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A Case of Lithium Intoxication With Severe Neurological Findings

Yıl 2023, , 60 - 66, 22.12.2023
https://doi.org/10.33716/bmedj.1283985

Öz

Lithium is used for the treatment of bipolar disorder and some other psychiatric disorders. Due to the narrow therapeutic range, intoxications are common. In this case, chronic lithium intoxication with severe neurological symptoms was discussed in light of the literature. A 72-year-old female patient. The patient had been receiving psychiatric treatment for 7 years with the diagnosis of unipolar depression. In the 6th month of lithium use, she was brought by her relatives with complaints of drowsiness, tremor, muscle twitching, and difficulty walking. On examination, consciousness was confused, there was no cooperation orientation and there was general rigidity, tremor, fasciculations, and ataxic gait. Vital signs; blood pressure 147/92 mmHg, heart rate 69 bpm, SpO2: 94%. The laboratory tests: lithium 2.98 mEq/L, potassium 5.8 mmol/l, sodium 129 mmol/l, creatinine 1.66 mg/dl, urea 166 mg/dl. The patient was transferred to the internal medicine clinic with the diagnosis of lithium intoxication. Lithium treatment was discontinued. On the 7th day, her neurological symptoms improved with supportive treatment, and biochemical parameters returned to normal. A lithium concentration of more than 3.5 mEq/L was defined as severe poisoning. Neurological findings are prominent in severe poisonings. Especially, geriatric population is at greater risk. In our case; age, use of three different groups of diuretics as antihypertensive treatment, and urinary tract infection were defined as factors that predispose to poisoning. In this case, it's emphasized that although the lithium blood level isn't very high, severe neurological symptoms can be seen clinically in the presence of risk factors.

Kaynakça

  • Meltzer E, Steinlauf S. The clinical manifestations of lithium intoxication. Isr Med Assoc J 2002; 4:265-267.
  • Haussmann R, Bauer M. Lithium, thyroid hormones and further augmentation strategies in treatment-resistant depression. In: Treatment-resistant depression, 1st edn. USA: Wiley. 2013. p. 129–57.)( Bschor T. Lithium in the treatment of major depressive disorder. Drugs. 2014;74:855–862.
  • Müller-Oerlinghausen B, Bauer M, Grof P. Commentary on a recent review of lithium toxicity: what are its implications for clinical practice? BMC Med. 2012 Nov 2;10:132.
  • Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. Int J Bipolar Disord. 2015 Dec;3(1):23.
  • Fiaccadori E, Maggiore U, Parenti E, Greco P, Cabassi A. Sustained low-efficiency dialysis (SLED) for acute lithium intoxication. NDT Plus. 2008 Oct;1(5):329-32.
  • Chien SC, Liu KT, Wu YH. Lithium intoxication presenting as altered consciousness and arrhythmia with cardiogenic shock: A case report. Medicine (Baltimore). 2018 Nov;97(45):e13129.
  • Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. Int J Bipolar Disord. 2015 Dec;3(1):23.
  • Haussmann R, Bauer M, von Bonin S, Lewitzka U. Non-fatal lithium intoxication with 5.5 mmol/l serum level. Pharmacopsychiatry. 2015;48(3):121–122.
  • Waring WS, et al. Pattern of lithium exposure predicts poisoning severity: evaluation of referrals to a regional poisons unit. QJM. 2007;100(5):271–276.
  • Timmer RT, Sands JM. Lithium intoxication. J Am Soc Nephrol. 1999;10(3):666–674.
  • Hampton LM, Daubresse M, Chang HY, Alexander GC, Budnitz DS. Emergency department visits by adults for psychiatric medication adverse events. JAMA Psychiatry. 2014;71(9):1006–1014. doi: 10.1001/jamapsychiatry.2014.436
  • Young W. Review of lithium effects on brain and blood. Cell Transpl. 2009;18(9):951–975.
  • Hedya SA, Avula A, Swoboda HD. Lithium Toxicity. [Updated 2022 Jun 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.
  • Boltan DD, Fenves AZ. Effectiveness of normal saline diuresis in treating lithium overdose. Proceedings, Baylor University. Medical Center. 2008;21(3):261-3.
  • Peng J. Case report on lithium intoxication with normal lithium levels. Shanghai Archives of Psychiatry. 2014 Apr;26(2):103-104.
  • Flint A. Ageing as a risk factor for lithium neurotoxicity at therapeutic serum levels. Br J Psychiatry. 1993;163:555–556.
  • Ott M, Stegmayr B, Salander Renberg E, Werneke U. Lithium intoxication: Incidence, clinical course and renal function - a population-based retrospective cohort study. J Psychopharmacol. 2016 Oct;30(10):1008-19.
  • Kirov G. Thyroid disorders in lithum-treated patients. J Affect Disord 1998;50:33
  • Persad E, Forbath N, Merskey H. Hyperthyroidism after treatment with lithium. Can J Psychiatry 1993;38:599.
  • Chow CC, LeeS, Shek CC ve ark. Lithium-associated transient thyrotoxicosis in 4 chinese woman with autoimmune thyroiditis. Aust N Z J Psychiatry 1993;27:246.
  • Lieber I, Ott M, Öhlund L, et al. Lithium-associated hypothyroidism and potential for reversibility after lithium discontinuation: Findings from the LiSIE retrospective cohort study. Journal of Psychopharmacology. 2020;34(3):293-303.
  • Kuman Tunçel O., Akdeniz F., Ozbek, S. S., Kavukcu, G., Kocabaş G. Lityumun Kalsiyum ve Parathormon Düzeyi Üzerine Etkisi: Sağlıklı Kontrollerle Karşılaştırmalı Kesitsel Bir Çalışma. Turkish Journal of Psychiatry. 2019; 30(3).
  • Ozdin S, Sarısoy G. (2013). Lityumun nörolojik yan etkileri . Journal Of Mood Disorders , 3 (3) , 119-27.
  • McKnight RF, Adida M, Budge K, Stockton S, Goodwin GM, Geddes JR. Lithium toxicity profile: A systematic review and metaanalysis. Lancet. 2012;379(9817):721-8.

Ciddi Nörolojik Bulgularla Birlikte Giden Lityum Zehirlenmesi Olgusu

Yıl 2023, , 60 - 66, 22.12.2023
https://doi.org/10.33716/bmedj.1283985

Öz

Lityum, bipolar bozukluğun ve diğer bazı psikiyatrik bozuklukların tedavisinde kullanılır. Dar terapötik aralık nedeniyle, zehirlenmeler yaygındır. Bu olguda ciddi nörolojik semptomlarla seyreden kronik lityum zehirlenmesi literatür ışığında tartışılmıştır. 72 yaşında, evli, eşiyle beraber yaşayan kadın hasta. Hasta unipolar depresyon tanısıyla 7 yıldır psikiyatrik tedavi alıyordu. Lityum kullanımının 6. ayında, halsizlik, uyku hali, vücutta yaygın titremeler, kas seyirmeleri, yürüme güçlüğü nedeniyle ile yakınları tarafından polikliniğe getirildi. Muayenesinde bilinç konfüzeydi, koopere değildi, oryantasyon bozlmuştu, yaygın rijidite, tremor, fasikülasyonlar ve ataksik yürüyüş mevcuttu. Vital bulgularında tansiyon 147/92 mmHg, nabız 69 atım/dakika, SpO2: %94 idi. Kan gazı normaldi. EKG normal sinüs ritminde idi. Kan tetkiklerinde; lityum 2.98 mmol/l, potasyum 5.8 mmol/l, sodyum 129 mmol/l , kreatinin 1.66 mg/dl, üre 166 mg/dl Hasta lityum zehirlenmesi ön tanısı ile dahiliye kliniğine sevk edildi. Lityum tedavisi kesildi. 7. gününde destek tedavisi ile nörolojik semptomları düzelen hastanın biyokimyasal parametreleri normale döndü. Lityum konsantrasyonunun 3.5 mEq/L'den fazla olması şiddetli zehirlenme olarak kabul edilir. Klinikte gastrointestinal, kardiyovasküler, endokrin, nörolojik, renal bulgular görülebilir. Şiddetli zehirlenmelerde nörolojik bulgular ön plana çıkar. Özellikle geriatrik popülasyon daha büyük risk altındadır. Olgumuzda; yaşın ileri olması, antihipertansif tedavi olarak 3 farklı grup diüretik kullanılması ve idrar yolu enfeksiyonunun varlığı zehirlenmeyi kolaylaştıran etkenler olarak tanımlanmıştır. Bu olguda lityum kan düzeyi çok yüksek olmamasına rağmen risk faktörlerinin varlığında şiddetli nörolojik belirtilerin klinikte görülebileceğinin akılda tutulması gerektiği vurgulanmaktadır.

Kaynakça

  • Meltzer E, Steinlauf S. The clinical manifestations of lithium intoxication. Isr Med Assoc J 2002; 4:265-267.
  • Haussmann R, Bauer M. Lithium, thyroid hormones and further augmentation strategies in treatment-resistant depression. In: Treatment-resistant depression, 1st edn. USA: Wiley. 2013. p. 129–57.)( Bschor T. Lithium in the treatment of major depressive disorder. Drugs. 2014;74:855–862.
  • Müller-Oerlinghausen B, Bauer M, Grof P. Commentary on a recent review of lithium toxicity: what are its implications for clinical practice? BMC Med. 2012 Nov 2;10:132.
  • Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. Int J Bipolar Disord. 2015 Dec;3(1):23.
  • Fiaccadori E, Maggiore U, Parenti E, Greco P, Cabassi A. Sustained low-efficiency dialysis (SLED) for acute lithium intoxication. NDT Plus. 2008 Oct;1(5):329-32.
  • Chien SC, Liu KT, Wu YH. Lithium intoxication presenting as altered consciousness and arrhythmia with cardiogenic shock: A case report. Medicine (Baltimore). 2018 Nov;97(45):e13129.
  • Haussmann R, Bauer M, von Bonin S, Grof P, Lewitzka U. Treatment of lithium intoxication: facing the need for evidence. Int J Bipolar Disord. 2015 Dec;3(1):23.
  • Haussmann R, Bauer M, von Bonin S, Lewitzka U. Non-fatal lithium intoxication with 5.5 mmol/l serum level. Pharmacopsychiatry. 2015;48(3):121–122.
  • Waring WS, et al. Pattern of lithium exposure predicts poisoning severity: evaluation of referrals to a regional poisons unit. QJM. 2007;100(5):271–276.
  • Timmer RT, Sands JM. Lithium intoxication. J Am Soc Nephrol. 1999;10(3):666–674.
  • Hampton LM, Daubresse M, Chang HY, Alexander GC, Budnitz DS. Emergency department visits by adults for psychiatric medication adverse events. JAMA Psychiatry. 2014;71(9):1006–1014. doi: 10.1001/jamapsychiatry.2014.436
  • Young W. Review of lithium effects on brain and blood. Cell Transpl. 2009;18(9):951–975.
  • Hedya SA, Avula A, Swoboda HD. Lithium Toxicity. [Updated 2022 Jun 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.
  • Boltan DD, Fenves AZ. Effectiveness of normal saline diuresis in treating lithium overdose. Proceedings, Baylor University. Medical Center. 2008;21(3):261-3.
  • Peng J. Case report on lithium intoxication with normal lithium levels. Shanghai Archives of Psychiatry. 2014 Apr;26(2):103-104.
  • Flint A. Ageing as a risk factor for lithium neurotoxicity at therapeutic serum levels. Br J Psychiatry. 1993;163:555–556.
  • Ott M, Stegmayr B, Salander Renberg E, Werneke U. Lithium intoxication: Incidence, clinical course and renal function - a population-based retrospective cohort study. J Psychopharmacol. 2016 Oct;30(10):1008-19.
  • Kirov G. Thyroid disorders in lithum-treated patients. J Affect Disord 1998;50:33
  • Persad E, Forbath N, Merskey H. Hyperthyroidism after treatment with lithium. Can J Psychiatry 1993;38:599.
  • Chow CC, LeeS, Shek CC ve ark. Lithium-associated transient thyrotoxicosis in 4 chinese woman with autoimmune thyroiditis. Aust N Z J Psychiatry 1993;27:246.
  • Lieber I, Ott M, Öhlund L, et al. Lithium-associated hypothyroidism and potential for reversibility after lithium discontinuation: Findings from the LiSIE retrospective cohort study. Journal of Psychopharmacology. 2020;34(3):293-303.
  • Kuman Tunçel O., Akdeniz F., Ozbek, S. S., Kavukcu, G., Kocabaş G. Lityumun Kalsiyum ve Parathormon Düzeyi Üzerine Etkisi: Sağlıklı Kontrollerle Karşılaştırmalı Kesitsel Bir Çalışma. Turkish Journal of Psychiatry. 2019; 30(3).
  • Ozdin S, Sarısoy G. (2013). Lityumun nörolojik yan etkileri . Journal Of Mood Disorders , 3 (3) , 119-27.
  • McKnight RF, Adida M, Budge K, Stockton S, Goodwin GM, Geddes JR. Lithium toxicity profile: A systematic review and metaanalysis. Lancet. 2012;379(9817):721-8.
Toplam 24 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Konular Klinik Tıp Bilimleri
Bölüm OLGU SUNUMU
Yazarlar

Tuba Tuğ 0000-0002-5689-4280

Merve Şahin Can 0000-0002-4985-5689

Sinan Altunöz 0000-0001-6043-2882

Hayriye Baykan 0000-0002-3288-2269

Erken Görünüm Tarihi 20 Aralık 2023
Yayımlanma Tarihi 22 Aralık 2023
Yayımlandığı Sayı Yıl 2023

Kaynak Göster

APA Tuğ, T., Şahin Can, M., Altunöz, S., Baykan, H. (2023). A Case of Lithium Intoxication With Severe Neurological Findings. Balıkesir Medical Journal, 7(2), 60-66. https://doi.org/10.33716/bmedj.1283985