Hydroxychloroquine in a G6PD-Deficient Patient with COVID-19
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Hydroxychloroquine is an old drug usually indicated for rheumatic disease. It was introduced as a first-line treatment in Belgium for COVID-19 patients requiring hospitalization. This recommendation was based on data suggesting in vitro efficacy against SARS-CoV-2.

A 32-year-old man of sub-Saharan African origin was hospitalized with suspected COVID-19. The patient was born in Belgium and reported no relevant medical history. He was obese with a body mass index of 37.6 kg/m².

Nasopharyngeal swab PCR testing was positive for SARS-CoV-2 and a CAT scan performed in the emergency department showed severe bilateral interstitial pneumonia involving more than 75% of the pulmonary parenchyma. The patient’s need for oxygen increased 24 hours after admission and he was admitted to the intensive care unit for observation. His respiratory parameters rapidly improved without intubation and he was transferred back to the ward. As recommended by national guidelines, the patient received a 5-day regimen of hydroxychloroquine (400 mg twice a day on day 1 then 200 mg twice a day from day 2 to day 5).

A rapid the drop in haemoglobin level to 7.7 g/dl on day 2 gave rise to concern. The patient reported no blood loss. A complete blood test was performed and showed signs of haemolysis. There were no schistocytes or reticulocytosis. There was no folate, vitamin B12 or iron deficiency. Screening for HIV and parvovirus B19 infection was negative.

Screening for congenital RBC disorders revealed a G6PD deficiency that was not known to the patient. The G6PD enzyme level was below 0.2 U/g Hb. The patient required a single transfusion of RBCs on day 2 after which his condition slowly improved. HCQ was stopped and provided folic acid to support bone marrow regeneration. The patient’s haemoglobin level on the day of discharge was stable at 8.7 g/dl.

Learning points:
- A rapid drop in haemoglobin in COVID-19 patients should alert physicians to test for haemolytic anaemia and enzymopathies.
- The review of the literature shows that use of hydroxychloroquine is safe in G6PD-deficient patients.

Source: https://www.ejcrim.com/index.php/EJCRIM/article/view/1875/2297