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Abstract

Introduction: Hydroxychloroquine is a Aminoquinoline derivative which is widely used for treatment of malaria, rheumatoid arthritis and lupus besides many other autoimmune diseases. Though neutropenia is listed as a potential side effect, there is no reported case in the literature. We present a very rare presentation of hydroxychloroquine toxicity. CASE PRESENTATION 36 year old female presented with fever, malaise, chills and a lip rash for 3 days duration.Her past history included eosinophilic fasciitis being treated with methotrexate for 2 years which was stopped due to intolerence 3 weeks ago and she was started on hydroxychloroquine 300mg daily. Investigation revealed WBC 300,absolute neutrophil 0, Hg 13.1, Hct 39.2, platelets 51,000. Hydroxychloroquine was stopped and she was admitted in ICU for septic shock. She was started on Filgrastim and broad spectrum antibiotics for neutropenic fever. Her blood cultures were positive for methicillin sensitive Staphylococcus aureus which was treated with appropriate antibiotics.. On day 4 her count were 21,700 with absolute neutrophil 17,190. Filgrastim was then stopped. White blood count increased up to 44,100. She was afebrile from day 2 and her repeat cultures were negative. She was successfully treated and discharged to home on day 10 of hospital admission. Discussion: Hydroxychloroquine has relative safety profile with 0.73% incidence of neutropenia. Though there are some case reports of its use to treat neutropenia in some condition like Felty's syndrome(1), this is the first reported case of profound neutropenia to the best of our knowledge. This case illustrates the importance of anticipation and early recognition of its potential fatal side effect. REFERENCES: 1 Neutropenia in Felty's syndrome successfully treated with hydroxychloroquine. Mahévas M, Audia S, De Lastours V, Michel M, Bonotte B, Godeau B. Chloroquine cardiomyopathy - a review of the literature.Tönnesmann E, Kandolf R, Lewalter T.Immunopharmacol Immunotoxicol. 2013 Jun;35(3):434-42. doi: 10.3109/08923973.2013.780078. Epub 2013 May 1.12. Efficient and effective screening for hydroxychloroquine toxicity.Marmor MF.Am J Ophthalmol. 2013 Mar;155(3):413-4. doi: 10.1016/j.ajo.2012.10.020.