had traveled from Myanmar 3 weeks prior to her presentation to the Emergency Department of the Institute of Mental Health in early March 2020. She was brought in to the Emergency Room by her employer for acute behavioral change of 2 days duration. Her employer had noticed that the domestic helper talked and smiled to herself. She was noted to be crying, and told the employer she wanted to apologize to her previous employer, however she could not explain why she felt apologetic. She had woken up at 3 a.m. to wash clothes and do house chores without being instructed to do so. When we interviewed Ms. A, she shared that she had many secrets and was feeling ashamed of her past. She revealed that these ruminative thoughts were sexual in nature. She was also ruminating about her previous employer and she wanted to thank the previous employer for being good to her. She felt that she knew "everything" that would happen in the future but was unable to elaborate on what "everything" meant. She reported that these thoughts were inserted into her mind by an external force. She believed that others were talking about her and monitoring her movements. As a result, she felt low in her mood. Additionally, she heard voices of spirits and sensed them surrounding her. She reported experiencing these symptoms for the past few days. Otherwise she was noted to be oriented to time, place and person during the interview and did not show signs of inattentiveness. Prior to the interview, at the triage counter of the emergency department, it was found that Ms. A had a temperature of 37.9 o C. She was surprised that she was having a fever as she was otherwise asymptomatic and was feeling well. According to her employer, there were no sick contacts at home. On physical examination, it was noticed that she had decreased breath sounds bi-basally. A decision was made to refer Ms. A to a general hospital for further investigations as part of a work up to rule out organic causes for her acute change in behavior as well as for the fever. We had provisionally diagnosed her with Acute Psychosis, with a possible Chest Infection. 2 days later, we were informed by the Ministry of Health Singapore as part of contact tracing, that Ms. A was found to be COVID-19 positive. She has not returned to our institution since then. It is known that viruses may cross the Blood Brain Barrier through a few means, namely: paracellularly, transcellularly, or by the "Trojan-horse" method. (Kwang, 2008) Through these methods, viruses may then cause central nervous system (CNS) infections. Historically, Coronaviruses such as the Severe Acute Respiratory Syndrome (SARS-CoV) and the Middle East Respiratory Syndrome (MERS-CoV) had been demonstrated to cause CNS morbidities. SARS coronavirus had been reported to cause neuropathies and myopathies (Tsai et al., 2004) . Guillian-Barre syndrome with Bikerstaff's encephalitis and neuropathies were reported in patients with MERS-CoV. Surprisingly, neurological sequelae of MERS-CoV did not accompany respiratory symptoms, rather, they were delayed by 2-3 weeks (Kim et al., 2017) . There have been reports of COVID-19 causing neurological complications as well. Rare neurological presentation such as acute hemorrhagic necrotizing encephalopathy initially presenting with fever and altered mental status was observed in a report (Poyiadji et al., 2020) . Another case of a young male with fever and altered mental state was reported in Japan where COVID-19 RNA was detected in cerebrospinal fluid. Magnetic Resonance Imaging of the brain was performed and revealed right lateral ventriculitis and right mesial lobe and hippocampus encephalitis (Moriguchi et al., 2020) . Our patient, Ms. A, was diagnosed with COVID-19 before Singapore experienced a surge in positive cases. Although we were not privy to the laboratory investigations for the workup for the cause of her psychotic episode, her acute onset of psychosis was remarkably coincident with the subsequent diagnosis of COVID-19 leading to the conjecture that her COVID-19 may be associated with her acute change in mentation. As the pandemic surges globally, more research is needed on atypical presentations of COVID-19 given the increasing literature that COVID-19 does not solely present with respiratory symptoms. This will aid diagnosis with prompt treatment for possible complications that may arise from the disease. 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