Not Quite Textbook II

This is the conclusion of the case from the previous post (scroll down). As one of the readers pointed out, this is lithium toxicity. Indeed, the patient had been tried on multiple agents, but lithium was the only one that controlled his bipolar disease without side effects. The patient's lithium level on admission was 3, and it is unclear why he was toxic (he had been managed without difficulty for ten years). Due to the severe bradycardia, we actually called renal who came in to dialyze him urgently. After several rounds of dialysis, his symptoms began improving.

Interestingly, the patient did not have the classic gastrointestinal symptoms of lithium poisoning. Often, this presents with nausea, vomiting, and diarrhea which can lead to dehydration, worsening renal function, and impaired lithium excretion. He did say that his oral intake was decreased over the last few weeks, which may have contributed to the overall picture. He did have the classic symptoms of bradycardia, ataxia, confusion, tremors, and hyperreflexia. Interestingly, neurologic findings can persist despite clearance of the drug.

Although the VA is generally considered a great source of "bread and butter" cases, this was one of the more interesting, fascinating, and educational cases I admitted last month.