Clozapine induced gastrointestinal hypomotility: A potentially life threatening adverse event. A review of the literature.

OBJECTIVE: The haematological and cardiac complications of clozapine have been well documented. Recent evidence from pharmacovigilance databases suggests that gastrointestinal (GI) complications are the leading cause of clozapine related deaths. This review aims to describe clinical features along with preventative and treatment options. METHOD: A review of MEDLINE via PubMed searching for all articles published up to February of 2016. Inclusion criteria were articles that provided clinical or epidemiological information relating to the diagnosis, outcome, management or pathophysiology of clozapine related gastrointestinal disorders in humans. RESULTS: Three large case series were identified with 104 cases, 20 of these reported clinical details. A further 52 cases reports were included. Median age was 40, with 79% being male, mean daily clozapine dose was 453 mg. Mortality was 38% with survivors being younger (39 vs. 42), on lower daily doses (400 mg vs. 532 mg), more likely to be female (32% vs. 6%). Four patients were re-challenged with clozapine following CIGH, two suffered a recurrence. CONCLUSION: Risk factors for CIGH appear to be older age, male gender, patients in the first four months of treatment, co-prescription of constipating agents, higher daily dose of clozapine, and previous CIGH. Risk factors for death were older age and male gender. Patients receiving clozapine should be counselled about the dangers of constipation and to report new GI symptoms. Once severe CIGH has occurred clozapine should be halted and reviewed with bowel symptoms managed promptly. Re-challenging with clozapine may present substantial risks due to the severity of CIGH and a paucity of evidence. From the available evidence a treatment strategy has been proposed. Further prospective data regarding CIGH are needed to allow a better assessment of the scale of the problem with the development and testing of treatment strategies.

Reversible hypertensive encephalomyelopathy - the spinal variant of the posterior reversible encephalopathy syndrome.

Posterior reversible encephalopathy syndrome (PRES) is characterised clinically by encephalopathy, headache, visual disturbance and/or focal neurological symptoms. Bilateral cerebral oedema on T2 MRI sequences within the posterior cerebral white matter is the radiological hallmark, although involvement of the frontal lobe, basal ganglia and brainstem can occur. PRES with spinal cord involvement has been rarely reported and is under-recognised due to lack of myelopathic features in nearly half of the reported cases. We report a patient with PRES with spinal cord involvement and review the literature.

Strategies to prevent the neuropsychiatric side-effects of corticosteroids: a case report and review of the literature.

PURPOSE OF REVIEW: The use of corticosteroids is increasing, and while the physical complications of their use are well known, the neuropsychiatric consequences are not. This review focuses on preventing these neuropsychiatric complications. Although there are limited data on this subject, it is a problem that clinicians face on a regular basis. RECENT FINDINGS: The incidence of neuropsychiatric complications rises rapidly once the daily dose of prednisone is greater than 40 mg. Other risk factors for neuropsychiatric symptoms are damaged blood-brain barrier and hypoalbuminemia. All patients receiving corticosteroids and their caregivers should be warned about the potential neuropsychiatric complications. Small trials have supported the use of various agents as prophylaxis. The development of neuropsychiatric symptoms secondary to corticosteroids should lead to prompt involvement of liaison psychiatry. SUMMARY: There is a lack of large randomized controlled studies to inform clinical practice. At present, lithium and olanzapine probably represent the best choices for prophylaxis. Patients with a prior history of steroid-related psychosis or mania should be considered for prophylaxis when future courses of steroids are prescribed as limited data, and our clinical experience suggests that this can reduce the future episodes of neuropsychiatric side-effects.

Hypogammaglobulinemia factitia- Munchausen syndrome masquerading as common variable immune deficiency.

BACKGROUND: We describe the first case of a patient with factitious disorder who closely simulated a primary immune deficiency disorder - Common Variable Immune Deficiency (CVID), by surreptitiously ingesting non-steroidal anti-inflammatory agents. CASE DESCRIPTION: He was treated with several expensive and potentially dangerous drugs before the diagnosis was established through collateral information. In retrospect he did not meet the proposed new criteria for CVID. These criteria may prove useful in distinguishing cases of CVID from secondary hypogammaglobulinemia. CONCLUSION: It is imperative clinicians recognise patients with factitious disorder at the earliest opportunity to prevent iatrogenic morbidity and mortality.