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A cautionary note when using zonisamide in youths: a case report of association with toxic epidermal necrolysis.

Case report. Ms. A, a 16-year-old white female with bipolar disorder, complained to her psychiatrist about weight gain during valproic acid and quetiapine treatment. Although she was psychiatrically stable, valproic acid was replaced with zonisamide in May 2003. The patient did not have a personal history of sulfonamide allergy and took no other medications. Her father had no drug allergies, and her mother reported being allergic to paroxetine and sulfa drugs. After 2 weeks of zonisamide treatment, several “fever blisters” appeared on Ms. A’s upper chest and zonisamide was stopped. However, a bright, erythematous rash soon covered her chest, back, and buttocks and extended onto her upper extremities bilaterally. The rash reddened and became painful, and on the third day bullae rapidly formed, causing large sheets of epidermis to be lost. Ms. A was admitted to an intensive care unit for fluid resuscitation, IV access, and management. Her temperature ranged from 39.0°C to 40.0°C (102°F to 104°F), and her white blood cell count reached a high of 15.3 × 10/μL, while her blood cultures remained negative. A biopsy taken within 36 hours of bullae formation showed extensive basal cell necrosis. In addition to extensive mucosal membrane involvement, she lost epidermis over an estimated 51% to 60% of her total body surface area. A diagnosis of toxic epidermal necrolysis was made. By the end of the second week of hospitalization, she was able to take food and medicine orally. Treatment with quetiapine and valproic acid was restarted, and she was discharged home.