Abstract
Catherine Mackirdy, Hassan Abass, Tauranga, New Zealand:
It is not widely known that lithium has rarely been associated with raised intracranial pressure.
We report the case of a 17-year-old woman who experienced headache over two weeks, mainly occipital area and cervical, with worsening over the previous four days. She described the pain as different to headaches she had experienced in the past. She presented to the Accident and Emergency Department experiencing clumsiness and visual impairment. The pain was not influenced by coughing, sneezing, bending down, or time of day.
The patient had a complex psychiatric history, with several admissions. She was under psychiatric care; lithium had been commenced six and a half weeks previously for affective disorder.
In addition to lithium in the usual therapeutic range, the patient had been taking clozapine 125 mg/day for the last six months. Paroxetine 20 mg/day had been reintroduced two weeks previously. She had taken paroxetine in the past without any adverse effects.
On neurological examination, the Glasgow Coma Scale score was 13/15. Her fundi showed bilateral papilloedema. Visual field examination showed bilateral peripheral loss but no diplopia.
A CT brain scan was normal. A range of blood tests on admission showed a white blood cell count of 11.8 b/L and neutrophil count of 9.44 b/L. On lumbar puncture, the opening pressure was 47. Samples were sent for biochemistry, microbiology and cytology; all returned normal results.
Lithium was discontinued; acetazolamide 25 mg bd was commenced, and there was an uneventful recovery. Raised intracranial pressure in association with lithium has been described on several occasions [1–3].
In this case, the patient was also taking clozapine and paroxetine which were possible contenders for causing the problem. But a literature search did not produce any evidence to incriminate them. The fact that cessation of lithium alone was associated with resolution of the problem suggests that it was the agent responsible.