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Complete atrioventricular block with diastolic mitral regurgitation due to severe lithium intoxication. A case report
Theodoros Kalpakos1,2, Gaëlle Vermeersch2, Bart Hendriks3
1Department of Cardiology, University Hospital of Brussels (UZB), Brussels, Belgium.
Insights
Severe lithium intoxication can cause complete atrioventricular block. Hemodialysis effectively normalized lithium levels and restored normal heart rhythm in a patient with bradyarrhythmias, highlighting its importance in managing toxicity.
Area of Science:
- Cardiology
- Psychiatry
- Toxicology
Background:
- Lithium is a first-line treatment for bipolar disorder, but has a narrow therapeutic window.
- Cardiac side effects, though uncommon, range from benign changes to life-threatening arrhythmias and conduction abnormalities.
- Complete atrioventricular block with cardiogenic shock is a rare but severe complication of lithium use.
Observation:
- A 79-year-old patient presented with bradyarrhythmias and complete atrioventricular block due to severe lithium intoxication.
- The patient required intensive care, fluid resuscitation, and intermittent hemodialysis.
- Cardiac ultrasound revealed diastolic mitral regurgitation, linked to the atrioventricular block.
Findings:
- Two cycles of hemodialysis normalized lithium blood levels.
- Sinus rhythm was restored within 24 hours post-hemodialysis, with resolution of atrioventricular block.
- The patient experienced a complete recovery.
Implications:
- Lithium intoxication should be considered in patients with cardiac arrhythmias and a history of lithium use.
- Hemodialysis is the primary treatment for severe lithium intoxication.
- Diastolic mitral regurgitation may indicate underlying atrioventricular conduction disturbances.
Background:
Lithium remains the first line therapy for treatment of bipolar disorder and is widely used in psychiatry despite its narrow therapeutic window. Cardiac side effects are uncommon, but when they are present, they can vary from benign repolarization changes to life threatening tachyarrhythmias as well as conduction time abnormalities. In extremely rare cases complete atrioventricular block with cardiogenic shock can be seen.
Methods:
We report the clinical course and outcome of a 79-year-old patient who presented with bradyarrhythmias and a complete atrioventricular block due to severe lithium intoxication. The patient was admitted to ICU where fluid resuscitation and intermittent haemodialysis were performed. Interestingly, the cardiac ultrasound on ICU showed a diastolic mitral regurgitation which was related to the underlying complete atrioventricular block.
Results:
After two cycles of haemodialysis lithium blood levels were normalised and 24 h later sinus rhythm was restored without any signs of atrioventricular block. The patient recovered completely.
Conclusion:
Lithium is widely used for the treatment of bipolar disorder and it can rarely lead to complete atrioventricular block. If the physician encounters a patient with a history of lithium use, who also shows cardiac arrhythmias, then lithium intoxication should always be ruled out. Haemodialysis is the treatment of choice in severe lithium intoxication. Diastolic mitral regurgitation can hint towards underlying atrioventricular conduction disturbances.
