A Case Report on an Atypical Presentation of the Syndrome ofIrreversible Lithium-Effectuated Neurotoxicity (SILENT) in a WarVeteran with Bipolar Disorder and PTSD

Lithium is still thefirst-line agent for bipolar disorder. Despite common knowledge on monitoring lithium levels toprevent toxicity, it still occurs at varying degrees. Here we present a rare sequela of lithium toxicity, the Syndrome of IrreversibleLithium-Effectuated Neurotoxicity (SILENT).Case Presentation. A 56-year-old male war veteran who is fully functional despitebeing on chronic lithium therapy for Posttraumatic Stress Disorder (PTSD) and bipolar disorder presented at the emergencyroom with altered mental status and seizures associated with elevated lithium levels and renal insufficiency. Antiepileptic drugswere given for seizure control, and intermittent hemodialysis was done to clear the lithium. Despite clearance of the offendingagent, the patient remained to have a generalized slowing on repeated EEG with only eye opening and nonpurposeful limbmovements regained even after more than 2 months of lithium cessation.Conclusion. SILENT has been coined after reports ofpersistent neurologic deficits were seen in patients who experienced lithium toxicity more than 2 months after cessation oflithium. Chronic lithium therapy predisposes to gradual accumulation of lithium in the brain. Demyelination is the typicallyreported feature of SILENT. It can also leave the patient in a persistent encephalopathic state. Chronic lithium toxicity fromfailure of monitoring puts patients on lithium therapy at risk.