Can treatment with lithium cause ataxia, nystagmus, diplopia and pulmonary infiltrate?/nA 25-year-o

Fråga: Can treatment with lithium cause ataxia, nystagmus, diplopia and pulmonary infiltrate? A 25-year-old manic-depressive woman with mitral insufficiency is treated with lithium since December 1996. The patient was admitted to the hospital in June 1997 due to ataxia, nystagmus, diplopia, increased thirst and difficulties in breathing. MRT of the brain showed unspecific changes in the pons and brain stem. Pulmonary x-ray showed changes consistent with infiltrate or oedema. At admittance the serum concentration of lithium was 0.87 mmol per liter (normal range 0.5 to 0.8 mmol per liter). The time for the latest dose intake and for the test is unknown. The treatment was discontinued on July 11.

Sammanfattning: Thirst and neurological symptoms such as ataxia, nystagmus and blurred vision are known to be concentration dependent, reversible adverse reactions in treatment with lithium. A concomitant explanation to the neurological symptoms could have been the emboli from the heart. In this case the serum concentration was slightly above the recommended range but could have been higher since the time for latest dose intake and blood test is unknown.

No information concerning pulmonary infiltrate or pulmonary oedema was found making the connection less probable. The heart failure is a more likely explanation.

Svar: Most side effects of lithium are reversible and more pronounced at higher doses, and serum levels above the recommended therapeutic interval (1). Central nervous adverse reactions such as ataxia are known (1). A case report described ataxia and dysarthria in a man treated with lithium when the serum lithium levels were within therapeutic range 0.7-0.9 mmol per liter 12 to 16 hours after dose and the symptoms gradually resolved during the next ten days after discontinued treatment (2). The drug information centre has received two questions concerning eye disorders and lithium treatment (3,4). Nystagmus and blurred vision may occur in patients treated with lithium but commonly when the serum concentration is above 2 mmol per liter (5).

Thirst is a common adverse reaction in treatment with lithium (6). Concerning pulmonary infiltrate the question has been answered before, but no information has been found about an association between pulmonary infiltrate and lithium therapy (7).

An updated search on Medline and pharmacological handbooks has not revealed any information concerning pulmonary infiltrate or oedema related to treatment with lithium.

Later on endocarditis was diagnosed and valvular surgery was perfomed. It was suspected that emboli were causally related to the neurological symptoms. The neurological symptoms have now resolved.

The suspected pulmonary change could be explained by oedema due to the heart failure, combined with large intake of water due to the increased thirst.