Appearance of extrapyramidal symptoms in adolescent psychiatry patients during COVID-19 infection.

Since the start of the pandemic, there has been an increase in the incidence of psychiatric morbidity among those infected with coronavirus disease 2019 (COVID-19) and those indirectly affected by COVID-19. There has been a considerable increase in the number of individuals with such psychiatric conditions as depression, acute stress disorders, anxiety, and posttraumatic stress disorder (PTSD). About one-third of patients with COVID-19 are reported to have developed short and long-term neuropsychiatric conditions such as delirium, agitation, altered consciousness, hypoxic encephalopathy encephalitis, dysexecutive syndrome, cerebrovascular complications (e.g., stroke), hypoxic encephalopathy, convulsions, neuromuscular dysfunction, demyelinating processes, or parkinsonism through several pathophysiological mechanisms. Nevertheless, as the pandemic progressed, data on neuropsychiatric manifestations implied that the pathologic capacity of COVID-19 and its association with the onset and/or exacerbation of psychiatric morbidity indicate that COVID-19 is potentially related to neuropsychiatric involvement. Patients with existing mental disorders under psychotropic treatment exposed to the COVID-19 infection have been represented by an increased risk of worsened psychiatric symptoms and expanded drug side effects. The present study aimed to describe five pediatric patients with various psychiatric illness that experienced COVID-19 infection and had potentially associated neuropsychiatric involvement, such as exacerbation of underlying psychiatric symptoms and extrapyramidal side effects. To the best of our knowledge, the present study is the first to describe adolescents with COVID-19 infection that presented with a series of manifestations in the form of an increase in extrapyramidal symptoms (EPS)  during exacerbation of underlying psychiatric disease.

Recognition and Treatment Challenges of Acute Clozapine Withdrawal Syndrome: A Case Report.

The limited psychiatric bedspace due to the COVID-19 pandemic and the lack of access to an up-to-date medication regimen delayed the recognition of the diagnosis and treatment for a 40-year-old man with schizoaffective disorder, bipolar type, who traveled from his home city and abruptly discontinued his prescription of clozapine. He developed a cholinergic rebound syndrome including delirium and extrapyramidal symptoms (EPS). The delay included time spent in two different medical hospitals: one awaiting psychiatric bedspace, and secondly, when the patient's cholinergic rebound syndrome was misdiagnosed as acute alcohol withdrawal. Once the etiology was recognized, he was promptly treated with anticholinergic medication (benztropine) and retitrated to his outpatient dose of clozapine leading to the resolution of symptoms including delirium and EPS. This case will discuss the challenges of continuity of care in delirious, psychotic, or otherwise confused patients, including contributions from the COVID-19 pandemic. A medication card or other improvements in medication databases that may reduce delays in treatment are discussed.