Elsevier

General Hospital Psychiatry

Volume 35, Issue 2, March–April 2013, Pages 213.e9-213.e11
General Hospital Psychiatry

Case Report
Safety and efficacy of combined clozapine–azathioprine treatment in a case of resistant schizophrenia associated with Behçet's disease: a 2-year follow-up

https://doi.org/10.1016/j.genhosppsych.2012.06.007Get rights and content

Abstract

Behçet's disease (BD) is a recurrent inflammatory disorder involving multisystems of the body. Neuropsychiatric symptoms, like psychosis and depression, often occur in BD, but the safety and efficacy of combined clozapine–azathioprine treatment have never been assessed. We here report on a 37-year-old man with BD and treatment-resistant schizophrenia who obtained an improvement following the introduction of clozapine in addition to azathioprine, without developing agranulocytosis or other severe adverse side effects during a 2-year follow-up.

Introduction

Behcet's disease (BD) is a chronic relapsing multisystem inflammatory disorder with mucocutaneous, ocular, articular, vascular, gastrointestinal and central nervous system (CNS) manifestations (Table 1) [1]. As psychosis and depression often occur in BD [2], the use of clozapine may be required, but the risk of hematological adverse effects with concomitant immunosuppressive agents should be taken into account [3].

We report on a patient with BD and treatment-resistant schizophrenia who improved following the introduction of clozapine in addition to azathioprine, without developing additional or unexpected immunosuppression.

Section snippets

Case report

A 37-year-old unemployed man was diagnosed with BD at the age of 24 and treated with steroids, cyclophosphamide and methotrexate. A brain magnetic resonance imaging (MRI) executed in November 1998 and March 2000 showed slight hyperintense signals in the left and right capsular–striatal regions and left midbrain, but more recent brain MRIs, executed in 2001 and 2005, showed no abnormalities. Due to the recurrence of anterior uveitis and oral ulcerations, he had been taking azathioprine 100/150

Discussion

To our knowledge, this was the first case that described the safe use of clozapine, an antipsychotic drug with a documented risk of agranulocytosis, in combination with azathioprine, a drug with immunosuppressive potential.

The patient was diagnosed with treatment-resistant schizophrenia following the National Institute for Clinical Excellence criteria [5]. However, we cannot exclude that, in this patient, onset of symptoms may be triggered by an involvement of CNS, as MRI findings across time

Acknowledgments

This manuscript was entirely funded by the authors, and no pharmaceutical companies were informed of or were involved in the paper. The authors have no potential conflicts of interest that are directly relevant to the contents of the manuscript. All authors have contributed to this case report with equal efforts. The authors thank Mrs. Roberta Polimanti for language editing.

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