Case Report Safety and efficacy of combined clozapine–azathioprine treatment in a case of resistant schizophrenia associated with Behçet's disease: a 2-year follow-up Domenico De Berardis, M.D., Ph.D. a,b, ⁎ , Nicola Serroni, M.D. b , Daniela Campanella, M.D., Ph.D. a , Luigi Olivieri, M.D. a , Stefano Marini, M.D. a,b , Francesco Saverio Moschetta, M.D. a , Giovanni Martinotti, M.D., Ph.D. b , Massimo Di Giannantonio, M.D. b a NHS, Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Hospital “G. Mazzini,” ASL 4, 64100 Teramo, Italy b Department of Neurosciences and Imaging, Chair of Psychiatry, University “G. D'Annunzio,” 66013 Chieti, Italy Received 18 March 2012; accepted 19 June 2012 Abstract Behçet's disease (BD) is a recurrent inflammatory disorder involving multisystems of the body. Neuropsychiatric symptoms, like psychosis and depression, often occur in BD, but the safety and efficacy of combined clozapine–azathioprine treatment have never been assessed. We here report on a 37-year-old man with BD and treatment-resistant schizophrenia who obtained an improvement following the introduction of clozapine in addition to azathioprine, without developing agranulocytosis or other severe adverse side effects during a 2-year follow-up. © 2012 Elsevier Inc. All rights reserved. Keywords: Schizophrenia; Behçet's disease; Azathioprine; Agranulocytosis; Immunosuppression 1. Introduction Behcet's disease (BD) is a chronic relapsing multisystem inflammatory disorder with mucocutaneous, ocular, articu- lar, vascular, gastrointestinal and central nervous system (CNS) manifestations (Table 1) [1]. As psychosis and depression often occur in BD [2], the use of clozapine may be required, but the risk of hematological adverse effects with concomitant immunosuppressive agents should be taken into account [3]. We report on a patient with BD and treatment-resistant schizophrenia who improved following the introduction of clozapine in addition to azathioprine, without developing additional or unexpected immunosuppression. 2. Case report A 37-year-old unemployed man was diagnosed with BD at the age of 24 and treated with steroids, cyclophospha- mide and methotrexate. A brain magnetic resonance imaging (MRI) executed in November 1998 and March 2000 showed slight hyperintense signals in the left and right capsular–striatal regions and left midbrain, but more recent brain MRIs, executed in 2001 and 2005, showed no abnormalities. Due to the recurrence of anterior uveitis and oral ulcerations, he had been taking azathioprine 100/150 mg since November 2008 on alternate days with full BD remission. He was voluntarily admitted 5 years ago in our psychiatric ward due to a clinical picture characterized by poverty of speech, affective flattening, reduced ability to plan or carry out activities, neglect of personal hygiene, severe social withdrawal and apathy in conjunction with auditory hallucinations, persecutory delusions and disorganization. Available online at www.sciencedirect.com General Hospital Psychiatry xx (2012) xxx – xxx ⁎ Corresponding author. Tel.: + 39 0861429708; fax: + 39 0861429706. E-mail address: dodebera@aliceposta.it (D. De Berardis). 0163-8343/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2012.06.007