Echocardiographic Evidence of Clozapine-Induced Myocarditis With Pericardial Involvement in a Young Woman

Chinelo Onyilofor; Bryce Wininger; Eric M. Isselbacher; Avanthi Raghavan

doi:10.1016/j.jaccas.2025.105435

October 1, 2025JACC Case ReportsOpen Access

Echocardiographic Evidence of Clozapine-Induced Myocarditis With Pericardial Involvement in a Young Woman

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Why the study?

Myocarditis is a rare adverse effect of clozapine that often occurs within the first month of use.

Does immediate clozapine cessation and initiation of colchicine improve left ventricular ejection fraction and resolve myocardial edema and pericardial effusion in a young woman with clozapine-induced myocarditis?

Structured PICO

Does immediate clozapine cessation and initiation of colchicine improve left ventricular ejection fraction and resolve myocardial edema and pericardial effusion in a young woman with clozapine-induced myocarditis?

P

Population

An 18-year-old woman of European ancestry with autism spectrum disorder, severe intellectual impairment, and severe behavioral dysregulation who developed clozapine-induced myocarditis with reduced LVEF (42%), symmetric LV wall thickening (interventricular septum 13 mm, posterior wall 12 mm), and pericardial effusion while concurrently taking valproic acid (n=1)

I

Intervention

Immediate discontinuation of clozapine (which had been initiated at 12.5 mg daily, increased to 62.5 mg daily, and reduced to 50 mg daily prior to cessation) and initiation of oral colchicine 0.6 mg daily for 3 months, alongside supportive care and restarting haloperidol 2.5 mg 3 times daily

O

Outcome

Resolution of left ventricular systolic dysfunction (LVEF improvement from 42% to 61% at day 5 and 71% at 12 days after clozapine withdrawal) and normalization of left ventricular wall thickness (interventricular septum from 13 mm to 8 mm, posterior wall from 12 mm to 9 mm) on transthoracic echocardiographysurrogate

This case demonstrates that clozapine-induced myocarditis with marked myocardial edema, reduced ejection fraction, and pericardial involvement—potentiated by concurrent valproic acid use—can rapidly resolve with prompt clozapine cessation and colchicine therapy.

Limitations

Single patient case report
Lack of a baseline echocardiogram prior to clozapine initiation to understand the chronicity of LV dysfunction or wall thickening
Baseline high-sensitivity troponin T level was not checked prior to clozapine initiation
Cardiac magnetic resonance imaging (the diagnostic gold standard) could not be safely undertaken due to behavioral dysregulation and need for general anesthesia
Endomyocardial biopsy was deferred
Patient was unable to provide a subjective history due to developmental disability

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Implication

Case of clozapine-associated myocarditis with valproate co-use supports vigilance; leaves open interaction mechanisms for prospective study.

Abstract

BACKGROUND: Myocarditis is a rare adverse effect of clozapine, often occurring within the first month of use. CASE SUMMARY: We present a case of an 18-year-old woman who developed recurrent somnolence, orthostatic hypotension, and elevated troponins days after starting a clozapine induction, while also on valproic acid. Transthoracic echocardiogram (TTE) revealed a reduced left ventricular ejection fraction and symmetric left ventricular wall thickening concerning for myocardial edema, as well as a pericardial effusion. Clozapine was promptly withdrawn, and the patient was started on colchicine. Follow-up TTE showed improved left ventricular ejection fraction and resolution of left ventricular wall thickening. DISCUSSION: Clozapine-induced myocarditis presents with elevated troponins and inflammatory markers; however, myocardial involvement may not always be detectable by TTE. Medication withdrawal and supportive care are the cornerstone of initial treatment. TAKE-HOME MESSAGE: This case highlights the significant effects that clozapine can have on the myocardium, especially with concurrent use of valproic acid.

Discussion

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Cite This Study

Onyilofor et al. (2025) studied this question.

synapsesocial.com/papers/6a708197f44fa9f079de2a7a https://doi.org/10.1016/j.jaccas.2025.105435

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Echocardiographic Evidence of Clozapine-Induced Myocarditis With Pericardial Involvement in a Young Woman

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Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Echocardiographic Evidence of Clozapine-Induced Myocarditis With Pericardial Involvement in a Young Woman

Figures

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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