COVID-19, Diagnostic Difficulties and Acute Psychosis

摘要

Background: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) or COVID-19, has emerged as an epidemic contributingto more than 247,000 deaths worldwide as of 4th May 2020. It commonly presents with respiratory and occasionally gastrointestinalsymptoms. Here we describe a rare case of COVID-19 presenting with acute psychosis which was also complicated by a false negative RTPCRnasopharyngeal swab upon hospital admission.Case Report: A 40 year old, previously fit and healthy male, presented to accident and emergency with respiratory tract symptoms andfever during the COVID-19 outbreak. His first RT-PCR nasopharyngeal swab tested negative for COVID-19, but due to a strong clinicalsuspicion of COVID-19, CT imaging was conducted which justified the sending of a repeat swab. In the meantime, he started to exhibitsymptoms of acute psychosis such as hallucinations, paranoid delusions, an attempted suicide, derealisation and depersonalization. Due tofailed conservative measures and haloperidol in managing acute psychosis, the patient was intubated for 24 hours. After extubating thepatient recovered to baseline within 2 days.Discussion: There are two clinically relevant learning points to be noted from this case report. Firstly, RT-PCR nasopharyngeal COVID19swabs are estimated to be only 70-75% sensitive, whereas CT scan changes are estimated to be as high as 97%-98% sensitive. CTimaging can thus be useful when there is a strong suspicion of COVID-19 despite negative nasopharyngeal swabs. Secondly, in order toreduce the work of breathing secondary to agitation, the cross-infection risks to others, and the risk of repeated suicide attempts, thispatient was successfully managed with intubation and ventilation, despite the absence of respiratory failure.Conclusion: False negative rate with RT-PCR COVID-19 nasopharyngeal swabs is high and this identifies a crucial diagnostic role for CTThorax in swab-negative, symptomatic patients with suspected COVID-19. Secondly, acute psychosis is an emerging indication forintubation to consider when managing patients with highly virulent respiratory infections, such as COVID -19.