Case Presentation: A 40-year-old male with no personal or family psychiatric history; presented to the emergency department displaying flight of ideas, a tangential thought process, grandiose delusions, and insomnia for the 10 days prior to admission. His symptoms began 10 days following an uncomplicated SARS-CoV-2 infection that required no treatment. The patient was a highly successful individual with multiple academic accomplishments and a prestigious job in education. He had no history of substance use disorder, reporting only a distant history of cannabis use from years prior. He had no pertinent past medical history. He took no prescription medications or supplements and reported no allergies.The patient was admitted to a general medicine floor for management of a manic episode where he received an extensive medical and neurological workup. Metabolic, toxic, infectious, and neurologic causes of mania were ruled out. The patient was treated with valproate and olanzapine, titrated up to 1250 mg/day and 10 mg/day respectively by the time of discharge. After four days of treatment the patient’s symptoms began to resolve. He was discharged on the seventh day to follow up outpatient with a psychiatrist. He has been stable since.

Discussion: Neuropsychiatric symptoms are not uncommon manifestations of viral infections. SARS-CoV-2 has been found in the CSF and has been associated with manic symptoms since the start of the pandemic. There is growing evidence that COVID-19 and psychiatric diagnoses have a complex bidirectional relationship, each acting as independent risk factors for each other. The strongest predictive factor of bipolar disorder remains a first-degree family member with a diagnosis of bipolar. Recent research has found multiple cases of manic episodes occurring in the setting of a SARS-CoV-2 infection in patients with no family history of bipolar disorder. However, despite growing research linking manic symptoms with SARS-CoV-2, a host of confounding factors are frequently present in these studies, which obscure the neuropsychiatric manifestations of the virus itself. These include past psychiatric history, family history of psychiatric illness, underlying psychiatric illness that has not yet presented, concomitant substance use, ICU/hospital associated delirium, and steroid induced psychosis/mania. This case is unique in that all the usual confounding variables are absent. The patient’s symptoms began shortly after infection with the virus for which he did not receive steroid therapy. He had no family history that might predispose him to a manic episode, no psychiatric history, and no substance use. Additionally, he presented at an uncommon age for a first manic episode: the average age being 20 years old. The only significant history was his recent SARS-CoV-2 infection. Although a causal link cannot be established by a single case, this presentation is unique and contributes valuable data to the growing evidence of neuropsychiatric manifestations of SARS-CoV-2 infection.

Conclusions: Neuropsychiatric manifestations of SARS-CoV-2 have been observed since the start of the pandemic. Unfortunately, many of these cases occur in the setting of significant confounders. Here we present a case of a first manic episode in a 40-year-old high functioning male occurring in the absence of all the usual risk factors. This case contributes data for future study to further elucidate the neuropsychiatric manifestations of SARS-CoV-2.