Aggressive Behavior in a Critically Ill COVID-19 Patient: Possible Role of Medication Discrepancies

Coronavirus disease 2019 (COVID-19) has different clinical manifestations that besides its iatrogenic intervention could affect brain cognitive function. Medication omission has serious effects on a patient’s clinical course changing the disease’s mortality and morbidity; herein possible role of the iatrogenic intervention that increased the risk of psychological disturbance including medication omission was reported. A 40-years-old man with a history of gout treated with allopurinol was admitted due to productive cough and hemoptysis. His physical exam and lung spiral chest CT scan revealed moderate to severe lung infiltrations in favor of COVID-19 which was confirmed with COVID-19 RT-PCR. Due to his clinical course tocilizumab, methylprednisolone pulse, and other conservative therapies were started while allopurinol was omitted. During his hospitalization anxiety and irritability appeared and progressed gradually making him refuse to get oxygen supplementation. Through immediate intervention and controlling his behavioral symptoms with psychotherapy, selective serotonin reuptake inhibitors, benzodiazepines, and initiation of allopurinol, the patient’s psychological disturbance were relieved. In the end, he died due to acute respiratory distress syndrome. COVID-19 and its iatrogenic interventions could trigger a psychiatric disturbance in patients with a variety of pathways. Corticosteroid therapy, non-hypnotic antihistamines, quarantine stress conditions, hypoxia, and medication omission are underlying factors for it. Reporting this medication omission would help physicians become familiar with this pharmacological phenomenon, its prevention, and the way to respond to it. On the other hand, researchers can study the etiology of this phenomenon to understand the mood-stabilizing role of allopurinol in additional studies.