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)