To The Editor: We describe an unprecedented case of a patient with bipolar mania who was successfully restarted on clozapine treatment while receiving ablation chemotherapy and an autologous stem cell transplant for Hodgkin’s lymphoma. While a few cases of clozapine use with cancer chemotherapy have been documented (1–4), our case is unique in that a stem cell transplant was involved.
“Mr. S” was a 39-year-old white male with a history of bipolar I disorder who presented on a responsive regimen of clozapine (300 mg b.i.d.) and lithium (1800 mg every night), with the occasional addition of benzodiazepines, for 10 years. In February 2006, he was admitted with an exacerbation of his mania, characterized by pressured speech, expansive affect, decreased sleep, and psychomotor agitation. He reported weight loss with episodes of night sweats, pruritic rash, and painless lymph node swelling. Oncology diagnosed the patient with Hodgkin’s lymphoma, nodular sclerosing type. Clozapine was discontinued because of the concern of clozapine-induced agranulocytosis, and the patient was switched to a regimen of olanzapine (30 mg b.i.d.). Lithium and lorazepam were continued.
Subsequently, in July 2006 the patient presented with a decompensation of his bipolar disease, despite treatment with olanzapine. Because of his poor response to olanzapine, we considered restarting clozapine, even in the context of active Hodgkin’s lymphoma.
The patient was scheduled to receive ablation chemotherapy and a stem cell transplant during that hospitalization. Concerned about the possibility of leukopenia from Hodgkin’s disease treatment, we contacted IVAX pharmaceuticals to determine whether the patient would be eligible for a waiver, because generally clozapine must be immediately discontinued if a patient develops leukopenia (white blood cell count <3000 cell/mm3 with a satisfactory neutrophil count) or neutropenia (neutrophil count <1500 cell/mm3). It was decided that the benefits outweighed the risks. The waiver was granted and clozapine was restarted.
In August 2006 the patient was transferred to another hospital to receive his stem cell transplant. During that treatment, his white blood cell count was 0.1 cell/mm3 with ANC <0.02. Postprocedure, his white blood cell count was 9.9 cell/mm3. He returned to our inpatient unit in September 2006. His white blood cell count since then has remained between 5.5 and 9.9 cell/mm3.
To our knowledge, this is the first reported case of successful use of clozapine during life-saving ablation chemotherapy and a stem cell transplant. Clozapine should be used with caution due to the risk of leukopenia and the varying degrees in which it affects patients. However, this suggests that in some cases after other options have been exhausted, it is worthwhile to consider restarting patients on clozapine to control acute mania while undergoing stem cell transplant.
1.Hundertmark J, Campbell R: Reintroduction of clozapine after diagnosis of lymphoma. Br J Psychiatry 2001; 178:5762.Miller PR: Clozapine therapy for a patient with a history of Hodgkin’s disease. Psychiatr Serv 2001; 52:10–113.Mckenna RC, Bailey L, Haake J, Desai PN, Prasad BR: Clozapine and chemotherapy. Hosp Comm Psychiatry 1994; 45:8314.Rosenstock J: Clozapine therapy during cancer treatment. Am J Psychiatry 2004; 161:175
The authors report no competing interests.
This letter (doi: 10.1176/appi.ajp.2007.06122021) was accepted for publication in May 2007.