Lithium toxicity and neurologic effects: probable neuroleptic malignant syndrome resulting from lithium toxicity

Acute kidney injury induced lithium toxicity with concomitant neuroleptic malignant syndrome

Lithium, despite being an indispensable agent in the treatment of psychiatric disorders, has a narrow therapeutic index and needs to be carefully administered. Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal complication due to central dopaminergic blockade. This case report illustrates the challenges in lithium therapy particularly related to the development of NMS when further risk factors such as polypharmacy and dehydration are present. We report a case of a 50-year-old man with underlying bipolar affective disorder who was previously able to tolerate olanzapine and lithium well, however developed chronic lithium toxicity due to diminished lithium elimination in acute kidney injury following a two-week history of viral acute gastroenteritis. He also developed NMS which could either be triggered independently by olanzapine; lithium toxicity; or attributed by a synergistic combination from lithium and olanzapine which led to an enhanced neurotoxicity in an already unstable dopaminergic pathway. Fluid therapy and supportive care allowed the patient to recover, and he was discharged well with a lower potency neuroleptic with slow dose titration.

Chronic Lithium Toxicity in Old Age Patients Taking Angiotensin Receptor Blocker: A Case Report

Chronic lithium toxicity is a potentially serious side effect on patients taking lithium for a prolonged period with the diagnosis of mood disorders. The toxicity is even higher in patients taking drugs that interfere with the metabolism of lithium like angiotensin receptor blockers and in older patients with reduced kidney function. In this report, we present the case of a 62-year-old woman who presented to the emergency department with symptoms including loose stools, generalised body weakness, slurred speech, coarse hand tremors, and dystonia persisting for fifteen days. She had been under lithium therapy for bipolar type 1 disorder for 15 years before experiencing these symptoms, which emerged shortly after the addition of telmisartan (angiotensinogen receptor blocker) for hypertension.

Keywords

angiotensin receptor blocker; bipolar disorder; case reports; lithium; telmisartan.

Movement disorders in psychiatric patients

The observability of movement gives it advantages when trying to draw connections between brain and mind. Disturbed motor function pervades schizophrenia, though it is difficult now to subtract the effects of antipsychotic treatment. There is evidence from patients never exposed to these drugs that dyskinesia and even parkinsonism are to some degree innate to schizophrenia. Tardive dyskinesia and drug-induced parkinsonism are the most common movement disorders encountered in psychiatric practice. While D2 dopamine receptor blockade is a causative factor, both conditions defy straightforward neurochemical explanation. Balanced against the need to manage schizophrenic symptoms, neither prevention nor treatment is easy. Of all disorders classified as psychiatric, catatonia sits closest to organic neurology on the neuropsychiatric spectrum. Not only does it occur in the setting of unequivocally organic cerebral disease, but the alterations of consciousness it produces have 'organic' qualities even when the cause is psychiatric. No longer considered a subtype of schizophrenia, catatonia is defined by syndromic features based on motor phenomenology. Both severe depression and obsessive-compulsive disorder may be associated with 'soft' extrapyramidal signs that resemble parkinsonian bradykinesia. As functional neuroimaging studies suggest, movement and psychiatric disorders involve the same network connections between the basal ganglia and the cerebral cortex.

Lithium induced reversible Splenial lesion in neuroleptic malignant syndrome like symptoms: two case reports

Background

Lithium is primarily used to treat bipolar disorder and is known to cause several acute neurological complications. Reversible splenial lesions (RSLs) may be evident in antiepileptic drug toxicity or withdrawal, infections, and other phenomena. We report two cases of RSL presenting as neuroleptic malignant syndrome-like symptoms (NMSLS) with lithium associated neurotoxicity.

Case presentation

A 28-year-old woman was admitted after taking increased dosages of lithium for schizophrenia. She experienced generalized tremor, rigidity, dysarthria, high fever, and tachycardia. Symptoms and brain lesion recovered 2 weeks after discontinuation of lithium. The second case involved a 59-year-old woman who was receiving treatment for bipolar disorder since 1988. When lithium was administered for impatience and aggressive behavior, her mental state deteriorated and fever developed, along with generalized tremor in the extremities. Brain magnetic resonance imaging (MRI) in both patients showed a reversible oval-shaped lesion localized to the splenium of the corpus callosum. Both patients were defined as neuroleptic malignant syndrome-like symptoms (NMSLS) based on the DSM-5 diagnostic criteria for neuroleptic malignant syndrome. The suspected etiology of our cases was lithium associated neurotoxicity according to their clinical course and medical information. Our patients fully recovered in 10–14 days after the discontinuation of lithium.

Conclusions

The patients experienced similar clinical courses and had similar radiological findings of RSL. Manifestations in both cases were related to lithium associated neurotoxicity and this should be considered in patients with RSL and NMSLS.

Drug Interactions with Lithium: An Update

Lithium has been used for the management of psychiatric illnesses for over 50 years and it continues to be regarded as a first-line agent for the treatment and prevention of bipolar disorder. Lithium possesses a narrow therapeutic index and comparatively minor alterations in plasma concentrations can have significant clinical sequelae. Several drug classes have been implicated in the development of lithium toxicity over the years, including diuretics and non-steroidal anti-inflammatory compounds, but much of the anecdotal and experimental evidence supporting these interactions is dated, and many newer medications and medication classes have been introduced during the intervening years. This review is intended to provide an update on the accumulated evidence documenting potential interactions with lithium, with a focus on pharmacokinetic insights gained within the last two decades. The clinical relevance and ramifications of these interactions are discussed.

Leukodystrophy Presenting as Hyperactivity and Bipolarity with Uncommon Adverse Drug Reaction

Leukodystrophy is a group of demyelinating neurodegenerative diseases of brain with varied presentation and multiple etiologies. Prognosis is predominantly dismal. Misdiagnosis and wrong treatment are common in this group of rare neurological disorders, especially when it presents with psychiatric symptoms. In this case, importance of neurological and radiological evaluation and need for high diagnostic suspicion in treatment-resistant psychiatric disorders is highlighted.

Neuroleptic malignant syndrome in a patient treated with lithium carbonate and haloperidol

A 39-year-old female with a 20-year history of bipolar disorder was admitted due to a recurrence of a manic episode with psychotic symptoms. She was treated with standard doses of lithium carbonate and clozapine. Three days after admission, she showed aggressive behavior and refused to take her medications so her oral clozapine was switched to intramuscular haloperidol. Three days later she developed a high temperature and exhibited symptoms of neuroleptic malignant syndrome (NMS) including excessive sweating, cramps and tremors in limb muscles, muscle rigidity, and impaired consciousness. The haloperidol and lithium were stopped immediately, symptomatic treatment was provided, and she was administered the dopamine agonist bromocriptine. The NMS symptoms resolved within three days but she continued to have severe psychotic symptoms. She was subsequently re-challenged with valproate and olanzapine but the NMS did not re-occur. After one month of this treatment she recovered and was discharged. Several case histories similar to this one suggest – but do not prove – that individuals concurrently receiving lithium and antipsychotic medications may be at higher risk of developing NMS than those receiving monotherapy with antipsychotic medication.

Neuroleptic Malignant Syndrome: A Review from a Clinically Oriented Perspective

Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening side-effect that can occur in response to treatment with antipsychotic drugs. Symptoms commonly include hyperpyrexia, muscle rigidity, autonomic dysfunction and altered mental status. In the current review we provide an overview on past and current developments in understanding the causes and treatment of NMS. Studies on the epidemiological incidence of NMS are evaluated, and we provide new data from the Canada Vigilance Adverse Reaction Online database to elaborate on drug-specific and antipsychotic drug polypharmacy instances of NMS reported between 1965 and 2012. Established risk factors are summarized with an emphasis on pharmacological and environmental causes. Leading theories about the etiopathology of NMS are discussed, including the potential contribution of the impact of dopamine receptor blockade and musculoskeletal fiber toxicity. A clinical perspective is provided whereby the clinical presentation and phenomenology of NMS is detailed, while the diagnosis of NMS and its differential is expounded. Current therapeutic strategies are outlined and the role for both pharmacological and non-pharmacological treatment strategies in alleviating the symptoms of NMS are discussed.

Neuroleptic malignant syndrome following combination of sertraline and paroxetine: a case report

Neuroleptic malignant syndrome (NMS) is a rarely observed life-threatening medical condition due mostly to antipsychotic use. Additionally, a few case reports have suggested an association between NMS and the use of selective serotonin reuptake inhibitors (SSRIs) alone or in combination with antipsychotics. This case report presents a female patient developing NMS following the use of a combination of sertraline and paroxetine.