Isolated nausea and vomiting as the cardinal presenting symptoms of clozapine-induced myocarditis: a case report
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CASE REPORT
Open Access
Isolated nausea and vomiting as the cardinal presenting symptoms of clozapineinduced myocarditis: a case report M. Z. van der Horst1,2,3* , F. van Houwelingen1,2 and J. J. Luykx1,2,3
Abstract Background: Clozapine is an atypical antipsychotic proven to be superior in the treatment of treatment-resistant schizophrenia. Myocarditis is a rare, but well-known complication of treatment with clozapine. Only few cases have been reported in which nausea and vomiting were prominent symptoms. This is the first described report in which nausea and vomiting were the only presenting symptoms of clozapine-induced myocarditis. Case presentation: We report a case of a 58-year-old woman, suffering from schizoaffective disorder, who is being treated with clozapine. Two weeks after initiation of clozapine, she developed nausea and vomiting, in absence of any other clinical symptoms. Laboratory examination and magnetic resonance imaging confirmed the diagnosis of clozapine-induced myocarditis. Clozapine was discontinued and the patient recovered fully. Conclusions: This case emphasizes the importance of recognizing myocarditis as a cause of isolated nausea and vomiting in patients treated with clozapine. Early recognition improves clinical outcome and reduces mortality. Keywords: Clozapine, Myocarditis, Clozapine-induced myocarditis, Schizophrenia, Case report
Background Clozapine is the most effective treatment in patients suffering from psychotic disorders. Furthermore, it is the only antipsychotic agent that reduces death from suicide [1]. However, clozapine is the most notorious antipsychotic agent associated with the development of myocarditis. Clozapine-induced myocarditis is a rare but life-threatening condition; mortality rates range from 10 to 30% [2–5]. Myocarditis is defined as an inflammation of the heart muscle (myocardium) and has various causes [6]. The most common cause of myocarditis is viral infection, particularly parvovirus B19 and herpes simplex virus [7]. * Correspondence: [email protected] 1 Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands 2 Department of Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands Full list of author information is available at the end of the article
Other types of infections, auto-immune diseases, and hypersensitivity or toxic reactions to drugs can cause this condition as well [6]. Due to underdiagnoses and a lack of shared standardized diagnostic approach worldwide, the true incidence of myocarditis remains unclear [8]. In patients using clozapine the reported incidence worldwide varies from < 0.1 to 3.2% [4, 5, 9]. In Australia incidence rates up to 8.5% are reported, possibly due to genetic factors, geographical differences and/or greater awareness and monitoring [10–12]. Bellissima et al. (2018) found in their systematic review that in 87% of cases, symptoms of myocarditis di
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