VA Boston Healthcare System, 940 Belmont St., Bld 2, Brockton, MA 02301, USA; Harvard South Shore Psychiatry Residency Training Program, 940 Belmont St., Bld 5 116-A7, Brockton, MA, 02301, USA; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA.
VA Boston Healthcare System, 940 Belmont St., Bld 2, Brockton, MA 02301, USA; Harvard South Shore Psychiatry Residency Training Program, 940 Belmont St., Bld 5 116-A7, Brockton, MA, 02301, USA; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, USA.
Schizophr Res. 2018 Sep;199:386-389. doi: 10.1016/j.schres.2018.02.058. Epub 2018 Mar 2.
Clozapine has been shown to be the most efficacious therapy for treatment resistant schizophrenia, estimated at one third of all schizophrenia cases. There is significant morbidity and mortality associated with clozapine including risk of agranulocytosis, aspiration pneumonia, bowel ischemia, myocarditis, seizures, and weight gain. Here we present a case of a 62-year-old man with chronic paranoid schizophrenia refractory to numerous antipsychotics who was started on clozapine therapy during an acute inpatient psychiatric admission. Within three weeks of starting clozapine, the patient developed flu-like symptoms, pleuritic chest pain, and was sent to a medical hospital for evaluation. After transfer, the patient had a rapidly deteriorating course with newly developed congestive heart failure, acute respiratory failure requiring intubation, and cardiovascular collapse requiring vasopressors. The patient expired within two days of transfer and four days after initial symptoms developed. The underlying etiology in this case is likely clozapine induced myocarditis leading to rapid cardiovascular collapse and death. Mortality with clozapine induced myocarditis has been estimated up to 24%. Given that 90% of clozapine cardiotoxic sequelae are seen in the first month post-initiation, more rigorous post-initiation surveillance is recommended for the first four weeks of clozapine with weekly cardiac enzymes (troponins, creatinine kinase-MB), EKG, and acute inflammatory markers (C-reactive protein, and erythrocyte sedimentation rate).
氯氮平已被证明是治疗难治性精神分裂症最有效的疗法，估计占所有精神分裂症病例的三分之一。氯氮平与严重的发病率和死亡率相关，包括粒细胞缺乏症、吸入性肺炎、肠缺血、心肌炎、癫痫发作和体重增加的风险。在这里，我们介绍了一例 62 岁男性慢性偏执型精神分裂症患者，对多种抗精神病药物均无反应，在急性住院精神病患者入院期间开始接受氯氮平治疗。开始服用氯氮平后 3 周内，患者出现流感样症状、胸膜炎性胸痛，并被送往一家医疗医院进行评估。转院后，患者病情迅速恶化，出现新发充血性心力衰竭、需要插管的急性呼吸衰竭和需要升压药的心血管衰竭。患者在转院后两天内死亡，在最初症状出现后四天死亡。本例的潜在病因可能是氯氮平诱导的心肌炎导致快速心血管衰竭和死亡。氯氮平诱导心肌炎的死亡率估计高达 24%。鉴于 90%的氯氮平心脏毒性后遗症发生在起始后第一个月，建议在起始后前四周每周进行心脏酶（肌钙蛋白、肌酸激酶-MB）、心电图和急性炎症标志物（C 反应蛋白和红细胞沉降率）的更严格的起始后监测。
