An 85-year-old woman was admitted to hospital with an exacerbation of heart failure secondary to cardiac arrhythmia. Her past history included atrial fibrillation, diastolic heart failure, emphysema, gastritis, Alzheimer's disease and anxiety. She was taking quetiapine, sertraline, donepezil, omeprazole, tiotropium, salbutamol and diltiazem.
Examination revealed rapid atrial fibrillation, with no systemic or focal signs of sepsis, and she was afebrile. Haemoglobin, thyroid function, liver function and serum creatinine were normal. Her chest X-ray showed changes consistent with pulmonary oedema and bilateral pleural effusions. She was treated with frusemide and aspirin.
On the day before admission her white cell count was normal (5.5 x 109/L) with a neutrophil count of 4.1 x 109/L. However, on admission her white cell count was low (2.9 x 109/L with a neutrophil count of 1.9 x 109/L). The day after admission her white cell count fell to 2.7 x 109/L and her neutrophil count to 1.5 x 109/L.
Following a detailed review of all her drugs and in consultation with the psychiatry team, we decided to start risperidone and cease her quetiapine as it could have been the cause of the neutropenia. She had started quetiapine 200 mg twice a day four months earlier for the control of psychotic behaviour related to Alzheimer's disease. Her white cell counts were normal before she started quetiapine.
Five days after admission, the white cell count had increased to 4 x 109/L and the neutrophil count to 2.6 x 109/L (see Table 1). Given her improvement, bone marrow biopsy was not performed. Her psychotic symptoms remained controlled with the switch to risperidone, and she was discharged from hospital.
The risk of agranulocytosis with quetiapine is significantly lower than with clozapine, so regular estimations of white cell and neutrophil concentrations are not indicated. However, vigilance is required, as blood dyscrasias can still occur.
We would like to acknowledge the advice received from Dr Sam Robson, Psychiatric registrar, Royal Melbourne Hospital.
Andersohn F, Konzen C, Garbe E. Systematic review: agranulocytosis induced by nonchemotherapy drugs. Ann Intern Med 2007;146:657-65.
Conflict of interest: none declared
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