LITHIUM WITHDRAWAL

Lithium withdrawal induced dystonia Lithium withdrawal induced dystonia - A Case ReportLocation of Work: Author 1 is a MD (Psychiatry) postgraduate, Author 2 is a Senior Resident and Author 3 is Associate Professor at the Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India. S, a 43 year old married male from south India presented with a five year history of insidious onset of forgetfulness personality change and a two year history of an acute right sided hemiparesis. At presentation patient had regressed behaviour and double incontinence. A detailed chronic meningitis workup was normal, besides a marginal VDRL seropositivity for syphilis. A course of crystalline penicillin was given without much improvement. A provisional diagnosis of Dementia NOS was made. Symptomatic treatment was started with haloperidol 7.5mg/day. It had to be stopped as the patient developed parkinsonian symptoms. The extrapyramidal symptoms remitted with a week of therapy with anticholinergics. As mood swings were noted as part of the behavioural disturbances, lithium was started and maintained at a dose of 450 mg, to which patient showed modest improvement in arousal. Later on loxapine was added to the regimen, at 20 mg/d and increased to 30 mg/day. He continued on this combination for four weeks with no untoward incident. After four weeks an attempt was made to decrease lithium to a minimum effective dose, by decreasing it to 300 mg/d. Within a day of decrease, patient developed left sided truncal dystonia. The dystonia did not remit for three days despite injectable promethazine 50mg/d and later oral promethazine 75mg/d. Lithium was restituted to 450 mg/d and concurrently loxapine was decreased to 20mg/d. Patient's dystonia remitted within 24 hours of these changes.