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QT interval prolongation and Torsade de Pointes: case report A 66-year-old woman developed QT-interval prolongation during treatment with chloroquine (for COVID-19; off label use) and erythromycin (for improvement of gastrointestinal motility). She subsequently developed Torsade de Pointes [time to reaction onset not stated]. The woman, who had a history of type II diabetes mellitus, hypercholesterolaemia, mild renal impairment and cardiac catheterisation in 2012, presented to the emergency department with fatigue, diarrhoea and coughing. She also reported meeting a relative who was COVID-19 positive. Her ongoing medications included gliclazide, lisinopril and metformin. Additionally, she was receiving ciprofloxacin, which was prescribed by a general practitioner after the initial onset of symptoms (fatigue and diarrhoea). On arrival at the emergency department, her body temperature was found to be 38°C, BP was 98/69mm Hg and HR was 92 bpm. After further examinations, she wad admitted to the internal medicine ward. Her treatment was started with ceftriaxone, and the ongoing ciprofloxacin was stopped. Subsequently, she tested positive for COVID-19. Several hours after the admission, her condition worsened. Therefore, off label treatment was started with oral chloroquine 600mg (loading dose) followed by a maintenance dose of 300mg twice daily for a scheduled duration of 5–7 days. At the time of chloroquine initiation, her baseline QTc interval was 429ms. In the following days, her condition progressively worsened. On day 3 of admission, she was shifted to ICU, and mechanical ventilation was started. On day 5, the QTc interval was found to be 482ms indicating prolongation of QT interval. The prolongation of QT-interval was considered as secondary to the chloroquine therapy. Consequently, the woman’s chloroquine therapy was stopped on day 5, and a slight decrease in QT-interval was noted. On the following day (day 6), erythromycin 250mg twice daily [route not stated] was started for the improvement of gastric motility. QTcinterval at the time of starting erythromycin was 453ms. Subsequently, prolongation of the QT-interval was noted (>500ms). On day 7, she developed Torsade de Pointes and requiring resuscitation. Hence, erythromycin therapy was also stopped. She received treatment with magnesium. Retrospective evaluation of telemetric monitor revealed slow progressive QTc interval prolongation upto 550ms and large U-waves. After the discontinuation of erythromycin, recurrence of Torsade de Pointes was not noted. On day 8, QTc-interval was found to be 507ms and on day 16 it improved to 476ms. On day 52, she tested negative for COVID-19, and she was discharged to a rehabilitation facility on day 62. Semedo E, et al. Drug-induced 'Torsade de Pointes' in a COVID-19 patient despite discontinuation of chloroquine. Importance of its long half-life: A case report. 803520824 European Heart Journal - Case Reports 4: no pagination, No. 1, Oct 2020. Available from: URL: http://doi.org/10.1093/ehjcr/ytaa218

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