Acute Psychosis and Delirium During Menstruation in a Premenopausal Woman With Urinary Tract Infection

Delirium is a recognized complication of urinary tract infection (UTI) in older adults, with proposed mechanisms including neuroinflammation, vascular dysfunction, metabolic disturbance, neurotransmitter imbalance, and impaired neuronal connectivity.¹ A 2015 systematic review² extending beyond geriatric populations found that 47% of included studies reported neuropsychiatric disorders precipitated or exacerbated by UTIs; among these, 19.4% developed delirium, 21.7% nonaffective psychosis, and 17.8% mood disorders. In adults aged 18–64 years hospitalized for psychosis,³ UTIs were significantly more common in those with nonaffective psychosis and major depressive disorder with psychotic features compared to controls. Similar associations have been observed in pediatric populations, particularly for nonaffective psychosis.⁴ However, acute psychiatric manifestations associated with UTIs in younger women remain underrecognized. Prior literature suggests that UTIs may precipitate or exacerbate neuropsychiatric symptoms, including delirium, psychosis, and mood disorders,⁵ outside of geriatric populations. We report a case of recurrent delirium and psychosis temporally associated with co-occurring UTI and menstruation in a premenopausal woman.

Case Report

A 34-year-old woman with a history of major depressive disorder presented with acute disorganized behavior following 5 days of worsening insomnia, agitation, loss of appetite, mutism, and hyperactivity. Symptom onset occurred during menstruation and was accompanied by urinary frequency and dysuria. Emergency department evaluation revealed tachycardia (119 beats per minute) and mild leukocytosis (11.85 × 10³/µL). Urinalysis revealed turbid urine, positive leukocyte esterase, >100 white blood cells/high-power field, 3+ bacteria, ketones, and red blood cells, findings consistent with a UTI. Urine drug screening and pregnancy testing were negative. She was discharged on nitrofurantoin 100 mg twice daily but returned within 48 hours because of worsening agitation and aggression.

Upon psychiatric admission, the patient exhibited severe behavioral disorganization, including pacing, licking the walls, attempting to enter other patients’ rooms, mutism, and intermittent reports of hearing her name called. She required one-on-one observation and received haloperidol and lorazepam for agitation. Repeat medical evaluation demonstrated resolution of the UTI, an unremarkable head computed tomography, and no alternative medical explanation for her symptoms.

Following exclusion of ongoing medical causes, the patient was treated with risperidone titrated to 1.5 mg twice daily, trazodone 50 mg at bedtime for sleep, and propranolol 10 mg 3 times daily for restlessness and anxiety. Collateral information from her mother revealed previous episodes of similar psychiatric decompensation occurring during UTIs while menstruating, with complete resolution after treatment. During an 11-day hospitalization, the patient’s sleep, appetite, orientation, insight, and behavioral control gradually improved. Intake and output were monitored due to poor oral intake, which gradually improved. At discharge, she had returned to baseline functioning and denied psychotic symptoms.

Discussion

This case highlights several potentially interacting contributors to acute psychiatric decompensation. Infection-related neuroinflammation may increase vulnerability to delirium and psychosis.¹ In addition, the recurrence of symptoms during menstruation raises the possibility that hormonal fluctuations contributed to symptom expression. While it is not formally recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or International Classification of Diseases, Tenth Revision, cyclic menstrual psychosis⁶ has been described as an acute psychotic syndrome occurring in temporal association with the menstrual cycle and followed by full remission. Estrogen and progesterone fluctuations may influence dopaminergic and GABAergic signaling, potentially lowering the threshold for psychiatric destabilization.⁷

Additional proposed contributors include genetic vulnerability⁸ and, in some cases, antibiotic-associated psychosis, most commonly reported with fluoroquinolones, penicillins, and trimethoprim-sulfamethoxazole.⁹ However, in this case, psychiatric symptoms emerged before antibiotic initiation, making a medication-induced etiology unlikely.

Overall, this case demonstrates that acute delirium and psychosis in the setting of UTI can occur in premenopausal women and may be influenced by underlying psychiatric history, recurrent infection-related vulnerability, and hormonal fluctuations. Increased clinical awareness and further investigation are needed to better define risk factors and mechanisms in this underrecognized population.

Article Information

Published Online: October 15, 2026. https://doi.org/10.4088/PCC.26cr04300
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(5):26cr04300
Submitted: June 9, 2026; accepted July 20, 2026.
To Cite: Ellias S, Hashmi A, Salcedo JS, et al. Acute psychosis and delirium during menstruation in a premenopausal woman with urinary tract infection. Prim Care Companion CNS Disord 2026;28(5):26cr04300.
Author Affiliations: Central Michigan University, Saginaw, Michigan (all authors).
Corresponding Author: Sara Ellias, MS, Central Michigan University, Saginaw, Michigan ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Patient Consent: Consent was received from the patient to publish the case report, and information has been de-identified to protect patient anonymity.