Pe

Labs

Imaging Gross Pathology Micro Pathology Treatment

Discussion

A 24-year-old female of Ashkenazi Jewish background complains to her family doctor of repeated URls (due to neutropenia), increasing fatigue, muscle aches, and headaches.

She had been showing flattening of affect, suspiciousness, a delusional mood, and auditory hallucinations that was diagnosed as schizophrenia three months ago. She has been receiving clozapine treatment, ever since.

VS: fever; tachycardia (HR 165). PE: patient in obvious discomfort; pallor (due to anemia); conscious and oriented to person, place, and time; petechiae (due to thrombocytopenia) on chest and arms; cardiopulmonary, abdominal, and genital exams normal; no extrapyramidal signs.

CBC: leukopenia; thrombocytopenia; anemia (= pancytopenia).

CXR: No signs of lung infection.

Discontinue clozapine and consider alternate pharmacotherapy.

Clozapine is a D4 dopamine receptor blocker used for the treatment of schizophrenia and psychosis. Its side effects include mild sedation and anticholinergic and extrapyramidal symptoms. This patient has drug-induced agranulocytosis, which is characterized by enhanced destruction or myelosuppression. Clozapine causes agranulocytosis in a small percentage of patients (< 2%). Given the potential lethal effects of this condition, however, patients must receive weekly blood counts. The mechanism is unknown, but an immune reaction may be involved. Agranulocytosis usually reverses with discontinuation of clozapine.

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