Leukopenia, agranulocytosis, and the occasional case of thrombocytopenia have been reported. There is some evidence that myelosuppression is dose-dependent. This is in line with the hypothesis that 4-aminoquinoline therapy merely accentuates the cytopenia linked to other forms of bone marrow damage. Some studies have pointed to inhibitory effects of chloroquine on platelet aggregability.
In an investigation, this aspect of chloroquine was studied in vitro in a medium containing ADP, collagen, and ristocetin. There was a highly significant effect at chloroquine concentrations of 3. However, there were no significant differences in platelet responses to ADP or collagen 2 or 6 hours after adding chloroquine, compared with pre-drug values. The investigators believed that these data provided no cause for concern in using chloroquine for malaria prophylaxis in patients with impaired hemostasis.
Pigmentation of the palate can occur as a part of a more generalized pigmentation in patients taking chloroquine. Several patients seen with chloroquine retinopathy in Accra have been observed to present with depigmented patches in the skin of the face. This may be associated with a greyish pigmentation of the mucosa of the hard palate. Two such cases are reported here to illustrate the condition. Stomatitis with buccal ulceration has occasionally been mentioned. Gastrointestinal discomfort is not unusual in patients receiving chloroquine, and diarrhea can occur.
Changes in intestinal motility may be to blame; intramuscular injection of chloroquine caused a shortened orofecal time in the five cases in which this was measured. Overdosage can cause vomiting. Chloroquine can turn the nail bed blue-brown and the nail itself can develop longitudinal stripes and show a blue-grey fluorescence.
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Allergic contact dermatitis, which progressed to generalized dermatitis and conjunctivitis, followed later by severe asthma, occurred in a year-old worker in the pharmaceutical industry after exposure to hydroxychloroquine. Patch-testing showed delayed sensitivity to hydroxychloroquine. Equivalent tests in five healthy volunteers were negative. The patch test reactions were pustular, and a biopsy was interpreted as multiform contact dermatitis. Bronchial exposure to hydroxychloroquine dust produced delayed bronchial obstruction over the next 20 hours, progressing to fever and generalized erythema hematogenous contact dermatitis.
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Skin lesions and eruptions of different types have been attributed to chloroquine, including occasional cases of epidermal necrolysis. The most common dermatological adverse event associated with chloroquine is skin discomfort often called pruritus. It is much more common in people with darker skins and has been ascribed to chloroquine binding to increased melanin concentrations in the skin.
In a pharmacokinetic study, the ratio of AUCo for chloroquine and its major metabolite desethylchloroquine was significantly higher in the plasma and urine of 18 patients with chloroquine-induced pruritus than in that of 18 patients without. These results imply that differences in metabolism and higher chloroquine concentrations may be partly responsible for chloroquine-induced pruritus.
Pruritus begins about 10 hours after the start of treatment, with a maximum intensity at about 24 hours. These times correspond to maximum serum concentrations of chloroquine and its metabolites after oral ingestion. In many cases, the itch is confined to the palms of the hands and the soles of the feet. In a second study, there was an even higher incidence.
Not surprisingly, pruritus is a major cause of non-adherence to treatment, and it may contribute largely to the emergence and spread of resistant P. Pruritus is more often seen in black-skinned than in white-skinned people in Africa, a difference that has been ascribed to the binding of chloroquine to melanin, and hence a racial predisposition. No such reports have come from America. Antihistamine treatment can have a preventive effect on pruritus. Other treatments that have been mentioned include prednisone and niacin, but the results were not impressive.
A few cases of psoriasis, or severe exacerbation of psoriasis shortly after the start of treatment, have been reported. Photosensitivity and photo-allergic dermatitis have been seen, particularly during prolonged therapy with high doses. Blue-black pigmentation involving the palate and facial, pretibial, and subungual areas occurs rarely, but it has been associated with retinopathy.
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The nail bed can turn blue-brown and the nail itself may develop longitudinal stripes and show a blue-grey fluorescence. A year-old woman with rheumatoid arthritis took hydroxychloroquine mg bd for painful synovitis, in addition to meloxicam, co-dydramol, and Gaviscon. She inadvertently took twice the prescribed dose of hydroxychloroquine, but stopped it after 2 weeks because of nausea.
The next day she developed a widespread blotchy erythema and 2 weeks later was admitted to hospital with clinical and histological toxic epidermal necrolysis and deteriorated rapidly with multiorgan failure; she died 1 week later. There have been only a few isolated reports of Stevens-Johnson syndrome associated with hydroxychloroquine.
Recently, a clear temporal relation to the start of treatment with hydroxychloroquine has been documented in a patient with rheumatoid arthritis. An increased frequency of skin reactions to hydroxychloroquine was noted in 11 patients seven of whom had systemic lupus erythematosus, two discoid lupus, and two a lupus-like syndrome when a coloring agent sunshine yellow E was removed from the formulation; the authors were unable to explain this unexpected finding. There have been four case reports of photosensitivity associated with hydroxychloroquine which has an estimated incidence of about 10 per patient-years.
Hydroxychloroquine causes skin reactions such as urticaria. There is some support for the contention that hydroxychloroquine causes skin reactions more often than chloroquine. Chloroquine and its congeners can cause two typical effects in the eye, a keratopathy and a specific retinopathy.
Both of these effects are associated with the administration of the drug over longer periods of time. Chloroquine-induced keratopathy is limited to the corneal epithelium, where high concentrations of the drug are readily demonstrable. Slit lamp examination shows a series of punctate opacities scattered diffusely over the cornea; these are sometimes seen as lines just below the center of the cornea, while thicker yellow lines may be seen in the stroma.
The commonest symptoms are the appearance of halos around lights and photophobia. Dust exposure can lead to similar changes. The condition is usually reversible on withdrawal and does not seem to involve a threat to vision. There are differences in incidence between chloroquine and hydroxychloroquine. The retinopathy encountered with the prolonged use of chloroquine or related drugs is a much more serious adverse effect and can lead to irreversible damage to the retina and loss of vision.
However, it is not possible to predict in which patients and in what proportion of patients an early retinopathy will progress to blindness. At this stage the retinal vessels are contracted, there are changes in the peripheral retinal pigment epithelium, and the optic disk is atrophic. In the early stages there are changes in the macular retinal pigment epithelium.
However, the picture is not always clear, and peripheral retinal changes may appear as the first sign. Another sign may be unilateral paramacular retinal edema. Retinopathy can occur after chloroquine antimalarial chemoprophylaxis for less than 10 years: the lowest reported total dose was g. A case of hydroxychloroquine-induced retinopathy in a year-old woman with systemic lupus erythematosus has illustrated that maculopathy can be associated with other 4-aminoquinolines.
The resulting functional defects are varied: difficulty in reading, scotomas, defective color vision, photophobia, light flashes, and a reduction in visual acuity. Symptoms do not parallel the retinal changes.
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By the time that visual acuity has become impaired, irreversible changes will have taken place. Testing of visual acuity, central fields with or without the use of red targets , contrast sensitivity, dark adaptation, and color vision provides no early indication of chloroquine retinopathy. Careful ophthalmoscopic examination of the macula can be a sensitive index when visual acuity remains intact.
More sophisticated tests, such as the measurement of the critical flicker fusion frequency and the Amsler grid test detection of small peripheral scotoma , can be useful. It is important to trace, if at all possible, the results of a pretreat-ment ophthalmological examination after dilatation of the pupils, thus reducing the possibility of confusing senile degenerative changes with chloroquine-induced abnormalities.
Despite the fact that the retinopathy has been known for many years, it is still not clear why certain patients develop these changes while others do not. There is a clear relation to daily dosage: the retinopathy is rarely seen with daily doses below mg of chloroquine or mg of hydroxychloroquine; the daily dose seems to be more important than the total dose. Nevertheless, cases of retinopathy have been described after the use of small doses for relatively short periods of time, while prolonged treatment and total doses of a kilogram or more have been used in many other patients without any evidence of macular changes.
In the published cases there is usually no information about other treatments given previously or concomitantly. More cases are seen in older people. Patients with lupus erythematosus are more susceptible than patients with rheumatoid arthritis.
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The presence of nephropathy increases the likelihood of retinopathy, as does the concomitant use of probenecid. Exposure to sunlight may be of importance, since light amplifies the risk of retinopathy. The retinopathic changes are probably connected with the concentrating capacity of the melanin-containing epithelium. Chloroquine inhibits the incorporation of amino acids into the retinal pigment epithelium. Little is yet known about the development of the retinopathy after withdrawal of treatment. Retinal changes in the early stages are probably reversible if the drug is withdrawn, and progression of a severe maculopathy to blindness seems to be less frequent than feared.
Three patients with chloroquine retinopathy have been studied with multifocal electroretinography.
All three had been taking chloroquine for rheumatological diseases and all had electroretinographic changes that were more sensitive than full field electroretinography. It may be that multifocal electroretinography will be a useful technique in the assessment of suspected cases of subtle chloroquine retinopathy. The best current opinion seems to be that at doses not exceeding 6. However, patients taking chloroquine or higher doses of hydroxychloroquine should be checked.
Rhegmatogenous retinal detachment and bitemporal hemianopsia have both been seen in association with chloroquine retinopathy. Diplopia and impaired accommodation characterized by difficulty in changing focus quickly from near to far vision and vice versa also affect a minority of patients.