Unrecognized acute lithium toxicity: a case report

Ristic, Dragana; Siapera, Marianna; Jović, Jelena; Marjanovic, Vesna Stojanovic; Radovanović, Milan; Fountoulakis, Konstantinos Ν.

doi:10.2478/s11536-012-0058-0

Cited by 4 publications

(5 citation statements)

References 19 publications

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“…Ristic et al has elaborated how the lithium level of 1.46 mmol/L in a 63-year-old male produced nephrotoxicity that led to severe renal insufficiency and neurological symptoms. This case report also explains that after HD due to fast redistribution plasma values almost reach the level before dialysis known as rebound effect and often require redialysis as happened in our patient after the first session of HD (15).…”

Section: Discussionsupporting

confidence: 56%

When numbers can be misleading: lithium induced irreversible neurotoxicity at therapeutic drug levels

Aggarwal

Mehdi

Kaur

et al. 2021

J Emerg Pract Trauma

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Objective: Lithium is a principal drug used in the treatment of bipolar disorder (BPD). Due to its narrow therapeutic index, serum levels need to be monitored regularly. In elderly patients with renal dysfunction lithium toxicity can develop paradoxically within the therapeutic range. This can lead to erroneous diagnosis and delayed treatment resulting in irreversible neurological sequelae as is described in our case. Case Presentation: A 65-year-old hypertensive female, with a 7-year history of BPD presented with decreased oral intake since 5-7 days, followed by altered sensorium. Neurological examination revealed coarse tremors in bilateral upper and lower limbs with spasticity, hyperreflexia, bilateral knee clonus. Twenty-five days earlier, she was prescribed Lithium carbonate. On evaluation she was found to have chronic kidney disease. Serum lithium levels came out to be 1.18 mg/dL (borderline high). After ruling out other differentials, a diagnosis of lithium toxicity was considered and she underwent two sessions of hemodialysis (HD) leading to significant improvement in sensorium; however, the patient had persistent dysarthria, difficulty in walking and proximal myopathy predominantly in the lower limbs. Nerve conduction studies confirmed the presence of axonal neuropathy. These findings of peripheral neuropathy (both sensory and motor) were suggestive of SILENT (syndrome of irreversible lithium-effectuated neurotoxicity). Conclusion: Unintended lithium toxicity can occur even at therapeutic levels especially in the elderlies owing to its narrow therapeutic window, complex pharmacokinetics and numerous drug interactions. Lithium can result in irreversible neurotoxicity including SILENT; therefore, a high level of suspicion is required to prevent such permanent disability.

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Section: Discussionsupporting

confidence: 56%

When numbers can be misleading: lithium induced irreversible neurotoxicity at therapeutic drug levels

Aggarwal

Mehdi

Kaur

et al. 2021

J Emerg Pract Trauma

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show abstract

“…Despite being a widely used drug, the mechanism of lithium neurotoxicity is still poorly understood and can sometimes occur at therapeutic levels [3,5]. It's a drug with a narrow therapeutic index [6][7][8], and the relationship between dose and adverse effects is not yet defined [6,9]. The risk of severe neurotoxicity is thought to be greater in patients on chronic medication [3].…”

Section: Discussionmentioning

confidence: 99%

“…The risk of severe neurotoxicity is thought to be greater in patients on chronic medication [3]. Other known risk factors are age over 50, kidney damage, and thyroid disease [3,9].…”

Section: Discussionmentioning

confidence: 99%

Lithium Intoxication in an Elderly Woman

Gomes¹,

Bonito²,

Santos³

et al. 2022

Cureus

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Acute confusional state or delirium in the elderly frequently requires a lengthy differential diagnosis in the emergency room (ER) to determine the factors of its multiple causes. Iatrogeny can be one of the causes, especially in elderly people with polypharmacy. We present a case of a 77-year-old female, independent in activities of daily living, with no cognitive impairment and a history of hypertension, dyslipidemia, and manic-depressive disorder. She arrived at the ER with diarrhea, vomiting, and myalgias. A blood test revealed an acute kidney injury. The patient was discharged with the diagnosis of acute gastroenteritis and prerenal acute kidney injury.The patient returned to the ER two days later due to worsening symptoms, including spatial and temporary disorientation and a marked prostration. The attending physician recommended a lithium blood level test due to the patient's history and the outpatient's psychiatric medication. The tests revealed a value of 2.18 mmol/L (toxic levels: >2.0 mmol/L). Support measures were initiated with diuresis control and vigorous hydration, with subsequent clinical and biochemical improvement (lithium blood levels reduced to 0.97 mmol/L).Lithium toxicity causes acute nausea, vomiting, diarrhea, and neurological symptoms that have a slower onset and correlate with chronic toxicity. A declining renal function and reduced volume of distribution (due to increased body fat mass and decreased total body water) contribute to more significant pharmacological toxicity in the elderly. In this case, dehydration triggered by diarrhea and vomiting may have been a cause or a consequence. Reviewing chronic medication and a detailed investigation of all etiological causes was essential for the patient's rehabilitation, avoiding possible irreversible neurological damage.

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Section: Introductionmentioning

confidence: 99%

“…Psychiatrists are cautious when using lithium, however, due to its narrow therapeutic index, which gives it the potential to result in toxicity [7]. Lithium toxicity may be the result of accidental or intentional overdose or intoxication for several reasons, including reduced renal clearance [7]. Lithium neurotoxicity is a spectrum of signs and symptoms that include confusion, mental slowing, dysarthria, mood changes, memory and executive dysfunction, seizures, and stupor [8][9][10].…”

Section: Introductionmentioning

confidence: 99%

Challenges in the Clinical Diagnosis of Lithium Toxicity: A Case Report

Almadani,

AlBuqami,

Aljaffer

2023

Cureus

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Lithium, a medication commonly used to treat bipolar disorders, has a narrow therapeutic index, putting patients at risk of lithium toxicity. Such toxicity could entail neurological-related complications and could be precipitated by several factors. In this paper, the authors discuss a case of a middle-aged woman taking lithium for bipolar disorder who presented to the emergency department with altered mental status, tremors, generalized weakness, and dysarthria. Multiple differential diagnoses were considered during her hospitalization, which included an admission to the intensive care unit. This case highlights the variability of lithium toxicity presentations and its management challenges. Further research is needed to understand such manifestations, potential precipitating factors, differential diagnoses, and effective detection and management.

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Unrecognized acute lithium toxicity: a case report

Cited by 4 publications

References 19 publications

When numbers can be misleading: lithium induced irreversible neurotoxicity at therapeutic drug levels

When numbers can be misleading: lithium induced irreversible neurotoxicity at therapeutic drug levels

Lithium Intoxication in an Elderly Woman

Challenges in the Clinical Diagnosis of Lithium Toxicity: A Case Report

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