Dr. Reuben A. Hendler (Psychiatry): A 37-year-old woman was admitted to this hospital because of fever, shortness of breath, and suicidal ideation in March 2020, during the pandemic of coronavirus disease 2019 (Covid-19).

Ten days before this admission, fever, fatigue, sore throat, cough, and myalgias developed. The symptoms did not abate after the patient took aspirin and acetaminophen. Five days before this admission, she sought evaluation at the urgent care clinic of this hospital because Covid-19 had been diagnosed in two coworkers. A test for Covid-19 was not performed because of limited test availability; tests for influenza A and B viruses and respiratory syncytial virus were not performed because of a statewide shortage of nasopharyngeal swabs. The patient was instructed to quarantine at home.

During the next 5 days, the patient quarantined in a room in her apartment. Her husband periodically brought food to the door of the room. The fever, fatigue, sore throat, cough, and myalgias persisted; new shortness of breath and anosmia developed. She had decreased appetite, and she consumed minimal food and drink.

One day before this admission, nausea, vomiting, and diarrhea developed, and the patient sought evaluation at the emergency department of another hospital. Intravenous fluid, ondansetron, and ketorolac were administered, and she was discharged home with instructions to continue to quarantine.

On the day of admission, the patient had dizziness while standing, as well as shortness of breath, and she returned to the urgent care clinic of this hospital. The temperature was 38.7°C, the heart rate 127 beats per minute, the respiratory rate 38 breaths per minute, and the oxygen saturation 97% while she was breathing ambient air. The patient was anxious and tearful. The lungs were clear on auscultation. Intravenous fluid, ondansetron, and oral acetaminophen were administered. The dizziness resolved, and the fever, shortness of breath, and anxiety decreased. The patient was advised to return home to quarantine; however, she disclosed that if she were sent home, she planned to overdose on medications to die by suicide because of her anxiety and feelings of sadness and loneliness. Owing to concern about the patient’s risk of harming herself, an order authorizing temporary involuntary hospitalization was implemented. Emergency medical services were called, and the patient was brought to the emergency department.

On evaluation in the emergency department, the patient reported anxiety, palpitations, and shortness of breath and noted that her anxiety and feelings of isolation and loneliness had developed during quarantine. She also reported poor sleep, decreased energy, and anhedonia. The patient described that she felt like a burden to her husband and was terrified that she would transmit severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to her children, including her 4-year-old son, who had been born prematurely and had a congenital pulmonary condition.

In addition, the patient reported a 1-week history of new, recurring nightmares in which she would see herself playing with her own severed body parts; these nightmares occurred more frequently during periods of high fever. She intermittently had the sensation that someone was in the room with her while she was awake, even though she was aware that she was alone. She disclosed that, on the previous day, she had had new suicidal ideation associated with fear of transmitting SARS-CoV-2 to her family and that she had taken five aspirin–paracetamol–caffeine pills at once. There had been no history of suicidal ideation or attempt, self-harm, or homicidal ideation.

The patient had a history of depression and panic attacks when she was a teenager and had been treated for less than 1 year with a medication that she could not recall; the symptoms had resolved by 19 years of age, and there had been no mental health follow-up. She also had a history of migraines, which occurred four times per week. She took aspirin, acetaminophen, and aspirin–paracetamol–caffeine as needed; there were no known drug allergies. The patient was born in Central America and had been living in the United States for 19 years. She lived with her husband, four children, and mother-in-law in an urban area of New England in a community that was predominantly Latinx and that had a high rate of Covid-19–related infections and deaths. The patient did not complete high school while she was living in Central America and was currently employed full time in a food-production factory. She reported that she enjoyed her job but that she had been reluctant to work during the Covid-19 pandemic because of concern about becoming ill; however, she described that she felt obligated to work to support her family. The patient did not smoke cigarettes, drink alcohol, or use illicit drugs. Her mother had died from cancer.

On examination, the temperature was 38.2°C, the blood pressure 148/84 mm Hg, the heart rate 110 beats per minute, the respiratory rate 22 breaths per minute, and the oxygen saturation 97% while the patient was breathing ambient air. She appeared well-groomed and fatigued, and she was tearful with a depressed and dysphoric mood. Her behavior was described as “sullen,” and there was limited eye contact and reduced psychomotor activity. Her speech, in Spanish, was fluent but was slow and mumbling, with reduced prosody. She had no derailment of thought, delusions, or obsessions, but she ruminated on her nightmares. She stated that she had no current suicidal ideation but that she might attempt suicide if she had to return to her children and expose them to SARS-CoV-2 again.

Nucleic acid testing of a nasopharyngeal swab for SARS-CoV-2 RNA was positive. Additional laboratory test results are shown in Table 1. Radiography of the chest revealed ground-glass opacities in the right middle and lower lobes and in the left lower lobe. Intravenous ceftriaxone, oral azithromycin, atorvastatin, and hydroxychloroquine were administered, and the patient was admitted to the hospital.

Management decisions were made.