Sir:Ziprasidone is an antipsychotic agent that is generally well tolerated. Allergic responses to ziprasidone have been reported, including immunoglobulin E (IgE)-related pedal edema, 1 lifethreatening hypersensitivity syndrome, 2 and angioedema. 3 We present a report of a patient who developed angioedema upon starting ziprasidone treatment.Case report. Mr A is a 30-year-old man who presented with psychotic symptoms characterized by persecutory delusions over a 6-week period. His diagnosis according to DSM-IV-TR was bipolar I disorder, most recent episode depressed, severe with psychotic features. He had had 2 previous episodes of mania with psychosis that were managed with short-term antipsychotic medication (olanzapine for the first episode and aripiprazole for the second) and maintenance mood stabilizers (lithium and sodium valproate for the second episode) without any adverse effects. Mr A's treating psychiatrist started him on ziprasidone therapy without any other concurrent medication. Prior to treatment with ziprasidone, Mr A had been free of all other prescription and nonprescription medication in the preceding 3 months. He commenced ziprasidone 20 mg twice daily on the first day and had a 40-mg tablet the next morning. Within 6 hours of taking the 40-mg dose, his tongue began to swell and he could not speak clearly. He experienced shortness of breath and was immediately transferred to the hospital by ambulance. Mr A had no past history of asthma, allergic rhinitis, urticaria, food allergies, eczematous dermatitis, or drug-related allergies.On examination, his tongue and lips were swollen, extending up to the jaw line. There was partial obstruction to the airway, and the patient found it difficult to breathe through the mouth. There was no swelling noted of the genitalia, palms, soles, or eyelids. He had tachycardia, mildly elevated blood pressure, and an oxygen saturation of 97%. There was no lymphadenopathy or urticarial lesions, and the findings from systemic examination were normal.The diagnostic impression was that Mr A's presentation possibly represented an anaphylactic reaction to ziprasidone. He was immediately treated with nebulized and intramuscular epinephrine, intravenous hydrocortisone, and promethazine. He responded to these interventions, and within 10 minutes, he was able to talk and breathe without distress. Within 4 hours, the swelling subsided completely, and he could tolerate oral fluids. Apart from a marginal increase in white cell count, the results of blood investigations were otherwise normal. Mr A was discharged from the medical unit after 48 hours and transferred to the psychiatric ward. The medical team advised the patient to continue oral prednisolone for 5 days.The adverse reaction scored 6 on Naranjo and colleagues' Adverse Drug Reaction (ADR) scale, 4 thus implicating ziprasidone as a probable cause for the event. While in the psychiatric unit, Mr A was commenced on amisulpride treatment after a 5-day medication-free period. There was no recurrence of angioedema with amisu...
