57-Year-Old Woman With Covid-19 and Delusions

The n e w e ng l a n d j o u r na l of m e dic i n e
Case Records of the Massachusetts General Hospital
Founded by Richard C. Cabot

Eric S. Rosenberg, M.D., Editor
David M. Dudzinski, M.D., Meridale V. Baggett, M.D., Kathy M. Tran, M.D.,
Dennis C. Sgroi, M.D., Jo‑Anne O. Shepard, M.D., Associate Editors
Emily K. McDonald, Tara Corpuz, Production Editors
Case 34-2022: A 57-Year-Old Woman

with Covid-19 and Delusions
Gregory L. Fricchione, M.D., Aaron B. Paul, M.D., Zeina Chemali, M.D., M.P.H.,
and Michael D. Kritzer, M.D., Ph.D.
Pr e sen tat ion of C a se
Dr. Michael D. Kritzer: A 57-year-old woman with major depressive disorder and coro- From the Departments of Psychiatry
navirus disease 2019 (Covid-19) was evaluated at a hospital affiliated with this (G.L.F., Z.C., M.D.K.), Radiology (A.B.P.),
and Neurology (Z.C.), Massachusetts
hospital because she was having delusions that she was dead. General Hospital, and the Departments
The patient had been in her usual state of health until 2 weeks before this of Psychiatry (G.L.F., Z.C., M.D.K.), Radi‑
presentation, when myalgias, cough, sore throat, nausea, and vomiting developed. ology (A.B.P.), and Neurology (Z.C.), Har‑
vard Medical School — both in Boston.
She sought evaluation at the primary care clinic of an academic medical center
affiliated with this hospital (the two hospitals are part of the same health care N Engl J Med 2022;387:1795-803.
DOI: 10.1056/NEJMcpc2115857
system). Nucleic acid testing of a nasopharyngeal swab was positive for severe Copyright © 2022 Massachusetts Medical Society.
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA, and the patient was
instructed to quarantine at home. She lived with her father and assisted him with CME
at NEJM.org
activities of daily living; he also received a diagnosis of Covid-19.
During the following week, the patient’s cough persisted, and new shortness of
breath developed. Her symptoms worsened; she felt that she was unable to take
care of her father. Emergency medical services were called, and the patient and her
father were taken to the emergency department of the other hospital, where they
were both admitted for worsening Covid-19 pneumonia. The patient was treated
with supplemental oxygen, remdesivir, and dexamethasone. Treatment with rem-
desivir was stopped on hospital day 4 when the blood aminotransferase levels
increased to three times the upper limit of the normal range.
During the hospitalization, the patient was noted to have intermittent anxiety,
particularly when discharge planning for her father was discussed. She and her
brother declined to have their father discharged to a rehabilitation center and in-
stead planned for him to eventually return home to quarantine with the patient.
On hospital day 6, the patient’s oxygen saturation was normal while she was
breathing ambient air, and the blood aminotransferase levels had improved. She
was discharged home with instructions to quarantine and continue taking dexa-
methasone.
One day after discharge, the patient’s brother spoke to her on the telephone.
n engl j med 387;19 nejm.org November 10, 2022 1795

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He thought that she seemed to be confused and previous hospitalization. She paced around the
unable to take care of herself, and he asked her room and perseverated about the care of her fa-
to return to the emergency department of the ther. The remainder of the examination was
other hospital. normal.
On evaluation in the emergency department, The blood levels of electrolytes and glucose
the patient explained that she was unsure why were normal, as were the results of liver-func-
her brother had asked her to return to the hos- tion and kidney-function tests. The white-cell
pital, and she said that she wanted to go home. count was 11,490 per microliter (reference range,
She also expressed that she felt anxious about 4000 to 11,000), with neutrophil predominance;
being home alone after discharge and over- the complete blood count with differential count
whelmed about needing to care for her father at was otherwise normal. Urinalysis and a radio-
home once he was discharged from the hospital. graph of the chest were normal. Treatment
The myalgias, cough, and shortness of breath with dexamethasone was stopped, and the pa-
had abated; she had no fevers, visual or auditory tient was admitted to the hospital to facilitate
hallucinations, or suicidal or homicidal ideation. discharge to a rehabilitation center for contin-
The patient had a history of major depressive ued care.
disorder, which had been diagnosed during the On hospital day 3, the patient was noted to be
second decade of life. At the time of diagnosis, more withdrawn, and she began responding to
she had been admitted to a psychiatric hospital questions with one-word answers or silence.
and had received electroconvulsive therapy; there- When she was encouraged to speak more, she
after, she had been discharged to a partial hos- continued to perseverate about the care of her
pital program. She had been hospitalized for father. When she was asked to elaborate on her
psychiatric symptoms twice since then, once for concerns, she stated, “He is dead. I am dead.”
major depressive disorder and once for a mixed The patient appeared disheveled, sullen, and
bipolar episode that was due to insomnia and anxious. She laid in bed motionless with her
anxious distress. The latter episode was associ- eyes open and looking forward, and she re-
ated with catatonic features and was treated sponded briefly to questions in a quiet voice
with electroconvulsive therapy. with slowed speech. Her thoughts were persev
The patient had no history of suicidal or erative and tangential. There was no evidence
homicidal ideation or attempts and no history that she had loosening of associations, halluci-
of violence. She had hypertension, diabetes, obe- nations, or suicidal or homicidal ideation. She
sity, and gastroesophageal reflux disease. Medi- had poor insight and judgment. Memory, atten-
cations included dexamethasone, bupropion, tion, concentration, abstract reasoning, and fund
fluoxetine, olanzapine, losartan, metformin, and of knowledge were normal. When her arms and
pantoprazole. Sulfa drugs had caused angio- legs were lifted against gravity and released,
edema, and lisinopril had caused cough. The they fell to the bed without resistance; with en-
patient was born in the Caribbean and had emi- couragement, she was able to move them. Mus-
grated four decades earlier, first to southwestern cle tone was normal, with no rigidity or waxy
Europe and then to the United States 2 years flexibility. Imaging studies were obtained.
later. She lived in an apartment in an urban area Dr. Aaron B. Paul: Computed tomography (CT)
of New England with her father, who had mild of the head (Fig. 1), performed without the ad-
dementia. She did not drink alcohol, smoke ministration of intravenous contrast material,
cigarettes, or use illicit substances. revealed no evidence of an acute territorial in-
On examination, the temperature was 37.2°C, farct, intracranial mass, or hemorrhage. There
the pulse 97 beats per minute, the blood pres- was nonspecific moderate confluent hypoattenu-
sure 153/95 mm Hg, the respiratory rate 20 ation involving the supratentorial white matter.
breaths per minute, and the oxygen saturation Dr. Kritzer: Clonazepam was administered, and
93% while the patient was breathing ambient the dose of olanzapine was increased. Admis-
air. The patient was alert and oriented but sion to an inpatient psychiatric unit was recom-
guarded, with a flat affect. She appeared to be mended. During the next week, while awaiting
more anxious than she had been during the placement in an inpatient psychiatric unit, the
1796 n engl j med 387;19 nejm.org November 10, 2022

Case Records of the Massachuset ts Gener al Hospital
disorder suggestive of bipolar disorder, neuro-

psychiatric symptoms developed 2 weeks after
the onset of Covid-19. The patient had psycho-
motor agitation, a flat affect, and anxious per-
severation that was focused on her father’s care.
Three days later, she was noted to become mo-
tionless and hypophonic, with staring, speech
latency, and verbal perseveration. Cognition was
intact, but insight and judgment were impaired.
In an attempt to explain her neuropsychiatric
symptoms, I will consider the potential effects
of medications that she had received, her un-
derlying psychiatric disease, and her recent in-
fection.
Medication Effects
This patient was receiving several medications
for the treatment of a mixed affective disorder,
including bupropion, fluoxetine, and olanzapine.
Antidepressant medications could trigger a sec-
ondary manic episode, especially in this patient
Figure 1. CT of the Head.
with suspected bipolar disorder. However, her
An axial image, obtained without the administration
of intravenous contrast material, shows no evidence of presentation was not typical of drug-related ma-
an acute territorial infarct, intracranial mass, or hemor‑ nia, which has classic symptoms of insomnia,
rhage. There is moderate confluent hypoattenuation euphoria or irritability, extreme hyperactivity,
involving the supratentorial white matter (arrow). and pressured speech. Although she was receiv-
ing psychotropic medications that have been
associated with serotonin syndrome, there were
patient continued to show signs of anxiety and a no findings suggestive of this diagnosis, such as
depressed mood. She said, “I am dead. I do not clonus, tremor, ataxia, hyperreflexia, or fever.1
exist. I am not real.” She also believed that her This patient had recently started taking dexa-
father and brother, as well as her nurses and methasone for the treatment of Covid-19. Gluco-
doctors, were dead. The patient was selectively corticoids, particularly when administered at
mute and motionless, but she talked and moved high doses, are potential triggers of a manic
with encouragement. She expressed that she felt response commonly referred to as “steroid-
directly responsible for the Covid-19 pandemic induced psychosis.” The use of glucocorticoids
and asked to be thrown out of the window. She can cause a myriad of neuropsychiatric affective,
had the sensation that her bladder was gone and cognitive, and behavioral symptoms.2 The per-
that she could not urinate, although she had sistence of this patient’s psychotic symptoms
been observed urinating independently. She felt after the discontinuation of dexamethasone ar-
that she could not eat, although she had been gues against the diagnosis of glucocorticoid-
observed eating breakfast daily. On hospital day associated psychosis, although it is possible that
9, the patient was transferred to the inpatient dexamethasone triggered an underlying primary
psychiatric unit of the other hospital. psychiatric disorder.
A diagnosis and management decisions
were made. Seizures
The patient was noted to appear withdrawn, and
at times, she would lie motionless and not re-
Differ en t i a l Di agnosis
spond to questions. These episodes suggest the
Dr. Gregory L. Fricchione: In this 57-year-old woman possibility of complex partial seizures. Status
with metabolic syndrome and a mixed affective epilepticus, including nonconvulsive status epi-

lepticus, has been reported in patients with times referred to as postacute syndrome of
Covid-19.3 In addition, the patient was taking Covid-19 or “long Covid”).10 In such cases,
bupropion, a medication that has been associ- neuropsychiatric symptoms can include fatigue,
ated with lowering of the seizure threshold. myalgias, headache, anxiety, depression, dysauto-
However, if her diminished responsiveness were nomia, and cognitive impairment (also referred
due to nonconvulsive status epilepticus, I would to as “brain fog”).
expect her to have phases of deeper unrespon- In one study involving more than 60,000 pa-
siveness fluctuating with brief phases of alert- tients with Covid-19, 18% of the patients had
ness with confusion. Because complex partial received a psychiatric diagnosis in the 14 to 90
seizure disorder is often difficult to diagnose, I days after infection.11 Neuroinflammation is
would perform long-term electroencephalo- thought to play a role in Covid-19–related neuro-
graphic (EEG) monitoring, while considering psychiatric disorders,12,13 and persistent autoanti-
alternative diagnoses. bodies have been detected in the CSF of patients
with these conditions.13-15
Autoimmune Encephalitis New-onset psychosis has been reported in
Could this patient have autoimmune limbic en- patients with Covid-19. In one report describing
cephalitis? The neuropsychiatric symptoms ap- 10 patients, psychotic symptoms developed at
pear to have had a subacute onset followed by least 2 weeks after the onset of Covid-19 symp-
rapid progression, which suggests involvement toms, and structured delusions were common.16
of the limbic system. In addition, the white- A recent systematic review of Covid-19–related
matter changes observed on CT of the head sug- psychosis cases confirmed that delusions were
gest bilateral brain abnormalities. However, if the most commonly reported psychotic symp-
the patient had autoimmune limbic encephalitis, tom.17 Of note, the majority of patients with
I would expect white-matter changes to be re- Covid-19–related psychosis had only mild acute
stricted to the medial temporal lobes and an Covid-19 symptoms.
EEG to show focal temporal slowing.4 I would CT of the head performed in this patient re-
perform magnetic resonance imaging (MRI) of vealed subcortical white-matter disease. The
the head and a lumbar puncture for cerebrospi- most frequent neuroimaging abnormalities ob-
nal fluid (CSF) analysis to help rule out the diag- served in patients with Covid-19 involve white-
nosis of autoimmune encephalitis, especially matter changes.18 Covid-19 has been associated
given the potential association of this condition with several white-matter diseases, including
with Covid-19.5,6 Encephalitis associated with Covid-19–related disseminated leukoencepha-
anti–N-methyl-d-aspartate (NMDA) receptor anti- lopathy and cerebral autosomal dominant arteri-
bodies can lead to a neuropsychiatric presenta- opathy with subcortical infarcts and leukoen-
tion that often includes catatonic withdrawal, cephalopathy (CADASIL).19,20 However, in this
and it has been associated with viral illnesses.7 patient, there was no report of features that
A connection between encephalitis associated would be suggestive of these diagnoses, such as
with anti–NMDA receptor antibodies and SARS- a clinically significant reduction in the level of
CoV-2 has not yet been established, but a poten- consciousness, headaches, cranial nerve signs,
tial relationship has been suggested.8 sensorimotor deficits, gait defects, or changes in
the deep-tendon reflexes. In addition, there were
Neuropsychiatric Symptoms Associated no other CT findings, such as microhemor-
with Covid-19 rhages or lacunar infarcts. MRI of the head
Could this patient’s neuropsychiatric symptoms would be the next step to help rule out neuropsy-
be related to her recent diagnosis of Covid-19? chiatric complications of Covid-19.
Early studies suggested that more than one third
of patients with Covid-19 had a neuropsychiatric Catatonia
syndrome.9 This patient had several features suggestive of
Some cases of Covid-19 lead to persistent catatonia. If the Bush–Francis Catatonia Rating
symptoms or long-term complications that ex- Scale were used, this patient would acquire
tend beyond acute disease (a condition some- points for mutism, withdrawal, immobility and

Table 1. DSM-5 Criteria for Catatonia Associated with a induced catatonia related to the use of olanza
Major Mood Disorder and a General Medical Condition.* pine is another possibility. In addition, the pa-
tient had a history of hospitalization for probable
≥3 of the following: bipolar affective psychosis and catatonia, and bi-
Catalepsy polar disorder is the most common cause of
Waxy flexibility psychogenic catatonia. There was no history
Stupor† suggestive of catatonia caused by conversion
Agitation
disorder.
The patient’s catatonic symptoms abated af-
Mutism†
ter treatment with a benzodiazepine, which is
Negativism†
the first-line treatment for catatonia. However,
Posturing one of the most striking features of her presen-
Mannerisms† tation remains to be explained: her persistent
Stereotypies thoughts that she was dead.
Grimacing
Cotard’s Syndrome
Echolalia
This patient expressed self-deprecation and guilt
Echopraxia
about not being able to care for her father, and
* DSM-5 denotes Diagnostic and Statistical Manual of she had mood-congruent delusions that she and
Mental Disorders, fifth edition. others were dead, along with a delusion that her
† These criteria were present in the patient on hospital day 3. bladder had disappeared. Her presentation is
consistent with Cotard’s syndrome, a syndrome
included in the DSM-5 category of delusional
stupor, staring, verbal perseveration, and auto- misidentification syndromes.27,28 Patients with
nomic instability, with a score of approximately Cotard’s syndrome have nihilistic delusions,
13 (on a scale ranging from 0 to 23, with higher such as the belief that they are dead, have lost
scores indicating more severe catatonia).21 On their souls, or are rotting inside, without func-
the basis of these reported findings on examina- tional organs or limbs. Three subtypes of Co-
tion, the patient would meet the criteria in the tard’s syndrome have been described: psychotic
Diagnostic and Statistical Manual of Mental Disorders, depression (a disorder associated with melan-
fifth edition (DSM-5), for catatonia associated cholia and nihilistic delusions), type 1 (a non-
with a major mood disorder and a general depressive delusional disorder), and type 2 (a dis-
medical condition (Table 1).22 order associated with mixed symptoms, including
Catatonia is a disorder of the cingulate cor- anxiety, depression, and auditory hallucina-
tico–striato–thalamo–cortical circuits that re- tions).29 Cotard’s syndrome has been reported in
sults in the disconnection of motivation and at least one patient with Covid-19,30 and catato-
movement, and it has multiple neuromedical nia and Cotard’s syndrome may occur concur-
and psychiatric causes.23,24 Catatonia has been rently.31,32
reported in several patients with Covid-19.25 In a Support and reassurance are key in the treat-
small study that evaluated the results of posi- ment of patients with Cotard’s syndrome, but
tron-emission tomography and CT of the head trying to talk patients out of their delusions is
performed in patients with Covid-19 encepha- futile. Successful treatment of the underlying
lopathy, there was evidence of persistent hypo- condition often helps the delusions to recede,
metabolism in the prefrontal cortex, anterior although the delusions may wax and wane in
cingulate cortex, insula, and caudate cortico– patients with persistent depression and may be-
striato–thalamo–cortical network.26 come chronic in patients with schizophrenia.
It is possible that this patient had Covid-19– Multiple antipsychotic medications have been
related changes in the blood–brain barrier and reported to reduce the symptoms of Cotard’s
choroid plexus that disrupted the cingulate syndrome. If medications fail, electroconvulsive
cortico–striato–thalamo–cortical circuits and therapy is an important therapeutic option. This
increased her risk of catatonia. Neuroleptic- patient had received electroconvulsive therapy in

the past for the treatment of catatonia, and such parenchymal volume loss that was advanced
therapy has a broad spectrum of effects for the given the patient’s age. The hippocampi were
treatment of multiple delusional conditions, in- normal with respect to size, signal, and mor-
cluding Cotard’s syndrome.27 Transcranial mag- phologic features. No cause of seizure was iden-
netic stimulation has had some promising ef- tified.
fects in patients with catatonia.33
I suspect that this patient had neuroinflam- Discussion of Sei zur e
mation associated with Covid-19 that contribut- M a nagemen t
ed to depression, catatonia, and Cotard’s syn-
drome. Dr. Zeina Chemali: An EEG recording (Fig. 3) re-
vealed bilateral slowing without epileptiform
discharges. There were several potential causes
Dr . Gr eg or y L . Fr ic chione’s
Di agnosis of a lowered seizure threshold in this patient,
including treatment with bupropion, a urinary
Cotard’s syndrome, catatonia, and depression af- tract infection, and hypomagnesemia. Could
ter coronavirus disease 2019. Covid-19 have contributed to the seizure?
In a study that evaluated EEG recordings ob-
tained from patients with Covid-19, nonspecific
Dise a se C our se
abnormalities of background rhythm were ob-
Dr. Kritzer: After the patient arrived in the in- served in most cases, with focal nonepileptic
patient psychiatric unit of the other hospital, a slowing found only around areas of other spe-
nurse witnessed a generalized tonic–clonic sei- cific brain insults. Epileptiform discharges were
zure that lasted 30 seconds and was accompa- observed in 20% of patients with Covid-19 who
nied by urinary incontinence. Intravenous loraze were in the intensive care unit, and nonconvul-
pam and levetiracetam were administered, and sive status epilepticus was diagnosed in 2.8% of
the patient was transferred to the medical clinic these patients.37 Potential mechanisms through
of the other hospital for further care. The evalu- which Covid-19 may contribute to seizures in-
ation for precipitating causes of the seizure include direct viral invasion of the central nervous
cluded a lumbar puncture for CSF analysis, includ- system (so far, this possibility has not been
ing CSF testing for antibodies associated with substantiated by research findings), exposure to
autoimmune encephalitis, which was negative. glucocorticoids or other immunomodulatory
The blood magnesium level was low, and there treatments, or secondary effects of the illness,
was evidence of a urinary tract infection. Addi- such as severe hypoxia, hyperthermia, thrombo-
tional imaging studies were obtained. embolic events, or cytokine storm.38 However,
Dr. Paul: MRI of the head (Fig. 2) revealed no seizures occur in 150,000 people each year, and
evidence of an acute infarct, intracranial mass, thus, the development of a seizure in this patient
or hemorrhage. There was moderate confluent after the onset of Covid-19 could be a coinci-
hypoattenuation involving the supratentorial dence.39 An international panel of experts re-
white matter. The study did not show preferen- cently determined that there is not enough evi-
tial involvement of the anterior temporal lobes dence to suggest any direct correlation between
and external capsules or show subcortical in- Covid-19 and the potentiation of epileptic sei-
farcts, findings that would suggest the diagno- zures.40
sis of CADASIL.34 In addition, the study did not This patient was initially treated with levetir
show restricted diffusion or microhemorrhages acetam, with a plan to administer a 6-week
within the juxtacortical white matter, findings course followed by a tapering course over a pe-
that would suggest the diagnosis of Covid-19– riod 1 to 2 weeks.41 In addition, hypomagnese-
associated diffuse leukoencephalopathy and mi- mia was corrected with the use of magnesium
crohemorrhages.35 There was no intracranial sulfate, the urinary tract infection was treated
hemorrhage, which would suggest cerebral amy- with nitrofurantoin, and the course of bupropi-
loid angiopathy.36 There was mild generalized on was tapered.

A B C
D E
Figure 2. MRI of the Head.

An axial fluid‑attenuated inversion recovery image (Panel A) shows moderate confluent hypoattenuation involving the supratentorial white
matter (arrow), a finding consistent with small‑vessel change, which is advanced given the patient’s age. There is equivalent prominence
of the ventricles and sulci (arrowheads), a finding consistent with mild generalized parenchymal volume loss, which is also advanced
given the patient’s age. A coronal T2‑weighted image (Panel B) shows that the hippocampi are normal with respect to size, signal, and
morphologic features (arrows). An axial T1‑weighted image (Panel C), obtained after the administration of intravenous contrast material,
shows no abnormal enhancement of the brain parenchyma. An axial diffusion‑weighted image (Panel D) shows no restricted diffusion.
An axial gradient–echo image (Panel E) shows no susceptibility signal. There is no evidence of a cause or consequence of seizure.
Discussion of Ps ychi at r ic for mutism, staring, verbigeration, rigidity, neg-

M a nagemen t ativism, withdrawal, constant grasp reflex, auto-
nomic instability, and repeatedly moving her arm
Dr. Kritzer: During the evaluation for precipitating in a circular manner). After one day of treatment
causes of seizure, the patient had signs of deliri- with intravenous lorazepam, the score decreased
um and catatonia. She had a score on the Bush– to 5. Because the patient had mania and deliri-
Francis Catatonia Rating Scale of 11 (with points um, the dose of fluoxetine was decreased.

A Figure 3. Electroencephalograms.
A bifrontal electroencephalographic (EEG) montage ob‑
tained after the patient had a seizure (Panel A) shows
bilateral slowing without epileptiform discharges; there
is a sharp frontal wave that may be an artifact (arrows).
A follow‑up EEG obtained 2 weeks later (Panel B)
shows more slowing.
Once the patient’s condition was considered

to be medically stable, without overt signs of
delirium, she was transferred back to the inpa-
tient psychiatric unit. Electroconvulsive therapy
was offered for the treatment of major depres-
sive disorder and Cotard’s syndrome, but the
patient and her brother declined this treatment
because they thought it had been ineffective in
the past. There was ongoing agitation, and leve-
tiracetam was switched to valproate to minimize
neuropsychiatric side effects. The patient’s con-
B dition improved during her monthlong hospital-
ization. The dose of lorazepam was gradually
tapered, and the doses of valproate and olanza-
pine were adjusted.
Since discharge, the patient has been admit-
ted to the inpatient psychiatric unit three times
for major depressive disorder with psychotic
features (mainly paranoia) or with poor self-
care. She has had no recurrence of seizures and
has reported a benefit from a recent trial of
transcranial magnetic stimulation.
Fina l Di agnosis
Cotard’s syndrome, catatonia, depression, and
seizure after coronavirus disease 2019.
This case was presented at Psychiatry Grand Rounds.

Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
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57-Year-Old Woman With Covid-19 and Delusions

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The n e w e ng l a n d j o u r na l of m e dic i n e

Case Records of the Massachusetts General Hospital

Founded by Richard C. Cabot

Case 34-2022: A 57-Year-Old Woman

Pr e sen tat ion of C a se

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disorder suggestive of bipolar disorder, neuro-

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Figure 2. MRI of the Head.

Discussion of Ps ychi at r ic for mutism, staring, verbigeration, rigidity, neg-

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Once the patient’s condition was considered

This case was presented at Psychiatry Grand Rounds.

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