On July 20, 2020, a 57-year-old male patient was brought to the psychiatric outpatient clinic in Zagazig University with symptoms of mood elation, hyperactivity, psychomotor agitation, pressured speech, decreased need to sleep (only 2 to 3 hours per night was enough), increased appetite, increased self-esteem, increased pleasurable (sexual) activity and delusion of persecution (claiming that the neighbors wanted to harm him). The patient had no previous or family history of primary mood or psychotic disorders. The patient was a nonsmoker, known asthmatic stabilized on bronchodilators, and denied any history of substance use disorders.
Ten days before the emergence of manic symptoms, the patient reported inability to smell and taste, rhinorrhea, fever 38.8, weight cough, and fatigue. His oxygen saturation was 94%, and his respiratory rate was 16. His chest CT scan showed multiple bilateral consolidation and ground glass patches. Later, the diagnosis of COVID-19 was confirmed by a positive throat swab. The laboratory findings revealed serum ferritin 420.8, D-dimer 0.42, ESR (first hour) 24 negative CRP, normal CBC, normal PT and PTT, normal kidney and liver function except for slightly elevated AST and ALT, and normal abdominal ultrasonography except for mildly enlarged liver displaying slightly coarse echo pattern. The following drugs were prescribed for the patient under the supervision of his chest physician: Paracetamol 500 every 8 hours, bromhexine 5 ml every 8 hours, clarithromycin, 500 mg twice daily, theophylline 150 mg twice daily and betamethasone one ampule once. Within one week, previous symptoms started to disappear. 3-days later, his family noticed the emergence of the previously reported mood and behavioral changes. Treatment included olanzapine 15 mg at night. After 3 weeks of treatment, the patient showed gradual and marked responses especially mood, sleep, and speech symptoms, and was advised to continue the prescribed drug.
On July 24, 2020, 69 years old female patient came with her family to the outpatient clinic in Zagazig University presented with symptoms of being talkative, irritable, energetic, and verbally aggressive. The family reported insomnia and early waking, increased appetite especially for pastries, increased pleasurable activity (wearing and buying gold pieces) delusion of persecution (claimed that others tried to hurt her).
The previous symptoms developed two weeks after the patient’s complaints of nausea and vomiting, dry cough, fever 38.9, headache, and fatigue. She sought medical treatment at the isolation hospital of her region for 7 days and continued her protocol of treatment at home. The diagnosis of COVID-19 infection was confirmed by a positive throat swap. The advised protocol prescribed for her was Paracetamol 1000 mg every 8 hours, Ceftriaxone 1000 mg ampule for 5 days, Azithromycin 500 mg once daily for 6 days, Levodropropizine 5ml every 8 hours, Ivermectin 6 mg 4 tablets once repeated after 3 days, Enoxaparin sodium 4000 IU, Lactoferrin 100 mg sachet twice daily, and Vitamin C 500 mg capsule twice daily. The patient improved within 1 week of treatment. The laboratory finding during the time of admission revealed high blood sugar 610 mg/dl (discovered for the first time). Other investigations showed moderate leukocytosis 17.81 and neutrophilia 92.5. Her CT brain showed nonspecific age-related brain atrophy. The patient had no history of medical illness except for hypertension 8 years ago controlled on amlodipine 5 mg, hydrochlorothiazide 12.5 mg, Olmesartan 20 mg. She has no psychiatric history or family history of any mental illness or substance abuse.
When she came to the psychiatric clinic, we prescribed risperidone 2 mg which was gradually increased to be 4 mg at night. She started to improve after 4 days of the last dose and completely recovered within 2 weeks of treatment. Psychiatric follow-up during the following weeks was reassuring. The patient showed a stabilized mood and became calm with normal sleep, speech, and appetite continuing the same prescribed drug.
On June 4, 2021, a 35-year-old female patient came with her husband to the emergency room in a general hospital after the death of her father with COVID-19. She claimed symptoms of depressed mood, insomnia, and tingling in both hands. A general practitioner prescribed her midazolam 5 mg ampoule STAT, and she was discharged as she became somewhat quiet. Two days later, she gradually became talkative, weeping most of the time, then her mood was switched to be irritable and in a loud voice refusing anyone to interrupt her. Later, the husband noticed her decreased sleep hours with early awakening and hyperactivity, as well as engagement in unnecessary pleasurable activities (excessive shopping). She accused her mother-in-law that she was making black magic for her husband, and neighbors were spying on her social media accounts. One week later, her husband took her to the same hospital where the GP gave her another midazolam 5 mg amp and consulted a psychiatrist who prescribed Haloperidol 5 mg IM twice daily, Biperiden 2 mg twice daily, and Olanzapine 10 mg at night. She became quiet and sedated with good vital signs. The patient had no history of chronic medical illness, primary mood or psychotic disorders, or substance use disorders.
Her husband informed that three weeks before the former symptoms, the patient complained of flu-like symptoms, cough, fever, generalized body ache, headache, and fatigue. These symptoms started 2 days after she visited her deceased father who was infected with the corona virus. She sought medical treatment with a pulmonologist who requested CT chest revealing multiple pneumonic patches. Her labs revealed elevated CRP and serum ferritin, and Oxygen saturation was 88. The diagnosis of COVID-19 infection was confirmed by a positive throat swap. Medications given included Ceftriaxone 1 gm ampoule once daily, dexamethasone ampoule twice daily for 5 days, and linezolid 600 mg daily for 5 days. She continued her protocol of treatment at home and started to be improved one week after treatment onset.
On June 13, 2021, a 34-year-old female patient came with her mother to a psychiatric clinic suffering from an insidious course of symptoms of irritable mood, insomnia, hyperactivity and talkativeness, and psychomotor agitation. Later, she started screaming and shouting, insulting her family members with obscene words, and spitting on them, and producing sounds like goats. On their way to the clinic, her family forcibly prevented her from standing in front of a running car. The patient had no history of chronic medical illness, primary mood or psychotic disorders, or substance use disorders. After the psychiatric interview, the patient had prescribed olanzapine 20 mg once daily at night, sodium valproate 500 mg three times daily, haloperidol 5 mg IM twice daily and biperiden 2 mg twice daily.
Four weeks before the symptoms, the patient complained of cough, fever, generalized body ache, and fatigue. She sought medical treatment with a pulmonologist who requested CT chest showing mild pneumonic patches, and labs revealing elevated CRP and serum ferritin, and lymphopenia. The diagnosis of COVID-19 infection was confirmed later by a positive throat swap. She received linezolid 600 mg daily for 5 days, four tablets Ivermectin 6 mg once daily for 4 consecutive days, and paracetamol 500 mg 4 times daily with home isolation. The patient’s condition started to improve after 5 days of treatment. After three weeks of recovery of Covid-19 symptoms, she started to gradually develop psychiatric symptoms.
On May 24, 2021, a 47-year-old male patient came alone to a psychiatrist complaining of symptoms of depressed mood, lack of interest, chest tightness, unexplained weeping, lack of concentration, fatigue, and suicidal thoughts which developed over two weeks. Later, the patient neglected his work and became socially withdrawn. CT brain was performed, which looked normal. The depressive symptoms persisted for the next four months despite prescribing venlafaxine 75 mg for one month then 150 mg for 3 months. After revising the patient’s psychiatric condition, it was documented that the patient was diagnosed one year earlier with bipolar disorder, manic episode by another psychiatrist when he had symptoms of elated mood, insomnia, talkativeness, hyperactivity, spending a lot of money on non-useful goods and grandiosity thoughts. The prescribed medications were olanzapine 10 mg once daily at night and sodium valproate 1000 mg twice daily. Manic symptoms disappeared gradually after one month of psychotropic medications. Therefore, this patient was eventually diagnosed with bipolar I disorder, recurrent, current episode depressive, and prescribed Olanzapine/Fluoxetine combination 6/25 mg once daily at night.
However, the patient’s family reported that the manic symptoms developed three weeks after symptoms of sore throat, mild cough, and anosmia. He sought medical treatment with an internist who requested CT chest showing mild pneumonic patches, and labs revealing elevated CRP and serum ferritin, and leukopenia. The diagnosis of COVID-19 infection was confirmed later by a positive throat swap. The prescribed medications included doxycycline 200 mg on the first day of the course, followed by a maintenance dose of 100 mg regularly for 7-10 days, three tablets of Ivermectin 6 mg once daily for 4 consecutive days and paracetamol 500 mg 4 times daily, with home isolation. The patient improved within 7 days of treatment and stopped his treatment.