A reappraisal of the role of fever in the occurrence of neurological sequelae following lithium intoxication: a systematic review

Syndrome of Irreversible Lithium-Effectuated Neurotoxicity (SILENT): A Preventable Cerebellar Disorder

We report a case study of a 60-year-old man with bipolar disorder on stable lithium treatment who developed severe toxicity while admitted to ICU with sepsis and multiorgan failure. Despite unchanged lithium administration, his serum levels escalated due to renal dysfunction, resulting in lithium toxicity. After regaining consciousness, he exhibited a cerebellar syndrome marked by ataxia, tremor, and scanning speech. MRI revealed cerebellar atrophy. Following discontinuation of lithium and hemodialysis, the patient's symptoms remained static. The patient was diagnosed with syndrome of irreversible lithium-effectuated neurotoxicity (SILENT), a chronic cerebellar disorder characterized by persistent ataxia, nystagmus, and gait abnormalities extending beyond two months post-lithium exposure. The disorder has a predilection for cerebellar and basal ganglia dysfunction. MRI findings include cerebellar gliosis and atrophy and leptomeningeal enhancement. This case report highlights that SILENT is both preventable and permanent, urging heightened awareness among clinicians to facilitate early detection and intervention. Patients on lithium with compromised renal function or fever necessitate vigilant lithium level monitoring, dose adjustment, or cessation, to forestall enduring morbidity. This case emphasizes the significance of recognizing and managing SILENT, particularly in critical care settings, to mitigate long-term cerebellar impairment and optimize patient outcomes.

Risks and benefits of clozapine and lithium co-prescribing: A systematic review and expert recommendations

OBJECTIVES

To identify the risks and benefits of clozapine‑lithium co-prescription.

METHODS

Articles published in English or French were identified with a MEDLINE, Web of Sciences and PsycINFO search, from inception through January 2023, using the term 'clozapine' in combination with 'lithium'. Data were synthesized narratively.

RESULTS

Of the 67 articles included in the review, more than half (n = 38, 56.7 %) were focused on clozapine-related blood dyscrasia. A body of evidence drawn from case reports and retrospective chart studies highlights the potential benefits of lithium prescription for clozapine-related neutropenia, since this strategy may avoid clozapine discontinuation or allow its rechallenge. The most documented adverse drug reactions (ADRs) associated with clozapine‑lithium co-prescription are neurotoxic events, which may be prevented or detected early by clinical, electroencephalographic and therapeutic drug monitoring. Causality assessment cannot be established for other reported ADRs occurring during clozapine‑lithium co-prescription. The benefits of the combined prescription on psychotic and/or mood symptoms are poorly documented.

CONCLUSION

The risks and benefits of clozapine‑lithium co-prescription require further exploration as the combination might significantly contribute to reducing underprescription or premature discontinuation of clozapine.

Warmer water, high light intensity, lithium and microplastics: Dangerous environmental combinations to zooplankton and Global Health?

Nowadays there is a high concern about the combined effects of global warming and emerging environmental contaminants with significant increasing trends of use, such as lithium (Li) and microplastics (MPs), both on wildlife and human health. Therefore, the effects of high light intensity (26,000 lx) or warmer water temperature (25 °C) on the long-term toxicity of Li and mixtures of Li and MPs (Li-MPs mixtures) were investigated using model populations of the freshwater zooplankton species Daphnia magna. Three 21-day bioassays were done in the laboratory at the following water temperatures and light intensities: (i) 20 °C/10830 lx; (ii) 20 °C/26000 lx (high light intensity); (iii) 25 °C/10830 lx (warmer temperature). Based on the 21-day EC50s on reproduction, high light intensity increased the reproductive toxicity of Li and Li-MPs mixtures by ~1.3 fold; warmer temperature increased the toxicity of Li by ~1.2 fold, and the toxicity of Li-MPs mixtures by ~1.4 fold based on the concentration of Li, and by ~2 fold based on the concentrations of MPs. At high light intensity, Li (0.04 mg/L) and Li-MPs mixtures (0.04 Li + 0.09 MPs mg/L) reduced the population fitness by 32 % and 41 %, respectively. Warmer temperature, Li (0.05 mg/L) and Li-MPs mixtures (0.05 Li + 0.09 MPs mg/L) reduced it by 63 % and 71 %, respectively. At warmer temperature or high light intensity, higher concentrations of Li and Li-MPs mixtures lead to population extinction. Based on the population growth rate and using data of bioassays with MPs alone done simultaneously, Li and MPs interactions were antagonistic or synergistic depending on the scenario. High light intensity and chemical stress generally acted synergistically. Warmer temperature and chemical stress always acted synergistically. These findings highlight the threats of long-term exposure to Li and Li-MPs mixtures to freshwater zooplankton and Global Health in a warmer world.

Long-term effects of lithium and lithium-microplastic mixtures on the model species Daphnia magna: Toxicological interactions and implications to 'One Health'

Environmental contamination with lithium (Li) and microplastics (MP) has been steadily increasing and this trend is expected to continue in the future. Many freshwater ecosystems, which are crucial to reach the United Nations Sustainable Development Goals, are particularly vulnerable to Li and MP contamination, and other pressures. The long-term effects of Li, either alone or combined with MP (Li-MP mixtures), were investigated using the freshwater zooplankton micro-crustacean Daphnia magna as model species. In the laboratory, D. magna females were exposed for 21 days to water concentrations of Li (0.02, 0.04, 0.08 mg/L) or Li-MP mixtures (0.02 Li + 0.04 MP, 0.04 Li + 0.09 MP mg/L, 0.08 Li + 0.19 MP mg/L). In the range of concentrations tested, Li and Li-MP mixtures caused parental mortality, and decreased the somatic growth (up to 20% and 40% reduction, respectively) and the reproductive success (up to 93% and 90% reduction, respectively). The 21-day EC₅₀s of Li and Li-MP mixtures on D. magna reproduction were 0.039 mg/L and 0.039 Li + 0.086 MP mg/L, respectively. Under exposure to the highest concentration of Li (0.08 mg/L) and Li-MP mixtures (0.08 Li + 0.19 MP mg/L), the mean of D. magna population growth rate was reduced by 67% and 58%, respectively. Based on the population growth rate and using data from a bioassay testing the same concentrations of MP alone and carried simultaneously, the toxicological interaction between Li and MP was antagonism under exposure to the lowest and the highest concentrations of Li-MP mixtures, and synergism under exposure to the medium concentration of Li-MP mixtures. These findings highlight the need of further investigating the combined effects of contaminants, and the threat of long-term environmental contamination with Li and MP to freshwater zooplankton, biodiversity, ecosystem services and 'One Health'.