Discussion
In this case, we present a middle-aged patient with no previous mental illness background who presented with full-blown manic symptoms following a severe course of SARS-COV2 infection. There were few other reported cases of first onset manic-like symptoms in patients following a severe SARS-COV2 infection. (5, 6) These cases discussed the possibility of the neuroinvasive properties of the virus being directly related to the emergence of symptoms given previous reports of CNS infections associated with the novel virus. (7) However, they have highlighted the limitations of the lack of CSF-PCR assays for validation of this hypothesis. Given the patient’s age, lack of past personal or family psychiatric history and the prodrome of an acute confusional state preceding the onset of manic symptoms, a neuroinvasive etiology is possible. However, the possibility of a primary mood disorder cannot be dismissed without a longer period of follow-up.
COVID-19’s clinical manifestations range from no symptoms to a more severe form of the disease resulting in multiorgan failure and sepsis requiring ICU care and mechanical ventilation. (8) Nalleballe et al. reported neuropsychiatric manifestations in 22.5% of more than 40,000 patients who had COVID-19; including Mood disorders, anxiety, stroke, seizures, and encephalopathy. The prevalence of mood disorders was estimated to be 3.8% in the study sample. (9)
The novel SARS-COV2 virus neurotropic properties were discussed in the literature. Several mechanisms were proposed to explain the neuropsychiatric manifestation of COVID-19 including direct cytokine network dysregulation, Central nervous system (CNS) infiltration, peripheral immune cell transmigration, and post-infectious autoimmunity. (10)
The possibility of a primary bipolar affective disorder cannot be ruled out in our patient. He initially experienced an acute confusional state during the acute phase of COVID-19 infection as evident by disorientation and visual hallucinations which subsided before his discharge from the COVID-19 facility. He later presented with classical features of mania after he was declared to have recovered from COVID-19 and was in clear sensorium at that time. The patient’s medical history of epilepsy can be considered another risk factor for developing a mood disorder. Reports from the united states revealed that around 12% of individuals with epilepsy screened positive for symptoms of bipolar disorder in comparison to 1 to 2% lifetime incidence in the general population. (11)