Blisters of the Skin in Coma Induced by Amitriptyline and Clorazepate Dipotassium

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Abstract
Skin blisters with underlying sweat gland necrosis have been reported in cases of poisoning due to barbiturates, methadone, diazepam, and carbon monoxide.1-4 We describe a patient in whom similar lesions developed after ingesting toxic amounts of amitriptyline hydrochloride and clorazepate dipotassium. Report of a Case A 23-year-old woman was in a comatose condition when admitted to the hospital. Blisters on erythematous bases were present on her right knee and on the medial and dorsal aspects of her left foot. They were 6 cm, 3 cm, and 2 cm in diameter, respectively, Histologic sections of a skin biopsy specimen from a blister margin on the left foot demonstrated an intraepidermal vesicle (Fig 1) with underlying sweat gland necrosis (Fig 2). The urinary amitriptyline level was 11.4 mg/dL (when blood levels of amitriptyline are in the therapeutic range, the urine concentration is usually 7 mg/dL). (Because blood levels of amitriptyline obtained

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