A case of COVID-19 presenting with insomnia, progressing to extreme agitation at end of life

ABSTRACT

Background: Covid-19 patients at end of life (EoL) suffer predominantly from rapidly escalating dyspnoea and agitation. An unusual symptom of Covid-19 is isolated extreme overwhelming cerebral agitation and Helms et al,1 report an observational series of 58 patients admitted to Intensive Care Unit with associated encephalopathy, prominent agitation and confusion. Case presentation Male 74 year old patient with end-stage leukaemia, admitted to hospital with mild flu like symptoms. Tested positive Covid- 19.Hospitalised for two weeks, then discharged to a Nursing Home. Only symptom remained was insomnia, however this was impacting with increasing irritability in a previously calm man. The irritability escalated to extreme agitation, screaming out in deep distress. No headache or signs of meningism. Patient hospitalised, Palliative Medical phone advice requested. The agitation was not associated with dyspnoea, chest secretions or pain. Management & outcomes: A continuous sub-cutaneous infusion (CSCI) was commenced with opioid and midazolam and symptoms did not settle with increasing doses. The patient's close relative was an Oncology Nurse Specialist and was the only visitor allowed on ward. The patient's extreme agitation was deeply distressing and on day 3 phenobarbitone was commenced and within hours the patient settled and slept for the first time in three weeks. Phenobarbitone was delivered via stat dose and CSCI. The following day the patient required a third CSCI with diclofenac for resistant hyperpyrexia not controlled on regular paracetamol. The patient remained comfortable and passed away a few days later. Discussion: This isolated symptom appeared to present with extremely poor sleep for weeks, then escalating into extreme overwhelming agitation. At EoL this isolated symptom is an indication for use of Phenobarbitone, that renders sustained benefit. Conclusion: For 'patients with reversibility' it may indicate earlier than usual need for ventilation.