J Korean Med Sci.  2005 Aug;20(4):691-694. 10.3346/jkms.2005.20.4.691.

Delirium and Extrapyramidal Symptoms Due to a Lithium-Olanzapine Combination Therapy: A Case Report

• Tuglu C
• Erdogan E
• Abay E

• KMID: 1712758
• DOI: http://doi.org/10.3346/jkms.2005.20.4.691

Abstract

We report an elderly patient who developed severe delirium and extrapyramidal signs after initiation of lithium-olanzapine combination. On hospital admission, serum levels of lithium were found to be 3.0 mM/L which were far above toxic level. Immediate discontinuation of both drugs resulted in complete resolution of most of the symptoms except for perioral dyskinesia which persisted for three more months. We critically discussed the differential diagnosis of lithium intoxication and assessed confounding factors which induce delirium and extrapyramidal signs related with combination therapy of lithium and olanzapine.

Keyword

Lithium; Drug Toxicity; Antipsychotic Agents; olanzapine; Delirium; Neurologic Manifestations; Neuroleptic

MeSH Terms

Antipsychotic Agents/adverse effects/therapeutic use
Basal Ganglia Diseases/*chemically induced
Benzodiazepines/adverse effects/therapeutic use
Bipolar Disorder/drug therapy
Delirium/*chemically induced
Drug Therapy, Combination
Female
Humans
Lithium/*adverse effects/therapeutic use
Middle Aged

Reference

1. Schou M. Lithium treatment at 52. J Affect Disord. 2001. 67:21–32.

2. Sadosty AT, Groleau GA, Atcherson MM. The use of lithium levels in the emergency department. J Emerg Med. 1999. 17:887–891.

3. Amdisen A. Clinical features and management of lithium poisoning. Med Toxicol Adverse Drug Exp. 1988. 3:18–32.

4. Emilien G, Maloteaux JM. Lithium neurotoxicity at low therapeutic doses. Hypotheses for causes and mechanism of action following a retrospective analysis of published case reports. Acta Neurol Belg. 1996. 96:281–293.

5. Cohen WJ, Cohen NH. Lithium carbonate, haloperidol, and irreversible brain damage. JAMA. 1974. 230:1283–1287.

6. Goldman SA. Lithium and neuroleptics in combination: is there enhancement of neurotoxicity leading to permanent sequelae? J Clin Pharmacol. 1996. 36:951–962.

7. Mani J, Tandel SV, Shah PU, Karnad DR. Prolonged neurological sequelae after combination treatment with lithium and antipsychotic drugs. J Neurol Neurosurg Psychiat. 1996. 60:350–351.

8. Normann C, Brandt C, Berger M, Walden J. Delirium and persistent dyskinesia induced by a lithium-neuroleptic interaction. Pharmacopsychiatry. 1998. 31:201–204.

9. Chen PS, Yang YK, Yeh TL, Lo YC, Wang YT. Nonketotic hyperosmolar syndrome from olanzapine, lithium, and valproic acid cotreatment. Ann Pharmacother. 2003. 37:919–920.

10. Rosebraugh CJ, Flockhart DA, Yasuda SU, Woosley RL. Olanzapine-induced rhabdomyolysis. Ann Pharmacother. 2001. 35:1020–1023.

11. Ghaemi SN, Ko JY. Quetiapine-related tardive dyskinesia. Am J Psychiat. 2001. 158:1737.

12. Bourgeois JA, Kahn DR. Neuroleptic malignant syndrome following administration of risperidone and lithium. J Clin Psychopharmacol. 2003. 23:315–317.

13. Dallocchio C, Mazzarello P. A case of parkinsonism due to lithium intoxication: treatment with pramipexole. J Clin Neurosci. 2002. 9:310–311.

14. Holroyd S, Smith D. Disabling parkinsonism due to lithium: a case report. J Geriatr Psychiat Neurol. 1995. 8:118–119.

15. Prakash R, Kelwala S, Ban TA. Neurotoxicity with combined administration of lithium and a neuroleptic. Compr Psychiatry. 1982. 23:567–571.

16. Engel J, Berggren U. Effects of lithium on behaviour and central monoamines. Acta Psychiatr Scand Suppl. 1980. 280:133–143.

17. Niethammer R, Keller A, Weisbrod M. Delirium syndrome as a side-effect of lithium in normal lithium levels. Psychiatr Prax. 2000. 27:296–297.

18. Omata N, Murata T, Omori M, Wada Y. A patient with lithium intoxication developing at therapeutic serum lithium levels and persistent delirium after discontinuation of its administration. Gen Hosp Psychiat. 2003. 25:53–55.

19. Honig PK, Cantilena LR. Polypharmacy. Pharmacokinetic perspectives. Clin Pharmacokinet. 1994. 26:85–90.

20. Lang EJ, Davis SM. Lithium neurotoxicity: the development of irreversible neurological impairment despite standard monitoring of serum lithium levels. J Clin Neurosci. 2002. 9:308–309.

21. Callaghan JT, Bergstrom RF, Ptak LR, Beasley CM. Olanzapine. Pharmacokinetic and pharmacodynamic profile. Clin Pharmacokinet. 1999. 37:177–193.

22. Prior TI, Chue PS, Tibbo P, Baker GB. Drug metabolism and atypical antipsychotics. Eur Neuropsychopharmacol. 1999. 9:301–309.

23. Wilson DR, D'Souza L, Sarkar N, Newton M, Hammond C. Newonset diabetes and ketoacidosis with atypical antipsychotics. Schizophr Res. 2003. 59:1–6.

24. Selva KA, Scott SM. Diabetic ketoacidosis associated with olanzapine in an adolescent patient. J Pediatr. 2001. 138:936–938.

25. Lindenmayer JP, Patel R. Olanzapine-induced ketoacidosis with diabetes mellitus. Am J Psychiat. 1999. 156:1471.

26. Devinsky O, Bear D, Volpe BT. Confusional states following posterior cerebral artery infarction. Arch Neurol. 1988. 45:160–163.

27. Pearlman CA. Neuroleptic malignant syndrome: a review of the literature. J Clin Psychopharmacol. 1986. 6:257–273.