Clinical Reasoning: Heart to swallow

Abstract

A 55-year-old woman was admitted to our intensive care department after intoxication with lithium. Her medical history was relevant for bipolar disorder for which she received medical treatment with lithium, haloperidol, and citalopram. In the week before admission, she had developed a clinical picture of gastroenteritis with diarrhea and vomiting, which resulted in dehydration and a marked deterioration in kidney function. During the last days before admission, she had become progressively lethargic and had developed dysarthria as well as postural tremors of the extremities. The tremors were coarse and irregular, most clearly present in the hands with a frequency of approximately 8 Hz. At admission, she opened her eyes spontaneously, localized pain, and showed normal verbal responses (E4M5V5). Physical examination showed severe dysarthria, ataxia, and no focal neurologic deficits. Reflexes were normal. Laboratory investigation revealed a de novo elevated creatinine level (220 mmol/L, normal 49-90) corresponding to an estimated glomerular filtration rate of 22 mL/min/1.73 m 2 (normal .60) and a lithium level that was 5.8 mmol/L (target value 0.6-0.8 mmol/L). ECG at admission was normal except for a prolonged QTc interval of 533 milliseconds (normal ,450).Questions for consideration: