recurrent hyperkalemia (potassium of 5.4 nmol/L). When informed about her electrolyte disturbance, Ms. A stated that she had eaten one pound of dried figs the previous night. Discussion There are only two case reports of nu- tritional hyperkalemia in patients with- out any predisposing medical condi- tions or medications. In both cases, patients had previously diagnosed psy- chiatric disorder. 3,4 In an adolescent with anorexia nervosa, recurrent hy- perkalemia was caused by obsessive eating of up to 20 bananas per day. 3 In another case, a patient with schizo- phrenia and psychogenic polydipsia was water-restricted but developed hy- perkalemia because she replaced water with excessive consumption of orange juice. 4 Her nurses reported being aware that the patient was drinking or- ange juice, but stated that they fol- lowed the orders to restrict free water. 4 Hyperkalemia in this self-proclaimed healthy volunteer may be a manifestation of an undiagnosed eating disorder. In her medical history self-report, Ms. A marked off binging on food in her early 20s, how- ever this was initially considered to be of no clinical significance and a subsequent psychiatric evaluation did not reveal any current or past eating disorders. Moreover, hypokalemia, not hyperkalemia, is a com- mon electrolyte disturbance associated with eating disorders. This case illustrates the impor- tance of screening for medical and psy- chiatric disorders and is an example of a probable eating disorder presenting as a medical problem. 5 Clinicians should consider bing- ing on potassium-rich foods in physi- cally healthy people who present with otherwise unexplained hyperkalemia. In addition to questioning about med- ications, supplements, and substance use, careful history regarding dietary and eating habits should be obtained. A possibility of disordered eating should be entertained even if the his- tory is negative. Given today’s preoc- cupation with healthy eating, readers should be aware that even healthy foods may be harmful if consumed in excessive quantities. Adriana J. Pavletic, M.D. National Institute of Mental Health Bethesda, MD This work was supported by the Intramural Research Program of the National Institute of Mental Health. References 1. Williams E, Fulop D: A puzzling case of hyperkalemia. Lancet 2001; 357:1176 – 1176 2. Nagasaki A, Takamine W, Takasu N: Se- vere hyperkalemia associated with “alter- native” nutritional cancer therapy. Clinical Nutrition 2005; 24:864 – 865 3. Tazoe M, Narita M, Sakuta R, et al: Hyperkalemia and hyperdopaminemia induced by an obsessive eating of ba- nana in an anorexia nervosa adolescent. Brain and Development 2007; 29: 369 – 372 4. Berk DR, Conti PM, Sommer BR: Orange juice-induced hyperkalemia in schizo- phrenia. Int J Psychiatry Med 2004; 34: 79–82 5. Pavletic AJ, Luckenbaugh MA, Pao M, et al: The importance of medical screening of vol- unteers participating in research on mental ill- ness. Primary Psychiatry 2008; 15:71–76 Lamotrigine-Induced Anticonvulsant Hypersensitivity Syndrome Associated with Acute Respiratory Distress Syndrome TO THE EDITOR: Lamotrigine (LTG)-associated rash is a rare but a po- tential serious side effect and a major cause of this medication discontinua- tion. 1,2 In most cases, LTG-associated rash is benign, however, serious rashes may occur such as in anticonvulsant hypersensitivity syndrome (AHS), 3 Stevens–Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). 1,2 AHS is a delayed (1 to 8 weeks) ad- verse drug reaction associated with the use of aromatic anticonvulsant drugs, which include carbamazepine, oxcar- bamazepine, phenytoin, phenobarbital, zonisamide, felbamate, and LTG. 3 Al- though its occurrence is rare, it may result in hospitalization and even death. 3 The clinical manifestations of AHS include a triad of symptoms consisting of dermatologic rashes, fever, and evidence of systemic or- gan involvement, which can be dif- ferentiated from other diseases such as SJS, which typically involves ery- thema of skin as well as mucosa, fol- lowed by extensive cutaneous and mu- cosal exfoliation particularly oral and conjunctival surfaces and TEN, which is a variant of SJS with skin detach- ment exceeding 30% of the body sur- face area. 3,4 It is well supported that AHS can affect various organs, resulting in multi-organ failure. 1,2 However, we have not located any case involving acute respiratory syndrome (ARDS) in the literature. Thus, we describe the presentation of a case and discuss the relevant information to prevent and treat this rare but life threatening man- ifestation of LTG. Case Report Ms. P, a 41-year-old woman with a medical history of a nonspecific auto- immune disorder, presented to the Ur- gent Care Clinic with a severe, gener- alized macular rash, fever (99.3˚ F) with rigors, and hypotension (69/45 mm Hg) 9 days after starting LTG (25 Letters to the editor 495 Psychosomatics 52:5, September-October 2011 www.psychosomaticsjournal.org