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Quinine induced coagulopathy - a near fatal experience

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The most common bleeding diatheses, including Haemophilia A and B, von Willebrand's disease and thrombocytopaenia, are congenital in nature.1A bleeding diathesis may be intentionally induced where anticoagulation is of therapeutic benefit in conditions such as deep vein thrombosis, atrial fibrillation and prosthetic heart valves.2Iatrogenically acquired bleeding diatheses occur as a side-effect of many prescription and non-prescription drugs.
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C A S E R E P O R T
Australian Dental Journal 2000;45:(4):282-284
Quinine induced coagulopathy – a near
fatal experience

M. Hawthorne,* R. Sim,† C.H.C Acton‡
Many of the chemotherapeutic drugs used in
Abstract
oncology may induce a coagulopathy and these
A 67 year old man presented to his local dentist for
restorative treatment. He stated he was fit and well
bleeding diatheses may also be acquired via the
and denied taking any medications. When he was
immunological consumption of circulating platelets.
given an inferior alveolar nerve block, excessive
Thrombocytopaenia is associated with a reduced
bleeding was noted at the injection site and the
platelet count, below the normal range of 150-
dentist advised the patient see an oral and maxillo-
facial surgeon. An appointment was made for the
400 109/L.
patient but he did not attend. Three days later, he
This case presentation will emphasize the serious
presented with evidence of massive deep haemor-
consequences of an induced thrombocytopaenia,
rhage to the point of airway compromise. He under-
which was not considered prior to dental treatment
went hospital admission, early intubation, intensive
care for nine days and hospitalization for six weeks.
as a result of the patient denying any relevant
The cause of his bleeding was a severe thrombo-
medical history. The complications experienced by
cytopoaenia, induced by chronic ingestion of
the patient could have been treated considerably
quinine. He was self-medicating with this to relieve
earlier had the patient complied with the treating
muscular cramps. Despite this experience, the
dental surgeon’s instructions.
patient continued to deny that quinine was the
cause of his problem and that he had failed in his
obligations to advise the dentist of his drug history.
Case report
Dentists need to be alert to the risk that patients
A 67 year old male presented to the department of
may not reveal their true medical history. There are,
Emergency Medicine, Royal Brisbane Hospital
however, obligations on the dentist to ensure the
accuracy of information the patient gives and to
(RBH), complaining of severe facial swelling which
ensure that patients whom they believe are at risk
had prevented him from eating and drinking for the
follow their advice.
previous three days. He said this had begun after a
Teamwork and skilful airway management
dental injection for restoration of a lower tooth. The
prevented this patient's demise.
Maxillofacial Registrar had received a call from a
Key words: Drug induced coagulopathy, inferior alveolar
dental surgeon three days previously to say this
nerve block, airway management.
patient was going to attend RBH on the day of the
(Received for publication February 1999. Revised April
initial treatment as there had been considerable
1999. Accepted April 1999.)
haemorrhage from the puncture site of an inferior
alveolar block. The patient’s medical history reported
no evidence of a bleeding diathesis, therapeutic or
Introduction
iatrogenic. Further history undertaken when the
The most common bleeding diatheses, including
patient presented at RBH revealed he had suffered
Haemophilia A and B, von Willebrand’s disease and
haematuria for the previous three weeks and, after
thrombocytopaenia, are congenital in nature.1 A
intense questioning, he admitted to self-medicating
bleeding diathesis may be intentionally induced
with quinine for muscular cramps. The patient had
where anticoagulation is of therapeutic benefit in
been doing this for the last 15 years.
conditions such as deep vein thrombosis, atrial
On examination, the patient was very distressed
fibrillation and prosthetic heart valves.2 Iatrogenically
and had an obvious large subcutaneous haematoma
acquired bleeding diatheses occur as a side-effect of
of his lower lip and left cheek extending in a caudal
many prescription and non-prescription drugs.3
direction to encompass the anterior neck bilaterally
*Oral and Maxillofacial Registrar, Royal Brisbane Hospital.
(Fig. 1). The tongue was engorged and protruding
†Tasmanian Dental Service.
‡Royal Brisbane Hospital.
between the lips, producing lip incompetence, and
282
Australian Dental Journal 2000;45:4.

Fig. 1. – Patient’s appearance on presentation to hospital.
Fig. 2. – Generalized petechiae of the lower limbs.
The gross haematoma of his tongue and submandibular
region bilaterally is evident.
Airway maintenance was of immediate concern
there was a foetid smell emanating from his oral
due to the progressive nature and anatomical
cavity. He was able to maintain his airway in an
location of the swelling – the submandibular, lateral
upright position, was alert and cognizant of time and
pharyngeal and retropharyngeal tissue spaces.
place, was tachycardic (heart rate 120/min) and his
Haematological consultation was sought and
respiratory rate was 16/min. The patient’s blood
infusion of gamma globulin, dexamethasone, fresh
pressure was within normal limits and he appeared
frozen plasma and platelets prior to securing an
dehydrated, had generalized lower limb petechiae
airway was recommended. The patient rapidly (over
(Fig. 2) and gross haematuria. On discussion, the
a period of two hours) became unable to maintain
patient admitted he had been advised on the day of
his airway and was taken to the operating theatre
the dental injection to attend the Oral and
and intubated via an awake fibre-optic nasal tech-
Maxillofacial Unit of RBH, for which he had been
nique. Preparation for surgical access to the airway
given an appointment. The patient declined to keep
(ie cricothyroidotomy or tracheostomy) was initiated
the appointment initially because he was ‘sure he
in case intubation was not possible. However,
would get better’ and later because ‘he felt too ill’.
intubation occurred uneventfully and the patient
Investigations included a full blood count and
was transferred to the ICU. The patient remained in
coagulation screen, lateral jaw and neck radiographs
the ICU for eight days and continued to bleed
and anaesthetic consultation and the Intensive Care
intra-orally for six days. During his stay in ICU, the
Unit (ICU) was notified of a potential admission.
patient developed an aspiration pneumonia. On the
Haematological examination revealed a platelet
ninth day, he was discharged to the care of the
count of 2 109, raised prothrombin time (PT) 19
Haematology Unit. The patient spent a further five
(normal 12-17), activated partial thromboplastin
weeks in hospital where his platelet count slowly
time (APPT) of 30 (normal 25-41), fibrinogen level
increased and he was counselled on the
of 948 (normal 150-400) and an international
consequences of further use of quinine. Fig. 3 shows
normalization ratio (INR) of 1.3 (normal 1). The
the patient’s current facial appearance.
patient’s haemoglobin dropped from 10.2g/L to
6.6g/L during his first four hours in the hospital
(normal=12-16g/L). Radiographs proved non-
Discussion
contributory and a CT scan was not performed at
This case report emphasizes a number of points
this time.
relating to patient history, self-medication and
Australian Dental Journal 2000;45:4.
283

Gottschall et al.5 It is also notable that quinine
sulphate is used commonly for the treatment of
nocturnal leg cramps although many studies have
shown it to be of minimal benefit.6-8 Thrombo-
cytopaenia is one of the most serious and well
recognized side-effects of quinine sulphate. The
mechanism of this reaction appears to be the
formation of drug antibody complexes with an
affinity for some component of the platelet
membrane.9
The hospital treatment the patient received
necessitated clear delineation of priorities in his
management. Airway maintenance was of prime
concern and was secured prior to treatment of the
bleeding. The involvement and teamwork of
anaesthetic, surgical and intensive care specialists
ensured an optimal outcome.
This patient’s poor understanding of the side-
effects of medications and refusal to acknowledge
them is a salutory lesson to all clinicians.
References
1. Rizza CR, Lowe GD, eds. Haemophilia and other inherited
bleeding disorders. London: WB Saunders Company, 1997.
Fig. 3. – Patient’s current appearance.
2. Becker RC, Ansell J. Antithrombotic therapy: an abbreviated
reference for clinicians. Arch Intern Med 1995;155:149-161.
3. HJ. Antiplatelets drugs and therapy. In: Beutler E, Lichtman MA,
airway management. The operator who noted the
Coller BS, Kipps TJ, eds. Williams Haematology. 5th edn.
McGraw-Hill, 1995.
bleeding from the inferior alveolar block site and
4. McDaniel F, Miller D, Jones R and Davis M. Assessing patient
referred the patient to hospital was concerned about
willingness to reveal health history information. J Am Dent Assoc
the uncharacteristic bleeding. However, there was no
1995;126:175-179.
reason at this stage to suspect a coagulopathy as the
5. Gottschall JL, Neahring B, McFarland JG, Wu GG, Weitekamp
patient had not indicated any mitigating factors and
LA, Aster RH. Quinine-induced immune thrombocytopenia with
haemolytic uraemic syndrome: clinical and serological findings in
did not think of quinine as a medication. Eliciting
nine patients and review of the literature. Am J Hematol
(over the counter) drug therapy may often be
1994;474:283-289.
difficult, particularly for the dental practitioner, with
6. Warburton JP, Royston CJ, O'Neill PW. A quinine a day keeps the
whom the patient sees no necessity to discuss drugs
leg cramps away? Br J Clin Pharmacol 1987;23:459-465.
of any sort. A study of 107 patients by McDaniel et
7. Manson-Hing M, Wells G. Meta-analysis of the efficacy of quinine
for the treatment of nocturnal leg cramps in elderly people. BMJ
al showed many patients will refuse to give
1995; 310:13-17.
information because dental health professionals do
8. NR. Effectiveness of quinine for night cramps. Br J Gen Pract
not need to be aware of the patient’s health status ‘as
1993;43:127.
they had concerns about privacy and concerns about
9. Williams J, Beutler E, Ersler AJ, eds. Haematology. 3rd edn. New
dental treatment being refused or withheld on the
York: McGraw-Hill, 1983.
basis of positive answers given’.4
Address for correspondence/reprints:
The side-effects of medications are many and
Dr C Acton,
usually disappear on cessation of that medication.
This patient’s thrombocytopaenia was associated
Royal Brisbane Hospital,
with platelet-reactive antibodies which are common
Herston Road,
in the ‘haemolytic uraemic syndrome’ described by
Herston, Queensland 4029.
284
Australian Dental Journal 2000;45:4.

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