Clozapine-Induced Microseizures, Orofacial Dyskinesia, and Speech Dysfluency in an Adolescent with Treatment Resistant Early Onset Schizophrenia on Concurrent Lithium Therapy

Table 1

Summary of patient’s clinical progress.

Date	Clinical event(s)	Description
May 2013	ED visit for poor glucose control and episodic visual hallucinations	The patient was diagnosed with Type 1 DM in 2009. The patient reported episodic visual hallucinations during the ED visit for diabetic ketoacidosis (DKA).
January 2015	Hospitalized for persistent visual and auditory hallucinations. Psychiatry service was consulted for psychiatric evaluation	During in-patient psychiatric evaluation, the patient endorsed visual hallucinations of seeing a tall man and little girls who he thought were stalking him. He also reported auditory hallucinations of hearing screams and voices telling him to harm himself and others. The symptoms persisted even after glucose levels were under control. The patient reported positive family history of schizophrenia in paternal grandfather and two paternal aunts. The psychotic symptoms resolved completely after several days of haloperidol while he was in the hospital.
February 2015	First psychiatry clinic visit	The patient reported having hallucinations of somebody touching his shoulder and whispering in his ears. CT and MRI were negative for acute intracranial pathology. The patient also reported sadness and was withdrawn as per family. He reported being anxious and having 7-8 panic episodes per day, often when he thinks about hallucinations. He denied current use of recreational drugs and the urine drug screen (UDS) was negative. Thyroid function was WNL. The patient was started on fluoxetine 10 mg PO daily and Cognitive Behavioral Therapy for Anxiety.
March 2015	Psychiatry clinic visit	The patient continued to experience hallucinations. He reported improvement with anxiety. He stopped taking insulin and wrote his plan for suicide. Fluoxetine increased to 20 mg PO daily and aripiprazole 5 mg PO daily was started to address psychotic symptoms and depression.
April 2015	Psychiatry clinic visit	The patient became violent and threatened family member with homicidal statements. Due to worsening symptoms, aripiprazole was switched to risperidone 1 mg PO BID. Fluoxetine continued at 20 mg PO daily.
July 2015	Psychiatry clinic visit	The patient’s psychotic symptoms worsened. He reported visual hallucinations of his brother being stabbed by two men and voice telling him to kill himself. UDS screen is negative. Due to the worsening symptoms while on risperidone and family history of good response to olanzapine, the patient was switched to olanzapine 5 mg PO QHS.
October 2015	Psychiatry clinic visit	The patient reported easily getting agitated. His school grades were dropping and he demonstrated less peer interaction. The patient was switched to home schooling. Psychotic symptoms were stable for few a months but worsened for the several weeks prior to the clinic visit. He threatened his family members. Olanzapine increased from 10 mg to 15 mg PO QHS.
December 2015	In-patient psychiatric hospitalization	The patient was hospitalized for worsening psychosis and violent behavior. The patient’s clinical evaluations and psychological testing confirm the diagnosis of schizoaffective disorder, bipolar type. Olanzapine was placed on hold and the patient received haloperidol for worsening psychotic symptoms during the in-patient stay. The patient’s symptoms stabilized with haloperidol. The patient was discharged on haloperidol.
February 2016	Psychiatry clinic visit	The patient’s psychotic symptoms worsened after discharge, even with the increase of haloperidol to 10 mg PO BID. Lithium 300 mg PO BID was added for mood stabilization.
March 2016	In-patient psychiatric hospitalization	Patient was admitted due to worsening of psychosis and family member being unable to take care of him at home. The patient reported thought broadcasting on television and paranoia about hidden microphones in the walls at home which were there to spy on his thoughts. Haloperidol was put on hold and the patient was started on clozapine. The dose of lithium was increased to 450 mg PO BID.
May 2016	Psychiatry clinic visit	The patient’s clozapine dose was 350 mg per day (with lithium continuing at 450 mg PO BID). The patient reported “rare mouth movements.” The patient and family reported improvement of psychotic symptoms and aggressive behavior.
June 2016	Psychiatry clinic visit	The patient’s clozapine dose was 400 mg per day (with lithium continuing at 450 mg PO BID). The patient reported worsening of stuttering. The patient and family reported continuing improvement of psychotic symptoms and aggressive behavior.
July 2016	Psychiatry clinic visit	The patient’s clozapine dose was 400 mg per day (with lithium continuing at 450 mg PO BID). The patient and family reported continuing improvement of psychotic symptoms and aggressive behavior. There was further worsening of stuttering; EEG demonstrates epileptiform activity (Figure 2). Family refused to change medications as the patient has excellent response with clozapine and lithium and was near resolution of his psychotic symptoms.
February 2017	Psychiatry clinic visit	The patient’s clozapine dose was increased to 450 mg per day (with lithium continuing at 450 mg PO BID) due to reported recurrence of visual hallucinations.
March 2017	Psychiatry clinic visit	The patient’s clozapine dose was 450 mg per day (with lithium continuing at 450 mg PO BID). Family reported worsening of stuttering but refused any changes in doses or alterations in medication regimen due to concerns of relapse of psychotic symptoms.
May 2017	Psychiatry clinic visit	Clozapine dose was 450 mg per day. Family reported worsening of stuttering and significant impairment in social interaction due to stuttering. However, the patient’s psychotic symptoms remain well under control. The patient and family agreed to switch from lithium to divalproex sodium. Divalproex sodium was started at 500 mg PO BID.
June 2017	Psychiatry clinic visit	Clozapine dose was 450 mg per day (with divalproex sodium 500 mg PO BID). Family reported improvement with stuttering. The patient is able to socialize with family and friends. The patient’s psychotic symptoms remain well under control.