Lithium's Disguise as a Wolf in Sheep's Clothing Mimicking Undifferentiated Shock

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

Chest

Abstract

INTRODUCTION: Lithium toxicity typically presents with neurological manifestations, ranging from mild confusion to severe encephalopathy. We present an unusual case of lithium toxicity manifesting with undifferentiated shock and acute encephalopathy in a patient with concurrent influenza A infection. CASE PRESENTATION: A 24-year-old man with schizoaffective disorder on multiple psychiatric medications presented with acute encephalopathy. Two days prior, he exhibited confused behavior, spatial disorientation, cough, and rhinorrhea. Initial examination revealed hypothermia (35.9◦C), tachycardia (130s beats per minute), and hypertension (150/80 mmHg). Laboratory studies showed leukocytosis and acute kidney injury (creatinine: 2.49 mg/dL). CT pulmonary angiography revealed three distinct solid densities in the right lower lobe concerning for septic emboli or cavitary pneumonia. Head CT showed no acute intracranial process. Electrocardiogram showed sinus tachycardia with an incomplete right bundle branch block. Transthoracic echocardiogram showed normal left ventricular ejection fraction (65%) without evidence of vegetation or paravalvular abscess. The patient's condition deteriorated, requiring intubation and vasopressor support. Extensive workup included peripheral blood cultures, lumbar puncture, and bronchoscopy with bronchoalveolar lavage of the right lower lobe. Respiratory viral panel was positive for influenza A. Despite broad-spectrum antimicrobials, he developed myoclonus and increased muscle tone. Cerebrospinal fluid analysis and continuous electroencephalogram were unremarkable. It was later discovered that the patient had been receiving lithium therapy for his schizoaffective disorder. Serum levels were obtained and found to be elevated at 1.99 mmol/L. Urgent hemodialysis was initiated. The patient showed marked improvement after one session of hemodialysis, with normalization of lithium levels and resolution of shock, though encephalopathy persisted during his hospitalization. DISCUSSION: This case merits reporting for its unique clinical presentation of lithium toxicity. Lithium is used for mood stabilization in bipolar disorder and schizoaffective disorder, with therapeutic serum levels typically ranging from 0.8 to 1.2 mmol/L. Levels above 1.5 mmol/L are associated with toxicity, which can manifest as neurological symptoms as seen in this patient. While lithium has been associated with nephrogenic diabetes insipidus and volume depletion, the rapid hemodynamic decline seen here suggests additional factors, possibly including an inflammatory response exacerbated by influenza A. Although extracorporeal removal is generally reserved for severe cases, the marked clinical improvement following hemodialysis supports its role in the management of lithium toxicity with multisystem involvement. Another significant aspect of this case is the persistence of neurological dysfunction despite normalization of lithium levels, raising concerns for the syndrome of irreversible lithium-effectuated neurotoxicity (SILENT). This phenomenon highlights the necessity for close neurological monitoring beyond lithium clearance, as delayed recovery or irreversible damage can occur. CONCLUSIONS: From a clinical perspective, this case emphasizes two critical points. First, acute on chronic lithium toxicity should be considered in the differential diagnosis of undifferentiated shock, particularly in patients on chronic lithium therapy. Second, Clinicians must remain vigilant for signs of toxicity, particularly in the context of renal impairment, and be prepared to initiate prompt treatment to mitigate the risk of severe neurological complications. This case reinforces the importance of early recognition and intervention in lithium toxicity, particularly in the setting of concurrent infection and renal impairment.

Volume

168

Issue

4S

First Page

2491A

Comments

American College of Chest Physicians CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

Last Page

2492A

DOI

10.1016/j.chest.2025.07.1438

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