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Verdoux H, Debruyne AL, Queuille E, De Leon J. A reappraisal of the role of fever in the occurrence of neurological sequelae following lithium intoxication: a systematic review. Expert Opin Drug Saf 2021; 20:827-838. [PMID: 33789560 DOI: 10.1080/14740338.2021.1912011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION We aimed to review cases of Syndrome of Irreversible Lithium-Effectuated Neurotoxicity (SILENT) characterized by neurological sequelae following acute lithium toxicity and to explore whether cerebellar sequelae are more frequent in cases presenting with fever and/or infection. AREAS COVERED Case reports were identified from: (i) 6 reviews published up to 2005; (ii) MEDLINE, Web of Sciences, Cochrane Library and PsycINFO search. EXPERT OPINION We identified 123 SILENT cases published from 1965 to 2019, in which cerebellar sequelae were observed in an overwhelming proportion (79%). SILENT may occur at any time during lithium treatment. This complication is most frequently observed during routine lithium treatment, with fewer than 10% of cases occurring after accidental or intentional overdoses. SILENT may occur even when lithium plasma levels are within the therapeutic range: 63% of cases had lithium plasma level <2.5 mEq/l (low/mild toxicity). Fever and/or infection were reported in nearly half of the patients (48%). The likelihood of presenting with cerebellar vs. other neurological sequelae was independently increased by elevated plasma lithium level (≥ 2.5 mEq/l) and by a history of fever and/or infection. Lithium users should be warned of the need to consult in case of fever to adjust their lithium dosage.
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Affiliation(s)
- Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, Bordeaux, France.,Centre Hospitalier Charles Perrens, Bordeaux, France
| | | | | | - Jose De Leon
- Mental Health Research Center at Eastern State Hospital, Lexington, KY and Psychiatry and Neurosciences Research Group (CTS-549), USA.,Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences, University of Granada, Granada, Spain.,Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apostol Hospital, University of the Basque Country, Vitoria, Spain
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Nobematsu A, Wakabayashi H, Hanada T, Watanabe N, Tachibana K. Post-acute Rehabilitation for Ataxia Associated with Acute Lithium Toxicity: A Case Report. Prog Rehabil Med 2018; 3:20180010. [PMID: 32789235 DOI: 10.2490/prm.20180010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 04/18/2018] [Indexed: 11/09/2022] Open
Abstract
Background Acute lithium intoxication is associated with neurological manifestations such as tremor, ataxia, dysarthria, seizures, and in more severe cases encephalopathy and coma; patients experiencing such manifestations require rehabilitation. The authors present a patient who received post-acute rehabilitation for lithium toxicity-associated ataxia. Case The patient was a man aged 30 years who had been diagnosed with bipolar disorder more than 10 years ago and had been prescribed lithium carbonate by a psychiatrist. The patient was admitted to the hospital with disturbance of consciousness, and physical therapy began on day 6 of hospitalization. Occupational therapy and speech therapy began on day 15. Physical therapy interventions focused on improving balance and coordination, and occupational therapy focused on improving stability while sitting, upper extremity control, and activities of daily living to improve the Functional Independence Measure motor subscale score. Speech therapy focused on dysarthria. On day 27 of hospitalization, the patient was able to walk 5 m with two Lofstrand crutches and could feed himself without assistance. From day 15 to day 30 of hospitalization, the Scale for the Assessment and Rating of Ataxia score improved from 28 to 19, and the Functional Independence Measure score increased from 25 to 77. On day 31, the patient was discharged to a convalescent rehabilitation hospital. Discussion Post-acute rehabilitation for ataxia caused by acute lithium toxicity may improve ataxia and the ability to perform activities of daily living, and therefore may be of benefit.
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Affiliation(s)
- Ayumi Nobematsu
- Department of Rehabilitation Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Hidetaka Wakabayashi
- Department of Rehabilitation Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Takuya Hanada
- Department of Rehabilitation Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Naoko Watanabe
- Department of Rehabilitation Medicine, Yokohama City University Medical Center, Yokohama, Japan
| | - Kae Tachibana
- Department of Rehabilitation Medicine, Yokohama City University Hospital, Yokohama, Japan
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Mohammad Jafari R, Ghahremani MH, Rahimi N, Shadboorestan A, Rashidian A, Esmaeili J, Ejtemaei Mehr S, Dehpour AR. The anticonvulsant activity and cerebral protection of chronic lithium chloride via NMDA receptor/nitric oxide and phospho-ERK. Brain Res Bull 2018; 137:1-9. [DOI: 10.1016/j.brainresbull.2017.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/30/2017] [Accepted: 10/31/2017] [Indexed: 02/08/2023]
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Rossi FH, Rossi EM, Hoffmann M, Liu W, Cruz RR, Antonovich N, Rezaei A, Gonzalez E, Franco MC, Estevez A, Thomas F. Permanent Cerebellar Degeneration After Acute Hyperthermia with Non-toxic Lithium Levels: a Case Report and Review of Literature. THE CEREBELLUM 2017; 16:973-978. [DOI: 10.1007/s12311-017-0868-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Atypical permanent neurological sequelae after an acute intoxication with lithium and aripiprazole. J Affect Disord 2017; 214:97-99. [PMID: 28288408 DOI: 10.1016/j.jad.2017.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/29/2017] [Accepted: 03/05/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The aim of the present case report was to describe atypical neurological sequelae after a lithium and aripiprazole co-intoxication in a suicide attempt. METHODS We report the case of a 31-year-old patient with bipolar disorder who developed, after lithium and aripiprazole massive ingestion, a severe pseudobulbar dysarthria and motor disorders suggestive of basal ganglia micro lesions. We review literature on neurological sequelae due to acute lithium intoxications. RESULTS Acute lithium intoxication can cause permanent neurological sequelae, the most frequent clinical feature being a permanent cerebellar syndrome. Moreover, the widely-prescribed combination of lithium with antipsychotics increases the neurotoxicity in lithium intoxications. In this case, both atypical neurological syndrome and normal paraclinical investigations lead first to misdiagnose the lithium neurological damages. CONCLUSIONS This case illustrates that acute lithium intoxications can result in serious and potentially permanent neurological deficits, which remain difficult to diagnose. Imaging abnormalities are not constant, and neurological presentation can be atypical.
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Baird-Gunning J, Lea-Henry T, Hoegberg LCG, Gosselin S, Roberts DM. Lithium Poisoning. J Intensive Care Med 2016; 32:249-263. [DOI: 10.1177/0885066616651582] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lithium is a commonly prescribed treatment for bipolar affective disorder. However, treatment is complicated by lithium’s narrow therapeutic index and the influence of kidney function, both of which increase the risk of toxicity. Therefore, careful attention to dosing, monitoring, and titration is required. The cause of lithium poisoning influences treatment and 3 patterns are described: acute, acute-on-chronic, and chronic. Chronic poisoning is the most common etiology, is usually unintentional, and results from lithium intake exceeding elimination. This is most commonly due to impaired kidney function caused by volume depletion from lithium-induced nephrogenic diabetes insipidus or intercurrent illnesses and is also drug-induced. Lithium poisoning can affect multiple organs; however, the primary site of toxicity is the central nervous system and clinical manifestations vary from asymptomatic supratherapeutic drug concentrations to clinical toxicity such as confusion, ataxia, or seizures. Lithium poisoning has a low mortality rate; however, chronic lithium poisoning can require a prolonged hospital length of stay from impaired mobility and cognition and associated nosocomial complications. Persistent neurological deficits, in particular cerebellar, are described and the incidence and risk factors for its development are poorly understood, but it appears to be uncommon in uncomplicated acute poisoning. Lithium is readily dialyzable, and rationale support extracorporeal treatments to reduce the risk or the duration of toxicity in high-risk exposures. There is disagreement in the literature regarding factors that define patients most likely to benefit from treatments that enhance lithium elimination, including specific plasma lithium concentration thresholds. In the case of extracorporeal treatments, there are observational data in its favor, without evidence from randomized controlled trials (none have been performed), which may lead to conservative practices and potentially unnecessary interventions in some circumstances. More data are required to define the risk–benefit of extracorporeal treatments and their use (modality, duration) in the management of lithium poisoning.
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Affiliation(s)
- Jonathan Baird-Gunning
- Department of General Medicine, The Canberra Hospital, Garran, Australian Capital Territory, Australia
- Medical School, Australian National University, Acton, Australian Capital Territory, Australia
| | - Tom Lea-Henry
- Department of Renal Medicine, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Lotte C. G. Hoegberg
- Department of Anesthesiology, Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Sophie Gosselin
- Department of Medicine and Emergency Medicine, McGill University & Health Centre, Montréal, Québec, Canada
- Centre Antipoison du Québec, Québec, Canada
- Province of Alberta Drug Information Service, Calgary, Alberta, Canada
| | - Darren M. Roberts
- Medical School, Australian National University, Acton, Australian Capital Territory, Australia
- Department of Renal Medicine, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
- Drug Health Clinical Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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van Gaalen J, Kerstens FG, Maas RPPWM, Härmark L, van de Warrenburg BPC. Drug-induced cerebellar ataxia: a systematic review. CNS Drugs 2014; 28:1139-53. [PMID: 25391707 DOI: 10.1007/s40263-014-0200-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Cerebellar ataxia can be induced by a large number of drugs. We here conducted a systemic review of the drugs that can lead to cerebellar ataxia as an adverse drug reaction (ADR). METHODS We performed a systematic literature search in Pubmed (1966 to January 2014) and EMBASE (1988 to January 2014) to identify all of the drugs that can have ataxia as an ADR and to assess the frequency of drug-induced ataxia for individual drugs. Furthermore, we collected reports of drug-induced ataxia over the past 20 years in the Netherlands by querying a national register of ADRs. RESULTS Drug-induced ataxia was reported in association with 93 individual drugs (57 from the literature, 36 from the Dutch registry). The most common groups were antiepileptic drugs, benzodiazepines, and antineoplastics. For some, the number needed to harm was below 10. Ataxia was commonly reversible, but persistent symptoms were described with lithium and certain antineoplastics. CONCLUSIONS It is important to be aware of the possibility that ataxia might be drug-induced, and for some drugs the relative frequency of this particular ADR is high. In most patients, symptoms occur within days or weeks after the introduction of a new drug or an increase in dose. In general, ataxia tends to disappear after discontinuation of the drug, but chronic ataxia has been described for some drugs.
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Affiliation(s)
- J van Gaalen
- Department of Neurology 935 and Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands,
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Ivkovic A, Stern TA. Lithium-induced neurotoxicity: clinical presentations, pathophysiology, and treatment. PSYCHOSOMATICS 2013; 55:296-302. [PMID: 24388123 DOI: 10.1016/j.psym.2013.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 11/26/2013] [Accepted: 11/26/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Ana Ivkovic
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Theodore A Stern
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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Heidari Z, Mahmoudzadeh-Sagheb H. Quantitative study of volumetric changes of cerebellum in male adult rat following lithium administration. INTERNATIONAL JOURNAL OF HIGH RISK BEHAVIORS & ADDICTION 2012; 1:66-70. [PMID: 24971235 PMCID: PMC4070107 DOI: 10.5812/ijhrba.4187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 06/09/2012] [Accepted: 06/11/2012] [Indexed: 11/16/2022]
Abstract
Background Lithium is a drug for treatment of bipolar disorder by correcting mania and reducing depressive mood swings. Objectives In this study, effects of Lithium on volumetric parameters of cerebellum were investigated using stereological methods. Materials and Methods In this experimental study, 20 sexually mature wistar male rats were selected and divided in two groups randomly (n = 10). Administration and control groups received continuously 0.1 percent Lithium carbonate solution and distilled water respectively with drinking water during a period of 12 weeks. Rat’s cerebellum excised and fixed in modified Lillie’s solution. Then tissues were dehydrated, cleared, and embedded in paraplast in random orientation, and exhaustively sectioned. Ten to twelve sections of ~ 5μm were sampled and stained from each cerebellum by systematic uniform random sampling. The whole section image projected on the table, and using Cavalier’s principle point-counting was employed to estimate the volumetric parameters. Data analyzed by nonparametric statistical test of Mann-Whitney, and differences between groups less than 0.05 considered significant. Results There were no significant difference in terms of total volume but gray matter volume of cerebellum increased and white matter decreased in administration group significantly (P < 0.05). Conclusions Administration of 0.1% Lithium carbonate for a period of 12 weeks can affect cerebellar gray and white matters in rat.
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Affiliation(s)
- Zahra Heidari
- Department of Histology, School of of Medicine, Zahedan University of Medical Sciences, Zahedan, IR Iran
| | - Hamidreza Mahmoudzadeh-Sagheb
- Department of Histology, School of of Medicine, Zahedan University of Medical Sciences, Zahedan, IR Iran
- Corresponding author: Hamidreza Mahmoudzadeh-Sagheb, Department of Histology, Zahedan University of Medical Sciences, Zahedan, IR Iran. Tel: +98-5413414572, Fax: +98-5413414572, E-mail:
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Ikeda Y, Kameyama M, Narita K, Takei Y, Suda M, Aoyama Y, Yuuki N, Sakurai N, Fukuda M, Mikuni M, Amanuma M. Total and regional brain volume reductions due to the Syndrome of Irreversible Lithium-Effectuated Neurotoxicity (SILENT): a voxel-based morphometric study. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:244-6. [PMID: 19852996 DOI: 10.1016/j.pnpbp.2009.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2009] [Revised: 10/05/2009] [Accepted: 10/13/2009] [Indexed: 11/25/2022]
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