A Rare Case of Acute Respiratory Distress Syndrome Secondary to Acute Lithium Intoxication

Abstract

Lithium carbonate is a widely administered antimanic drug used for the treatment of bipolar disorder, schizoaffective disorder, and depression. Despite the established clinical efficacy of lithium, its usage must be approached with caution due to its narrow therapeutic index. Lithium poisoning results in multisystem toxicity, and characteristic clinical manifestations are directly correlated to serum lithium concentration. We describe a rather rare but fatal side effect of lithium: acute respiratory distress syndrome (ARDS) in a 46-year-old female on lithium for the treatment of bipolar disease. She was referred for generalized weakness, found in hemodynamic compromise, and had laboratory data significant for a lithium level of 3.3 mmole/L, needing emergent hemodialysis. Subsequently, she developed hypoxic respiratory failure requiring intubation. Her chest x-rays showed new bilateral pulmonary edema, the computed tomography scan showed extensive alveolar consolidation and V/Q scan of low probability for pulmonary embolism. She underwent 3 dialysis sessions and supportive care and was able to be extubated in 5 days. To our knowledge, 4 cases of ARDS after the onset of lithium toxicity have been documented. All patients presented with altered mental status at serum lithium levels ranging from 3.8 to 4.9 mmole/L and cardiogenic etiologies in addition to other likely causes of ARDS were ruled out in each case. The patients were treated with saline hydration (50%) or hemodialysis (50%), indicating that hemodialysis may be a permissive factor in lithium-associated ARDS development rather than a required component. Taken together, we believe that lithium is a likely culprit in the initiation of ARDS and propose the addition of ARDS to the family of clinical manifestations of severe lithium toxicity.

Electrocardiographic changes caused by lithium intoxication in an elderly patient

“…Despite the clinical efficacy of lithium is known to all, however, we must use it with caution due to its narrow therapeutic index. Lithium intoxication can result in multisystem toxicity (Kansagra et al 2014 ), just like Table 1 (Aruna 2009 ).…”

Hemodialysis Treatment for Patients with Lithium Poisoning

“…Respiratory failure is an uncommon manifestation of lithium poisoning; however, it can be induced by consciousness disturbance, severe neurological symptoms, aspiration pneumonia or acute respiratory distress syndrome (ARDS). Five cases of lithium-associated ARDS have been reported in the literature [ 27 , 28 , 29 , 30 ]. These five patients had blood lithium levels of 3.3–4.9 mEq/L.…”

Group A Streptococci-Associated Necrotizing Fasciitis following Cat Bite in an Immunocompromised Patient

“…Patient had to undergo forearm debridement twice in the next few days by hand surgeon. Her hospital course was further complicated by acute respiratory distress syndrome [ 3 ], right femoral deep vein thrombosis, and multiple acute infarcts involving the bilateral cerebral and cerebellar hemispheres. A performed transthoracic echo confirmed the presence of Patent Foramen Ovale.…”