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First-episode psychosis — MCCQE Part 1 MCQ

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EasyPsychosisFirst-episode psychosisMCCQE Part 1

Eighteen days after starting clozapine, a patient develops fever, chest pain, dyspnea and a resting heart rate of 128/min. CRP is 135 mg/L and troponin is three times the upper limit of normal. What is the best immediate management?

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Correct answer: E — Stop clozapine and arrange urgent hospital and cardiology assessment for myocarditis

The timing, systemic symptoms, chest pain, marked tachycardia and substantially elevated CRP and troponin make clozapine-associated myocarditis highly likely. Stop clozapine and arrange urgent medical admission, ECG, serial cardiac biomarkers, echocardiography and cardiology assessment while evaluating alternative infectious and cardiac causes and supporting hemodynamics. Early clozapine titration can cause mild tachycardia, but it must not be used to dismiss this high-risk cluster. A beta blocker alone may obscure deterioration, monthly review is unsafe and increasing clozapine could be fatal. Any future rechallenge is a separate specialist, multidisciplinary risk-benefit decision after full recovery, not an immediate substitution exercise.

Reference: International clozapine optimization consensus: https://pmc.ncbi.nlm.nih.gov/articles/PMC10318876/