This report concerns a case of Lithium induced Raynaud’s phenomenon in a 71 year old male with a history of recurrent depressive disorder. His depression was treatment resistant from his first presentation which required admission and subsequent detention under the mental health act as an in-patient. He presented with a nine week history of low mood, anhedonia, agitation, anxiety, sleep disturbance in the context of a recent road traffic accident and financial stressors. He was preoccupied with financial concerns to the point of delusional intensity. He had been commenced on Escitalopram 20mg and Zolpidem 5mg prior to admission. Prior to a trial of Lithium, this patient had multiple trials of antidepressant medication and augmentation with antipsychotics but continued to present as severely depressed. Following various medication trials, a combination of Olanzapine 5mg nocte, Lofepramine 70mg tds and Lithium Carbonate (Priadel) 600mg nocte led to improvement in symptoms.
Development of symptoms of Raynaud’s phenomenon:
During out-patient reviews in subsequent months he was noted to have a deep purplish discoloration on the fingers of his left hand, most markedly on his index finger, which he attributed to the cold (Figs. 1 and 2). There was no evidence of vascular compromise and the notably cold temperature of his hands and fingers was equal bilaterally. He was asymptomatic aside from discoloration. He had no prior history of development of these symptoms. Autoimmune screen was negative. He was a non-smoker and had no other risk factors for Raynaud’s phenomenon such as injury, autoimmune disease, repetitive actions through hobbies or work or chemical exposure. It was noted that Raynaud’s phenomenon has been rarely reported with Lithium and reverses with Lithium discontinuation (FDA, 2011). Discoloration of his fingers resolved on gradual discontinuation of Lithium Carbonate and remained absent when reviewed two months following discontinuation.
Re-trial of Lithium Carbonate:
His mood progressively deteriorated on cessation of Lithium, with low mood, diurnal mood variation, loss of interest and enthusiasm, fatigue, financial ruminations. As a result, Lithium Carbonate (Priadel) was restarted at a dose of 600mg and further augmented with T4. He was readmitted three weeks following recommencement of Lithium and medications were further adjusted during this time. There was no resurgence of Raynaud’s phenomenon during his two month admission. Lithium level was 0.66. He was discharged on the following combination of medications: Agomelatine 25mg nocte, Modafinil 400mg mane, Aripiprazole 15mg nocte, Priadel 600mg nocte, Clomipramine 150mg nocte.
Re-emergence of Raynaud’s phenomenon:
As he remained well, his medications were reduced gradually in a stepwise fashion over the coming years while Lithium was continued at a dose of 600mg. There was no re-emergence of Raynaud’s in the coming two years and he remained well. When reviewed again three years following his second admission he had once again developed purple discolouration of his fingers and his hands were cold to the touch. Signs of Raynaud’s phenomenon remained on subsequent review. Lithium was continued due to his not being troubled by the Raynaud’s side effect, the severity of previous depressive episodes and speed of relapse after weaning off Lithium. He remained well on this combination of medications for a number of years.
Long-term outcomes:
In recent years he sadly developed delirium and cognitive impairment. This became apparent when he developed acute deterioration in mental state and cognitive function following commencement of Midodrine for postural hypotension. At the time of writing he remains resident in a nursing home. He presents as having a mixed form of cognitive impairment with features of Alzheimers and Parkinsons disease dementia. Symptoms of Raynaud’s phenomenon have not re-emerged in recent years despite ongoing treatment with Lithium Carbonate.