Initial evidence of the beneficial effects of glutamate-modulating agents in the treatment of self-injurious behavior associated with borderline personality disorder.

Sir: Clozapine is an antipsychotic medication introduced to the United States in 1989. It is a tricyclic dibenzodiazepine derivative chemically related to the traditional antipsychotic medication loxapine. 1 Side effects pose a significant problem during clozapine therapy. Adverse reactions occur most frequently during the initiation of clozapine treatment and during the acute treatment and dose titration phase. 3 Reports in the literature of uncommon and rare side effects of clozapine include cutaneous reactions with urticaria or ec-zematous exanthema with pruritus, 4 allergic asthmatic reaction , 5 polyserositis, 6,7 a syndrome resembling systemic lupus erythematosus (SLE), 8 papular rash and bilateral pleural effu-sion, 9 pericarditis and elevated troponin I, 10 pericarditis with pericardial effusion, 11 myocarditis, 12 Sweet syndrome with polyserositis, 13 and sudden death. 14 We report a case of pericar-ditis, polyserositis, and rash that developed after the initiation of clozapine therapy and that subsequently resolved after dis-continuation of clozapine. Case report. Ms. A, a 36-year-old woman, has had a diagnosis of schizophrenia (DSM-IV criteria) since the age of 20 years and a remote medical history of seizure disorder. On arrival in 2003 to the emergency department of an urban general hospital with her case manager, Ms. A was delusional and paranoid. She was making racial slurs and vague threats and was religiously preoccupied. She thought Jesus was on the walls and in her apartment, was talking to angels, and believed the Lord had been sitting on her shoulders for 17 years. She thought that people were trying to break in to her apartment and rape her and that she was controlled via implanted devices. At the time of her presentation Ms. A's medications included quetiapine, 400 mg q. She had no significant past medical history except for a distant history of a seizure disorder. Specifically, she had no history of heart disease, rheumatologic conditions, intravenous (IV) drug use, chest surgery or injury, or hypersensitivities to any medications or drugs. She also had no family history of relevant medical conditions. She was placed on a 72-hour hold and admitted to an inpatient psychiatry unit. Once Ms. A was hospitalized, divalproex sodium was started for her manic symptoms and all other medications except ari-piprazole were discontinued. While receiving the combination of aripiprazole and divalproex sodium, Ms. A improved behav-iorally but continued to manifest prominent delusions. Because of the ongoing delusions, aripiprazole was discontinued and a trial of clozapine was initiated on …