A 54-year-old man comes to the emergency department for evaluation of fever and sore throat, and also due to trouble sleeping, poor energy, and hearing voices for the past 3 days. He has a history of hypertension, hypercholesterolemia, and schizoaffective disorder. The patient has been hospitalized several times in the past for auditory hallucinations ordering him to kill himself and has attempted suicide twice in the past 3 years. His symptoms have been stable on his current regimen of lithium and clozapine for the past 8 months. The patient's other medications include metoprolol and atorvastatin. He has started to feel depressed again and is concerned that the voices may get worse. He has no current suicidal ideation.
Temperature is 39.4 C (103 F), blood pressure is 110/70 mm Hg, pulse is 108/min, and respirations are 16/min. Examination is significant for pharyngeal erythema.
Laboratory results are as follows:
In addition to antibiotic therapy, which of the following is the most appropriate next step in management of this patient?

Question

A 54-year-old man comes to the emergency department for evaluation of fever and sore throat, and also due to trouble sleeping, poor energy, and hearing voices for the past 3 days.  He has a history of hypertension, hypercholesterolemia, and schizoaffective disorder.  The patient has been hospitalized several times in the past for auditory hallucinations ordering him to kill himself and has attempted suicide twice in the past 3 years.  His symptoms have been stable on his current regimen of lithium and clozapine for the past 8 months.  The patient's other medications include metoprolol and atorvastatin.  He has started to feel depressed again and is concerned that the voices may get worse.  He has no current suicidal ideation.
Temperature is 39.4 C (103 F), blood pressure is 110/70 mm Hg, pulse is 108/min, and respirations are 16/min.  Examination is significant for pharyngeal erythema.
Laboratory results are as follows:
 In addition to antibiotic therapy, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Clozapine is a second-generation antipsychotic that is highly effective in treating schizophrenia and schizoaffective disorder. It is not, however, used as a first-line agent due to its potential for causing life-threatening neutropenia and agranulocytosis. Clozapine is prescribed through a central registry that monitors absolute neutrophil counts (ANCs), and patients must be told to report any symptoms of infection promptly. If the ANC falls below 1,000/mm³, clozapine should be held until the ANC is above 1,000/mm³; an ANC below 500/mm³ requires discontinuing clozapine indefinitely. This patient has symptoms consistent with infection (eg, fever, sore throat) and an ANC of 475/mm³. His clozapine must be stopped. ³ ³ (Choices A, B, and E) Increasing lithium and/or adding an antidepressant or another antipsychotic could be considered for management of this patient's psychiatric condition. However, the most pressing concern is stopping his clozapine as clozapine-induced agranulocytosis can be life-threatening. (Choice D) Clozapine must be stopped due to this patient's agranulocytosis. Educational objective: Clozapine treatment can result in the development of life-threatening neutropenia and agranulocytosis. Clozapine should be held if the absolute neutrophil count falls below 1,000/mm³ and discontinued indefinitely at levels below 500/mm³. ³ ³ __________ References: Medical management of patients on clozapine: a guide for internists. (http://www.ncbi.nlm.nih.gov/pubmed/25809850) Guide to the management of clozapine-related tolerability and safety concerns. (http://www.ncbi.nlm.nih.gov/pubmed/27732102) Evaluating the effect of the changes in FDA guidelines for clozapine monitoring. (http://www.ncbi.nlm.nih.gov/pubmed/28742291)

A 54-Year-Old Man Comes to the Emergency Department for Evaluation