Parathyroid/Bone Disorders
Junting Liu, MB
University of Cincinnati College of Medicine
Cincinnati, Ohio, United States
A 62-year-old female with a past medical history of bipolar disorder requiring intermittent lithium use since 2010 was hospitalized after a fall.
Upon admission, the patient's laboratory results indicated hypercalcemia at 11.5 mg/dL (8.7-10.7 mg/dL). Other results included the following: albumin 4.3 g/dL (3.5-5.7 g/dL), TSH 1.28 uIU/mL (0.45-4.12 uIU/mL), and lithium level 1.3 mmol/L (0.6-1.2 mmol/L). Further testing revealed an increased PTH level of 150 pg/mL (12-88 pg/mL), and an unremarkable 25-hydroxy vitamin D level of 47.9 ng/mL (30-100 ng/mL).
On hospital day 9, the patient exhibited neurologic symptoms and signs indicative of catatonia, including moaning, unresponsiveness to verbal queries, gegenhalten, grasp reflex, and waxy flexibility in the left upper extremity. This coincided with a peak albumin-corrected serum calcium level of 12.1 mg/dL. Despite treatment with Ativan and electroconvulsive therapy (ECT), her condition did not improve.
On day 31, an Endocrinology consultation was sought. In addition to hydration, lithium was discontinued, and IV zoledronic acid was administered on day 33. Subsequently, her calcium level decreased to 9.4 mg/dL. By day 36, she showed significant clinical improvement, displaying appropriate verbal responses and increased movement. She was discharged to a skilled nursing facility, with plans for an outpatient surgical evaluation for possible parathyroidectomy.
Hypercalcemia and hyperparathyroidism are well-recognized complications of lithium therapy. While many patients with lithium-associated hyperparathyroidism remain asymptomatic, some may exhibit symptoms like fatigue(47%), constipation(20%), nephrolithiasis(13%), bone pain(13%) and abdominal pain(7%).3 Severe cases may present with catatonia, although few case reports document this association.6,7,8
This case highlights a patient who developed hypercalcemia and hyperparathyroidism due to lithium use, subsequently experiencing catatonia with only moderate levels of hypercalcemia. Despite treatment involving Ativan and ECT, her catatonia persisted for over 3 weeks until normalization of her serum calcium level, indicating a potential link between lithium-induced hyperparathyroidism and catatonia. Managing lithium-induced hyperparathyroidism is an important consideration in patients presenting with catatonia.