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.

Toxicological impacts of excessive lithium on largemouth bass (Micropterus salmoides): Body weight, hepatic lipid accumulation, antioxidant defense and inflammation response

The unreasonably anthropogenic activities make lithium a widespread pollutant in aquatic environment, and this metallic element can enter the food chain to influence humans. Therefore, the study was designed to explore the influence of dietary lithium supplementation on body weight, lipid deposition, antioxidant capacity and inflammation response of largemouth bass. Multivariate statistical analysis confirmed the toxicological impacts of excessive lithium on largemouth bass. Specifically, excessive dietary lithium (≥87.08 mg/kg) significantly elevated weight gain and feed intake of largemouth bass. Meanwhile, overload lithium inclusion aggravated the accumulation of hepatic lipid and serum lithium. Gene expression results showed that lithium inclusion, especially overload lithium, promoted the transcription of lipogenesis related genes, PPARγ, ACC and FAS, inhibited the expression of fatty acid oxidation related genes, PPARα and ACO, and lipolysis related genes, HSL and MGL. Meanwhile, high lithium inclusion caused the oxidative stress, which was partly through the inhibition of Nrf2/Keap1 pathway. Moreover, dietary lithium inclusion significantly depressed the activity of hepatic lysozyme, and promoted the transcription of proinflammation factors, TNF-α, 5-LOX, IL-1β and IL-8, which was suggested to be regulated by the p38 MAPK pathway. Our findings suggested that overload lithium resulted in increased body weight, hepatic lipid deposition, oxidative stress and inflammation response. The results obtained here provided novel insights on the toxicological impacts of excessive lithium on aquatic animals.

Lithium induced, oxidative stress and related damages in testes and heart in male rats: The protective effects of Malva sylvestris extract

Malva sylvestris is widely used in Mediterranean and European traditional medicine and ethnoveterinary for the treatment of various diseases. This study, carried out on male Wistar rats, evaluates the beneficial effects of Malva sylvestris extract upon lithium carbonate-induced damages in testes and heart. For this purpose, Malva sylvestris extract at a dose of 0.2g/kg was orally administrated, followed by 25mg/kg lithium carbonate (intraperitoneal injection, twice daily). Lithium carbonate treatment significantly (p<0.01) decreased the weight of testes, accessory sex organ and heart, sperm count and motility, and serum testosterone level. In addition, exposure to lithium carbonate significantly (p<0.01) increased lipid peroxidation level (LPO) and decreased superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx) activities in testes and heart. Treatment with M. sylvestris extract affords substantial protection in testes and heart by altering all the parameters to near normal levels that were further confirmed by histological examination. The beneficial effect of M. Sylvestris extract in several organs could be attributed to the interaction of antioxidant components, such as complex polysaccharides, as confirmed by phytochemical analysis.

Lithium toxicity in a neonate owing to false elevation of blood lithium levels caused by contamination in a lithium heparin container: case report and review of the literature

Lithium toxicity in a neonate can occur owing to antenatal exposure as a result of maternal treatment for psychiatric illnesses. False elevation of lithium levels has been reported in the paediatric population when the sample was mistakenly collected in a lithium heparin container. A term, male infant was born to a mother who was on lithium treatment for a psychiatric illness. On day 1, the infant was jittery, had a poor suck with difficulties in establishing feeds. Blood taken from the infant approximately 8 hours after birth demonstrated a lithium level of 4.9 mmol/L (adult toxic level w1.5 mmol/L). However, the sample for lithium levels was sent in a lithium heparin container and the probability of false elevation was considered. He was closely monitored in the neonatal intensive care unit and his hydration was optimised with intravenous fluids. Clinically, he remained well and commenced feeding, and his jitteriness had decreased the following day. A repeat blood lithium level, collected in a gel container, was only 0.4 mmol/L. The initially raised lithium level was owing to contamination from the lithium heparin container.

Nonconvulsive status epilepticus and Creutzfeldt-Jakob-like EEG changes in a case of lithium toxicity

We report a case of a 63-year-old lady with bipolar affective disorder on lithium who was brought to our emergency center in a comatose state.

Neurologically, the patient was comatose and had generalized hypotonia and hyporeflexia. Lithium toxicity was considered. Laboratory examinations revealed leukocytosis, normal blood sugar, blood level of lithium was 4.7 mEq/L and she had renal dysfunction. Cerebrospinal fluid examination and cranial computerized tomography were unremarkable. Blood lithium level was 4.7 mEq/L. Hemodialysis was initiated. However, in spite of dialysis and decreasing lithium levels, the patient remained unconscious. A possibility of nonconvulsive status epilepticus was considered; hence, EEG was advised. The EEG demonstrated bihemispheric slowing (4- to 5-Hz theta range) with bilateral periodic triphasic waves of 1- to 2-Hz frequency, similar to the EEG changes seen in Creutzfeldt–Jakob disease.

She was started on lorazepam. Her sensorium improved gradually, which correlated with the decline in blood lithium levels. A normal background alpha rhythm on EEG was ensured prior to discharge. At discharge, clinically, she had recovered completely, with no apparent neurological deficit or cognitive impairment.

This case highlights the importance of therapeutic drug-level monitoring of lithium, especially where toxicity is suspected, and the important role electroencephalography plays in diagnosing NCSE and its management.