Agranulocytosis and neutropenia with typical and atypical neuroleptics

Olanzapine-induced and Risperidone-induced Leukopenia: A Case of Synergistic Adverse Reaction?

Leukopenia is a known hematological side effect of atypical antipsychotics. We report a case of an antipsychotic-naive patient with schizophrenia who developed leukopenia after a single dose of olanzapine, which worsened during subsequent treatment with risperidone. Normalization of the white blood cell counts occurred within 24 hours of risperidone discontinuation. Possible synergistic mechanisms underlying olanzapine-induced and risperidone-induced leukopenia are discussed. This case highlights the challenges in identifying and managing nonclozapine antipsychotic-induced leukopenia in a susceptible patient.

Risperidone-induced leukopenia: a case report and brief review of literature

A Caucasian, male, young adult with recurrent agitated depression and suicidal ideation received lithium and oral olanzapine. His white blood cell count was normal at that time. Due to unsatisfactory response, he received 4 mg/day risperidone. While symptoms improved, leukopenia emerged, specifically directed towards neutrophils. Upon risperidone discontinuation, white blood cell count returned to reference values within 1 week. As symptom control was satisfactory, we attempted no risperidone rechallenge. Accurate blood testing must accompany atypical antipsychotic drug administration since blood dyscrasias are always possible with these drugs.

Does switching to another antipsychotic in patients with clozapine-associated granulocytopenia solve the problem? Case series of 18 patients

Clozapine is a well-known drug that is used in treatment-resistant schizophrenia, but granulocytopenia, which may lead to a potentially fatal condition such as agranulocytosis, limit its use. The question about which antipsychotic should be used after a diagnosis of clozapine-associated granulocytopenia is difficult to answer, because antipsychotics other than clozapine may also have hematologic toxicity, or they may prolong clozapine-associated granulocytopenia. In this study, we aimed to find out the incidence of clozapine-associated granulocytopenia in our treatment sample and discuss suitable antipsychotic drug options in terms of hematologic toxicity, for management of clozapine-associated granulocytopenia.

SUBJECTS

One thousand five hundred twenty-four schizophrenia patients, treated with clozapine, were included in the study.

METHODS

Patients' white blood cell counts were monitored closely. Should granulocytopenia related to clozapine be diagnosed, clozapine was stopped immediately, and a new antipsychotic that the patient did not have a history of use was begun, according to the clinical profile of the patient. Persistent low white blood cell count after the 10th day of cessation of clozapine was accepted as prolongation effect.

RESULTS

Of the 1524 schizophrenia patients, 18 were diagnosed to have granulocytopenia, which means that 1.18% of the clozapine users developed granulocytopenia related to clozapine. Six of the patients were treated with olanzapine, 5 patients were treated with quetiapine, 1 patient was treated with risperidone, and 6 patients were treated with amisulpride after clozapine is stopped. None of the patients treated with risperidone or amisulpride showed prolonged low white blood cell count. Two of the patients treated with olanzapine (33.3%) and 2 of the patients treated with quetiapine (40.0%) showed prolonged leukopenia.

DISCUSSION

It is noteworthy that 33.3% of the patients treated with olanzapine and 40.0% of the patients treated with quetiapine showed prolonged leukopenia. This finding is also consistent with the literature that declares higher numbers of cases about prolongation of clozapine-associated granulocytopenia for olanzapine and quetiapine than risperidone and amisulpride. After switching to another antipsychotic drug, close monitoring of white blood cell count on a daily basis for the first 2 weeks should be continued until white blood cell counts are stabilized. Quetiapine and olanzapine especially need attention after clozapine-associated granulocytopenia. Further studies with larger series and longer follow-up should be carried out.

Fatal agranulocytosis: the use of olanzapine in a patient with schizophrenia and myelodysplasia

Neutropenia and agranulocytosis are risks known to occur with phenothiazines and clozapine. The mechanisms responsible for these conditions currently remain unclear. To our knowledge, no case of fatal agranulocytosis as a result of olanzapine treatment was reported in the literature. Thus any case of severe neutropenia occurring in a patient receiving olanzapine is alarming to clinicians. First, a review of the literature produced 41 anecdotic cases of neutropenia or agranulocytosis during treatment with olanzapine (Zyprexa) reported in a total of 24 publications. Second, we report a case of neutropenia, which proved to be fatal in a schizophrenia patient receiving olanzapine and thiazide. The cause of the death was Myelodysplastic syndrome. There is not enough evidence to prove the involvement of either olanzapine or hydrochlorothiazide or the interaction between them in this patient's myelodysplasia. Bone marrow cytogenetic study confirmed the deletion of the long arm of chromosome 11, as reported in myeloid leukemia. If this patient would have died suddenly without the laboratory investigations that lead to the diagnosis of myeloblastic leukemia, the cause would have been probably and wrongfully allotted to treatment with olanzapine.

Olanzapine-induced agranulocytosis in systemic lupus erythematosus: a case report

Systemic lupus erythematosus (SLE) patients may have psychiatric manifestations during the illness course. Psychotropic agents are indicated in treating these symptoms. Second-generation antipsychotics, such as risperidone, olanzapine and quetiapine, have been thought to be safer than clozapine with regard to the side effect of neutropenia or agranulocytosis. We report a case of SLE who developed agranulocytosis during the treatment with olanzapine for the SLE-related psychiatric symptoms.

QSAR modeling and transmission electron microscopy stereology of altered mitochondrial ultrastructure of white blood cells in patients diagnosed as schizophrenic and treated with antipsychotic drugs

Treatment of patients diagnosed as schizophrenic with antipsychotic drugs (neuroleptics) is known to cause occasional unexplained depletion of white blood cells, especially neutrophil granulocytes. It has been known for many years that neuroleptics can interfere with the mitochondrial respiratory chain in vitro. Because there has been a growing interest recently in mitochondrial targeting of drugs, and since a quantitative structure-activity relationship (QSAR) model that predicts mitochondrial accumulation of neuroleptics has been published, we investigated the effects of neuroleptics on white blood cell mitochondria. Venous blood samples were collected from both patients undergoing treatment with neuroleptics and healthy volunteers. The samples were processed for transmission electron microscopy. The resulting images of white blood cells were analyzed using stereology to compare quantitatively mitochondrial morphology in the patient and control groups. We found that in patients, but not in controls, there was swelling of mitochondria and fragmentation of the mitochondrial cristae. There also were fewer mitochondria in patients than in controls, although due to the swelling of the organelles, the volume density of mitochondria in the two groups was not significantly different. Such changes are typical of a toxic insult. Consequently, it seems plausible that, since schizophrenia is not a disease considered to affect white blood cells per se, these changes probably are due to the medication.

Olanzapine-induced leucopenia and neutropenia

Atypical antipsychotics, including olanzapine, were originally expected to reduce the risk of haematological toxicity and to be safe alternatives to clozapine. We report a case of patient who developed leucopenia and neutropenia during treatment with olanzapine.

Granulocytopenia associated with neuroleptic therapy in a patient with benign familial leukopenia

Benign familial leukopenia (BFL) has been reported in several ethnic groups, including Ethiopians of Jewish origin. To date, there are no reported cases of patients with BFL developing granulocytopenia following administration of neuroleptics. We report a case of a young Ethiopian Jew suffering from schizophrenia, who exhibited premorbid benign reduced white blood cells (WBC) count and developed leukopenia and neutropenia following exposure to typical (zuclopentixol, perphenazine, haloperidol) antipsychotics and the atypical antipsychotic risperidone. The diagnosis of BFL was established and tissue typing of the patient was determined. To the best of our knowledge, this is the first report of leukopenia with neutropenia in an ethnically susceptible (due to BFL) schizophrenia patient following exposure to typical and atypical antipsychotics. HLA typing of this patient was distinct from that reported in patients susceptible to clozapine-induced agranulocytosis. Further extensive investigations including HLA typing in a larger cohort of schizophrenic patients is needed in order to define the association between HLA haplotypes and neuroleptic-induced hematological reactions and to identify the potentially vulnerable individuals.