quetiapine-fumarate and Myocarditis

We report the case of an 18-year-old woman with personality disorders who was hospitalized a few hours after suicidal ingestion of acetaminophen, quetiapine, acetylsalicylic acid, and ethanol. Twelve hours after admission, severe liver damage was evident, but the patient was stable and awaiting hepatic transplantation. Electrolytes were successfully controlled. The condition of the liver stabilized. Cardiac biomarkers then deteriorated unexpectedly. Localized ST-segment elevations were noted on electrocardiogram, but angiography ruled out myocardial infarction. A computed tomographic scan ruled out cerebral edema. The patient died of irreversible cardiac arrest 40 hours after admission. Heart failure remained unexplained, and the body underwent forensic autopsy.At autopsy, histologic findings were indicative of acute toxic myocarditis and were concluded to be caused by acetaminophen intoxication. Acetaminophen overdose is common and typically leads to liver failure requiring supportive treatment and emergency liver transplantation. Toxic myocarditis is an extremely rare complication of acetaminophen overdose. It has only been reported 4 times in the literature despite the widespread use and misuse of acetaminophen. Toxic myocarditis remains a possibility in many cases of overdose but can be overlooked in a clinical picture dominated by hepatorenal failure and encephalopathy. Clinicians and forensic pathologists should be aware of this rare potential complication.

Topics: Acetaminophen; Adolescent; Analgesics, Non-Narcotic; Anti-Inflammatory Agents, Non-Steroidal; Antipsychotic Agents; Aspirin; Borderline Personality Disorder; Central Nervous System Depressants; Drug Overdose; Ethanol; Female; Gas Chromatography-Mass Spectrometry; Heart Failure; Humans; Myocarditis; Quetiapine Fumarate; Suicide

An 18-year-old man diagnosed with attention-deficit hyperactivity disorder was recently started on quetiapine in addition to regular methylphenidate, which he had been taking for a number of years. He presented with chest pain and inferolateral ST elevation, and underwent urgent coronary angiography, which showed normal coronary arteries. The initial troponin level was raised and an inpatient echocardiogram showed mild left ventricular systolic dysfunction with no evidence of regional wall motion abnormality. Cardiac MRI showed subepicardial late gadolinium enhancement, which was suggestive of myocarditis. Quetiapine and methylphenidate were discontinued and the patient was discharged home after 1 week. He was followed up within 8 weeks with complete recovery and no symptoms.

Topics: Adolescent; Antipsychotic Agents; Attention Deficit Disorder with Hyperactivity; Bipolar Disorder; Chest Pain; Diagnosis, Differential; Dibenzothiazepines; Dopamine Uptake Inhibitors; Humans; Male; Methylphenidate; Myocardial Infarction; Myocarditis; Quetiapine Fumarate; Treatment Outcome

Several detailed case reports have described cardiac muscle disorders (cardiomyopathy and myocarditis) in patients treated with quetiapine, some of which have been fatal. The symptoms included shortness of breath and oedema. The disorders sometimes resolved on withdrawal of quetiapine. Quetiapine is chemically similar to clozapine and olanzapine, which are known to sometimes provoke this type of adverse effect. In practice, a patient who develops dyspnoea or other signs of heart failure during quetiapine therapy may benefit if the drug's role is recognised and quetiapine withdrawn.

Topics: Antipsychotic Agents; Cardiomyopathies; Clozapine; Dibenzothiazepines; Dyspnea; Edema; Humans; Myocarditis; Quetiapine Fumarate

Clozapine is the drug of choice for treatment-resistant schizophrenia. Prompted by a patient who developed reversible clozapine-induced myocarditis after long-term treatment with clozapine for several years for chronic-resistant schizophrenia, we undertook a review of the relevant literature. Concerning the myocarditis, the patient recovered rapidly by withdrawal of clozapine and with supportive management. Psychiatric stabilisation of the patient was at least possible with a combination of quetiapine (600 mg) and amisulpride (800 mg). Well-designed studies with the aim to specifically investigate treatment options after clozapine are limited and clinical possibilities are discussed in this paper. Olanzapine and combinations using non-clozapine atypical neuroleptics have partly shown improvement, whereas evidence for successful augmentation with mood stabilisers, anticonvulsants or electroconvulsive therapy in treatment-resistant schizophrenia is limited.

Topics: Amisulpride; Antipsychotic Agents; Clozapine; Dibenzothiazepines; Humans; Male; Middle Aged; Myocarditis; Quetiapine Fumarate; Schizophrenia; Sulpiride

Topics: Adult; Antipsychotic Agents; Dibenzothiazepines; Humans; Male; Myocarditis; Quetiapine Fumarate; Schizophrenia, Paranoid