Intravenous Lipid Emulsion Use for Severe Hydroxychloroquine Toxicity

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Hydroxychloroquine (HCQ) is a drug commonly prescribed in the treatment of rheumatologic conditions.1 Overdose is exceedingly rare.1–3 Of 1408 fatalities reported to the American Association of Poison Control Centers in 2014, 2 involved HCQ.4 It causes severe toxicity in overdose with high mortality rates.2 The toxic dose of HCQ is as little as four grams.1 HCQ is rapidly absorbed and leads to high blood concentrations shortly after ingestion.5
Symptoms related to overdose manifest rapidly because blood concentrations peak within hours. These include altered mental status, visual disturbances, seizures, ventricular dysrhythmias, hypotension, and depressed cardiac output. Patients may develop profound hypokalemia.1–3,5–7 Rebound hyperkalemia can develop as the derangement is reversed. Criteria for severe poisoning are hypotension, prolonged QRS, ventricular dysrhythmias, and severe hypokalemia.5 Greater than 4 g has been proposed as a criterion for severe HCQ overdose.
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