A Case of Bipolar Affective Disorder and Aspiration Pneumonia

Adults with mental illness are at a higher risk of aspiration pneumonia than the general population. We describe the case of a patient with bipolar affective disorder and two separate episodes of aspiration pneumonia associated with acute mania. We propose that he had multiple predisposing factors, including hyperverbosity, sedative medications, polydipsia (psychogenic and secondary to a comorbidity of diabetes insipidus), and neuroleptic side effects. 1. Background Aspiration pneumonia is often a severe illness. There are multiple predispositions that increase the risk of aspiration, some of which are especially important in mental health patients. To the best of our knowledge, this is the first documented case report of recurrent life-threatening aspiration pneumonia separated in time. 2. Case Presentation We present, with the patient’s consent, the case of a 63-year-old gentleman with longstanding bipolar affective disorder who presented hypomanic and went on to develop life-threatening aspiration pneumonia and nephrogenic diabetes insipidus. He had a long history of bipolar affective disorder extending back 25 years. Other comorbidities include asthma, type 2 diabetes mellitus, hypertension, and chronic kidney disease. In a hospital admission in 2009, he had presented in a state of mania and required rapid tranquilisation. He subsequently suffered from a severe aspiration pneumonia and hypernatraemia, necessitating intensive care treatment, tracheostomy, and PEG feeding due to dysphagia. He has since suffered from a nonspecific muscle weakness, the cause of which remains unclear. He was able to eat normally at home, and the PEG had been removed four months prior to admission. In this informal admission, he presented in a hypomanic state, with hyperverbosity, loud speech, disinhibition, and excessive drinking of milk. The likely trigger for this episode was the change from lithium to lamotrigine (25？mg bd) two months earlier by his community team, due to mildly impaired renal function. The other psychotropic medications on admission were promethazine 25？mg nocte, clonazepam 0.5？mg bd and sodium valproate 1？g bd. His renal function had improved since stopping lithium; eGFR on admission was 53, while other blood tests were unremarkable. Of note, sodium levels were 145？mmoL/L. On the ward, there were episodes of agitation, which were easily managed with verbal deescalation and oral lorazepam. A decision was taken to stop clonazepam, lamotrigine, and promethazine. Due to a long history of different antipsychotics in the past, a trial of asenapine was