11 Apr 2021

3/3/21: Lithium Toxicity

PGY2 Michelle Lin presented a case of a 69 year old male with history of bipolar disorder/schizophrenia, HTN and DM who presents from jail with altered mental status.  The day prior to admission, patient as noted to have a small contusion on his forehead, and noted to be mildly altered.  On morning of admission, patient found to be only A&Ox1 and was not able to provide further history.

Home Medications: Amldipine 5mg qday, Benztropine 1mg BID, HCTZ 12.5mg qday, Lisinopril 10mg qday, Lithium 600mg qHS, Olanzapine 30mg qday, Simvastatin 10mg qday, Glargine 12U qHS, lispro TID, Trazodone 100mg qHS

SH: Incarcerated.

Vitals: T 33.8, HR 85, RR 17, BP 112/64,O2 sat 96% on RA

Physical Exam significant for non-toxic appearing male, in no acute distress, A&Ox1 (name only), speech entirely incoherent, normal cardiac and pulmonary exam, +tender to L abdominal side, dysarthric, not following commands, 3+ patellar reflexes, negative Babinski, no clonus.

CBC: WBC 10.3> Hb 14/Hct 40.5 <Plt 213 (MCV 93.9, RDW 14.1%)

CMP:

Na 135/K 5.2/Cl 104/HCO3 22/BUN 63/Cr 2.14<Glucose 237 (Baseline Cr: 1.09)

ALP 83>T.protein 7.1/Albumin 4.5/AST 34/ALT 28/Tbili 1.1/Dbili 0.3

Ca 10.3, Mg 2.5, Phos 3.2

Coags: PT 14.8, INR 1.17

Infectious workup initiated and was negative (BCx, UA, UCx, COVID, HIV, Hepatitis Panel, RPR).

CTH done without any focal mass effect, midline shift or basal cistern effacement or acute intracranial hemorrhage.

Toxicology workup initiated and urine tox, negative ETOH, neg aspirin level, neg Tylenol level and negative volatile panel.

Lithium Level checked and was elevated at 2.08 mmol/L (normal 0.5-1.2).

Treatment: Renal was consulted for concern of lithium toxicity after found to have elevated lithium levels.  EEG showed diffuse slowing.  He was started on IVF and mental status improved by hospital day 8 for discharge.

Teaching points:

  1. Lithium Toxicity
    • Acute: Nausea, vomiting, diarrhea with neurologic symptoms presenting later
    • Chronic: neurologic findings such as ataxia, confusion, agitation, encephalopathy and seizures
    • Other complications: nephrogenic DI
    • Treatment: mostly supportive with IV hydration.  HD if lithium level >5 (or >4 in renal impairment), significant encephalopathy, life threatening complications, unable to handle aggressive fluids

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