Could a combination of symptoms consisting of edema, nausea and erythematous rash be caused by lith

Fråga: Could a combination of symptoms consisting of edema, nausea and erythematous rash be caused by lithium? Could carbamazepine be given instead?

Background: The patient concerned is a 44-year-old woman who was surgically treated for Cushing´s disease, ten years ago. She receives supplementation therapy with Cortone (cortisone) (37.5 mg per day) and Florinef (fludrocortisone) (0.05 mg per day). For many years, she has also been treated with Tofranil (imipramine) (150 mg per day) because of manic-depressive disease. Since September 1995, she´s also being treated with lithium (Litarex). Since the beginning of January 1996, she has had episodes of nausea, vomiting, edematous swelling of the face, lower arms and legs and also an erythematous rash in these areas. Her lithium concentrations were within the normal range (not further specified).

Sammanfattning: Lithium is known to give rise to sodium retention during the initial phase of the therapy. This may lead to pretibial edema, which usually disappears spontaneously. Intermittent episodes of edema of the ankles and feet and to a lesser extent the face has been reported in about 10 per cent of patients on long-term treatment with lithium. No documentation could be found on the specific combination of edema, rash and vomiting caused by lithium. Fluid retention has been reported as a side effect of carbamazepine. The condition of the present patient could well have been caused by lithium even if the supplementation treatment for her adrenal insufficiency may complicate the clinical picture. Carbamazepine could certainly be tried.

Svar: Side effects of lithium therapy, such as nausea, diarrhea, daytime drowsiness, polyuria, polydipsia and weight gain may be common, even in therapeutic dose ranges. Initiating therapy with lithium may give rise to pretibial edema due to temporary retention of sodium. This edema appears within a few days after starting the treatment and usually normalizes spontaneously. The edema also responds to treatment with spironolactone (1). According to a survey on 237 patients on long-term treatment with lithium (2), about 10 per cent of patients reported the development of edema. It was mostly located in the feet and ankles, and more rarely in the face and in most cases, it was intermittent. Seven patients reported skin problems, mostly acne. Only patients who had been given lithium for 6 months or longer were included in the survey, so it did not concern initial side effects. No relationship was observed between the development of edema and factors such as age, sex, duration of lithium treatment, serum lithium concentration, type of lithium preparation or additional therapy. Concerning carbamazepine, hyponatremia, reduced plasma osmolality and water intoxication due to inappropriate secretion of antidiuretic hormone or the potentiation of its effect, are known side-effects of this drug (3). A case report was found of a 42-year-old man who was treated with gradually increasing doses of carbamazepine up to 1.0 g per day (4). After 5 months of treatment, he developed fluid retention, dyspnea, headache and confusion, which responded to treatment with furosemide. According to the authors, this side effect seems more common in the higher dose range.