title: Asymptomatic myocarditis during clozapine re-titration, in a patient who had previously been stable on clozapine for 10 years.
abstract: OBJECTIVE
  We present a case of confirmed clozapine-induced myocarditis in a patient who was not naïve to the drug.
  
  
  METHODS
  This patient, who had been stable on clozapine for 10 years, relapsed following self-cessation. Asymptomatic throughout inpatient re-titration, serum cardiac enzymes were nonetheless routinely taken.
  
  
  RESULTS
  Occult myocarditis was only discovered due to an elevated Troponin I, and was confirmed by cardiac imaging.
  
  
  CONCLUSIONS
  Once thought to be the preserve of initial exposure to the medication, clozapine-induced myocarditis can occur at any re-titration point if the immunological milieu permits. We therefore recommend routine monitoring of serum cardiac enzymes with all patients undergoing titration of clozapine, regardless of whether they have previously been stable on the drug.
authors.affiliation: Psychiatry Registrar, Alfred Hospital, Department of Psychiatry, Melbourne, VIC, Australia leotomsmith@doctors.org.uk.
authors.forename: Leo T
authors.initials: LT
authors.lastname: Smith
authors.affiliation: Psychiatrist, Alfred Hospital, Department of Psychiatry, Melbourne, VIC, Australia.
authors.forename: Evan
authors.initials: E
authors.lastname: Symons
authors.affiliation: Cardiologist, Alfred Hospital, Heart Centre, Melbourne, VIC, Australia, and Senior Research Fellow, Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia.
authors.forename: James L
authors.initials: JL
authors.lastname: Hare
authors.affiliation: Senior Pharmacist, Alfred Hospital, Department of Psychiatry, Melbourne, VIC, Australia.
authors.forename: Michelle
authors.initials: M
authors.lastname: Hooper
authors.affiliation: Professor of Psychiatry and Deputy Director, Monash Alfred Psychiatry Research Centre, The Alfred and Monash University Central Clinical School, Melbourne, VIC, Australia.
authors.forename: Paul B
authors.initials: PB
authors.lastname: Fitzgerald
mesh_terms: D014150:Antipsychotic Agents / Q000009:adverse effects*; D003024:Clozapine / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009205:Myocarditis / Q000139:chemically induced*
chemical_list: D014150:Antipsychotic Agents; D003024:Clozapine
keywords: cardiac monitoring; clozapine; late-onset; myocarditis