Case report:
Mr. L.A, a 29-year-old male patient, from a rural place, presented to
the emergency of Razi hospital, a Tunisian psychiatric hospital, with
disorganized behavior, hallucinations, and delusions.
He had a recent history of impulsive and aggressive behaviors. Overt
social isolation existed with under-eating and insomnia. The onset was
insidious with the context of the COVID-19 pandemic. He was afraid of
being infected, worried about the possibility of being a contagious
asymptomatic carrier of coronavirus. He was isolated in order to avoid
the spread of the disease. His family were struggled with financial loss
due to quarantine.
Mr. L.A was diagnosed with TSC, epilepsy, moderate learning disability
at an early age without any psychotic manifestations. The prescribed
medication for epilepsy was 600 mg of carbamazepine, 75mg of
phenobarbital, and 1500 mg of valproate acid.
There was no family history of epilepsy, psychotic, or bipolar disorder.
Mental status examination revealed poor contact, decreased personal
hygiene, restricted affect, decreased speech, altered attention,
delusional ideas of reference, persecution, and demonic possession with
a total adhesion. He was convinced that everyone was talking about him
behind his back. He had visual hallucinations of his pictures published
on billboards around the world with a coronavirus sign above. Voices on
television were talking about him and accused him to be responsible for
this pandemic. Strangers claimed that he conspired with enemies to hurt
people. Moreover, he believed that his skin lesion emitted waves rich in
viruses in order to get people infected.
Because of his delusional ideas, he was no longer taking his
antiepileptic drugs regularly; and he had multiple seizures with loss of
consciousness during the last two weeks.
Physical examination revealed hypopigmented macules in the forehead. An
EEG revealed epileptic discharge foci in the temporal region. Previous
and current magnetic resonance imaging of the brain demonstrated
cortical-subcortical tuberous and subependymal nodules compatible with
TSC without any overt radiological aspect modification within the time
course of the illness (Figure 1). The biological assessment was normal.
The patient received Olanzapine in the daily posology of 15 mg, in
addition to an adjustment of antiepileptic treatment where the posology
of phenobarbital was optimized until 150mg.
The carbamazepine and valproate acid blood levels were within the
therapeutic range.
The evolution was favorable with maintaining good seizure control, an
improvement of mood, a progressive reduction of psychotic symptoms, and
the development of initial insight.
This case report was revised to comply with recommendations of the Case
Report guidelines, and an informed consent publication was obtained from
the patient.