SHM Converge Scientific Abstract ePoster Gallery-Lithium Toxicity Induced Posterior Reversible Encephalopathy Syndorme

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This case report describes a rare instance of posterior reversible encephalopathy syndrome (PRES) caused by lithium toxicity. PRES is a neurologic condition marked by encephalopathy and imaging findings consistent with vasogenic edema, and it is most commonly linked to severe hypertension, though other triggers include sepsis, eclampsia, immunosuppressants, renal failure, and toxins.<br /><br />The patient was a 47-year-old woman with bipolar disorder who presented to the emergency department with dizziness and altered mental status. Initial labs showed significant lithium toxicity with a level of 3.7 and acute kidney injury with creatinine of 4.58. She was treated with aggressive IV hydration, and both lithium and renal function improved rapidly over the first 48 hours.<br /><br />Despite improvement in laboratory values, she developed worsening encephalopathy on hospital day 2, progressing to a nonverbal state with catatonic features affecting her upper extremities. Her vital signs, including blood pressure, remained normal. Neurologic examination showed extensor posturing, mild tremor, and nonpurposeful hip flexion. MRI findings showed increased T2 and FLAIR signal changes, concerning for PRES.<br /><br />She was transferred to the neuro ICU, where she underwent elective intubation and dialysis. After this intervention, her encephalopathy and catatonia resolved quickly. She was ultimately discharged to an inpatient psychiatric facility.<br /><br />The discussion highlights that PRES pathophysiology is not fully understood, but leading theories involve hypertension-related hyperperfusion and toxin-induced endothelial injury. Lithium-induced PRES is rare, and reported cases often occur after lithium has been stopped and are associated with normal labs and new hypertension. Proposed mechanisms include VEGF-mediated endothelial dysfunction and ADH-related cerebral edema. Management focuses on treating the underlying cause, controlling blood pressure if elevated, and using antiepileptics when needed, but no specific guidelines exist for lithium-induced PRES.

Asset Subtitle

Elizabeth Klingensmith

Meta Tag

Author List Elizabeth Klingensmith, Justin Nichols, Shahmir Naveed

Category Clinical Vignettes

Concept Posterior Reversible Encephalopathy Syndrome

Concept Vasogenic Edema

Concept Lithium Toxicity

Concept Endothelial Dysfunction

Concept Cerebral Edema

Distinguished Non-Finalist

Presenter Organization Sidney Kimmel Medical College

Presenting Author Elizabeth Klingensmith

Track Adult

Keywords

posterior reversible encephalopathy syndrome

PRES

lithium toxicity

encephalopathy

vasogenic edema

acute kidney injury

MRI T2 FLAIR

catatonia

dialysis

bipolar disorder

Posterior Reversible Encephalopathy Syndrome

Vasogenic Edema

Lithium Toxicity

Endothelial Dysfunction

Cerebral Edema