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Doctors have reported the case of a man suffering an acute manic episode following a SARS-CoV-2 infection – the virus responsible for Covid-19.
A 41-year-old man with no significant medical history began to show potential symptoms of Covid-19, including a dry cough and fever, his doctors write in BMJ Case Reports. Nine days after the first symptoms occurred, he developed what he described as the "worst headache ever".
During the night, he woke up agitated and his "brain was racing", telling his wife that he thought he was going to die. At this point, he began to inform his wife about previously undisclosed sexual encounters, which she described to doctors as uncharacteristic of her husband.
"As the ambulance came, I confessed to my wife that I had sex with men (most of which before marriage), although I am heterosexual," the patient explained in the report. "I felt that I was incapable of lying or hiding the truth and thought I was dying."
He was brought to the emergency department at St Thomas' Hospital in London, where he began to show sexually disinhibited behavior and pressured speech (urgent, frenzied, and erratic speech patterns). He also showed signs of having grandiose ideas with a strong religious element, during which he attempted to anoint other hospital patients with water. As the behavior worsened, he was sedated and transferred to intensive care for mechanical ventilation.
Upon investigation, a swab taken from his nose and throat tested positive for Covid-19, while a chest X-ray showed inflammation of the lung tissue consistent with the illness. A psychiatric assessment, when he was off ventilation, found his symptoms consistent with acute mania, after which he was detained under the Mental Health Act. He was moved to the psychiatric unit for recovery, where he improved and was discharged after 12 days. A follow-up 23 days after he initially showed up at the hospital found him improved and at baseline levels of function.
The team said it's possible he was experiencing a first manic episode of bipolar disorder, a condition that his sister was diagnosed with following an episode of postpartum psychosis. With other neurological symptoms and conditions associated with Covid-19, however, the team stress the possibility of his changed mental state being the result of the SARS-CoV-2 infection.
"The entry of SARS‐CoV-2 into human host cells is mediated mainly using ACE-2 as a receptor, and although the lungs and the gastrointestinal tract are the principle sites of expression of ACE-2 in the body, the protein is also expressed throughout endothelial cells in the brain providing a theoretical route of entry into the central nervous system," the team write in their report.
"More specifically, the amygdala, which has key functions in emotional intelligence as well as those related to sexual arousal, has been demonstrated to express ACE-2 in animal models thus providing a focus to which the spike proteins of the virus may bind."
Though they say they it wasn't confirmed in this case and further research is required, they highlight the need to consider Covid-19 patients displaying psychiatric symptoms.
"This is, to the best of our knowledge, the first report of an acute episode of mania or psychosis as a result of SARS-CoV-2 infection," the authors write. "This case indicates the need to consider testing for and diagnosis of Covid-19 in a wider series of clinical presentations including new onset psychiatric and neurological disorder."
The patient, since recovered, described his experience as "fascinating".
"This may seem strange from an outside perspective, but I was, in my mania, trying to help the doctors as much as I could, while at the same time trying to make sense of my condition. I began to think that I was part of a TV show, in which I was sent back from the future to save the NHS, and I was curious to see how this would end."
