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.