LAUSR

the first 3 weeks of clozapine treatment. Our findings confirm other studies in their assumption of the highest risk of CIM during the first 3 to 4 weeks of treatment. Both patients were males, and none of them had a known familial disposition of cardiac disease or any clinically remarkable finding prior to clozapine treatment in clinical examination, blood tests, ECG, electroencephalography, TTE, or magnetic resonance imaging, which is in accordance to previous reports in adults. Whereas patient A developed first signs of CIM between days 9 and 15, patient B presented with vomiting and diarrhea on day 14, before cardiac impairment was evident on day 19 of treatment. The earlier onset of symptoms in patient A might be caused by a faster titration, which has been linked with higher risk of developing CIM in literature. Nevertheless, titration in our patients still was in accordance with several guidelines such as the Dutch recommendation for slow clozapine titration. Both patients were below therapeutic doseswhen CIM occurred. Other reported risk factors that were not relevant in our cases include initiating clozapine at a high dose, older age of treated patients, or interaction effects between clozapine and valproate, respectively, and selective serotonin reuptake inhibitors. They developed unspecific inflammation such as fever and an increase of CRP before elevated heart enzymes were obvious several days later. These findings are consistent with other reports in adults. Regular assessments of CRP and troponin T as well as a baseline TTE are recommended in a currently developed cardiac monitoring protocol from Australia. According to a systematic review by Knoph et al, a baseline ECG and a low threshold for assessing CRP and troponin during the first 4 weeks of clozapine treatment should be applied, at least if clinical signs of myocarditis occur. An additional baseline TTE was recommended in patients with a history of cardiac disease or familial disposition only. Still, a lack of feasibility of specific laboratory or a TTE in patients without cardiac risk must not impede the initiation of clozapine with a clear indication as long as clinicians are aware of the clinical signs of myocarditis, particularly during the first 4 weeks of treatment. In our second case, the previous experience of CIM might have increased our level of awareness tomake a suspected diagnosis based on the clinical signs, which was confirmed by further diagnostics. In contrast to the small number of reported cases worldwide, we observed an accumulation of 2 adolescent patients with CIM in our department within a few