40-Year-Old Man With Fatigue, Dyspnea, and Nausea

Abstract

A 40-year-old white man with bipolar I disorder, neurolepticinduced parkinsonism, and nonmalignant catatonia presented with a 2-day history of worsening fatigue, dyspnea, and nausea. He had been admitted to the psychiatric unit 3 weeks previously for catatonia, where he gradually improved following medication adjustments. Specifically, risperidone was tapered off and replaced by clozapine to minimize extrapyramidal effects. He continued to improve, showing independence both in his activities of daily living and other self-cares. However, amid his progress, he experienced fatigue, dyspnea, and nausea, warranting further evaluation. At the time of the current presentation, he had no known exposures or sick contacts. He had never smoked and had no notable family history of any medical problems.Vitals were notable for a temperature of 39.5 C, heart rate of 121 beats/min, blood pressure of 122/73 mm Hg, respiratory rate of 16 breaths/min, and oxygen saturation of 93% while breathing room air. Physical examination revealed a flushed, inattentive man lying in bed. Notably, he was quite lethargic, which was an acute change compared to his mental state on the previous day. Cardiac examination revealed a regular rhythm with no appreciable jugular venous distention or lower extremity peripheral edema. Pulmonary, abdominal, neurologic, and skin examination findings were within normal limits. Laboratory evaluation yielded the following results (reference ranges provided parenthetically): hemoglobin, 14.4 g/dL (13.2-16.6 g/dL); leukocytes, 13.1 0.8 mg/dL (0.74-1.35 mg/dL); thyroidstimulating hormone, 0.5 mIU/L (0.3-4.2 mIU/L); and C-reactive protein, 62.1 mg/ L ( 8.0 mg/L). His troponin T level increased from 0.09 ng/dL (<0.04 ng/mL) at initial measurement to 0.2 ng/dL at 3 hours and 0.33 ng/dL at 6 hours. During this time, he reported no chest pain, pressure, or discomfort. Results of urinalysis and blood cultures were unremarkable. Polymerase chain reaction was negative for influenza A and B and respiratory syncytial virus.Chest radiography revealed no consolidation, pleural effusion, cardiomegaly, or signs of heart failure. Initial electrocardiography (ECG) showed only sinus tachycardia with no ST-T wave abnormalities. Transthoracic echocardiography (TTE) was notable for generalized hypokinesis with a calculated ejection fraction of 43% and normal right ventricular size, function, and pulmonary pressures. No previous echocardiograms were available because the patient had never undergone echocardiography.

Isolated nausea and vomiting as the cardinal presenting symptoms of clozapine-induced myocarditis: a case report

“…A systematic search was performed in Pubmed (last updated on 12 June 2020) using the following terms: clozapine, leponex, clozaril, clozapine-induced myocarditis, myocarditis, nausea, and vomiting. The search yielded one result; a case report of a patient who suffered from nausea, and in addition, fever, dyspnea, fatigue, sinus tachycardia, elevated troponin, and C-reactive protein (CRP) levels, and reduced ejection fraction, leading to the diagnosis of clozapine-induced myocarditis [25]. When studying (systematic) reviews, a few cases were found in which nausea and vomiting were prominent symptoms [26][27][28].…”