title: Cutaneous adverse reaction during lithium treatment: a case report and updated systematic review with meta-analysis.
abstract: OBJECTIVE
  To present a new case of adverse cutaneous reaction during lithium treatment and to update the systematic review and meta-analysis of the incidence of this adverse reaction.
  
  
  METHODS
  We conducted a systematic search (performed in September 2016) for peer-reviewed articles in English indexed in Medline (2011-present). Meta-analytical estimates were obtained using the "Metafor" package.
  
  
  METHODS
  Ms. H., a 31-year-old Caucasian woman with BD1, was admitted to the inpatient unit for a full-blown psychotic episode and treated with carbamazepine 400 mg q.d., lithium carbonate 450 mg q.d., and risperidone 4 mg q.d. with clinical improvement. After 12 days from the start of psychopharmacological treatment, she manifested a cutaneous reaction that motivated the stop of carbamazepine treatment, as well as the increase in lithium carbonate dose (750 mg q.d.). Risperidone dose remained unvaried. Since the skin lesion persisted after 8 days from withdrawal of carbamazepine, the private practitioner stopped also lithium carbonate treatment (de-challenge), maintaining risperidone treatment. The cutaneous reaction resolved spontaneously after six days from withdrawal of lithium carbonate. Subsequently, the worsening of psychopathological conditions motivated a new admission during which lithium carbonate was reintroduced (16 days after its suspension) (re-challenge). On the following day, we observed an itching erythematous maculopapular rash involving the trunk, the four limbs, and the oral mucosa.
  
  
  CONCLUSIONS
  Our case of an erythematous maculopapular rash during lithium treatment was the first to present a challenge-de-challenge-re-challenge sequence that suggests causality. Although meta-analysis does not point to an increased rate of adverse skin reaction during lithium treatment, clinicians should not neglect to monitor cutaneous symptoms during lithium treatment.
authors.affiliation: Psychiatry Unit, San Martino Hospital-Regional Health Agency, Oristano, Sardinia, Italy.
authors.forename: Martina
authors.initials: M
authors.lastname: Pinna
authors.affiliation: Section of Psychiatry, Department of Medical Science and Public Health, University of Cagliari, Via Liguria, 13, 09127, Cagliari, Sardinia, Italy. mirkomanchia@unica.it.|Department of Pharmacology, Dalhousie University, Halifax, NS, Canada. mirkomanchia@unica.it.
authors.forename: Mirko
authors.identifier: http://orcid.org/0000-0003-4175-6413
authors.initials: M
authors.lastname: Manchia
authors.affiliation: Regional Health Agency, National Health System, Oristano, Sardinia, Italy.
authors.forename: Sergio
authors.initials: S
authors.lastname: Puddu
authors.affiliation: Psychiatry Unit, San Martino Hospital-Regional Health Agency, Oristano, Sardinia, Italy.
authors.forename: Giampaolo
authors.initials: G
authors.lastname: Minnai
authors.affiliation: Department of Psychiatry, Harvard Medical School, Boston, MA, USA.|The International Consortium for Mood & Psychotic Disorders Research, McLean Hospital, Belmont, MA, USA.|Lucio Bini Mood Disorders Centers, Cagliari and Rome, Italy.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Tondo
authors.affiliation: Psychiatry Unit, San Martino Hospital-Regional Health Agency, Oristano, Sardinia, Italy.
authors.forename: Piergiorgio
authors.initials: P
authors.lastname: Salis
keywords: Bipolar disorder; Long-term treatment; Skin disorders