Patient B A 30-year-old white man, diagnosed with schizophrenia 11 years previously, had been treated as a refractory patient for 10 years, initially with CLZ during the first 5 years, with good response. However, due to syncope that was attributed to the irregular use of CLZ, this medication was discontinued and olanzapine and then quetiapine were both tried without good results, which led to the reintroduction of CLZ 4 years ago, with the patient showing acceptable symptom

control without any noticeable major side effects with regular use of CLZ 500 mg/day and citalopram 20 mg/day. During one of his evaluations in our outpatient clinic, he complained of 7 days of headache Inhibitors,research,lifescience,medical and bone pain, with high fever in the last 2 days, associated with skin rash and nausea during the Inhibitors,research,lifescience,medical last 24 h. A physical exam revealed a BT of 38.5ºC, BP of 100 × 60 mmHg, PR of 80/min, no signs of dehydration and a disseminated maculopapular rash. A CBC

showed a Hct of 47%, WBC count of 2600 (ANC 1700 and L 500) and a plt count of 114,000. He was rehospitalized to receive supportive care and all medications were immediately discontinued due to fever and neutropenia onset. A day 1 dengue rapid test (IgM) came back positive, confirming the suspicion of classic dengue fever. The third CBC 48 h later came back with better results, namely an Hct of 38%, a WBC count of 3700 and a plt count of 119,000. However, the patient had a worsening Inhibitors,research,lifescience,medical of gastric symptoms, presenting with continuous nausea and episodes of vomiting. At day 5, the CBC was normalized (Hct 40%, WBC count 8000 and plt count 337,000) and the physical complaints were gone, but the psychopathology was much worse, with the patient evolving into a catatonic state. Inhibitors,research,lifescience,medical Aripiprazole 15 mg/day was introduced, along with lorazepam 2 mg three times a day. There was an improvement in the symptoms after 8 days, but this was not sustained, despite increasing the aripiprazole dose to 30 mg. After 1 month, aripiprazole was substituted by ziprasidone, but after 40 days there was not an acceptable response; the patient developed catatonia associated

with tremors due to the antipsychotic. Inhibitors,research,lifescience,medical Because of this poor treatment response, rechallenge with CLZ was carefully tried. Three months later, with a complete improvement of positive symptoms and no hematologic alterations, the patient was discharged on CLZ 500 mg/day, the same dosage used before dengue infection. At 18 months after CLZ found reintroduction, the patient maintained the psychopathology improvement without any new hematologic alterations. Patient C A 26-year-old white man, diagnosed with schizophrenia 6 years previously, was treated as a refractory patient for 10 months after treatment failures with risperidone, olanzapine and ziprasidone. CLZ had been introduced 4 months TGF-beta assay earlier, and after reaching a dose of 300 mg, with partial improvement (without hallucinations, but still delusional), the patient was transferred to our day hospital to continue his treatment.