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Case Reports
. 2021 Apr 20:2021:8876256.
doi: 10.1155/2021/8876256. eCollection 2021.

Nearly Fatal Hydroxychloroquine Overdose Successfully Treated with Midazolam, Propofol, Sodium Bicarbonate, Norepinephrine, and Intravenous Lipid Emulsion

Goswin Onsia  1   2 , Sarah Bots  1   3
Affiliations
Case Reports

Nearly Fatal Hydroxychloroquine Overdose Successfully Treated with Midazolam, Propofol, Sodium Bicarbonate, Norepinephrine, and Intravenous Lipid Emulsion

Goswin Onsia et al. Case Rep Emerg Med. .

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.

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Conflict of interest statement

GO and SB declare that they have no competing interests.

Figures

Figure 1
Figure 1
Two screenshots of bedside cardiac monitoring at admission: (a) a run of ventricular tachycardia and (b) a short episode of ventricular fibrillation.
Figure 2
Figure 2
ECG at admission showing QRS widening and ventricular extrasystoles with varying morphology.
Figure 3
Figure 3
Evolution of plasma potassium in the first 4 days of hospitalization.
See this image and copyright information in PMC

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