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A rare case of vertical nystagmus, truncal ataxia and peripheral neuropathy due to lithium intoxication is reported.A 56 year old male had been under treatment for four years with lithium carbonate for a manic psychosis. He ingested 1, 800mg lithium carbonate daily combined with chlorpromazine (150mg/day) and levopromazine (150mg/day). During the first week of admission, he was considerably agitated, and wandered about in the hospital, but during the second week he became much quieter and somnolent. After this he developed muscular rigidity of the cogwheel type and myoclonus-like involuntary movements.All medication was discontinued immediately. The serum lithium level was elevated to 4.6mEg/l. Normal saline solution and lactated Ringer's solution were infused and even though the serum lithium level decreased to 0.9mEq/l, he lasped into coma.Twice every 5 hours hemodyalysis was administered and he regained consciousness after 2 days.He recovered gradually from this episode of intoxication, but still retained neurological and neuro-otological symptoms. He was free from dementia and extrapyramidal symptoms, but neurological examination revealed marked dysarthria, truncal ataxia with mild limb ataxia, vertical nystagmus, diminished deep tendon reflexes of the lower extremities and decreased vibratory sense in the feet as sequelae of the intoxication. On neurotological examination, optokinetic nystagmus was severely suppressed. Eye tracking test revealed saccadic eye movements. Dysrhythmia was evident in the caloric test.Although disturbance of equilibrium (truncal ataxia) is also termed syndrome of the vermis, this case of equilibrium disturbance and vertical nystagmus probably does not involve only a small area of the cerebellum, but also the median portion (the entire vermis).

A Case of Lithium Intoxication with Severe Vertical Downbeat Nystagmus