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Objectives: To examine temporal trends of FDA-approved and off-label second-generation antipsychotic (SGA) prescribing for adolescents over time through the Covid-19 pandemic. Method(s): This is a new-user, retrospective longitudinal panel study using electronic health record data from a large, integrated health care system. Outpatient prescription orders for a new SGA (index date) for adolescents (age 10-17 years) during 2013-2021 were analyzed. Prescription orders were linked to diagnoses at time of encounter to examine prescribing behavior. A one-year lookback period was used for baseline inclusion and exclusion criteria, including one-year "washout" of SGAs and continuous insurance enrollment. FDA-approved use was determined by two outpatient diagnoses (one baseline diagnosis and the prescription order diagnosis) for autism, psychotic disorders, bipolar disorders, or Tourette's;the remaining proportion was considered potentially off-label. We report crude annual prescribing rates per 1,000 youths. Result(s): There were 8,145 unique patients with new SGA prescription orders, of which 5,828 (71.6%) had linked diagnoses available. Calendar year 2013 had the highest prescribing rate prior to Covid-19 onset (2.1 per 1,000) but then declined through 2016 (1.7 per 1,000). Prescribing rates in 2020 (2.0 per 1,000) and 2021 (2.2 per 1,000) were higher than those between 2017-2019. Across all study years, SGA prescriptions were mostly off-label and ordered for aripiprazole, quetiapine, or risperidone. The proportion of off-label indications was highest in 2013 (80.1%) and lowest (69.1%) in 2019. Off-label proportions increased again in 2020 (76.1%) and in 2021 (74.1%). At baseline, patients frequently had other psychotropic prescriptions (e.g., antidepressants 63.3%, stimulants 22.9%, and sedatives/hypnotics 20.7%). Conclusion(s): A general decline in SGA prescribing rates among adolescents was observed from 2013 to 2019, but then increased following Covid-19 onset. Despite known safety risks, off-label use of SGAs remains prominent. Future studies are needed to better understand prescribing outside of pediatric professional society guidelines.Copyright © 2023
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Introduction: There is sparse literature on child and adolescent consultation liaison psychiatry during the COVID pandemic in India. Aims and objectives: To study the patterns of Child and Adolescent Consultation Liaison Psychiatry Services at a Covid-19 Designated Tertiary Medical College and Hospital Material(s) and Method(s): This was a retrospective chart-based study. Institutional Ethics Committee clearance was obtained. It was conducted from April 2020-21. The inclusion criteria comprised records of children and adolescents who were referred for consultation liaison services while they were admitted in COVID-19 designated tertiary hospital. Incomplete records were excluded. Data was tabulated and analysed with descriptive analysis. Result(s): We found 50 referrals out of which 42 records were complete and 8 incomplete were excluded. There were 47.62% boys and 52.38% girls with the mean age (10.8 years) All the 42 patients had been tested for COVID-19 at the time of intake admission as per hospital protocol. We found that 11.9% were confirmed cases of COVID-19 disease and 88.1% had tested negative for COVID-19 disease .The referrals were received mostly from Paediatric Intensive Care Unit (57.14%) followed by Paediatric ward (26.19%) and Special Paediatrics COVID High Dependency Unit (16.67%). The most common psychiatric disorder in COVID negative patients was adjustment disorder with deliberate self-harm (35.14%) and in COVID positive patients was delirium (60%) .The most commonly used medication were Escitalopram, Risperidone and Clonazepam. Conclusion(s): We conclude that psychiatric disorders were prevalent in child and adolescent patients admitted during COVID 19 pandemic and had a distinct profile.
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Behaviors maintained by automatic reinforcement are often more difficult to treat due to difficulty with identifying the relevant maintaining variable(s). One common intervention to treat automatically maintained behavior includes competing stimuli. Competing stimuli promote item engagement which may replace challenging behavior (i.e., response competition). Competing stimuli have shown to be a widely successful intervention across diverse topographies of challenging behavior;however, few studies have evaluated the use of competing stimuli on destructive behavior. The purpose of the current study was to treat automatically maintained destructive behavior with a competing stimuli intervention package for an adolescent with developmental disabilities. Results showed a decrease in destructive behavior when access to competing stimuli was a component of an intervention package in a clinic setting. Also, preliminary data are provided showing treatment effects when caregivers implemented the intervention. Due to the complexity of the final intervention package, recommendations for clinicians are provided which focus on improving feasibility, practicality, and sustainability of treatment components.Copyright © The Author(s) 2022.
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Introducao: No item 5, do paragrafo 4, do artigo 76, da Secao III, Da Coleta de Sangue do Doador, da Portaria da Consolidacao ndegree5, consta que os doadores serao instruidos para que comuniquem o servico de hemoterapia caso apresentem qualquer sinal e sintoma de processos infecciosos, como febre ou diarreia, ou que tenham tido o diagnostico de alguma doenca infectocontagiosa ate 7 dias apos a doacao. Na Nota Tecnica ndegree5/2020-CGSH/DAET/SAES/MS de 21/02/2020, sobre atualizacao dos criterios tecnicos para triagem de dengue, chikungunya, zica e coronavirus, estendeu-se este prazo de 7 para ate 14 dias apos a doacao. Ate janeiro de 2022, no Hemonucleo Regional de Araraquara (HN), o registro da comunicacao do doador, do resgate dos hemocomponentes em estoque e da busca ativa dos receptores era realizado na Tela do Doador Positivo da Tela da Triagem do Sistema HEMOVIDA. Com a elevacao dos registros da comunicacao no inicio de janeiro 2022 foi necessario criar o Formulario de Rastreabilidade de Sinais e Sintomas de Infeccao apos Doacao. Os comunicados eram recebidos pelas funcionarias da Recepcao via telefone ou WhatsApp, e se necessario, as enfermeiras ou os medicos contatavam os doadores para tirar duvidas sobre o inicio dos sinais e sintomas ou confirmar resultados de exames. Objetivos: Analisar os registros dos comunicados de sinais e sintomas de processos infecciosos, dos resgastes dos hemocomponentes e da busca ativa dos receptores nas Agencias Transfusionais (AT) de 24/01 a 04/07/2022. Material e metodos: Para obter os dados utilizamos a Tela do Servico Social do Sistema Hemovida e os Formularios de Rastreabilidade de Sinais e Sintomas de Infeccao apos Doacao dos periodos de 24/01 a 04 /07/2022. Resultados: No periodo de 24/01 a 04/07/2022, do total de 3130 doadores, 38 (1,2%) entraram em contato com o HN para informar sinais e sintomas de processos infecciosos. Destes, 52,5% eram relacionados a COVID, 39,5% aos sinais e sintomas de infeccao como febre, cefaleia, mialgia e dor de garganta e 8% a dengue. Estes doadores comunicaram o HN, em media, 7 dias apos a data da doacao de sangue. Destes, 2 contatos assintomaticos de casos de COVID estavam negativos para a doenca e os hemocomponentes retornaram para o estoque. Discussao: Neste periodo expurgamos 19 (57,6%) concentrados de hemacias (CH), 10 (34,5%) concentrados de plaquetas (CP) e 32 plasmas frescos congelados (PFC) que estavam no estoque do HN. Dos CH, 14 foram distribuidos para as AT e destes, 7 foram (21,2%) devolvidos para expurgo e 7 (21,2%) foram transfundidos. Dos CP, 19 foram distribuidos e destes, 10 (34,5%) devolvidos para o HN e 9 (31%) transfundidos. Na busca ativa dos 16 receptores das AT, apenas 1 apresentou reacao adversa febril apos transfusao de CP. No total, expurgamos 78 hemocomponentes (83%) e transfundimos 16 (17%). Conclusao: Com as analises do estudo, observamos a importancia do doador nos comunicar estes sinais e sintomas de infeccao o mais rapido possivel para que na busca ativa evitemos a transfusao dos hemocomponentes e possamos acompanhar os receptores envolvidos. Observamos tambem que alguns doadores levaram ate 7 dias apos o aparecimento da febre para comunicar o HN, esperando, talvez, diagnostico definitivo de doenca infectocontagiosa. Para que isto nao ocorra, comecamos a reforcar nas informacoes pos doacao, a importancia de os doadores contatarem o servico logo no inicio dos sinais e sintomas do processo infeccioso, principalmente a ocorrencia de febre. Copyright © 2022
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Risperidone/olanzapine are antipsychotics used in Peru to control symptoms of psychosis. The objective was to review the available evidence on potential pharmacokinetic interactions mediated by CYP1A2 and CYP2D6 polymorphic genes between risperidone or olanzapine and selected drugs for the treatment of COVID-19. A bibliographic search was conducted in SciELO and PubMed/Medline. The selection criteria included all types of articles in English and Spanish languages. In this review, the CYP1A2/CYP2D6/CYP3A4 genes that encode their respective enzymes have been described. The olanzapine/risperidone association increases the risk of prolonging the QT interval; chloroquine/hydroxychloroquine decreases metabolism and increases plasma concentration of risperidone; ritonavir decreases metabolism and increases plasma levels of hydroxychloroquine and lopinavir with the risk of prolonging the QT interval of the cardiac cycle and with a tendency to progression towards Torsades de Pointes. Ritonavir increases metabolism and decreases plasma levels of olanzapine. A low incidence of adverse effect was found between risperidone/azithromycin and olanzapine with azithromycin and hydroxychloroquine. Regarding the association of genes: CYP1A2*1D increases and CYP1A2*1F decreases the plasma concentration of olanzapine. Risperidone plasma levels are increased in CYP2D6 intermediate and poor metabolizers compared with normal metabolizers. Other studies indicate no significant association between poor metabolizers of CYP1A2 and CYP2D6 with increased pharmacokinetic parameters. It is concluded that there are potential risks of prolonging the QT interval due to pharmacokinetic interactions mediated by polymorphic genes CYP1A2 and CYP2D6 between risperidone or olanzapine and the drugs selected for the treatment of COVID-19.
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An 11-year-old boy with juvenile neuronal ceroid lipofuscinosis (JNCL) is admitted because of acute agitation and hallucinations. Upon admission, the patient takes lorazepam, which does not induce the expected rest. A PCR-test had a positive result for SARS-CoV-2. Juvenile neuronal ceroid lipofuscinosis (JNCL) is a rare neurodegenerative disease in children and adolescents. Hallucinations are a known symptom in the course of the disease. In the case discussed in this article, however, the pronounced hallucinations fit within a broader clinical picture of a hyperactive delirium. A delirium is by definition provoked by a physical cause. In the presented case, JNCL was an existing risk factor for a delirium, the SARS-CoV-2 infection and lorazepam were presumably the triggering factors. Recent literature shows that an asymptomatic or mildly symptomatic SARS-CoV-2 infection can also trigger a delirium. Treatment consists of treating the physical cause (if possible), supportive measures for the patient and context, as well as medication. The antipsychotics risperidone and haloperidol are recommended. Within the context of JNCL, cautious initiation of a second-generation antipsychotic, such as risperidone, along with great alertness to possible side effects, such as extrapyramidal symptoms and neuroleptic malignant syndrome, are advised. For the young patient in the discussed case risperidone was started, supplemented with olanzapine as rescue medication. The medication had a good effect and no side effects were observed.
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Introduction: Comparatively little is known about drug requirements in patients admitted to ICU with COVID-19 pneumonitis. We analysed drug usage for patients admitted during the first wave of the pandemic, comparing these with a retrospective cohort admitted with Influenza pneumonia. Methods: Forty-nine ventilated patients with COVID-19 pneumonitis were identified through ICNARC, ten were excluded as duration of stay < 7 days or not needing ventilation. Further three were excluded due to missing data and one due to ECMO escalation. Results: The median age was 61 years;length of stay 22 days and 68% survived ICU. Table 1 describes the use of Infusions and enteral medications. Discussion: Propofol was used in most (43% patient-hours in ICU/median duration = 234 hours). All patients received opiate infusions (mainly morphine or alfentanil in similar proportions) and 91% received muscle relaxants, for prolonged periods. Over half received Midazolam (median 106 hours) as an adjunct or substitute to Propofol as patients were difficult to sedate, required longer ventilation, paralysis and concerns with Propofol associated hypertriglyceridemia. Over two-third received alpha agonist infusions (median 68.5 hours) as adjunctive sedation or delirium management. Three quarters of patients received a furosemide infusion (median 90 hours), the evidence extrapolated from studies such as FACTT.1 Around three quarters received Human Albumin (median 100 grams over 3 days). Nearly a quarter received nebulized Prostacyclin for refractory hypoxia, often associated with saturation of HME filters and ventilatory difficulties.2 Over half of patients received Carbocisteine (median 13 days). Clonidine and Risperidone to manage delirium were used in a third (median 10.5 and 11 days respectively), as was Acetazolamide to restore pH and aid weaning. Over a third were prescribed enteral opiates and nearly a quarter received benzodiazepines to manage withdrawal symptoms. Just under a half of patients received Melatonin. Antibiotic usage was high with a median of 3 Antibiotics used (median duration 15 days/61% of patient days). Diagnosing superadded infection such as VAP was challenging3 and we did not routinely monitor serum Procalcitonin levels. We also compared prescribing habits with 12 influenza patients (11 survivors) identified using similar inclusion criteria and found patients with COVID-19 were older (61 versus 51 years ) with longer ICU stays (median 22 versus 20 days). They were also more likely to receive enteral Carbocisteine, Clonidine, Acetazolamide, Morphine and Diazepam. Conclusion: We were able to generate valuable data on prescribing in ventilated patients with COVID-19 pneumonitis during the first wave. Through this, we are able to use drug usage as a surrogate for issues such as delirium, drug withdrawal, antibiotic prescribing and nursing workload in general.
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BACKGROUND: Cotard syndrome is a rare neuropsychiatric condition in which individuals have delusions of being deceased or losing their organs. It is often seen in patients with severe depression and is associated with catatonia.1 Neurosyphilis is a severe sequelae of untreated treponema pallidum infection in which the paretic form of this disorder commonly has a psychiatric presentation. 2 We present a rare case of Cotard syndrome in a patient with neurosyphilis with successful treatment. OBJECTIVE: To understand Cotard syndrome and underlying neuropsychiatric conditions, and characterize the diagnosis and management of psychiatric symptoms in a patient with neurosyphilis. METHODS: Review of a case using electronic medical records and relevant literature. Key terms searched: 'Cotard syndrome,' 'neurosyphilis,' 'COVID-19 infection' using Medscape and Google Scholar. RESULTS: We present a 49-year-old male with a history of alcohol use disorder in remission, depression, and history of COVID-19 (asymptomatic) 6 months prior. The patient presented to the emergency department for recent changes in behavior. He was agitated, threatening, and required chemical and physical restraint. Evaluation was notable for illogical thought processes with somatic delusions. He repeatedly stated, 'I am already dead, my organs have died,' and had an episode of catatonia. All tests including drug screen and COVID-19 were negative. Rapid plasma regain (RPR) titer was 1:64. Neurology and Infectious Disease were consulted. Lumbar puncture revealed positive venereal disease research laboratory (VDRL) titer of 1:4. The patient was diagnosed with neurosyphilis and major depressive disorder with psychosis with Cotard syndrome. He was treated with intravenous (IV) penicillin G and was discharged on oral mirtazapine 30 mg and olanzapine 20 mg nightly at bedtime, oral donepezil 5 mg daily, thiamine, and folate. CONCLUSIONS: Cotard syndrome is often seen in depression with psychotic features.1 Neurosyphilis can present with depression, anxiety, psychosis, and dementia. Early identification is the key for successful treatment. This is a unique case of neurosyphilis with features of Cotard syndrome in a patient with a history of depression with treatment noncompliance. Studies show that quetiapine and risperidone improve psychosis in neurosyphilis.5 In this case, neurosyphilis was successfully treated with IV penicillin G for 2 weeks. The patient was also tried on antipsychotics and mood stabilizers ' specifically aripiprazole, valproic acid, and haloperidol ' and was eventually stabilized on oral olanzapine 20 mg taken nightly at bedtime. Our differential diagnosis also included COVID-19 delirium with Cotard syndrome, which was ruled out due to a negative COVID test. To our knowledge, there are 2 cases of COVID-19 delirium with Cotard syndrome.6 We present this case to inform clinicians of rare manifestations of neurosyphilis in patients with comorbid psychiatric illness and to advance research into treatment options for psychosis in neurosyphilis.
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Background: Pediatric patients with increasing psychiatric needs introduce a substantial challenge for inpatient care. This study illustrates how the COVID-19 pandemic has influenced the number and acuity of psychiatry and psychology consults among pediatric inpatients at a tertiary care hospital. Methods: The study population included all pediatric patients (ages 0-25) admitted to University of Michigan's C.S. Mott Children's Hospital between March 2019 and March 2021 who received a psychology and/or psychiatry consult. Three time periods were defined: pre-pandemic, 3/1/19-3/15/20;early pandemic, 3/16/20-6/30/20;and steady-state pandemic, 7/1/20-2/28/21. The patients were described demographically and clinically. To assess differences among time periods, ANOVA testing was conducted for numeric variables and chi-square tests were used for categorical variables. The number of pediatric inpatients receiving psychiatry and/or psychology consults was reported for each month of the study period as a count and as a percent of all pediatric admissions. Psychiatric acuity was described in terms of length of stay and use of restraints and as-needed medication. Logistic regression was used to estimate the odds of requiring restraints based on time period, controlling for relevant demographic and clinical variables (age, sex, race, length of stay, and use of benzodiazepines and psychotropics). Logistic regression was also used to estimate the odds of patients requiring as-needed medications (midazolam, lorazepam, diazepam, clonazepam, alprazolam, haloperidol, chlorpromazine, quetiapine, risperidone, aripiprazole, olanzapine, and ziprasidone) based on time period, controlling for clinical and demographic variables (age, sex, race, length of stay, and restraint use). Results: Among the 1,636 patients in the study, average age was 14.0 years (IQR 8.1 to 17.2) and 57.9% were female. Overall, 68.6% were White, 13.6% were Black, and 2.4% were Asian. Among all races, 5.7% identified as Hispanic. Percent of pediatric patients receiving psychiatry and/or psychology consults was higher on average during the pandemic months (71.2% during steady-state pandemic compared to 47.9% pre-pandemic). Across all participants, 2.1% required restraints, 34.4% used psychotropics, and 42.6% used benzodiazepines. During the pandemic, admissions became proportionally more female (64.1% during steady-state pandemic vs. 55.3% pre-pandemic) and older (average age 14.8 years during steady-state pandemic vs. 13.4 years pre-pandemic). During steady-state pandemic, children admitted had 5.70 times higher odds of requiring restraints and 1.78 times higher odds of using psychotropics, compared to children admitted pre-pandemic. Length of stay decreased during the pandemic, and was associated with psychotropic use, benzodiazepine use, male sex, and younger age. Conclusion: A higher proportion of pediatric admissions during the COVID-19 pandemic required psychiatry and/or psychology consults. Additionally, these patients were of higher psychiatric acuity, based on increased use of as-needed medications and restraints. These findings highlight the dramatic changes experienced by individual patients and their healthcare teams during the pandemic.
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Introduction Safety studies have shown that COVID-19 vaccinations can provoke inflammatory processes in patients. The subsequent release of cytokines is accompanied by an increased inflammatory marker, C-reactive protein (CRP) [1]. For some antipsychotic drugs, inflammatory processes have been associated with increased drug levels, even above therapeutically approved ranges [2] [3]. It is not clear, whether this holds also true for COVID-19 vaccinations. Methods We present a case series comprising of 10 inpatients at the CIMH treated with an antipsychotic drug. Patients received a first, second or third dose of the COVID-vaccination Comirnaty in the morning. Blood samples were taken directly before the injection and were followed on day 1 and 4 while constant dosing. Blood testing included drug levels, safety laboratory, and CRP. Results CRP levels were elevated in nine patients;four of those also presented an increase in antipsychotic drug levels within a few days after COVID-19 vaccination. Blood level changes were i)+0%,+24%,+125%,+116% in quetiapine-, ii)+0%,+0%,+100% in olanzapine-, iii)+0,+42% in clozapine-treated patients, and iv)+205% in one risperidone-treated patient. As a result, three patients had drug levels above the therapeutically recommended range. Conclusion We present a series of patients with increased antipsychotic drug levels after COVID-19 vaccinations mediated via inflammatory processes. The intensity of inflammatory reactions strongly varies across patients. Hence, COVID-19 vaccinations may constitute an unpredictable risk factor for increased drug levels. Therapeutic drug monitoring can help to prevent safety risks in those patients with supra-therapeutic drug levels.
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Objective: To report a pediatric case of severe, treatment-resistant, COVID-19-associated acute longitudinally extensive transverse myelitis (LETM). Background: Since the COVID-19 global pandemic, there is evolving literature reporting the neurological manifestations of the novel coronavirus. COVID-19-associated acute LETM was first reported in an elderly Asian man with lower-extremity weakness <1-week after onset of fever and respiratory distress. In childhood, this is rarely reported with only few reports of COVID-19-associated acute LETM. Design/Methods: We reviewed clinical and radiographic reports of our patient. We searched PubMed for literature using terms “transverse myelitis & COVID-19” and “pediatric transverse myelitis&COVID-19.” Results: A 5-year-old previously healthy boy presented with altered mental status. Prior to admission, he was exposed to COVID-19 and had consumed an unknown quantity of sertraline and risperidone tablets. Thereafter, he stated that he could not feel his legs, fell, and hit his head. In the emergency department, he was intubated. EKG revealed QTc prolongation (486-ms). SARS-CoV-2-PCR positive. Thereafter, flaccid quadriparesis, bulbar dysfunction, left-sided numbness, and hyperreflexia were noted;he communicated by eye blinking. MRI-spine revealed C1-C4 hyperintensity (T2-weighted) consistent with LETM;DWI negative for acute stroke. CSF basic labs, viral and MS panels, and ACE unremarkable. Serum anti-aquaporin-4 and myelin-oligodendrocyte-glycoprotein antibodies negative. Serum West Nile-IgM-IgG negative. Mycoplasma pneumoniae IgM-reactive, IgG-positive;confirmatory IgM immunofluorescence assay-negative. He received IV-methylprednisolone ×5-days, plasmapheresis ×10-sessions, pulsed steroid ×3-days. Minimal neurological improvement was noted. Repeat MRI-spine 2-weeks later unchanged. Tracheostomy and gastric tube were placed. He was transferred to a neurology topic. Conclusions: COVID-19-associated acute LETM in childhood can have a rapid, devastating clinical course. Clinicians should maintain a high-index of suspicion for LETM in COVID-19 pediatric patients presenting with neurological manifestations and consider alternative strategies for severe, treatment-resistant cases.
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The article examines incidence of psychosis in patients with Covid-19 infection. Topics discussed include link between viral infections and effects on the central nervous system, brief background of coronaviruses, and evidence that the neuropsychological stress associated with the diagnosis of Covid-19 as well as the therapeutic use of corticosteroids during care can induce psychosis.
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Schizophrenia is a debilitating, genetic brain condition caused by anomalies that appear early in infancy and interrupt normal brain development. It has a lifetime risk of 1% and affects people of all ages, with around 10% dying by suicide. COVID-19 may raise the risk of mortality and morbidity in people with schizophrenia. Although antipsychotic medications of the first, second, and third generations are the most commonly prescribed treatments for schizophrenia, they are linked to major side effects such as tardive dyskinesia, oxidative stress, and EPS. Ayurvedic herbal medications and some dietary supplements score well in this category since they can be taken for a long time without causing major adverse effects and have antioxidant properties. Low potency first generation antipsychotics, sedating antihistamines, and benzodiazepines, as well as inhalable antipsychotics, oral and short acting injectable olanzapine, and ziprasidone, as well as low potency first generation antipsychotics, sedating antihistamines, and benzodiazepines, should be avoided or closely monitored for patients with COVID-19. Mentally ill patients with COVID-19 should be segregated if at all possible, and employees should be adequately protected.
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Case Report Transverse myelitis is the segmental inflammation of the spinal cord with motor and sensory abnormalities at and below the level of the lesion. Often, the etiology is unknown but may be attributed to autoimmune conditions or viruses. Here we describe a rare case of transverse myelitis secondary to severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]/coronavirus disease (COVID-19). Case A 5-year-old male with a history of asthma presented for vomiting and altered mental status. The patient was noted to be altered, lethargic, and in respiratory distress. Intubation was performed. After family collateral was obtained, it was revealed that patient possibly ingested Sertraline and/or Risperidone at an unknown time prior to arrival. History also revealed that he had slurred speech, ataxia, and a fall with trauma to forehead 1 day prior to arrival. He tested positive for COVID-19 via PCR and chest x-ray revealed RLL consolidation. Dexamethasone was started. When sedation was weaned in hopes of extubation, patient was noted to be alert, but not moving extremities and had minimal gag and cough reflex. MRI of Brain and Spine were conducted and revealed findings suggestive of long segment transverse myelitis involving C2 to C3. LP was performed with unremarkable CSF studies and IV Solumedrol was started. In light of active COVID-19 infection, and worsening respiratory status, patient started on 5 days Remdesivir. Further, patient underwent ten sessions of plasmapheresis. Repeat MRI was consistent with previous. Physical and occupational therapy initiated at the onset of illness in hopes of achieving musculoskeletal improvement. Patient had some minimal musculoskeletal improvement, however, given his condition, decision was made for patient to undergo placement of gastrostomy and tracheostomy tubes. Patient was weaned off of sedatives and withdrawal was treated with a clonidine taper. Once stabilized, patient was transferred to neurological inpatient rehabilitation center. Discussion Neurological manifestations in children affected by SARS-CoV-2 are relatively common but are often non-specific. Worldwide data reports only 1% of children with COVID-19 present with severe symptoms of encephalopathy, seizures, and meningeal signs. Pathophysiology is multifactorial, including direct invasion of the CNS, vascular insufficiency, immune dysregulation and autoimmunity. Imaging is paramount in the diagnosis of transverse myelitis. Treatments are emerging and may include steroids, immunoglobulin, plasmapheresis, and monoclonal antibodies. Conclusion Much is unknown about COVID-19. Information is emerging and evolving daily. Cases of transverse myelitis in COVID-19 have been reported in few adult patients and minimal pediatric patients. Practitioners should keep transverse myelitis on their list of differentials for neurological complications of SARS-CoV-2 infections and initiate aggressive treatment with a multidisciplinary approach.
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Background: Ornithine-transcarbamylase deficiency (OTC) is the most common type of urea cycle disorder, and it is the only one with X-linked inheritance. The clinical presentations can vary from severe symptoms caused by hyperammonemia in childhood or adolescence to milder cases with late-onset in adulthood (similar to delirium or acute psychosis) [1], in the context of precipitating factors such as pregnancy, high protein intake, acute stress, infections, certain medications (valproate, steroids, haloperidol) [2]. Method: We present a case of a 31-year-old female, with no history of mental disorders, with a personal history of Hashimoto thyroiditis and urticaria, and a family history of OTC deficiency (her two-year-old niece). She was also a heterozygous carrier for the OTC deletion, reporting periods of meat avoidance and anorexia. She was single, lived alone, and complained of work-related stress, mainly as she worked from home during the COVID-19 pandemic as an IT consultant. The patient presented at our clinic in emergency for psychomotor agitation, slurred speech, complex auditory and visual hallucinations, and mystical delusional ideas. Furthermore, one week before her presentation, she started fasting because of her Christian orthodox religious beliefs (before Easter celebration), but she also complained of insomnia, fatigue, and tachycardia. The patient reported being vaccinated with the first dose of Pfizer's SARS-CoV-2 vaccine one week before the presentation. Results: Laboratory tests showed iron-deficient anemia and ketonuria;hepatic function was normal. Thyroid function was also normal, but anti thyroperoxidase antibodies were elevated. Serum ammonia levels were normal, and urinary orotic acid levels were within normal range. The result of head CT was unremarkable. Neurological examination was normal. She was started on 10 mg i.m. Haloperidol per day, but given the possibility of inducing hyperammonemia in urea cycle disorders patients, she was switched to Risperidone 6 mg/day, which was gradually reduced to 3 mg/day. Also, she was started on a protein-restricted diet. On the second and third days of admission, she was partially disoriented and somnolent but showed no signs of metabolic encephalopathy;therefore, metabolic treatment was not initiated. On the sixth day, she was almost completely recovered, with no psychotic symptoms. After the remission of psychotic symptoms, the neuropsychological evaluation showed significant cognitive deficits: executive functions (impaired performance on Tower of London task), deficits of focused and distributed attention, and decreased immediate verbal memory, even though the patient had received higher education, being at the top of her class during her studies. Given that metabolic profiles were normal, we discuss the complex interactions between autoimmune disorders, genetic factors, precipitating factors, and psychosocial factors that could have contributed to the psychotic episode. Conclusion: Clinicians should consider various factors that can influence the psychological state of a patient, paying attention to atypical factors or symptoms. Also, regarding the treatment of psychiatric symptoms in patients with urea cycle disorders with a normal metabolic profile, psychiatrists must avoid certain medications (haloperidol, valproate) that can worsen the patient's status. No conflict of interest
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Patients with severe mental illness are more susceptible to infections for a variety of reasons, some associated with the underlying disease and some due to environmental factors including housing insecurity, smoking, poor access to healthcare, and medications used to treat these disorders. This increased susceptibility to respiratory infections may contribute to risk of COVID-19 infection in patients with severe mental illness or those in inpatient settings. Atypical antipsychotic (AA) medications are FDA approved to treat symptoms associated with schizophrenia, bipolar disorder, depression and irritability associated with autism. Our team and others have shown that AA may have anti-inflammatory properties that may contribute to their efficacy in the treatment of mental health disorders. Additionally, AA are widely prescribed off-label for diverse indications to non-psychotic patients including older adults, who are also at increased risk for COVID-19 complications and mortality. The aim of this study was to determine if AA medications such as risperidone (RIS) alter the ability to mount an appropriate response to an acute inflammatory or adaptive immune challenge using a preclinical model. Short-term treatment of healthy mice with a dose of RIS that achieves plasma concentrations within the low clinical range resulted in disrupted response to an inflammatory (LPS) challenge compared to vehicle controls. Furthermore, RIS also prevented treated animals from mounting an antibody response following vaccination with Pneumovax23®. These data indicate that short-to intermediate-term exposure to clinically relevant levels of RIS dysregulate innate and adaptive immune responses, which may affect susceptibility to respiratory infections, including COVID-19.