Agranulocytosis and Neutropenia With Typical and Atypical Neuroleptics

Ms. A was a 19-year-old woman with a diagnosis of schizophrenia. She had been receiving clozapine (up to 400 mg/day) for 7 weeks when she developed a temperature of 40°C. Her WBC count was 0.5 ×10⁹/liter, and her absolute neutrophil count was 0.2 × 10⁹/liter. Her WBC count continued to decrease to 0.1 ×10⁹/liter, and she had a zero absolute neutrophil count the next day. A bone marrow biopsy revealed almost complete discontinuation of the proliferation and maturation involved in granulocytopoiesis, and so granulocyte-colony-stimulating factor was administered to Ms. A in addition to supportive measures. On the 24th day after treatment, her blood counts returned to normal.

One year later, Ms. A had a relapse of schizophrenia. She began taking perphenazine (up to 20 mg/day). In the 4th week, her WBC count was 3.0 ×10⁹/liter, and her absolute neutrophil count was 1.2 ×10⁹/liter. She stopped taking perphenazine. On the 14th day after discontinuation Ms. A had normal blood counts. One month later, Ms. A began taking olanzapine, 2.5 mg/day; on the 8th day of treatment, her dose was 5 mg/day. On the 17th day, her WBC count was 2.0 ×10⁹/liter, and her absolute neutrophil count was 0.88 ×10⁹/liter. She stopped taking olanzapine. Granulocyte-colony-stimulating factor was again administered. Ten days later Ms. A’s blood profiles had again returned to normal.

Three months later, Ms. A experienced again psychotic symptoms, including auditory hallucinations; she began taking risperidone, 1 mg/day. On the 14th day of treatment, her WBC count was 3.0 ×10⁹/liter, and her absolute neutrophil count was 0.75 ×10⁹/liter. She then stopped taking risperidone.