SHM Converge Scientific Abstract ePoster Gallery-Real-Li? Lithium as a Cause of Prolonged Severe Delirium

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A 67-year-old woman with well-controlled bipolar disorder on chronic lithium presented with six weeks of worsening delirium, severe insomnia, bizarre behavior, labile mood, poor short-term memory, and disorientation. She had multiple recent hospitalizations for presumed urinary tract infection, but her mental status continued to worsen despite antibiotics. She had no fever, focal neurologic deficits, or other clear infectious or metabolic symptoms.<br /><br />On exam, she was severely disoriented, inattentive, tangential, and intermittently agitated. She had hyperreflexia and occasional spontaneous muscle twitching but no evidence of stroke, meningitis, or systemic illness. An extensive evaluation was unrevealing: brain CT and MRI showed only chronic microvascular changes; EEG showed generalized periodic discharges consistent with encephalopathy but no seizures; lumbar puncture was normal; and broad infectious, autoimmune, endocrine, and nutritional testing was negative. Her serum lithium level was 1.4 mmol/L, within the laboratory reference range.<br /><br />Because no other cause was identified, lithium neurotoxicity was suspected. After three weeks of persistent severe delirium, lithium was discontinued. Her mental status improved within two days and completely resolved by hospital day 26. She was discharged to subacute rehabilitation and later recovered to normal mental status at four-month follow-up.<br /><br />The case emphasizes that lithium can cause prolonged delirium even when serum levels are “normal” and that lithium toxicity should remain in the differential diagnosis for unexplained delirium. The main treatment is stopping lithium, with psychiatry involvement to monitor for relapse of mania and to consider an alternative mood stabilizer.

Asset Subtitle

David Goese

Meta Tag

Author List David Goese

Category Clinical Vignettes

Concept Lithium

Concept Delirium

Concept Lithium Neurotoxicity

Concept Lithium Discontinuation

Concept Disorientation

Distinguished Non-Finalist

Presenter Organization Northwestern Memorial Hospital

Presenting Author David Goese

Track Adult

Keywords

lithium neurotoxicity

delirium

bipolar disorder

normal serum lithium

elderly patient

encephalopathy

hyperreflexia

insomnia

disorientation

mood stabilizer

Lithium

Delirium

Lithium Neurotoxicity

Lithium Discontinuation

Disorientation