A 35-year-old man is currently detained in a psychiatric unit under section 3 of the mental health act after an acute deterioration of his schizophrenia two months ago, for which he was started on clozapine. He complains of a two-day history of a sore throat and general malaise. On examination his respiratory rate is 16, oxygen saturations are 100% on room air, heart rate 95, blood pressure 118/65, temperature 38.0°C. He looks well, and has an erythematous oropharynx with no purulent discharge and no deviation of his uvula. 

Routine bloods and blood cultures have been taken.


Which of the following is the best next step in the management of this patient?

Options:
explanation: This patient has recently started clozapine for his schizophrenia and has now developed pyrexia, general malaise, and symptoms of pharyngitis. Clozapine is associated with a relatively high risk of agranulocytosis and neutropenia within the first few months of treatment. They are therefore at risk of neutropenic sepsis.
 

 Unfortunately we do not know this patients neutrophil count yet although, given his risk factors, he should be started on intravenous antibiotics within one hour of recognition of signs of sepsis. As patients with neutropenia cannot mount the normal immune response to infection that others can, they can look and feel completely well for some time, with relatively normal observations, before rapidly becoming unwell and deteriorating. It is therefore important to have a high index of suspicion and treat aggressively early
name: Start broad spectrum intravenous antibiotics
label: a
answer: yes
explanation: This patient has recently started clozapine and so is at risk of agranulocytosis and neutropenia (black box warning). We do not have his blood results back but, given he has developed new pyrexia with general malaise, he must be treated as suspected neutropenic sepsis
name: Prescribe a 10 day course of penicillin V
label: d
answer: no
explanation: This patient is at risk of agranulocytosis and neutropenia and has signs and symptoms of possible sepsis so reassurance is not a safe option, and he requires urgent treatment
name: Reassure
label: c
answer: no
explanation: Nasendoscopy is an excellent way to assess pathology within the nasal passage, larynx, and vocal cords. If epiglottitis or supraglottitis were suspected in this patient, then urgent referral to ENT would be warranted with help from anaesthetics for airway support. This patient is not showing signs of airway obstruction e.g. drooling, stridor, hoarse voice, or respiratory distress and so epiglottitis is unlikely
name: Refer to ENT for nasendoscopy
label: e
answer: no
explanation: This patient has recently started clozapine and so is at risk of agranulocytosis and neutropenia (black box warning). We do not have his blood results back but, given he has developed new pyrexia with general malaise, he must be treated as suspected neutropenic sepsis
name: Hourly observations for further temperature spikes
label: b
answer: no

Correct answer: a

Start broad spectrum intravenous antibiotics

Learning point: Clozapine treatment increases the risk of agranulocytosis which si treated with broad spectrum intravenous antibiotics.