Covid-19, diagnostic difficulties and acute psychosis

Background: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) or COVID-19, has emerged as an epidemic contributing to more than 247,000 deaths worldwide as of 4th May 2020 It commonly presents with respiratory and occasionally gastrointestinal symptoms Here we describe a rare case of COVID-19 presenting with acute psychosis which was also complicated by a false negative RT-PCR nasopharyngeal swab upon hospital admission Case Report: A 40 year old, previously fit and healthy male, presented to accident and emergency with respiratory tract symptoms and fever during the COVID-19 outbreak His first RT-PCR nasopharyngeal swab tested negative for COVID-19, but due to a strong clinical suspicion of COVID-19, CT imaging was conducted which justified the sending of a repeat swab In the meantime, he started to exhibit symptoms of acute psychosis such as hallucinations, paranoid delusions, an attempted suicide, derealisation and depersonalization Due to failed conservative measures and haloperidol in managing acute psychosis, the patient was intubated for 24 hours After extubating the patient 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 COVID-19 swabs are estimated to be only 70-75% sensitive, whereas CT scan changes are estimated to be as high as 97%-98% sensitive CT imaging can thus be useful when there is a strong suspicion of COVID-19 despite negative nasopharyngeal swabs Secondly, in order to reduce the work of breathing secondary to agitation, the cross-infection risks to others, and the risk of repeated suicide attempts, this patient 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 CT Thorax in swab-negative, symptomatic patients with suspected COVID-19 Secondly, acute psychosis is an emerging indication for intubation to consider when managing patients with highly virulent respiratory infections, such as COVID-19