A case report on hydroxychloroquine poisoning. History A 40 year old man Suffered from depression +...
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Transcript of A case report on hydroxychloroquine poisoning. History A 40 year old man Suffered from depression +...
History
A 40 year old man Suffered from depression + dermatomyositis Followed up in PWH On 24th March, 2003, quarreled with wife Took 40 tablets of hydroxychloroquine after
drunk Accompanied by wife to hospital (AHNH)
No other medication was taken On presentation to ED, Generalised weakness, nausea, vomiting. Drowsy and responded slowly No abdominal pain No chest pain or palpitation
Physical examination
Obese, sleepy GCS E3M5V3 Hypotensive (BP 100/53) Pulse: 70/min, regular Heart sound : dual, no murmur Respiratory and abdominal examination:
unremarkable H’stix: 5.1
Condition detriorates
During physical examination, blood pressure dropped to 80/40, pulse: 52/min
GCS 3/15 Nasopharyngeal airway was put in 500mlNS given in bolus BP 90/50, no tachycardia ECG: SR, prolonged QTC interval Adrenaline infusion started 2mg /hr
ICU admission
Patient remained comatose
ICU contacted
Beds full
Tranferred to another hospital’s ICU
Investigation results
Blood investigation: Na: 134; K :3.6 U: 5.6; creatinine: 100 LFT: normal Phosphate : 0.75; adjusted Ca:2.02 WBC: 21.6 Hb & platelet: normal
Discussion
Hydroxychloroquine : 4-aminoquinoline derivative of chloroquine
Indications: malaria, rheumatoid arthritis, dermatomyositis and lupus erythematosus
Plaquenil 1 tablet: 200mg of hydroxychloroquine
phosphate Each contain 155 mg of hydroxychloroquine
Rarely used for drug overdose Life threatening symptoms : within an hour of
ingestion Treatment recommendation: controversial
Chloroquine poisoing
Chloroquine poisoning is more common Used an analogy for study of
hydroxycholorquine poisoning Mortality rate in adults: 10-30% Therapeutic dose: 10mg/kg Toxic dose: 20mg/kg Lethal dose: 30mg/kg Fatality rate in children : 80%
Pharmacokinetics
Readily absorbed from the GIT Large volume of distribution (61 L/kg) Protein binding 50-65%; highly bound to
tissues particularly kidney, liver and lung. Main metabolite is monodesethylchloroquine Mainly eliminated in urine.
Pathophysiology
Cardiotoxicity is related to quinidine-like effects
Hypokalemia is due to direct chloroquine-induced intracellular shifts and will exacerbated by epinephrine therapy.
Clinical manifestations
Serious and rapid clinical consequence Onset of symptoms: 30 minutes Death: 1-3 hr Drowsiness, dizziness, visual disturbance Seizures, apnea, dysrythmias and
hypotension Cardiotoxicity: > 50%
respiratory difficulty -> pulmonary edema + arrest
Hypokalemia: 85% Related to severity of intoxication Criterias associated with fatal outcome:
1) > 5gm
2) SBP < 80mmhg
3) Prolongation of QRS interval > 0.12msec
4) Ventricular rhythm disturbance
5) Blood concentration > 5mcg/ml
Cardiotoxicity of chloroquine
Cardiotoxicity – quinidine like action Negative inotropic Inhibits spontaneous diastolic depolarization Slow conduction Lengthen effective refractory period Raised electrical threshold
Consequences
Decreased contractility Impaired conduction Decreased excitablility Abnormal stimulus to reentry
Treatment model for HCQ poisoning
Early intubation + mechanical ventilation Cardiovascular monitoring Epinephrine : hypotension, dysrhythmia,
QRS widening, circulatory collapse Diazepam : seizure, sedation Alkalinization: NaHCO3 for widen QRS,
hypotension Activated Charcoal (AC) for GI
decontamination, but multiple dose AC had no effect on the rate of elimination
Gastric lavage Treat hypokalemia Avoid drugs with Na channels blocking
activities Hemodialysis, hemoperfusion, peritoneal
dialysis, plasmaphersis and diuresis are of little value in removing drug from the body because cholorquine has large volume of distribution.
Back to the patient
Characteristic rapid onset of symptoms Drowsiness progressive rapidly to coma Hypotension Widen QRS complex No hypokalemia Absence of seizure, early recovery and short
hospital stay IV inotrope was given with BP maintained