(039) Olfactory and gustatory hallucinations in new onset psychosis due to COVID-19: an atypical presentation

Abstract:

Background: The novel coronavirus (COVID-19) pandemic has caused detrimental effects on mental health worldwide (Taquet, 2021). Cases of COVID-19 psychosis share features: agitation, insomnia, paranoia, disorganized thinking, and auditory hallucinations; however, neuropsychiatric manifestations remain poorly understood (Ferrando, 2020).


Case: A 35-year-old female was admitted to the internal medicine service due to altered mental status. Ten days prior to hospitalization, she reported mild upper respiratory symptoms and tested positive for COVID-19 despite two doses of COVID-19 vaccine approximately three months earlier. Five days prior to hospitalization, she experienced abrupt onset of paranoia, mood lability, olfactory hallucinations, and insomnia. The patient had treated herself with daily quercentin and veterinary praziquantel/ivermectin for seven days. Past psychiatric history was significant for anxiety with no family history of psychiatric illness. Mental status exam demonstrated disorganized behavior, dysphoria, circumstantiality, olfactory and gustatory hallucinations related to helium gas, paranoia, slowed concentration, and mild short term memory impairments. Documented periods of mutism, facial grimacing and migratory paresthesia were found. Diagnostic testing was negative. She was started on olanzapine 10mg at bedtime. Three days after admission, she demonstrated more organized behavior, improved sleep, and a more linear thought process. Visual and olfactory hallucinations as well as paranoia had resolved, but intermittent gustatory hallucinations remained present. She was discharged in improved condition. At two-month follow up, her symptoms were completely resolved.

Discussion: We present a patient with new onset psychosis experiencing both gustatory and olfactory hallucinations, in contrast to anosmia and ageusia, which are commonly observed in COVID-19 infection (Mehraeen, 2021). Literature suggests potential pathophysiologic mechanisms related to COVID-19 psychosis, such as direct neurotropic viral infection, cytokine dysregulation, and post-infectious cellular/antibody mediated response (Ferrando, 2020). Heightened anxiety secondary to COVID-19 diagnosis and medication misuse may have contributed to her clinical presentation.


Conclusion: Based on epidemiologic associations between viral infections and psychosis, we believe COVID-19 may increase the risk of psychosis in certain infected individuals. Further research identifying populations most at risk for developing psychotic symptoms from viral infection may allow for quicker identification and treatment of neuropsychiatric symptoms. COVID-19 related psychosis has appeared to respond well to antipsychotics.

References:
1. Ferrando S, Klepacz L, Lynch S, et al. COVID-19 Psychosis: A Potential New Neuropsychiatric Condition Triggered by Novel Coronavirus Infection and the Inflammatory Response?. Psychosomatics. 2020;61(5):551-555. doi:10.1016/j.psym.2020.05.012

2. Mehraeen E, Behnezhad F, et al. Olfactory and gustatory dysfunctions due to the coronavirus disease (COVID-19): a review of current evidence. Eur Arch Otorhinolaryngol. 2021;278(2):307-312. doi:10.1007/s00405-020-06120-6

3. Taquet M, Geddes JR, Luciano S, Harrison PJ. 6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using electronic health records. Lancet Psychiatry. 2021;8(5):416-427. doi:10.1016/S2215-0366(21)00084-5