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Introduction
Coronaviruses constitute a large family of respiratory viruses that can lead to a spectrum of illnesses ranging from the common cold to more severe conditions, such as Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). The emergence of SARS-CoV-2 and the ensuing COVID-19 pandemic in December 2019 initially originated in central China and swiftly spread to various populations [1].
On March 11, 2020, the World Health Organization (WHO) declared this novel virus a global pandemic. As of July 4, 2022, the reported cases of coronavirus infection have surpassed 546.3 million, resulting in more than 6.4 million confirmed deaths and 400,000 additional casualties [2]. Symptoms of SARS-CoV-2 infection include fever, fatigue, and respiratory and gastrointestinal symptoms, such as cough, shortness of breath, anorexia, and diarrhea [3]. There are concerns about the link between acute respiratory syndrome of the coronavirus and psychiatric diseases, but it is not clear whether the SARS-COV-2 virus can damage the central nervous system and cause mental symptoms [4].
This is the first case reported in Iran and aims to raise awareness regarding the impact of the coronavirus on the central nervous system, potentially leading to mental health issues. In this report, we provided details about the clinical progression, diagnosis, and treatment of the initial case of SARS-CoV-2 infection featuring manic symptoms. We also confirm the presence of SARS-CoV-2 through polymerase chain reaction (PCR) testing conducted on the patient’s upper respiratory tract.
This patient exhibited manic symptoms following hospitalization for acute respiratory issues and subsequent discharge. After the onset of the manic episode, a PCR test confirmed a positive diagnosis for SARs-CoV-2. The patient, a 40-year-old woman, had previously undergone cervical disc surgery for herniation between vertebrae 4 and 5. There was no prior history of psychiatric hospitalization (neuropsychology) for the patient.
Following her cervical disc surgery, the patient was discharged but readmitted two days later due to severe coughing, chest tightness, and fever. In addition, her test results were positive for the novel SARS-COV-2 virus. Over a period of ten days, the patient received a regimen of antibiotics (azithromycin and cefuroxime), hydroxychloroquine, and dexamethasone, following which she was discharged with medication instructions. Four days after her initial discharge, the patient’s husband brought her to the Psychiatric Emergency Department of Razi Psychiatric Hospital, affiliated with the University of Social Welfare and Rehabilitation Sciences due to symptoms, such as euphoria, insomnia (reduced need for sleep), irritability (bursts of anger and franticness), and incoherence. Prior to re-admittance, a PCR test was conducted, yielding a positive result, and subsequently, the patient was admitted to the quarantine ward of Razi Psychiatric Hospital. 
Additionally, to mitigate aggression and alleviate the symptoms of COVID-19, she received treatment with prednisolone and haloperidol, and concurrently, an evaluation by a psychiatrist was conducted. During the clinical interview, the patient made several extraordinary claims, stating that she possessed substantial wealth with multiple properties, held passports from all countries worldwide, could converse in all languages globally, held a doctoral degree in artificial intelligence from Sharif University of Technology, and possessed a divine aura with the ability to accurately determine heart rate, body temperature, and oxygen levels. The patient also asserted that she was God’s daughter and had been endowed with the power to cure COVID-19. Assessment of the patient’s mental state revealed symptoms of psychomotor restlessness, excessively intimate demeanor, pressured speech, euphoric mood, overt affection, distractibility, auditory and visual hallucinations, grandiose delusions, and a lack of insight, judgment, attention, and orientation. No abnormalities were observed during the physical and neurological examinations. Treatment for the patient involved administering haloperidol 5 mg, biperidin 2 mg, sodium valproate 500 g, and clonazepam 2 mg. 
There was no history of mental illness in the patient’s family, and for the past eight years, she has been employed in designing traffic signs. She has been married for 14 years and has one child. She resides with her family, does not smoke, and has no history of alcohol consumption or illicit substance use. 

Treatment and Follow-up Results
After 17 days of hospitalization and successful control of the euphoric and psychotic symptoms, the patient was discharged from the hospital with the following medication instructions: Haloperidol 5 mg twice a day was administered as an antipsychotic, 500 mg sodium valproate three times a day as a mood stabilizer, biperidin three times a day to reduce the extrapyramidal side effects of haloperidol, and clonazepam 2 mg before bedtime. The patient was followed up by telephone two weeks after discharge and the patient’s family and the patient herself reported the improvement of symptoms. With the guidance of a psychiatrist, the patient decided to discontinue her medication after six months. To monitor her progress, a psychiatric resident from the emergency department at Razi Psychiatric Hospital evaluated the patient every three months. The last assessment was performed two years after the initial diagnosis of the disease, and it revealed no mood symptoms or hypomanic episodes. Additionally, the patient’s psychosocial and occupational functioning had returned to a completely normal state.

Discussion
In this study, we investigated a case of prolonged SARS-COV-2 infection with manic symptoms. COVID-19 has been associated with the emergence of mental illnesses for many reasons. Studies have shown that in general, manic symptoms in patients with SARS-CoV-2 are caused by neural cascades due to SARS-CoV-2 invasion and increased pro-inflammatory and inflammatory responses, hypoxia, and iatrogenic factors, such as antibiotics and steroids [5]. Iqbal et al. [6] showed that the emergence of mania could be caused by a psychosocial factor or due to an inflammatory mechanism. Park et al. [7] showed that COVID-19 infection can cause a primary mania period, and SARS-CoV-2 can stimulate the production of cytokines by penetrating the blood-brain barrier. The main symptoms experienced by mania due to COVID-19 in different patients include insomnia [4, 8] abnormal behavior [7, 9], delirium [10, 11], irritability [12], restlessness [13], auditory hallucinations [6, 7] and aggressive behavior [14], which were also observed in our treated patient. These findings support the hypothesis that the psychiatric condition experienced represents a period of mania and does not necessarily indicate a separate diagnosis [5]. Furthermore, the observed improvement in mood swings and psychosis following appropriate medical treatment, including antipsychotics and mood stabilizers, further supports this idea.

Conclusion
The occurrences of mania in the context of COVID-19 are on the rise. Understanding that psychological, biological, and environmental factors all contribute to the development and exacerbation of bipolar disorder underscores the multifactorial nature of the disease With the high global prevalence of SARS-CoV-2 infections, this serves as a warning to mental health professionals. Consequently, physicians should be more vigilant when they encounter manic symptoms in COVID-19 patients, even if these patients are physically asymptomatic and have no prior history of psychiatric issues. COVID-19 may exacerbate a pre-existing bipolar disorder [5] or due to social and psychological effects and biological pathways, it can cause bipolar disorder without a prior context [5]. Therefore, there is a growing emphasis on paying attention to psychiatric symptoms in COVID-19 patients who lack a family or personal history of mental disorders. It can also be concluded that bipolar patients need more clinical attention due to their susceptibility to re-exacerbation caused by pandemic-related stress, social isolation, difficulties in accessing medical care, and changes in treatment follow-up

Limitations 
This study has specific limitations. This is a case report and the assumptions raised should be confirmed by future studies. In addition, COVID-19 real-time PCR testing in cerebrospinal fluid (CSF) was not conducted.

Ethical Considerations

Compliance with ethical guidelines
The present study is a case report and does not require obtaining an ethics code.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank colleagues who contributed in some way to the work described in this case report.





References