Inflammatory response to clozapine in the absence of myocarditis: case report

Davey, Patrick; Gee, Siobhan; Shergill, Sukhi

doi:10.1192/bjpo.bp.116.003228

Cited by 8 publications

(3 citation statements)

References 11 publications

(12 reference statements)

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“…Our patient demonstrated multiple infective symptoms, such as dry cough, severe headache, photophobia and diarrhoea. Though elevated CRP has been recorded in previous cases of clozapine-induced fever and associated complications, very high CRP as recorded in our patient, is not standard in other reported cases of clozapine-induced fever 8–10. Furthermore, our patient had elevated procalcitonin, which is not reported in reviewed case reports.…”

Section: Discussioncontrasting

confidence: 69%

Clozapine-induced pneumonitis mimicking an atypical pneumonia

Vaselli,

Du Preez,

Jasenthu Kankanamage

2024

BMJ Case Rep

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Clozapine is an antipsychotic used for treatment-resistant schizophrenia with a significant side effect profile, including agranulocytosis, myocarditis and fever. Clozapine-induced fever often occurs in the first 2 weeks of treatment and settle after a few days. We report a case of a woman in her mid-30s who developed fever and infective symptoms suggestive of an atypical pneumonia while on clozapine titration. She was on clozapine for 16 days before developing high-grade fever, dry cough, diarrhoea, headache and photophobia with a very high CRP. We performed an extensive infection workup that returned negative results except for bilateral upper lobe ground glass changes of the lungs on CT. Despite antibiotic therapy, which would cover an atypical pneumonia, her CRP remained elevated and her fever persisted. Focus was directed to clozapine-induced pneumonitis as the cause for her symptoms. Her antibiotics were ceased, and clozapine was downtitrated. With the adjustment of her clozapine dose, her fevers and associated symptoms resolved, and CRP downtrended. Her fevers did not return when clozapine was uptitrated in the community subsequently. Clozapine-induced fever or other immune-allergic reactions should be systematically considered when patients develop fever during the initiation phase of clozapine therapy. Ruling out infective causes is desirable prior to attributing fevers to clozapine especially when they are accompanied by infective symptoms and high inflammatory markers. Careful downtitration of clozapine should be considered rather than abrupt cessation in managing clozapine-induced fevers and subsequent slow uptitration could be considered.

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Section: Discussioncontrasting

confidence: 69%

Clozapine-induced pneumonitis mimicking an atypical pneumonia

Vaselli,

Du Preez,

Jasenthu Kankanamage

2024

BMJ Case Rep

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“…Clozapine use per se is also a known cause of elevated inflammatory markers and fever, although this phenomenon is usually associated with Clozapine-induced myocarditis. The presence of CRP elevation in association with Clozapine therapy and without myocarditis is also known from case reports [ 16 , 17 ] where a modest CRP elevation was observed (55.4–122 mg/L). However, in this case, the patient remained febrile for forty-eight hours with temperatures exceeding 39.0 C and had a CRP value of 520 mg/L, more consistent with sepsis.…”

Section: Discussionmentioning

confidence: 67%

Caffeine-clozapine interaction associated with severe toxicity and multiorgan system failure: a case report

Yartsev

Peisah

2021

BMC Psychiatry

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Background Caffeine is a known inhibitor of Clozapine metabolism mediated by inhibition of CYP1A2. Hitherto, the effects of caffeine on Clozapine levels have always been modest, as have the clinical manifestations of toxicity resulting from their interaction. We present a case of severe toxicity associated with the co-consumption of caffeine and Clozapine culminating in life-threatening complications requiring management in Intensive Care. Case presentation A 34 year old male with a history of chronic schizophrenia, who had been managed stably on 400 mg Clozapine for the previous 5 years, changed his dietary behaviour and began consuming caffeine-containing energy drinks over the course of 3 weeks. The total daily dose of caffeine was estimated as 600 mg/day (four cans of Red Bull). He subsequently presented to the Emergency Department with life-threatening Clozapine toxicity, resulting in a decreased level of consciousness, severe metabolic acidosis, acute respiratory failure, raised inflammatory markers and acute renal failure attributed to interstitial nephritis. Maximum recorded Clozapine level was 1796 ng/ml. Conclusions This case describes the interaction between a common caffeine-containing beverage and a commonly prescribed antipsychotic medication, associated with severe adverse effects. We call for clinical and scientific attention to the possible interaction between these substances and draw attention to the implications for prescribing practices and patient counselling.

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“…This is in keeping with the reported pro-inflammatory nature of clozapine in the initial course of its treatment. 16,17 This information may have implications for the development of re-challenge guidelines, with particularly careful monitoring recommended in the first week following re-challenge. Given the emerging literature of successful re-challenge after clozapine-induced myocarditis, this is an option clinicians should now seriously consider, given the difficulty in managing TRS with alternative antipsychotic medication.…”

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confidence: 99%