A Rare Case of Bipolar Affective Disorder with Dextrocardia: A Case Report

INTRODUCTION

Bipolar disorder (BD) is a chronic psychiatric illness characterized by mood dysregulation, with increased prevalence of cardiovascular disease (CVD) due to autonomic imbalance, metabolic disturbances, lifestyle factors, and medication-related risks. Several studies emphasize the under-recognition of CVD risk among BD patients, despite being a major cause of premature mortality.^[1]

Research also shows dysregulation of the autonomic nervous system, increased inflammatory markers, sleep disturbances, and metabolic pathway abnormalities that predispose BD patients to cardiac events. During manic episodes, sympathetic overactivity may exacerbate cardiac strain, while psychotropic medications (e.g., lithium, antipsychotics) may influence conduction and metabolic parameters. The American Heart Association recognizes BD as a condition that increases the risk of early CVD and recommends earlier screening and tighter control of cardiovascular risk factors.^[2]

Dextrocardia is a rare congenital condition where the heart is positioned on the right side of the chest, with its apex pointing rightward. This condition can occur in isolation or alongside other congenital anomalies, such as situs inversus or structural heart defects.^[3]

Case literature shows that visceral transposition conditions, such as situs inversus or dextrocardia, may coexist with neuropsychiatric disorders and present unique diagnostic challenges.^[4]

This case illustrates the cardio-psychiatric interface in a young patient with bipolar affective disorder (BPAD) and coexisting dextrocardia.

CASE REPORT

The patient, an 18-year-old female from Bilha with no prior psychiatric or medical history, was brought by her family with a 20–25-day history of excessive talkativeness, markedly increased activity, irritability, reduced need for sleep, overspending, and grandiosity, suggestive of a manic episode. Over the same period, she also exhibited social disinhibition and anger outbursts. She had no family history of psychiatric disorders and denied substance use, seizures, or head injury. Additionally, for the past 2–3 months, she had experienced intermittent palpitations and mild exertional breathlessness, although without chest pain or syncope.

On admission, she was conscious and cooperative but distractible, with increased psychomotor activity, pressured speech, elated and labile affect, flight of ideas, grandiose ideation, and poor insight. Her young mania rating scale (YMRS) score was 68, consistent with severe mania. Physical examination was largely unremarkable except for a pulse rate of 104/min, and routine laboratory investigations were within normal limits.

Based on the clinical presentation, the diagnosis was established according to the International classification of Diseases -11 (ICD-11) criteria as bipolar type I disorder, current episode manic, with psychotic symptoms. The patient fulfilled ICD-11 criteria for mania, including persistently elevated and irritable mood, increased activity and energy, decreased need for sleep, pressured speech, flight of ideas, grandiosity, psychotic features, and significant impairment necessitating hospitalization.

She was started on treatment for acute mania with lithium carbonate along with antipsychotic therapy. For rapid behavioral control, injectable haloperidol was initiated in standard parenteral doses, and oral quetiapine was started and gradually titrated to 600 mg/day. However, routine ECG monitoring revealed persistent U waves, most prominently in lead augmented vector right (aVR), along with persistent tachycardia (baseline heart rate 110–130/min). Considering the potential of typical antipsychotics such as haloperidol to affect cardiac conduction and repolarization, the injectable antipsychotic was discontinued as a precautionary measure. Following discontinuation, tachycardia gradually improved.

Further evaluation of the electrocardiogram (ECG) abnormalities included a chest X-ray [Figure 1], which demonstrated a right-sided cardiac shadow consistent with dextrocardia with situs inversus. Following this, a repeat ECG using right-sided mirror-image lead placement demonstrated normalization of P-QRS-T morphology and complete disappearance of the previously noted U waves, confirming that the earlier ECG abnormalities were positional artefacts arising from unrecognized dextrocardia rather than pathological conduction changes. Lithium therapy was therefore safely continued.

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Figure 1: Chest X-ray (posteroanterior view) showing dextrocardia with situs inversus, evidenced by right-sided cardiac apex and right-sided gastric bubble indicating reversal of thoracoabdominal organs.

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Over the next two weeks of inpatient management, the patient showed marked clinical improvement, including better sleep, decreased irritability and overactivity, normalization of appetite, reduction in psychotic features, and stabilization of behavior. Her YMRS score reduced from 68 at admission to 17 at discharge, indicating a mild residual manic state.

After stabilization in the psychiatry ward, a cardiology consultation was obtained at the government superspeciality hospital. Cardiac evaluation confirmed dextrocardia without a significant structural abnormality. No immediate intervention was required as per the cardiologist.

At discharge, she was maintained on lithium carbonate (1050 mg/day) and quetiapine (600 mg/day). Lithium therapy was continued after discharge with regular monitoring of serum levels and ECG. At her last follow-up in February 2026, she remained clinically stable on lithium carbonate 900 mg/day along with quetiapine 600 mg/day, with no cardiac complications and sustained symptomatic improvement.

DISCUSSION

This case illustrates the complex interplay between bipolar affective disorder and congenital cardiac malposition, highlighting the importance of integrating cardiovascular assessment into routine psychiatric evaluation. Numerous studies have consistently shown that individuals with bipolar disorder possess a significantly elevated risk for cardiovascular disease, driven by a combination of lifestyle factors, inflammatory activation, metabolic dysregulation, and autonomic nervous system imbalance.^[1] Pathophysiological reviews further emphasize that bipolar mania is associated with heightened sympathetic arousal, increased heart rate, elevated blood pressure, and cardiometabolic disturbances, all of which intensify during acute manic states and render patients more vulnerable to conduction abnormalities and arrhythmias.^[2] Additionally, emotional dysregulation and stress reactivity seen in bipolar disorder may further contribute to cardiovascular strain, as outlined in heart-brain interaction literature describing the bidirectional influence of mood instability and cardiac function.^[5]

The presence of dextrocardia in this patient adds another clinically significant layer. Reports of psychiatric conditions in patients with situs inversus or dextrocardia, although rare, demonstrate that congenital visceral malposition may complicate routine clinical interpretation, particularly ECG morphology, cardiac axis deviation, and physical examination findings. Case literature on schizophrenia associated with situs inversus totalis has described misinterpretation of ECG patterns, the potential for conduction anomalies, and diagnostic challenges that arise when the heart is mirrored in the thorax.^[4] Such cases reinforce the relevance of considering congenital cardiac anomalies when evaluating atypical ECG appearances in psychiatric patients. In the present case, the persistent U waves initially raised concern for lithium-induced cardiac changes; however, the abnormalities were positional artefacts resulting from unrecognized dextrocardia rather than drug toxicity.

Another crucial consideration is the cardiometabolic impact of psychotropic medications. Both mood stabilizers and antipsychotics are known to influence cardiac conduction, prolong QTc intervals, and exacerbate metabolic risk factors, requiring careful selection in patients with underlying cardiac anomalies.^[2] Although lithium remains a first-line treatment for mania, its potential for sinoatrial dysfunction and T-wave changes necessitates caution, particularly in patients where baseline cardiac evaluation is complicated by dextrocardia. Valproate and low-dose atypical antipsychotics are generally considered safer alternatives in such circumstances. Thus, medication choices must be individualized, balancing psychiatric efficacy against cardiologic safety.

In this patient with incidental dextrocardia with situs inversus, no absolute contraindications to mood stabilizers or antipsychotics were identified. However, special precautions were necessary due to initial ECG abnormalities and tachycardia. Injectable haloperidol was discontinued because typical antipsychotics can affect cardiac conduction and prolong the Q wave–T wave (QT) interval, and the abnormal ECG findings initially raised concern for repolarization disturbances. After confirmation that the ECG changes were positional artefacts related to dextrocardia, oral quetiapine was safely continued. Lithium has no specific contraindication in dextrocardia but can rarely cause ECG changes; therefore, periodic ECG and serum lithium level monitoring are advised. Overall, careful cardiac evaluation and appropriate ECG lead placement were essential to ensure safe psychopharmacological management.

Finally, the case underscores the need for a multidisciplinary approach in managing bipolar disorder with cardiac comorbidities. Cardiovascular screening, including ECG, chest imaging, metabolic profiling, and cardiac risk assessment, is strongly recommended across cardiology and psychiatry guidelines.^[5] Lifestyle interventions, monitoring for metabolic syndrome, and ongoing collaboration between psychiatry and cardiology can significantly improve outcomes by detecting early abnormalities, preventing complications, and guiding safe psychotropic use. The improvement observed in this patient after coordinated care reinforces the effectiveness of integrated management strategies.

CONCLUSION

This rare case of bipolar mania with coexisting dextrocardia highlights the critical need for comprehensive cardiovascular evaluation in psychiatric patients before initiating pharmacotherapy. Congenital cardiac anomalies can profoundly influence ECG interpretation, lead placement, and the detection of conduction disturbances, thereby affecting therapeutic decisions. Evidence from cardiovascular and psychiatric literature emphasizes that individuals with bipolar disorder already face heightened cardiac risk due to autonomic, inflammatory, and metabolic factors, making careful monitoring indispensable. Integrating cardiology expertise into psychiatric care—particularly during acute manic episodes—ensures accurate diagnosis, prevents misinterpretation of ECG abnormalities, and guides the safe selection of mood stabilizers and antipsychotics. Multidisciplinary collaboration ultimately enhances patient safety, reduces morbidity, and supports optimal clinical outcomes in complex presentations such as bipolar disorder with dextrocardia.