Abstract Title: Transient Eosinophilic Colitis in Clozapine Use
Background
Two main pathways have been implicated in the etiology of eosinophilia including an increased cytokine-mediated differentiation of eosinophils evident in extrinsic eosinophilic disorders. A study following 66 patients who remained on clozapine for one year showed a cumulative incidence rate of 5.9% for eosinophilia. This case report illustrates a presentation of Eosinophilic Colitis and the clinical significance of absolute eosinophil thresholds in patients on Clozapine

Case Presentation
A 59-year-old male, with past psychiatric history of schizoaffective disorder, presented following a pretrial evaluation for criminal charges, with delusions and hallucinations. His records showed multiple psychiatric inpatient hospitalizations, 20 electroconvulsive treatments and successful management with Paliperidone. On admission, he voiced delusional statements. Mental status exam revealed delusions but no gross thought disorganization or hallucinations. He received a trial of Clozapine with baseline Complete Blood Count (CBC) with differential showing Absolute Neutrophil Count (ANC) 7,051cells/uL, Eosinophils 0 and Hemoglobin 12.0g/dL. Clozapine was titrated up to only 150mg given he developed explosive diarrhea. A repeat CBC with differential showed ANC 9,449 cells/uL, Eosinophils 12.0 x 109/L (High) with C-Reactive Protein (CRP) 5.3mg/L. Clozapine was immediately discontinued without any protocol for restarting clozapine following symptom resolution. Following the Risk Evaluation and Mitigation Strategies (REMS) protocol, subsequent monitoring of CBC with differentials, revealed ANC 10,377cells/uL, CRP 9.9mg/L, with eosinophils normalizing within a week. He was started on Aripiprazole for better control of mood and psychotic symptoms. 

Discussion
Eosinophilic colitis (EC) is a rare inflammatory condition with many factors including psychotropic drugs implicated in the pathogenesis of secondary EC. The pathophysiology of eosinophilia induced particularly by clozapine is still unknown, but given almost immediate resolution with continued treatment, the possibility of an acute allergic reaction has been suggested in literature. While EC lacks guidelines with regards to diagnostic criteria, particularly threshold values for eosinophilia, a review article implied that eosinophilia is not a potential ground for clozapine discontinuation. Given it is a diagnosis of exclusion with no standardized monitoring recommendations, exceedingly high values need to be evaluated for setting threshold values as one criterion for clozapine discontinuation.





Transient Eosinophilic Colitis in Clozapine Use

Clinical Vignettes | Psychiatry

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