Enalapril/lithium overdose
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Arrhythmias and other toxicities: case report A 61-year-old man developed severe arrhythmias due to lithium intoxication. He was also receiving enalapril, which may have contributed to the intoxication. The man was admitted with a 5-day history of progressively decreased consciousness level. He had been receiving lithium 600 mg/day [route not stated] for 5 years for bipolar disorder. accidentally ingested an overdose. He was also receiving enalapril 40 mg/day [route and indication not stated]. On admission, sleepiness, prostration, mental confusion and rigidity of the lower extremities were observed. His general condition was suggestive of lithium intoxication. Physical examination was notable rales in his pulmonary base, a RR of 29 breaths/min, irregular cardiac rhythm, a HR of 130 beats/min and a BP of 80/40mm Hg. Lithium poisoning was strongly suggested as a diagnostic hypothesis and he was transferred to the ICU. Haemodialysis was performed after the man was haemodynamically stable. A serum lithium concentration of 2.9 mmol/L confirmed the initial diagnosis. Mechanical ventilation and dopamine were started the following day due to hypotension and bradycardia. Metabolic encephalopathy developed, and echocardiography revealed left ventricular hypertrophy and left atrial dilation. His creatine kinase-MB fraction (CKMB) and cardiac troponin I levels were elevated. On admission, an ECG showed atrial fibrillation, ST-segment elevation, left ventricular overload and T-wave inversion. The following day, he developed a new event of atrial fibrillation with alternating bradycardia and tachycardia and required electrical cardioversion. He developed ventricular tachycardia and bradyarrhythmia 3 days after admission, which required implantation of a temporary pacemaker. Two days later, his pacemaker was turned off and his serum lithium concentration had decreased to 0.6 mmol/L. A follow-up ECG revealed sinus rhythm and no arrhythmias. He subsequently underwent tracheostomy, but developed haemorrhagic complications 4 days following the procedure. Cardiorespiratory arrest ensued and resuscitation was unsuccessful. Author comment: "[T]he enalapril, a potentially nephrotoxic drug, may have contributed to worsening the intoxication illness observed in this case report." Menegueti M, et al. Severe arrhythmia after lithium intoxication in a patient with bipolar disorder admitted to the intensive care unit. Indian Journal of Critical Care Medicine 16: 109-111, No. 2, Apr-Jun 2012. Available from: URL: http:// 803077866 dx.doi.org/10.4103/0972-5229.99134 - Brazil
0114-9954/10/1422-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
Reactions 6 Oct 2012 No. 1422
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