Acute psychosis unmasking severe non-ischaemic cardiomyopathy with biventricular thrombosis and cardioembolic cerebral infarcts.

A woman in her early 30s with major depressive disorder and generalised anxiety disorder presented with a 3- to 4-week history of progressive paranoia, auditory hallucinations and behavioural disorganisation, initially admitted with a provisional diagnosis of mood disorder with psychotic features. Investigation revealed severe non-ischaemic dilated cardiomyopathy (left ventricular ejection fraction 10%-15%) with extensive biventricular thrombi and a large mobile left ventricular thrombus. She developed cardiogenic shock requiring vasopressors and inotropic support with transfer to critical care. Brain MRI confirmed cardioembolic infarcts, resolving on repeat imaging at 8 weeks. Electroencephalograms normalised following clinical improvement. Extensive autoimmune, infectious and toxicological investigations were unrevealing. Psychotic symptoms resolved in parallel with cardiac stabilisation and did not recur following antipsychotic discontinuation. At follow-up, she demonstrated sustained psychiatric remission without medication. This case underscores the importance of systematic medical evaluation in first-episode psychosis and the risks of premature diagnostic closure.