Unrecognized clozapine-related constipation leading to fatal intra-abdominal sepsis – a case report

Abstract

Clozapine is the preferred antipsychotic used for the treatment of resistant schizophrenia with suicidal ideation. The drug is started at a low dose and gradually increased to a target dose of 300–450 mg/day. It is well known to cause agranulocytosis and neutropenia. Several cases of fatal sepsis have been reported in neutropenic patients and emphasis is placed on monitoring for agranulocytosis; however, clozapine also causes intestinal hypomotility and constipation, which if unrecognized can lead to intestinal obstruction, bowel necrosis, and intra-abdominal sepsis. Reduced behavioral pain reactivity in schizophrenics may alter the ability to express pain, potentially leading to a delay in the presentation for medical attention. We report a case of fatal intra-abdominal sepsis secondary to an unrecognized case of clozapine-related constipation.

Clozapine-Induced Constipation: A Case Report and Review of Current Management Guidelines

“…Complications in the published cases were bowel obstruction, septic shock, peritonitis, pneumonia, bowel infarction/perforation, and abdominal compartment syndrome [8,10,[12][13][14][15][16][17][18]. Death was observed in patients on a higher clozapine dosage.…”

“…Death was observed in patients on a higher clozapine dosage. The cause of death in 50% of these cases was due to sepsis, either from infection or post-surgical complication [5,8,14,15]. Other complications that lead to death were bowel infarction, bowel obstruction, abdominal compartment syndrome, and severe uncontrollable diarrhea.…”

Clozapine-induced stercoral colitis: a surgical perspective

“…Clozapine is a second-generation antipsychotic which antagonises the following receptors: serotonin, dopamine, muscarinic, histamine, alpha-1 and alpha 2 2 7. Clozapine is considered the most effective treatment for refractory schizophrenia; however, careful clinical monitoring is essential 8.…”

A fatal fecaloma

“…Chronic constipation with fecal impaction is a well-known complication of long-term neuroleptic treatment [ 1 , 2 ]. Severe forms may be life-threatening [ 3 , 4 ] and may require an emergency laparotomy [ 5 ] before the onset of intraabdominal complications. In this context, prevention with systematic administration of laxatives appears of paramount importance.…”