title: Fatal agranulocytosis associated with psychotropic medication use.
abstract: OBJECTIVE
  A patient's death due to severe hematologic adverse effects of the concomitant use of four psychotropic medications is reported.
  
  
  CONCLUSIONS
  A 40-year-old Caucasian woman with a 9-year history of depression and anxiety (managed with alprazolam) was admitted to a psychiatric hospital for the treatment of acute psychotic symptoms. After nine days, the patient was discharged home on a regimen of lamotrigine, mirtazapine, quetiapine, and venlafaxine. Five weeks later, the development of severe ocular cellulitis, severe oral thrush, and febrile neutropenia necessitated the woman's urgent rehospitalization; on admission, her white blood cell count was 600 cells/mm(3), her absolute neutrophil count was 18 cells/mm(3), and microbial pathogens were isolated in peripheral blood and tracheal aspirate cultures. Despite treatment with antibiotics and filgrastim, the patient developed multiorgan dysfunction and died five days later from septic shock. The woman's concomitant use of multiple psychotropics and the late recognition of drug-induced agranulocytosis likely contributed to her severe symptoms and ultimate death. The application of the Naranjo scale to this case yielded a score of 6, indicating a probable adverse drug reaction. Although hematologic adverse effects have been reported with the use of each of the four drugs implicated in the woman's death, this is thought to be the first report of fatal agranulocytosis associated with any of the drugs.
  
  
  CONCLUSIONS
  A 40-year old woman with a history of acute psychotic symptoms developed agranulocytosis and neutropenia after starting therapy that included lamotrigine, mirtazapine, quetiapine, and venlafaxine.
authors.affiliation: Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan.
authors.forename: Lama H
authors.initials: LH
authors.lastname: Nazer
authors.forename: Gollapudi
authors.initials: G
authors.lastname: Shankar
authors.forename: Basel Al-Haj
authors.initials: BA
authors.lastname: Ali
authors.forename: Taghreed
authors.initials: T
authors.lastname: Al-Najjar
mesh_terms: D000328:Adult; D000380:Agranulocytosis / Q000139:chemically induced*; D018687:Antidepressive Agents, Second-Generation / Q000009:adverse effects / Q000627:therapeutic use; D018692:Antimanic Agents / Q000009:adverse effects / Q000627:therapeutic use; D014150:Antipsychotic Agents / Q000009:adverse effects / Q000627:therapeutic use; D001772:Blood Cell Count; D003511:Cyclohexanols / Q000009:adverse effects / Q000627:therapeutic use; D003865:Major Depressive Disorder / Q000150:complications / Q000188:drug therapy; D003987:Dibenzothiazepines / Q000009:adverse effects / Q000627:therapeutic use; D017809:Fatal Outcome; D005260:Female; D000069585:Filgrastim; D016179:Granulocyte Colony-Stimulating Factor / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D000077213:Lamotrigine; D008803:Mianserin / Q000009:adverse effects / Q000031:analogs & derivatives / Q000627:therapeutic use; D000078785:Mirtazapine; D009102:Multiple Organ Failure / Q000139:chemically induced; D009503:Neutropenia / Q000139:chemically induced; D054517:Orbital Cellulitis / Q000139:chemically induced; D011618:Psychotic Disorders / Q000150:complications / Q000188:drug therapy; D011619:Psychotropic Drugs / Q000009:adverse effects*; D000069348:Quetiapine Fumarate; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D012772:Shock, Septic / Q000209:etiology; D014227:Triazines / Q000009:adverse effects / Q000627:therapeutic use; D000069470:Venlafaxine Hydrochloride
chemical_list: D018687:Antidepressive Agents, Second-Generation; D018692:Antimanic Agents; D014150:Antipsychotic Agents; D003511:Cyclohexanols; D003987:Dibenzothiazepines; D011619:Psychotropic Drugs; D011994:Recombinant Proteins; D014227:Triazines; D016179:Granulocyte Colony-Stimulating Factor; D008803:Mianserin; D000069348:Quetiapine Fumarate; D000069470:Venlafaxine Hydrochloride; D000078785:Mirtazapine; D000069585:Filgrastim; D000077213:Lamotrigine