Lithium Toxicity Precipitated by Thyrotoxicosis Due to Silent Thyroiditis: Cardiac Arrest, Quadriplegia, and Coma

Abstract

Thyrotoxicosis may be a contributing cause of lithium toxicity, particularly if it is abrupt in onset and even with cessation of lithium therapy if renal function is compromised. Thyroid function should be assessed immediately in patients with suspected lithium toxicity.

Coma in Thyroid Storm: Review of Aggregated English-Language Case Reports

“…More than one event precipitating the TS-related coma was identified in 21 cases [3, 8, 14–16, 21–24, 33, 35, 36, 38]. No precipitating event could be identified in eight cases [10, 11, 30, 40, 42, 43, 45], and 10 cases had no information on the TS-precipitating event.…”

“…Iodine exposure from amiodarone was reported in two cases [16, 31] and from CT contrast medium in three cases [15, 34, 38]. There were five cases each of thyroid hormone overdose [14], dehydration [16, 18, 27, 33, 39], and hypoglycemia [22, 29, 32, 35]. Diabetic ketoacidosis or hyperosmotic diabetic coma was reported in four cases [3, 8, 18], and there were three cases each of cardiac events [25, 28, 33], obstetric-related events [13, 21, 36], and trauma [15, 37, 44] or following use of radioactive iodine [3, 35, 41].…”

“…The minimum BW score ranged from 30 to 120 points, with a mean (SD) score of 69 (19) points for cases with adequate detail to make the calculation. Not all reports described the thyrotoxic state with coma as a “TS” [9, 14, 15, 18, 23, 24, 29, 33, 44]. Calculation of the BW score of 13 such cases revealed a range of 30 to 110 points, with a mean (SD) score of 59 (23) points, despite having incomplete data for specific calculation of all BW categories in one of the reports (specifically, fever or tachycardia was present in all cases but not in sufficient detail to assign a BW score) [14].…”

“…Neurologic testing in association with TS-related coma may have included electroencephalogram (EEG), lumbar puncture (LP), or brain CT or MRI. EEG was performed in 11 cases [11, 15, 20, 37], seven of which reported diffuse slowing [19, 30, 33, 38, 39, 42, 45]. LP was performed in 15 cases [11, 15, 19, 20, 22, 29, 30, 37, 38, 40, 42, 43, 45].…”

“…Head CT was reported in 18 cases and was read as normal in 11 cases (65%). Brain MRI was reported in only seven cases [33, 38] and had abnormal results in five, including reversible lesion of the splenium in the corpus callosum [37], diffuse atrophy [34], chronic lacunar infarcts in bilateral pons [30], and stroke [35]. There are no reports of functional MRI or fluorodeoxyglucose positron emission tomography in TS-related coma.…”