0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Letter   |    
Lithium-Treated Mood Disorders, Paroxysmal Rhinorrhea, and Mesial Temporal Lobe Epilepsy
Jon Berner, M.D., Ph.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 1999;11:414-415.
View Author and Article Information

EpilepsyMood DisordersSyndromes Secondary to General Medical Disorders

SIR: We report two cases of carbamazepine-responsive mood disorders that are inferred to be secondary to mesial temporal lobe epilepsy. Paroxysmal rhinorrhea, exacerbated or invoked by lithium use, was prominent in the clinical history.

+

Case Reports

Case 1. A 48-year-old woman was seen for a rapid-cycling bipolar II disorder, which was partially responsive to 2 years of lithium. Lithium was effective in controlling shoplifting and major discrete cycles. Residual problems were mild cycling, anergia, anhedonia, 30-pound weight gain, intense body dysmorphia with occasional bulimia, and poor concentration.

Her full history suggested partial epilepsy. Sensations of or actual postural instability occurred suddenly 1 or 2 times a week and usually lasted 4 to 6 seconds. If standing at the time, she would sit down; however, often these experiences would occur while she was in bed. Nausea attacks, constipation, and unilateral headache were frequent. Along with numerous gaps in her childhood memories, she was frequently troubled by vague and bizarre improbable dreams of sexual abuse by her mother in her childhood. For 10 years she had experienced 3- to 5-second periods when she would read or hear a common word and would be unable to recognize its meaning. Her EEG was reported as abnormal secondary to irregular slowing, sometimes sharply contoured, in the left temporal area. MRI was unremarkable.

Lithium discontinuation immediately led to a reduction in the frequency of a previously unreported, unexplained paroxysmal rhinorrhea. Treatment with carbamazepine (augmented with low-dose valproic acid) has essentially eliminated presenting symptoms over 1 year of follow-up. Occasionally, perhaps monthly, the patient will experience a brief 2- to 3-hour period with rhinorrhea, restlessness, mood elevation, and logorrhea.

Case 2. A 38-year-old male prison inmate was seen for follow-up of chronic depression, refractory to adequate doses of doxepin and nortriptyline. Ten percent of his time was spent in severe but remitting melancholic depressions of a few days' duration. His medical history was significant for atypical chest pain requiring frequent, inconclusive emergency room evaluations.

Lithium, at a blood level of 0.7, resulted in marked mood stability, with one mild brief mania and depression over a 6-month period. Concurrent with lithium use, however, came unpredictable neurological events: sudden attacks of profuse rhinorrhea ("they drown you"), diarrhea, and disequilibrium without dizziness. Ultimately, the patient was found collapsed in his cell. Prior to his collapse, he experienced sensations of nausea and of being unable to initiate breathing, which progressed over a period of 30 minutes. Commands by the guards could, however, initiate voluntary breathing. Hospital cardiac and neurological evaluation (without a surface EEG) was unremarkable.

He has been maintained on carbamazepine, without chest pain or mood disturbance, over a 6-month period.

+

Discussion

Evidence for intermittent rhinorrhea as a manifestation of mesial temporal lobe epilepsy has been accumulating recently, based on observations of nose-wiping behavior during video-monitored ictal events.1,2 Consistent with our experience, lithium clearly has proconvulsive effects in case series of temporal lobe epilepsies.3,4 The hypothesis needing to be examined is whether paroxysmal vasomotor rhinitis, with or without interictal epileptiform discharges on the surface EEG,5 implies the need for anticonvulsant treatment.

Rajan AB, Baker NS, Agostini MA, et al: Seizure lateralization and localization by nose-wiping behavior (abstract). Neurology 1998; 50:A396
 
Leutmezer F, Serles W, Aull S, et al: Post-ictal nose-wiping: a new lateralizing sign in temporal lobe CPS (abstract). Epilepsia 1998; 39:S71
 
Jus A, Villeneuve A, Gautier J, et al: Influence of lithium carbonate on patients with temporal epilepsy. Can Psychiatr Assoc J  1973; 18:77—78
[PubMed]
 
Bell AJ, Cole A, Eccleston D, et al: Lithium neurotoxicity at normal therapeutic levels. Br J Psychiatry  1993; 162:689—692
[CrossRef] | [PubMed]
 
Monroe RR: Episodic behavioral disorders and limbic ictus. Compr Psychiatry  1985; 26:466—479
[CrossRef] | [PubMed]
 
+

References

Rajan AB, Baker NS, Agostini MA, et al: Seizure lateralization and localization by nose-wiping behavior (abstract). Neurology 1998; 50:A396
 
Leutmezer F, Serles W, Aull S, et al: Post-ictal nose-wiping: a new lateralizing sign in temporal lobe CPS (abstract). Epilepsia 1998; 39:S71
 
Jus A, Villeneuve A, Gautier J, et al: Influence of lithium carbonate on patients with temporal epilepsy. Can Psychiatr Assoc J  1973; 18:77—78
[PubMed]
 
Bell AJ, Cole A, Eccleston D, et al: Lithium neurotoxicity at normal therapeutic levels. Br J Psychiatry  1993; 162:689—692
[CrossRef] | [PubMed]
 
Monroe RR: Episodic behavioral disorders and limbic ictus. Compr Psychiatry  1985; 26:466—479
[CrossRef] | [PubMed]
 
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Web of Science® Times Cited: 1

Related Content
Books
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 1.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 62.  >
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 2.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 11.  >
Dulcan's Textbook of Child and Adolescent Psychiatry > Chapter 19.  >
Topic Collections
Psychiatric News
APA Guidelines