Hydroxychloroquine
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Haemolytic anaemia: case report A 26-year-old man developed haemolytic anaemia following an off label therapy with hydroxychloroquine for COVID-19 associated pneumonia. He also received other off label medicines including oseltamivir, lopinavir/ritonavir, azithromycin, ceftriaxone and piperacillin/tazobactam for Covid 19 associated pneumonia. The man presented with headache sore throat, rhinitis, nonproductive cough and low-grade fever. The polymerase chain reaction (PCR) test for COVID-19 was positive. A chest x-ray was suggestive of COVID-19 associated pneumonia. Subsequently, he started receiving off label therapy with oral oseltamivir 150mg twice daily, oral lopinavir/ritonavir 400mg/100mg twice daily, IV azithromycin 500mg once daily, hydroxychloroquine 400mg twice daily followed by once daily [route not stated] and ceftriaxone 2 g/day, as per hospital protocol. Haemoglobin electrophoresis pattern was suggestive of haemoglobin D disease. Screening of glucose 6-phosphate dehydrogenase (G6PD) level was done as a part of the protocol during initiation of hydroxychloroquine treatment, and he was found to be G6PD deficient. Thus, he had simultaneous haemoglobin D thalassemia and G6PD deficiency. Thus, hydroxychloroquine was discontinued after 3 doses, to avoid major haemolytic crisis. Considering the progression of COVID-19 associated pneumonia, treatment of ceftriaxone was escalated to piperacillin/tazobactam. Before admission, his serum aspartate transaminase (AST) and alanine aminotransferase (ALT) levels were normal. From day 7 to 14, there was a transient rise in liver transaminases. His WBC and RBC count decreased. His Hb level also decreased from 12.2 to 9.1 gm/dL over the next 10 days. Haemolysis workup showed elevated lactate dehydrogenase (LDH). Peripheral smear revealed moderate hypochromic microcytic anaemia with anisocytosis, schistocytes, spherocytes, fragmented RBCs, few teardrop cells and few ovalocytes. Reticulocyte count was 0.7%, 0.8% and 0.7% on admission, on day 10 and on day 18, respectively. There was no evidence of haemoglobinuria or haematuria. However, there was evident haemolytic anaemia [duration of treatment to reaction onset not stated]. He had a baseline microcytic hypochromic anaemia, which worsened during the period of hospitalisation. Anaemia was influenced by multiple factors such as underlying haemoglobinopathy, possible iron deficiency, B12 deficiency, acute illness and acute haemolysis. From day 3 of admission, his clinical condition worsened and oxygen requirement increased. After day 12, his condition improved. Concomitantly, he also received methylprednisolone. After day 12, Hb was stable and returned to baseline by day 22, without need for transfusion. On day 28, COVID-19 PCR was negative. The total duration of off label medications were as follows:hydroxychloroquine 2 days, azithromycin 9 days, ceftriaxone 3 days, lopinavir/ritonavir 5 days, oseltamivir 10 days and piperacillin/tazobactam 10 days. Sasi S, et al. A Case of COVID-19 in a Patient with Asymptomatic Hemogl
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