Delirious mania is a life-threatening condition, presenting with symptoms of acute delirium and psychotic mania as a complication of medical or psychiatric condition. It is not recognized as a diagnosis in DSM-V and is under recognized in clinical practice. It was first described by Calmeil (Calmeil, 1832). In 1849 Luther Bell described 40 cases with an associated 75% mortality rate. More recently, Jacobowski et al (2013) compiled a comprehensive review of clinical characteristics, diagnostic work up, and treatment recommendations for delirious mania. In addition to acute onset, clinical course is frequently worsened by psychosis and catatonia. Delirium leads to disequilibrium of neurotransmitters, particularly depletion of acetylcholine and elevation of dopamine.Lithium has been used for the treatment of mania for many decades. Suppes et al performed a meta-analysis of 14 studies including 257 patients with Bipolar I disorder and concluded that patients relapsed 28 times more when stopping lithium compared to those who continued this medication. Baldessarini et al (1999) completed analysis of 227 patients with Bipolar I and II disorders, dividing the sample into “abrupt” (1-14 days) and “gradual” (15-30 days) discontinuation groups and concluded that the frequency of relapse following “abrupt” cessation was four times higher compared to following “gradual” cessation. In a study of 450 bipolar patients, Baldessarini et al (2003) reviewed the long-term treatment of lithium as monotherapy (86 % of the study’s population) in the context of lithium maintenance population morbidity. Greater pretreatment morbidity lead to larger relative reduction in morbidity as a result of treatment with lithium. A subgroup of bipolar patients with “abrupt” discontinuation became refractory when re-challenged with lithium.Describing three clinical cases of delirious mania following conclusions can be derived:•Patients with bipolar disorder and comorbid chronic kidney injury currently or formerly receiving long-term therapy with lithium are at increased risk for delirious mania.•Abrupt lithium discontinuation in patients with bipolar disorder and comorbid chronic medical conditions (especially chronic kidney disease) increases risk for mania refractory to conventional treatment with medications.•In such patients, definitive treatment is ECT.