Clozapine-Induced Eosinophilic Colitis
Mr. A was a 45-year-old man with schizophrenia who had psychotic decompensation in the setting of medication noncompliance and developed neuroleptic malignant syndrome when haloperidol and risperidone were restarted. He was treated with ECT. Concurrently, clozapine was started at a low dose and gradually increased. On the 14th day of clozapine therapy, he developed a fever of 103.6°F and profuse nonbloody diarrhea. His clozapine dose was 200 mg/day. His other medications at the time were lorazepam, aspirin, and metoprolol. His other vital signs were stable, and there was no muscle rigidity or elevation of creatine kinase to suggest recurrence of neuroleptic malignant syndrome.His laboratory values showed mild elevation of his WBC count (to 12,300/mm3). The results of multiple blood cultures, urine cultures, a chest X-ray, stool studies, and an HIV test were negative. Mr. A continued to have fever and profuse diarrhea in the ensuing 10 days. Laboratory studies were significant for peripheral eosinophilia, with a peak of 22% and an absolute count of 2,140/mm3, as well as an elevated erythrocyte sedimentation rate of 116 mm/hour. A colonoscopy was performed on the 10th day of the fever and diarrhea. Mr. A’s colon was normal upon gross examination, and random biopsies were taken. Microscopically, patchy eosinophilic infiltrate and histiocytic aggregates, focally associated with crypt destruction, were noted in the architecturally preserved colonic mucosa.Clozapine was thought to be the culprit and discontinued. Mr. A’s fever and diarrhea disappeared the next day; his eosinophilia and erythrocyte sedimentation rate returned to normal within several days.
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