Chloroquine cardiomyopathy: beyond ocular adverse effects

Abstract

SUMMARYA 36-year-old woman who had received long-term treatment with chloroquine for systemic lupus erythematosus developed a third degree atrioventricular block and required a permanent pacemaker. Notably, left ventricular thickening and mild systolic dysfunction were noticed on echocardiography as well as on cardiac MRI. As there was no clear explanation for myocardial findings, the patient underwent an endomyocardial biopsy that demonstrated vacuolar degeneration of myocytes on light microscopy and curvilinear bodies on electron microscopy, both findings consistent with chloroquine toxicity. The drug was withheld and treatment with candesartan and carvedilol was prescribed. At 2-year follow-up, the patient remained asymptomatic and left ventricular systolic function had improved. Physicians who prescribe antimalarial drugs for rheumatic diseases should be aware of the potentially life-threatening effects of chloroquine on the heart. BACKGROUND

Antimalarial-induced cardiomyopathy: a systematic review of the literature

“…17,38,40 Syncope (or presyncopal episodes) was the initial clinical manifestation in eight patients (17%); 20,23,26,33,37,46,47 of note, one patient had syncope one year before AMIC diagnosis, 23 while three patients did not have any symptoms to suggest heart failure. 20,26,47 Symptom duration before diagnosis ranged between 15 days and four years. Their primary disease was inactive at the time of AMIC diagnosis in all cases where such data were provided.…”

“…Conduction abnormalities were the most common finding with complete atrioventricular block (AVB) being reported in 17 cases (48.6%). 11–13,15,16,20,22,23,25,33,36,37,39,41,43,47,48 One patient had a second-degree AVB 30 and two patients first-degree AVB. 19,26 Sick sinus syndrome was diagnosed in three patients, 27,34,43 right bundle branch block (BBB) in nine 17,19–21,26,27,29,30,39 and left BBB in five patients.…”

“…19,26 Sick sinus syndrome was diagnosed in three patients, 27,34,43 right bundle branch block (BBB) in nine 17,19–21,26,27,29,30,39 and left BBB in five patients. 17,19,38,44,49 Interestingly, 24 patients (51%) received a permanent pacemaker, 11–13,16,17,19,20,23–25,27,28,30,33–37,39,41,43,47,48 some of them up to four years before AMIC diagnosis. 16,23,25,47,48…”

Evaluation of Crimean-Congo hemorrhagic fever virus in vitro inhibition by chloroquine and chlorpromazine, two FDA approved molecules

“…Reversible side effect can be observed for mucosal pigmentation after months of discontinuation of chloroquine treatment (Armor et al, 2002). Cardiomyopathy side effect can be lessened after cessation of chloroquine treatment and prescription of a combined therapy of candesartan and carvedilol treatment (Lopez-Ruiz and Uribe, 2014). Contrary to hyperpigmentation and cardiomyopathy, retinopathy is an irreversible side effect of long term chloroquine treatment and can appear even after usage of chloroquine has stopped (Kazi et al, 2013).…”

Ocular involvement in systemic lupus erythematosus

“…Antimalarials, such as chloroquine and hydroxyl chloroquine, have been reported to be effective in treating SLE. However, these therapies can cause irreversible vision loss as a result of drug-induced maculopathy and should, therefore, be used with caution [3,23]. For patients exhibiting ocular manifestations associated with highly active disease, that is retinal vasculitis, nephritis and choroiditis, rapid and more aggressive therapy is required [3].…”