Clozapine
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Grgas M, et al. Clozapine-induced myocarditis: 2 case reports. Journal of Clinical Psychopharmacology 30: 91-92, No. 1, Feb 2010. Available from: URL: http:// dx.doi.org/10.1097/JCP.0b013e3181ca3c99 - USA 803007557
Myocarditis: 2 case reports Two men, aged 27 and 30 years, developed myocarditis while receiving inpatient therapy with clozapine for paranoid schizophrenia. An ECG, conducted prior to the 30-year-old man starting clozapine, was unremarkable. He initially received clozapine 12.5mg, with the dosage increased by 25 mg/day. On day 12 of therapy, he was febrile, was feeling unwell and had night sweats. At this point he was receiving clozapine 250mg at bedtime. An ECG on day 14 revealed sinus tachycardia, a corrected QT (QTc) interval of 463 msec and mild global hypokinesis. Echocardiography results suggested an ejection fraction (EF) of 40%–45%. He was transferred to the medical service and clozapine was stopped on day 14. Sinus tachycardia and a prolonged QTc interval (466 msec) were evident on ECG the following day; the results also suggested right ventricular hypertrophy. Radionuclide ventriculography showed an EF of 34%. Laboratory investigations determined that his eosinophil count remained within normal limits throughout his admission. However, troponin T, B-type natriuretic peptide (BNP) and creatine kinase (CK) levels were elevated. On day 15, his concomitant psychotropic medications were withheld and treatment with carvedilol and lisinopril was started. An infectious disease consult excluded bacterial and viral infections. At the end of his medical admission (around day 17), his laboratory test results had returned to normal. On discharge, he was receiving olanzapine, carvedilol, hydroxyzine and trazodone. As all other medical aetiologies had been ruled out, myocarditis secondary to clozapine was diagnosed. His last ECG showed normal sinus rhythm. On admission, the 27-year-old man received clozapine 50mg at bedtime, with the dosage increased by 25 mg/day to 300mg at bedtime. His concomitant medications included haloperidol, valproate semisodium, extendedrelease venlafaxine and ziprasidone; the latter was tapered starting on day 2 of therapy. Atomoxetine was added on day 10; all his other medications were unchanged. Two days postdischarge, he presented to the emergency department with chest pain, productive cough, low-grade fevers, dysphagia, dehydration and night chills. His HR was 120bpm. His symptoms had started during his psychiatric admission and had deteriorated over the last 2–3 days. He was admitted to a medical service on day 13. An ECG showed sinus tachycardia and a QTc interval of 423 msec. All psychotropic medications were discontinued. Laboratory investigations revealed elevated levels of troponin T, BNP, CK and CK-MB throughout his admission; his eosinophil count was normal throughout . Empirical therapy with ceftriaxone and azithromycin was started on day 14 after an infectious disease consult indicated possible pneumonia. However, chest x-ray results were less supportive of pne
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