Suspected hydroxychloroquine‐induced thrombotic thrombocytopaenic purpura

Abstract

Background Thrombotic thrombocytopaenic purpura (TTP) is a rare illness characterised by haemolytic anaemia, thrombocytopaenia and microvascular thrombosis with a 90% mortality rate if left untreated. It is a known adverse reaction to quinine; hydroxychloroquine, as a synthetic derivative of this parent compound, may also put patients at risk of this complication. However, reports of hydroxychloroquine‐induced TTP are extremely rare in the literature. Aim This report describes a potential association between consumption of hydroxychloroquine and the development of TTP. Clinical details A 64‐year‐old woman presented with confusion, ataxia, fevers and chills, poor urine output and muscle weakness after receiving three doses of hydroxychloroquine for rheumatoid arthritis. Initial investigations were consistent with haemolytic anaemia, thrombocytopaenia and renal and neurological deterioration. Management and outcome The patient's usual medications were withheld, intravenous corticosteroids were started and total plasma exchange began on day three of her admission. She remained febrile without a source of sepsis, her platelet count and haemoglobin level recovered only slightly and her brain computed tomography showed microvascular ischaemia. Poor prognosis and likely significant long‐term neurological disability led to active treatment being withdrawn on day 15 of her admission and she died the following day. Conclusion This reaction appears similar to the presentation of quinine‐associated TTP and could evolve via a similar mechanism given the structural similarities of these molecules. This case report, sparse reports of hydroxychloroquine‐induced thrombocytopaenia and only one published case report of TTP secondary to this drug highlight a possible association between TTP and hydroxychloroquine.

Thrombotic microangiopathy (aHUS/iTTP) reported so far in Covid-19 patients: The virus alone or an omnium gatherum of mechanisms and etiologies?

“…The typical drug induced TMA (DITMA)including quinine induced TMA is a clinical syndrome of TMA without developing critically low ADAM-TS 13 levels or a circulating inhibitor. However, the potential of HCQ to spark a TMA has been extrapolated against a literature background of quinine associated TMA since only a few cases of HCQ associated TMA have been reported so far without a detailed evaluation ( Fromm, 2018 ; Mar and Mendoza Ladd, 2011 ). Notwithstanding some cases of the classic iTTP with critically low ADAM-TS 13 levels and presence of an inhibitor have been reported in literature in association with the thienopyridine group of anti- platelet drugs ( Zakarija et al, 2021 ).…”

Safety of Short-Term Treatments with Oral Chloroquine and Hydroxychloroquine in Patients with and without COVID-19: A Systematic Review

“…Cases of hypoglycaemia (including a case of hypoglycaemic coma) [ 99 , 100 , 101 , 102 ], thrombocytopaenia [ 104 ], thrombotic thrombocytopaenic purpura [ 105 , 203 ], methaemoglobinaemia, sense organ adverse effects (including cases of severe positional vertigo [ 107 ], severe vestibular toxicity [ 108 ], loss of hearing [ 109 ], complete ageusia [ 110 ], diplopia and blurred vision) [ 106 ], porphyria variegata [ 116 ], severe myopathies [ 118 , 119 ], myasthenic syndrome [ 194 ], anaphylaxis [ 121 ], urinary incontinence [ 122 ], diffuse interstitial lung disease [ 123 ], and acute eosinophilic pneumonias [ 120 ], were described in connection with short-term CQ and HCQ treatments.…”

Case report: Thrombotic thrombocytopenic purpura in a pregnant woman with lupus membranous nephropathy: a diagnostic challenge

“…The only medication utilized by the patient that may be associated with thrombotic microangiopathy (TMA) was hydroxychloroquine ( 15 ), a derivative of quinine, that has not caused a reoccurrence of the phenomenon, even with ongoing use to date.…”