We describe a patient who developed rhabdomyolysis 6 weeks after starting combination therapy with hydroxychloroquine and quinacrine for the treatment of chronic cutaneous lupus erythematosus (CCLE). Myopathy due to 4-aminoquinolone antimalarials has been well documented. It is plausible that quinacrine may induce muscle injury in a manner similar to other antimalarials but, to our knowledge, rhabdomyolysis associated with antimalarial therapy has not been reported.
A healthy 45-year-old African-American female with a history of chronic cutaneous lupus erythematosus (CCLE) presented for evaluation. She had no symptoms of systemic lupus erythematosus and no other medical problems. In the past she had taken hydroxychloroquine at a dose of 200 mg twice a day for several years. Clinically, the patient had scattered hyperpigmented atrophic plaques on her face and scalp. On her knees she had hyperpigmented patches with focal firm nodules. A biopsy of one of the nodules was consistent with chronic cutaneous lupus erythematosus and dystrophic calcinosis. She had no evidence of heliotrope, Gottron's papules or poikilodermatous patches on her skin. She denied myalgias or weakness. In an attempt to improve control of her active lesions, the patient was started on hydroxychloroquine 200 mg twice a day. Because of lack of complete response, quinacrine 100 mg per day was later added. She was instructed to use a broad-spectrum sunscreen daily. Three weeks after beginning quinacrine, the patient developed a pruritic urticarial eruption on her legs. Quinacrine was discontinued at that time.
The patient subsequently developed symptoms of muscle pain and severe weakness with general malaise. Laboratory evaluation revealed an elevated BUN and creatinine and an elevated serum creatine kinase (CK) of 39,000 IU/L (normal 24-173 IU/L) consistent with rhabdomyolysis. History was negative for trauma, overexertion, alcohol, or recreational drug use. The patient denied a family history of genetic defects in muscle enzymes and had no evidence of infection. The patient was hospitalized for supportive care and hydroxychloroquine was discontinued. The patient's muscle status improved over several months.
Rhabdomyolysis is a condition defined by acute necrosis of striated muscle. Clinical symptoms include intense muscle swelling and tenderness with markedly elevated serum CK. Elevations of serum CK over 2,000 times normal may occur. (1) Muscular symptoms and serum enzymes usually resolve when the toxic insult is removed. Common precipitating factors of rhabdomyolysis include severe muscle trauma, ischemia, overexertion, toxins, infections, genetic enzyme defects, and medications.
Autoimmune diseases may be associated with myopathy, but are not often associated with rhabdomyolysis (Table 1). Rarely, dermatomyositis may present with rhabdomyolysis. (1)
Dermatomyositis more commonly presents with insidious onset of proximal muscle weakness and enzyme elevation developing over several months. Systemic lupus erythematosus is associated with myopathy in up to 50% of patients with the disease. (2) Lupus myopathy is characterized by proximal muscle weakness and elevated serum CK. Muscle biopsy may show inflammation, vasculitis of small vessels, and type II muscle fiber atrophy. (2)
Several medications used in dermatology can cause myopathies or rhabdomyolysis (Table 2). Hydroxychloroquine and chloroquine are classified as 4-aminoquinolone antimalarials. Myopathy due to these agents was first described in 1963. (3) Subsequent case reports of antimalarial myopathy describe patients with reversible proximal muscle weakness. Symptoms may be associated with neuropathy and cardiomyopathy. Serum CK may be normal or elevated. (3,4) The antimalarials accumulate in lysosomes and interfere with lysosomal functions. Muscle toxicity may result from a disruption in lysosomal storage in which phospholipids, glycogen, and myeloid accumulate in vacuoles. (2) Muscle biopsy specimens typically show vacuolar changes in myocytes and electron microscopy reveals distinct vacuoles known as curvilinear bodies. Quinacrine is an acridine compound that differs from 4-aminoquinolones because of an extra benzene ring in its chemical structure. It was first developed as a synthetic quinine in the 1920s and became the official medication for antimalarial prophylaxis during World War II. From 1943 to 1945, over 4 million allied soldiers took quinacrine. (5) After the war, quinacrine became widely recognized as effective treatment for lupus erythematosus. (6) Later, the combination of quinacrine and hydroxychloroquine was noted to have synergistic effects. (5,7,8) The production of quinacrine tablets in the US ceased in 1992 due to widespread use of other antimalarials. (9) Quinacrine powder is still available in the US and can be made into a capsule by compounding pharmacies.
Quinacrine is effective in combination with hydroxychloroquine for patients with cutaneous lupus erythematosus not responsive to hydroxychloroquine alone. (10) It also has a role as a single agent if hydroxychloroquine is contraindicated due to ocular toxicity or other intolerance, although it is less effective when used alone. Quinacrine, like hydroxychloroquine, has additional beneficial hypoglycemic, anti-platelet, and lipid-lowering effects in patients with systemic lupus erythematosus. It is also helpful as a cortical stimulant in patients with fatigue. (9)
Aplastic anemia is the most serious adverse reaction to quinacrine. Based on data from World War II, this is a rare reaction associated with drug dose and duration of therapy. (6) Some patients develop a lichenoid eruption prior to development of aplastic anemia and stopping the medication at that point may reverse the process. (6) Other more common side effects include gastrointestinal intolerance, headache, or dizziness. Minor cutaneous side effects include yellow skin discoloration, bluish bruise-like marks in the skin, and urticarial, lichenoid, or eczematous eruptions. Quinacrine does not cause ocular toxicity and it does not cross react with chloroquine and hydroxychloroquine. (5)
The myotoxic potential of quinacrine is not well elaborated. In a review of muscle toxins, quinacrine is listed as a myotoxin associated with pain, sensorimotor polyneuropathy, and cardiomyopathy. (11) The related pathologic findings listed are necrosis, fibroblast proliferation, and lymphocytic infiltration. Another review of muscle toxins links quinacrine with destruction of skeletal muscle and associated myoglobinuria. (12) Neither review included clinical descriptions or references to specific cases of myotoxicity. Additional evaluation of patients with myopathy includes muscle biopsy, electron microscopy, and electromyelogram (EMG), which were not performed on our patient.
Several medications used in dermatology may induce rhabdomyolysis or myopathy. It is critical to recognize the myotoxic effects of these medications. Patients with autoimmune disease may have several factors contributing to myopathy, including a disease flare, overlapping autoimmune disease, steroid myopathy, and antimalarial myopathy. Referral for muscle biopsy or EMG is recommended when the etiology is not clear. (2) Quinacrine should be considered along with other antimalarial agents in the differential of a medication-induced myopathy. In this case rhabdomyolysis was attributed to quinacrine, an adverse effect that has not been reported previously.
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CPT Naomi Creel MC USA, (a) Victoria Werth MD (b)
a. Department of Dermatology, Walter Reed Army Medical Center, Washington DC
b. Department of Dermatology, University of Pennsylvania and Philadelphia VA Hospital, Philadelphia, PA
Address for Correspondence
Victoria P. Werth, MD
Department of Dermatology
University of Pennsylvania
2 Rhoads Pavilion, 36th and Spruce
Philadelphia, PA 19104
Phone: 215-662-2399 Fax: 215-349-8339
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