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Kandy Psychiatrists differentiate between primary psychiatric illness and COVID neuro-psychiatric Manifestations

Article from The Sunday Times (SriLanka ) (April 3. 2022)

Kumar Hettiarachchi and Ruqayyah

COVID

The diagnosis of this link had been made by De Shani Ekanayaka  Senior Registrar in Psychiatry under the mentorship of Consultant Psychiatrist De Gthan Abeywardena who is also President of the Sri Lanka College of Psychiatrists.

COVID-19 and its neuropsychiatric manifestations have been documented worldwide. Here in Sri Lanka, most probably in a first for the country, four such patients have been treated at the Kandy National Hospital.

Before focusing on the four patients whose illness had been diagnosed systematically and correctly at the Kandy Hospital   Dr.Ekanayake gives the context 

She explains that though the virus causing COVID-19 predominantly affects the respiratory system, there has been increasing recognition that it is also a neuro-pathogen. 

Up to 35% of COVID 19 cases have been recognized to have neurological learning referring to recent literature worldwide 

COVID encephalitis is a debating neurological complication-a form of Inflammation of the brain matting rise to neurological and neuropsychiatric manifestations. There is a reported incidence of 0.22% high mortality   (death) rate of   13 .4%. according to global data. 

She reiterates that in the absence of other systemic features, COVID-19  Nero – Psychiatrie manifestations can feature mistaken primary psychiatric illness,  resulting in devastating outcomes.  

When considering the four patients with neuropsychiatric manifestations at the Kandy Hospital, there had been a previous diagnosis of a COVTD 19 infection. Later however all forces had been confirmed as  encephalitis caused by coved 19 with neurological and neurophysiological evidence

Two of the patients had me history of psychiatrists in the past, it is learned

Just two weeks after the delivery her first baby, a 26 year.s  old postpartum mother, had been referred for a psychiatry ric opinion. She had had an acute onset of depressive symptom progression, says Dr. Ekanayake 

Psychomotor retardation is a main Feature of depression and is the slowing owner hampering of a person’s me or physical activities

With this mother now showing the rapid progression of symptoms, such subtle episodes of disorientation and changing psychotic symptoms had led to ‘clinical suspicion’ of organic causes are the result of an injury or disease affecting brain tissue. As such, further Investigations and a neurology referral had been requested.

Later when this mother was gripped by fever, unstable vital parameters (such as pulse, respiration, and blood pressure) had required Intensive Care Unit  (ICU) care. An RT-PCR had also been positive. An MR (Magnetic   Resonance Imaging )of the brain had shown high intensities in bilateral medial temporal areas

 Dr. Ekanayake says that she remained stuporous (confused and slow to react) for six weeks. “The good news is that the brain issues had been linked to COVID-19 and she recovered six weeks later with medical and not psychiatric management. Soon there was a joyous reunion with her baby.”

The 53-year-old woman with end-stage renal failure also had no history of psychiatric illness but was referred with acute onset depressive symptoms, once again progressing to psychomotor retardation over two days. Here too, there had been a clinical suspicion, and screening by the psychiatric team had been requested.

An RT-PCR was positive and a CT (Computed Tomography) scan of the brain had shown cerebral edema (swelling of the brain). This had been followed by fits and she had been put on a ventilator due to unstable vital parameters  

The first had been a 52-year-old man with a history of bipolar affective disorder, a condition in which a person suffers extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). 

According to Dr. Ekanayake, the other two patients had been receiving psychiatric treatment earlier.

He had been referred to the psychiatric team due to a manic relapse during the treatment of COVID pneumonia. There had been episodes of delirium even after recovery from pneumonia. Neurological investigations had been requested which had revealed encephalitis. Slow recovery over many months it had been, but he had recovered.

The fourth patient had been a 61-year-old woman with a history of schizo-affective disorder, characterized by a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms such as depression or mania. She was unvaccinated against COVID-19 and had presented with disturbing behavior and persistent confusion, following high-risk COVID-19 exposure.  

Even though an RT-PCR test was negative, an electroencephalogram (EEG-a record of brain activity) had revealed encephalitis. 

She had developed fever and seizures but made a slow recovery over many months, after medical management.

A COVID antibody test later had been positive. These examples point to the fact that a high degree of suspicion is mandatory in differentiating primary psychiatric illnesses from COVID-19 neuro-psychiatric manifestations in the context of the pandemic, says Dr. Ekanayake.

 She adds: “In these cases, no psychiatric interventions were necessary for the acute stages of infection.” 

 Appreciating the immense support extended by Consultant Neurologist Dr. Janaka Peiris in the assessment of these COVID patients, Dr. Abeywardena and his team were also very thankful for the collaborative care given by the neurologists and psychiatrists which facilitated the patients’ recovery. 

Meanwhile, these four cases had been presented as a poster by Dr. Ekanayake at the sessions of the Sri Lanka College of Psychiatrists in December last year.

In some illnesses, if there is a brain involvement, it can give rise to neurological and neuropsychiatric manifestations, explains Dr. Shanika Ekanayake.

Neuro-psychiatric manifestations: They are common when brain areas like the limbic system and temporal lobes get involved.

 Dr. Ekanayake points out that there is much worry among psychiatrists about cases which can mimic primary psychiatric illnesses.”If misdiagnosed, it can give rise to devastating outcomes with routine treatments. Therefore, a clinician needs to have a high degree of suspicion in differentiating between a true psychiatric illness and one that comes in the guise of a psychiatric illness but is due to a different cause,” she adds.

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