ABSTRACT
Introduction During the course of coronavirus disease-2019 (COVID-19) pandemic, many neuropsychiatric manifestations of the disease have been observed while the precise pathophysiology remains unknown [1]. New variants of coronavirus such as the 501.V2 and B.1.1.7 have emerged and obscurities in pathogenesis have increased even further with these variants. Here, we describe a patient with long-term effects of COVID-19, manifesting first episode psychosis accompanied by Cotard's Syndrome (CS) after infection with the B.1.1.7 variant of SARS-CoV-2. Case A 41-year-old female with no adverse medical history was admitted to the emergency department with symptoms of loss of smell, myalgia and sore throat and COVID-19 infection was confirmed by a positive RT-PCR test result for the B.1.1.7 variant of coronavirus. Two months after the completion of treatment for COVID-19, the patient started to have thoughts of being annihilated by viral occupation of her body and of her nervous system getting decomposed. The patient's family brought her to the psychiatric emergency department. The patient was found to have strong suicidal ideations, referential thoughts, belief of being physically dead and her children being in danger of obliteration by COVID-19. Clinical evaluation of the mental state of the patient was significant for decreased speech output and speed as well as psychomotor activity. Nihilistic, persecutory and referential delusions with no insight were recorded. Upon hospitalization and treatment with olanzapine 20mg/day orally and electroconvulsive therapy, her psychiatric symptoms and suicidal ideation ameliorated. The patient was discharged from the hospital with olanzapine 20mg/day orally and she is currently being followed-up in our outpatient clinic. Discussion To the best of our knowledge, this is the first report of a patient who developed CS and psychotic symptoms associated with COVID-19 following infection with a new variant of coronavirus. CS is a rare self-perceptual anomaly with the presentation of nihilistic delusions. While the exact pathogenesis of CS remains unexplained, defective mechanisms of proprioception or interoception may lead to a self-misattribution following a perceptual dysfunction which might trigger CS [2]. Although blood tests indicated no systemic inflammation for the index patient, an indistinct neuroinflammatory process may lead to neurotoxicity that might result in perceptual disruption and CS or psychotic features, as suggested in previous reports [3]. Considering well-described anosmia and ageusia with COVÍD-19 and our case's symptoms after the infection, new variants of SARS-CoV-2 might affect the perceptual pathways. The angiotensin-converting enzyme-2 (ACE-2) receptor which might modulate smell and taste perception, has been identified as a potential viral receptor. Such interaction may disrupt chemosensory perception. Overall, COVID-19 may cause abnormal processing of perceptions. This in turn can lead to anosmia, ageusia and defective proprioception, resulting in self-misattributions as seen in the patient in the current case report who was diagnosed with CS. Clinicians should keep in mind that infections with the rapidly spreading B.1.1.7 variant of SARS-CoV-2 might result in more severe symptoms or long-term consequences of COVID-19 compared to other strains. No conflict of interest