Multidisciplinary Diagnostic and Rechallenge Workflow for Suspected Escitalopram-Associated Neutropenia in Adolescent Obsessive-Compulsive Disorder

Summary

This case report presents a multidisciplinary workflow for evaluating suspected escitalopram-associated neutropenia in an adolescent with obsessive-compulsive disorder, integrating diagnostic assessment, structured complete blood count monitoring, cognitive behavioral therapy with exposure and response prevention, and monitored escitalopram rechallenge to support clinical decision-making under hematologic uncertainty.

Abstract

Selective serotonin reuptake inhibitors are evidence-based pharmacologic treatments for obsessive-compulsive disorder (OCD) in adolescents; however, hematologic adverse effects such as leukopenia and neutropenia are rare and incompletely characterized. Management becomes particularly challenging when an effective medication is suspected to contribute to clinically significant hematologic abnormalities. This case report describes a multidisciplinary diagnostic and monitoring workflow for evaluating suspected escitalopram-associated neutropenia in a 14-year-old female with moderate-to-severe OCD and substantial functional impairment. The patient was initially treated with escitalopram, titrated from 10 mg/day to 20 mg/day, resulting in a 39–55% reduction in symptom severity as assessed by retrospectively reconstructed Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) scores. Persistent leukopenia and neutropenia identified during routine complete blood count (CBC) monitoring prompted escitalopram discontinuation and a structured multidisciplinary evaluation involving hematology, rheumatology, infectious diseases, allergy and immunology, endocrinology, neurology, and cardiology. Extensive investigations, including laboratory testing, peripheral blood smear examination, brain magnetic resonance imaging, and pelvic ultrasonography, did not identify a definitive alternative etiology. Following medication discontinuation, white blood cell counts did not normalize and OCD symptoms relapsed despite cognitive behavioral therapy with exposure and response prevention, delivered in nine weekly sessions by a clinical psychologist. After multidisciplinary risk-benefit assessment and shared decision-making with the patient and legal guardian, escitalopram rechallenge was initiated using gradual dose escalation from 5 mg/day to 20 mg/day over three weeks, with weekly CBC monitoring, predefined stopping criteria, and infection surveillance. The final CY-BOCS score improved to 11/40 (65% reduction from baseline), while hematologic parameters remained stable. The procedural objective of this report is to present a reproducible multidisciplinary framework for diagnostic evaluation, risk stratification, monitoring, and cautious pharmacologic rechallenge in adolescents with suspected SSRI-associated hematologic abnormalities.

Introduction

Obsessive-compulsive disorder (OCD) is defined by the presence of obsessions (recurrent and intrusive thoughts, images, or impulses) and/or compulsions (repeated behavioral or mental acts) that disrupt daily life and generate significant distress¹. OCD ranks among the 10 most disabling medical and psychiatric conditions, with a lifetime prevalence of 2%–3% in the general population^2,3,4,5. For several decades, research has focused on identifying effective therapies for OCD, including psychotherapy, pharmacologic....

Protocol

The case report was prepared in accordance with institutional policies and standard ethical guidelines. Under institutional policy, anonymized case studies, including case reports and case series that do not involve experimental interventions, are exempt from ethics committee approval. The principles outlined in the Declaration of Helsinki were followed throughout the clinical assessment and documentation process. Written informed consent was obtained from the patient’s legal guardian for publication of this case report and accompanying clinical details. Efforts were made to ensure complete anonymization of the patient's identity.

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Results

Obsessive-compulsive symptom severity, assessed via retrospectively reconstructed CY-BOCS scores, followed a trajectory consistent with the clinical course across all treatment phases. At baseline, the estimated CY-BOCS total score was 31/40, consistent with severe OCD. Following escitalopram titration to 20 mg/day, scores decreased to 19/40 at month 1 (−39%) and to 14/40 at month 3 (−55%), accompanied by functional improvement in daily activities, academic participation, and family interaction. Following escitalopram di.......

Discussion

This case presents a multidisciplinary framework for managing a high-stakes therapeutic decision under irreducible diagnostic uncertainty: whether to maintain precautionary pharmacotherapy discontinuation at the cost of progressive psychiatric deterioration or to attempt cautious rechallenge in the absence of a confirmed etiological diagnosis. Thus, beyond presenting as suspected drug-induced neutropenia, this case illustrates the diagnostic complexity, ethical reasoning, and procedural rigor required when a hematologic .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Anti-Streptolysin O (ASO) Titer Assay	Not available retrospectively	Not available retrospectively	Streptococcal exposure assessment
Autoimmune Panel (RF, C3, C4)	Not available retrospectively	Not available retrospectively	Autoimmune evaluation
Brain Magnetic Resonance Imaging (MRI) System	Not available retrospectively	Not available retrospectively	Exclusion of neurologic pathology
Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS)	Yale University OCD Program	N/A	OCD severity assessment
Clinical Medical Record System	Oasis Plus Electronic Medical Record (EMR) System	N/A	Retrospective clinical data retrieval
Cognitive Behavioral Therapy (CBT) Protocol	Clinical Psychology Service	N/A	Psychotherapy intervention
Complete Blood Count (CBC) Analyzer	Not available retrospectively	Not available retrospectively	Hematologic monitoring
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Diagnostic Criteria	American Psychiatric Association	N/A	OCD diagnosis
Endocrine Laboratory Panel (TSH, prolactin, estradiol, progesterone, parathyroid hormone [PTH], vitamin D)	Not available retrospectively	Not available retrospectively	Endocrine evaluation
Epstein–Barr Virus (EBV) Serology Assay	Not available retrospectively	Not available retrospectively	Infectious disease evaluation
Erythrocyte Sedimentation Rate (ESR) Assay	Not available retrospectively	Not available retrospectively	Inflammatory evaluation
Escitalopram	Lundbeck	Not documented	SSRI treatment and rechallenge
Exposure and Response Prevention (ERP) Materials	Clinical Psychology Service	N/A	ERP intervention
Ferritin Assay	Not available retrospectively	Not available retrospectively	Nutritional and hematologic assessment
Folate Assay	Not available retrospectively	Not available retrospectively	Nutritional assessment
Hemophagocytic Lymphohistiocytosis (HLH) Screening Panel	Not available retrospectively	Not available retrospectively	Exclusion of hematologic disorders
Informed Consent Documentation	Institutional Clinical Records System	N/A	Guardian consent for publication
Multidisciplinary Consultation Workflow	Psychiatry, Hematology, Rheumatology, Infectious Diseases, Allergy and Immunology, Endocrinology, Neurology, and Cardiology Services	N/A	Diagnostic assessment and treatment decision-making
Pelvic Ultrasound System	Not available retrospectively	Not available retrospectively	Endocrine and developmental evaluation
Peripheral Blood Smear Analysis	Institutional Clinical Laboratory	N/A	Morphologic hematology evaluation
Protein C and Protein S Assays	Not available retrospectively	Not available retrospectively	Hematologic evaluation
Structured Clinical Psychiatric Interview	Child and Adolescent Psychiatry Clinic	N/A	Baseline and follow-up psychiatric assessment