1
|
Nearly Fatal Hydroxychloroquine Overdose Successfully Treated with Midazolam, Propofol, Sodium Bicarbonate, Norepinephrine, and Intravenous Lipid Emulsion. Case Rep Emerg Med 2021; 2021:8876256. [PMID: 33968450 PMCID: PMC8081608 DOI: 10.1155/2021/8876256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 03/31/2021] [Accepted: 04/03/2021] [Indexed: 12/14/2022] Open
Abstract
Background In the context of the current COVID-19 pandemic, there has been renewed interest in the drug hydroxychloroquine. However, clinicians should be aware of the dangers of hydroxychloroquine intoxication, an insufficiently studied condition. Case Report. We present a case of autointoxication with 20 g hydroxychloroquine in a 35-year-old woman. Cardiac monitoring showed ventricular arrhythmias for which high-dose midazolam and propofol were initiated, resulting in a brief normalization of the cardiac rhythm. Because of the reoccurrence of these arrhythmias, intravenous lipid emulsion was administered with fast cardiac stabilization. Treatment with continuous norepinephrine, potassium chloride/phosphate, and sodium bicarbonate was initiated. On day 6, she was extubated and after 11 days, she was discharged from the hospital without complications. Conclusion Since high-quality scientific evidence is lacking, treatment options are based on experience in chloroquine toxicity. Activated charcoal is advised if the patient presents early. Sedation with diazepam, early ventilation, and continuous epinephrine infusion are considered effective in treating severe intoxication. Caution is advised when substituting potassium. Despite the lack of formal evidence, sodium bicarbonate appears to be useful and safe in case of QRS widening. Intravenous lipid emulsion, with or without hemodialysis, remains controversial but appears to be safe. As a last resort, extracorporeal life support might be considered in case of persisting hemodynamic instability.
Collapse
|
2
|
Holvoet W, van Soest K, Havenith T, Lorusso R, van Mook WNKA, Delnoij T. Bail-out extracorporeal membrane oxygenation for hydroxychloroquine intoxication: a warning for COVID-19 health-care givers. Acta Cardiol 2021; 76:200-203. [PMID: 33308005 DOI: 10.1080/00015385.2020.1802903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This case report describes an intentional intoxication with 18 g of hydroxychloroquine (HCQ) presenting with unconsciousness, ventricular dysrhythmias, cardiogenic shock and pulmonary oedema. Initial treatment consisted of sodium bicarbonate, lipid emulsion, diazepam and norepinephrine. Because of persistent cardiogenic shock veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was successfully used as a bridge to recovery. This case underscores the possible side effects of HCQ and the importance of considering ECMO in cardiogenic shock caused by HCQ intoxication which may occur also in patients with coronavirus disease 2019 (COVID-19) based on the currently frequent use of such a compound.
Collapse
Affiliation(s)
- Wouter Holvoet
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Kaja van Soest
- Department of Clinical Pharmacy, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Thomas Havenith
- Department of Clinical Pharmacy, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Roberto Lorusso
- Department of Cardio-thoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Thijs Delnoij
- Department of Intensive Care and Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
3
|
Bakhsh HT. Hydroxychloroquine Toxicity Management: A Literature Review in COVID-19 Era. J Microsc Ultrastruct 2021; 8:136-140. [PMID: 33623735 PMCID: PMC7883488 DOI: 10.4103/jmau.jmau_54_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 06/28/2020] [Accepted: 06/30/2020] [Indexed: 11/04/2022] Open
Abstract
Background Hydroxychloroquine (HCQ) has been widely investigated for the treatment of COVID-19. Although it is rare, several case reports of acute toxicity of HCQ due to overdose have been reported during the last two decades. The aim of this review is to summarize the management options of acute HCQ toxicity. Methods A literature review that was conducted using an electronic search in the Google Scholar search engine. The inclusion criteria include any patient over 12 years old presenting with HCQ intoxication symptoms from January 1999 to January 2020. Results Sixteen cases were found that have the inclusion criteria of this study. Most patients presented with altered mental status, electrocardiogram abnormalities, visual disturbance, and decrease cardiac output. Activated charcoal was the first line of management in nearly two-thirds of patients whereas 93.8% received fluid resuscitation and 81.3% of the patients need at least one type of vasopressor agent. Furthermore, potassium is given for 93.8% of the patient while 75% of the patients need sodium bicarbonate and intubation, lipid emulsion was used in three patients only and 13 patients survived. Conclusion The acute HCQ toxicity may result during the treatment period of COVID-19. The most common options can use in this situation include included gastric lavage and decontamination, IV fluid resuscitation, potassium replacement, sodium bicarbonate, intravenous lipid emulsion, and extracorporeal circulation membrane oxygenation. The role of diazepam is not clear but can be used in the significant toxicity while hyperkalemia associated with severe ingestions.
Collapse
Affiliation(s)
- Hussain T Bakhsh
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| |
Collapse
|
4
|
Fram G, Wang DD, Malette K, Villablanca P, Kang G, So K, Basir MB, Khan A, McKinnon JE, Zervos M, O’Neill WW. Cardiac Complications Attributed to Hydroxychloroquine: A Systematic Review of the Literature Pre-COVID-19. Curr Cardiol Rev 2021; 17:319-327. [PMID: 33059567 PMCID: PMC8640856 DOI: 10.2174/1573403x16666201014144022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Hydroxychloroquine has been used for rheumatological diseases for many decades and is considered a safe medication. With the COVID-19 outbreak, there has been an increase in reports associating cardiotoxicity with hydroxychloroquine. It is unclear if the cardiotoxic profile of hydroxychloroquine is previously underreported in the literature or is it a manifestation of COVID-19 and therapeutic interventions. This manuscript evaluates the incidence of cardiotoxicity associated with hydroxychloroquine prior to the onset of COVID-19. METHODS PubMED, EMBASE, and Cochrane databases were searched for keywords derived from MeSH terms prior to April 9, 2020. Inclusion eligibility was based on appropriate reporting of cardiac conditions and study design. RESULTS A total of 69 articles were identified (58 case reports, 11 case series). The majority (84%) of patients were female, with a median age of 49.2 (range 16-92) years. 15 of 185 patients with cardiotoxic events were in the setting of acute intentional overdose. In acute overdose, the median ingestion was 17,857 ± 14,873 mg. 2 of 15 patients died after acute intoxication. In patients with long-term hydroxychloroquine use (10.5 ± 8.9 years), new onset systolic heart failure occurred in 54 of 155 patients (35%) with median cumulative ingestion of 1,493,800 ± 995,517 mg. The majority of patients improved with the withdrawal of hydroxychloroquine and standard therapy. CONCLUSION Millions of hydroxychloroquine doses are prescribed annually. Prior to the COVID-19 pandemic, cardiac complications attributed to hydroxychloroquine were uncommon. Further studies are needed to understand the impact of COVID-19 on the cardiovascular system to understand the presence or absence of potential medication interactions with hydroxychloroquine in this new pathophysiological state.
Collapse
Affiliation(s)
- Georgi Fram
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, MI 48202, USA
| | - Dee D. Wang
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, MI 48202, USA
| | - Kelly Malette
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, MI 48202, USA
| | - Pedro Villablanca
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, MI 48202, USA
| | - Guson Kang
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, MI 48202, USA
| | - Kent So
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, MI 48202, USA
| | - Mir B. Basir
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, MI 48202, USA
| | - Arfaat Khan
- Section of Cardiac Electrophysiology, Henry Ford Health System, Detroit, Michigan, MI 48202, USA
| | - John E. McKinnon
- Divison of Infectious Disease, Henry Ford Health System, Detroit, MMichigan, MI 48202, USA
| | - Marcus Zervos
- Divison of Infectious Disease, Henry Ford Health System, Detroit, MMichigan, MI 48202, USA
| | - William W. O’Neill
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan, MI 48202, USA
| |
Collapse
|
5
|
Della Porta A, Bornstein K, Coye A, Montrief T, Long B, Parris MA. Acute chloroquine and hydroxychloroquine toxicity: A review for emergency clinicians. Am J Emerg Med 2020; 38:2209-2217. [PMID: 33071096 PMCID: PMC7369162 DOI: 10.1016/j.ajem.2020.07.030] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/11/2020] [Accepted: 07/11/2020] [Indexed: 02/08/2023] Open
Abstract
Background Acute chloroquine and hydroxychloroquine toxicity is characterized by a combination of direct cardiovascular effects and electrolyte derangements with resultant dysrhythmias and is associated with significant morbidity and mortality. Objective This review describes acute chloroquine and hydroxychloroquine toxicity, outlines the complex pathophysiologic derangements, and addresses the emergency department (ED) management of this patient population. Discussion Chloroquine and hydroxychloroquine are aminoquinoline derivatives widely used in the treatment of rheumatologic diseases including systemic lupus erythematosus and rheumatoid arthritis as well as for malaria prophylaxis. In early 2020, anecdotal reports and preliminary data suggested utility of hydroxychloroquine in attenuating viral loads and symptoms in patients with SARS-CoV-2 infection. Aminoquinoline drugs pose unique and significant toxicological risks, both during their intended use as well as in unsupervised settings by laypersons. The therapeutic range for chloroquine is narrow. Acute severe toxicity is associated with 10–30% mortality owing to a combination of direct cardiovascular effects and electrolyte derangements with resultant dysrhythmias. Treatment in the ED is focused on decontamination, stabilization of cardiac dysrhythmias, hemodynamic support, electrolyte correction, and seizure prevention. Conclusions An understanding of the pathophysiology of acute chloroquine and hydroxychloroquine toxicity and available emergency treatments can assist emergency clinicians in reducing the immediate morbidity and mortality associated with this disease.
Collapse
Affiliation(s)
- Alessandra Della Porta
- University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Emergency Medicine, Jackson Memorial Health System, Miami, Florida, USA; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA; Emergency Department, Jackson South Medical Center, Miami, Florida, USA
| | - Kasha Bornstein
- University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Emergency Medicine, Jackson Memorial Health System, Miami, Florida, USA; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA; Emergency Department, Jackson South Medical Center, Miami, Florida, USA
| | - Austin Coye
- University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Emergency Medicine, Jackson Memorial Health System, Miami, Florida, USA; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA; Emergency Department, Jackson South Medical Center, Miami, Florida, USA
| | - Tim Montrief
- University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Emergency Medicine, Jackson Memorial Health System, Miami, Florida, USA; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA; Emergency Department, Jackson South Medical Center, Miami, Florida, USA
| | - Brit Long
- University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Emergency Medicine, Jackson Memorial Health System, Miami, Florida, USA; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA; Emergency Department, Jackson South Medical Center, Miami, Florida, USA.
| | - Mehruba Anwar Parris
- University of Miami Miller School of Medicine, Miami, Florida, USA; Department of Emergency Medicine, Jackson Memorial Health System, Miami, Florida, USA; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA; Emergency Department, Jackson South Medical Center, Miami, Florida, USA.
| |
Collapse
|
6
|
Chary MA, Barbuto AF, Izadmehr S, Hayes BD, Burns MM. COVID-19: Therapeutics and Their Toxicities. J Med Toxicol 2020; 16:284-294. [PMID: 32356252 PMCID: PMC7192319 DOI: 10.1007/s13181-020-00777-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 02/07/2023] Open
Abstract
SARS-CoV-2 is a novel coronavirus that emerged in 2019 and is causing the COVID-19 pandemic. There is no current standard of care. Clinicians need to be mindful of the toxicity of a wide variety of possibly unfamiliar substances being tested or repurposed to treat COVID-19. The United States Food and Drug Administration (FDA) has provided emergency authorization for the use of chloroquine and hydroxychloroquine. These two medications may precipitate ventricular dysrhythmias, necessitating cardiac and electrolyte monitoring, and in severe cases, treatment with epinephrine and high-doses of diazepam. Recombinant protein therapeutics may cause serum sickness or immune complex deposition. Nucleic acid vaccines may introduce mutations into the human genome. ACE inhibitors and ibuprofen have been suggested to exacerbate the pathogenesis of COVID-19. Here, we review the use, mechanism of action, and toxicity of proposed COVID-19 therapeutics.
Collapse
Affiliation(s)
- Michael A Chary
- Division of Emergency Medicine, Harvard Medical Toxicology Fellowship, Boston Children's Hospital, Boston, MA, USA.
- Regional Center for Poison Control and Prevention Serving Massachusetts and Rhode Island, Boston, MA, USA.
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Alexander F Barbuto
- Division of Emergency Medicine, Harvard Medical Toxicology Fellowship, Boston Children's Hospital, Boston, MA, USA
- Regional Center for Poison Control and Prevention Serving Massachusetts and Rhode Island, Boston, MA, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sudeh Izadmehr
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bryan D Hayes
- Department of Pharmacy, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michele M Burns
- Division of Emergency Medicine, Harvard Medical Toxicology Fellowship, Boston Children's Hospital, Boston, MA, USA
- Regional Center for Poison Control and Prevention Serving Massachusetts and Rhode Island, Boston, MA, USA
| |
Collapse
|
7
|
Merino Argumánez C, Sáez de La Fuente I, Molina Collado Z, Suárez Pita D, Mestre Gómez B, Sanchez Izquierdo JA. Hydroxychloroquine, a potentially lethal drug. Med Intensiva 2018; 41:257-259. [PMID: 27480672 DOI: 10.1016/j.medin.2016.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/04/2016] [Accepted: 05/08/2016] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Z Molina Collado
- Sección de Medicina Intensiva, Hospital 12 de Octubre, Madrid, España
| | - D Suárez Pita
- Sección de Medicina Intensiva, Hospital 12 de Octubre, Madrid, España
| | - B Mestre Gómez
- Sección de Medicina Intensiva, Hospital 12 de Octubre, Madrid, España
| | | |
Collapse
|
8
|
Novel Therapies for Myocardial Irritability following Extreme Hydroxychloroquine Toxicity. Case Rep Emerg Med 2015; 2015:692948. [PMID: 26351590 PMCID: PMC4553308 DOI: 10.1155/2015/692948] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 08/03/2015] [Indexed: 11/17/2022] Open
Abstract
Introduction. Hydroxychloroquine (HCQ) overdose is rare and potentially deadly when consumed in large doses. Management of severe HCQ toxicity is limited and infrequently reported. This report presents the case of a massive ingestion of HCQ. Case Report. A 23-year-old female presents following an intentional ingestion of approximately 40 g of HCQ. Within six hours after ingestion, she developed severe hemodynamic instability resulting from myocardial irritability with frequent ventricular ectopic activity leading to runs of polymorphic ventricular tachycardia (PMVT) and ventricular fibrillation (VF) requiring multiple defibrillations. Additional treatments included intravenous diazepam, epinephrine, norepinephrine, sodium bicarbonate, and magnesium sulfate. Despite the ongoing hemodynamic instability, the patient was also treated with Intralipid (ILE) and received hemodialysis. Improvements in her hemodynamics were observed after 18 hours. She survived her massive overdose of HCQ. Conclusion. HCQ poisoning is rare but serious because of its rapid progression to life-threatening symptoms. Hemodynamic support, gastric decontamination, electrolyte monitoring and replacement, and management of arrhythmias are the mainstays of treatment. The combined role of dialysis and ILE in the setting of massive HCQ overdose may improve outcomes.
Collapse
|
9
|
Soichot M, Mégarbane B, Houzé P, Chevillard L, Fonsart J, Baud FJ, Laprévote O, Bourgogne E. Development, validation and clinical application of a LC-MS/MS method for the simultaneous quantification of hydroxychloroquine and its active metabolites in human whole blood. J Pharm Biomed Anal 2014; 100:131-137. [DOI: 10.1016/j.jpba.2014.07.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 06/24/2014] [Accepted: 07/08/2014] [Indexed: 10/25/2022]
|
10
|
|
11
|
Gunja N, Roberts D, McCoubrie D, Lamberth P, Jan A, Simes DC, Hackett P, Buckley NA. Survival after massive hydroxychloroquine overdose. Anaesth Intensive Care 2009; 37:130-3. [PMID: 19157361 DOI: 10.1177/0310057x0903700112] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hydroxychloroquine overdose is infrequently reported and the majority of recommendations come from the greater experience with chloroquine poisoning. We report two cases of massive hydroxychloroquine poisoning (20 g in each case), both of which received advanced cardiac life support and a treatment regimen consisting of sodium bicarbonate, adrenaline and potassium. Both these patients survived beyond their initial rapid deterioration and cardiovascular collapse to be discharged from hospital without sequelae. These patients had the highest reported non-lethal serum concentrations (13.8 and 26.0 mg/l). They both demonstrated rapid recovery from a pre-arrest condition, following aggressive correction of electrolyte and pH disturbance and rapid distribution of the drug to peripheral tissues.
Collapse
Affiliation(s)
- N Gunja
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Isetta C. Départ imprévu en CEC. Ing Rech Biomed 2008. [DOI: 10.1016/s1959-0318(08)74449-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
13
|
Thomas S, Terrier N, Padilla M, Durand M, Chavanon O. [Kidney allograft harvesting on a donor patient under cardiopulmonary bypass]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2008; 27:166-168. [PMID: 18162360 DOI: 10.1016/j.annfar.2007.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 11/07/2007] [Indexed: 05/25/2023]
Abstract
We report the case of a kidney allograft harvesting on a donor patient under cardiopulmonary bypass (CPB) after a cardiac arrest. The two kidneys were successfully transplanted with immediate graft function. CPB may provide an option to expand the number of harvested grafts.
Collapse
Affiliation(s)
- S Thomas
- Pôle d'anesthésie réanimation, hôpital Michallon, B.P. 217, 38043 Grenoble cedex 09, France
| | | | | | | | | |
Collapse
|