Neurological complication of Lithium toxicity- A case report

Lithium is a potential drug in treating Neuro-psychiatric disorders.Lithium toxicity can present with acute encephalopathy, cerebellar ataxia, tremor, muscle twitches, choreoathetoid movements with other systemic manifestations.we present a case of a 25yr old female a case of schizoaffective disorder on chronic lithium therapy for 10 years presented with vomiting , abdominal pain-20 days, fever -2 days, tremor- all limbs, hyperpigmentation all over the body, urinary incontinence and altered sensorium of 1 day. On admission, pt. awake, not alert, dehydrated, responding for painful stimuli. GCS - 7. No meningeal signs, fundus- N,Rigidity - all 4 limbs. spontaneously moving all limbs, DTR- N, plantar- bil. withdrawal. Pulse-110min, BP- 90)70 mmHg, Temp- 102 deg.F. With this clinical background a DD of Acute CNS infection, Dyselectrolytemia , lithium toxicity and porphyria were considered. On investigation Hb 7.4gms otherwise normal hemogram, s.electrolytes , RFT, LFT, urine routine- all are normal, fever profile cultures- negative , s.cpk 2388UL, Tsh- 6.5mIUL Patient was treated with IV fluids, antipyretics, IV antibiotics.On 3rd day of admission patient sensorium worsened ( GCS-5) with mild renal dysfunction. After analysing the clinical profile , elevated S.CPK , elevated s.creatinine along with background lithium intake for 10 years. We suspected lithium toxicity and proceeded with Serum lithium, which was found to be elevated ( 3.2mmolL). Pt. was taken for hemodialysis for lithium removal. After dialysis there was decline in lithium level and pt. improving. Two days after hemodialysis , pt. sensorium improved , GCS-11, but pt. had pancerebellar features with mild proximal muscle weakness. On follow up after 2 weeks, her cerebellar features were improving, weakness completely improved.