A 63-year-old female with a three-year history of rheumatoid arthritis (RA) presented to the emergency department with persistent generalized body aches and bilateral leg pain for eight days, unresponsive to medication. She denied any symptoms of cough, flu, diarrhea, constipation, urinary incontinence, neck rigidity, or photophobia, and did not report rash, purpura, bleeding gums, or hematuria. The patient was self-medicating with hydroxychloroquine for RA and had no significant past medical or allergic history. Family history was unremarkable.
On examination, the patient appeared pale and dehydrated. Vital signs were stable, with a blood pressure of 110/70 mmHg, heart rate of 76 beats/min, respiratory rate of 30 breaths/min, and oxygen saturation of 97% on room air. Neurological examination was normal, with a Glasgow Coma Scale (GCS) of 15/15. Chest auscultation was clear, and the abdomen was soft and non-tender with normal bowel sounds.
Serial complete blood counts (CBCs) showed a declining platelet count from 28,000 to 21,000 over several days before treatment was started. Further investigations revealed elevated levels of Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), Alkaline Phosphatase (ALP), and Gamma Glutamyl Transferase (GGT) on Liver Function Test (LFT) while rest of the testing turned out normal. Dengue RNA qualitative and genotyping PCR tests were negative. The investigation findings over the 3 day treatment course are summarized in Table 1.
Table 1. Laboratory Investigations
Laboratory Test
|
Day 1
|
Day 2
|
Day 3
|
Reference Range(Females)
|
Hemoglobin
|
10.7
|
11.7
|
11.4
|
12.3-16.6 g/dl
|
Hematocrit
|
25
|
26
|
27.2
|
38.4-50.7
|
WBC
|
5.5
|
4.96
|
9.10
|
4.8-11.3x10E9/l
|
Platelets
|
22
|
38
|
93
|
154-433x10E9/l
|
Potassium
|
4.5
|
-
|
-
|
3.5-5.1 mmol/l
|
Sodium
|
141
|
133
|
140
|
136-145 mmol/l
|
Creatinine
|
0.84
|
-
|
-
|
0.9-1.3 mg/dl
|
BUN
|
16
|
-
|
-
|
6-20 mg/dl
|
Bicarbonate
|
27
|
-
|
-
|
20-31 mmol/l
|
Chloride
|
102
|
-
|
-
|
98-107 mmol/l
|
Total Bilirubin
|
0.24
|
-
|
-
|
Upto 1.2 mg/dl
|
Direct Bilirubin
|
0.13
|
-
|
-
|
>0.2 mg/dl
|
Alkaline Phosphatase
|
125
|
-
|
-
|
42-98 U/L
|
SGPT (ALT)
|
35
|
-
|
-
|
<34 U/L
|
GGT
|
160
|
-
|
-
|
<38 U/L
|
SGOT (AST)
|
60
|
-
|
-
|
<35 U/L
|
WBC: White Blood Cell, BUN: Blood Urea Nitrogen, SGPT: Serum Glutamate-Pyruvate
Transaminase, ALT: Alanine Transaminase, SGOT: Serum Glutamic-Oxaloacetic Transaminase, GGT: Gamma Glutamyl Transpeptidase, AST: Aspartate Transaminase
|
A chest X-ray and ECG were unremarkable. Abdominal ultrasound showed an increased liver span with altered texture. The gall bladder had a thick-walled appearance with a pericholecystic fluid zone. The kidneys appeared normal, and the urinary bladder wall was thickened.
Regarding the patient’s management, based on a negative dengue PCR, clinical evaluation, and unexplained acute thrombocytopenia, the diagnosis of drug-induced thrombocytopenia secondary to hydroxychloroquine intake was made. As a result, the administration of hydroxychloroquine was immediately stopped. The patient’s management is summarized in Table 2.
Table 2. Management
|
Medication
|
Dosage & Frequency
|
Route
|
Normal Saline
|
75 mg/kg on flow
|
IV
|
Vitamin B Complex
|
1 ampule OD
|
IV
|
Multibionta (Multivitamins)
|
1 ampule OD
|
IV
|
Famotidine
|
20mg BD
|
Oral
|
Ascorbic Acid
|
BD
|
Oral
|
Domperidone
|
TID
|
Oral
|
Dimenhydrinate
|
BD
|
IV
|
Acetaminophen
|
1gm SOS
|
IV
|
Dexamethasone
|
8mg
|
IV
|
IV: Intravenous, OD: Once daily, BD: Twice daily, TID: Thrice daily, SOS: as needed
|
Management of the patient accordingly and the elimination of hydroxychloroquine led to a subsequent rise in the patient’s platelet count. Consequently, the patient was discharged in stable condition after three days.