(034) COVID-19 Auto-Immune Encephalitis presenting as First-Break Psychosis: A Case Report and Literature Review

Abstract:

Background/Significance:

A growing literature describes neurological complications of COVID-19, including several reports of Guillain-Barre Syndrome (GBS) [Gagarkin, 2021; Vakili, 2021]. However, few cases report a subsequent progression to encephalitis. Although uncommon, COVID-19-associated encephalitis results in significant morbidity with a mortality rate of 13.4% [Siow, 2021]. The morbidity associated with COVID-19-encephalitis leads to poor patient outcomes, underscoring the need for further understanding. Here we present a case of new-onset severe psychosis following COVID-19-associated inflammatory demyelinating polyneuropathy (IDP).

Case:

Ms. H is a 53-year-old female with a psychiatric history of Alcohol Use Disorder with no prior psychosis. She was initially admitted for severe proximal weakness and paresthesias after testing positive for COVID-19. EMG, imaging studies, and nerve biopsy confirmed a diagnosis of GBS. Ms. H received IVIG and IVMP with limited effect. She was readmitted three times over the following month for conversion of Acute IDP to Chronic IDP. Seven weeks after her initial presentation, staff at Ms. H’s rehabilitation center noted new-onset psychosis. She was transferred back to the hospital in significant distress with paranoid delusions, persecutory beliefs, confabulation, and a tangential thought process. Psychiatry initiated a regimen of risperidone 1mg BID and haloperidol 1mg q6H; haloperidol was transitioned to olanzapine 10mg BID after an acute onset of dystonia. LP and EEG were concerning for autoimmune encephalitis. GAD65 antibody was positive. Plasmapheresis was initiated for five rounds, during which Ms. H’s symptoms of psychosis greatly improved. Olanzapine was subsequently lowered. Ms. H returned to her cognitive baseline before transferring back to the rehabilitation center.

Discussion:

Limited literature is available to describe COVID-19-induced encephalitis and the poor outcomes associated with its complications. Our case depicts a highly functioning, employed individual who rapidly decompensated into a severely psychotic, bed-bound individual over two months. The severity of this decline highlights the significant neurological morbidity associated with COVID-19 and further provides insight into the potential for associated IDP with progression to encephalopathy with psychosis.

Conclusion/Implications:

Clinicians must better understand varying manifestations of severe COVID-19-related complications to improve prognosis and long-term outcomes. Further characterization of COVID-19-induced encephalitis is necessary to improve prognosis, optimize patient care, and minimize the rapid decline and significant morbidity highlighted in our case.

References:

1. Gagarkin D, et al. Acute inflammatory demyelinating polyneuropathy or Guillain-Barré syndrome associated with COVID-19: a case report. J Med Case Rep. 2021;15:219.

2. Vakili K, et al. Neurological Symptoms, Comorbidities, and Complications of COVID-19: A Literature Review and Meta-Analysis. Eur Neurol 2021; 84:307-324.

3. Siow I, et al. Encephalitis as a neurological complication of COVID-19: A systematic review and meta-analysis of incidence, outcomes, and predictors. Eur J Neurol. 2021; 28:3491–3502.

Presenting Author(s)

Erin Davidowicz, MD (she/her/hers)

Psychiatry Resident
Yale University
New Haven, CT, United States

Co-Author(s)

Shannon Mazur, DO

Assistant Professor of Clinical Psychiatry
Yale Psycho-Oncology Program at Smilow Cancer Hospital
New Haven, Connecticut, United States