Thrombocytopenic purpura following quinidine therapy

THROMBOCYTOPENIC I&port

PURPURA

FOLLOWING

QUINIDINE

THERAPY

of a Case

Vernon D. Foshager, D.D.S.,* Milwaukee, Dc!ntnl &rvicc,

Wood Veterans

Admin~tration

Wis. Center

is listed by Beckman’ as the classic drug for treatment of cardiac arrhythmias, but in 1927 Seyderhelm2 associated thrombocytopenic purpura with quinidine administration. Broch3 is credited with reporting the first detailed case, that of a 27-year-old woman who developed thrombocytopenic purpura during a second course of administration 7 months after the first treatment. Diagnosis was established by a 0.4 Gm. test oral dose of quinidine sulfate, resulting in a reduction in platelet count from 345,000 to 24,000 within 5 hours. Bolton and Dameshek,4 in a thorough review, listed chronologically the first twenty-three reasonably well-documented cases, to which they added five case reports. According to Bishop, Spencer, and Bethell, forty-seven cases had been reported by February, 1958, and a recent review of the lit.erature revealed three additional cases.a-RThis idiosyncrasy is thus rather rare. It is quite conceivable, however, that it is not as uncommon aa the above figures would indicate. It should be realized that quinidine is used quite commonly, and the possibility exists that additional cases may not have been recognized or, more likely, have not been reported in the literature.

Q

UINIDINE

CASE. REPORT A 55year-old white female employee WM referred to the Dental Serviee for consultation and emergency treatment on Nov. 28, 1960. Chief Compla&nt.-The chief complaint was that of a “blood clot in the mouth” when she arose that morning. History of Present Illness.-The patient gave a history of having noticed a ~‘lumpJ’ above the left ankle 3 days prior to admission, but she could recall no traumatic incident. Two daya prior to admission she had been out of town on a shopping trip, and she recalled that she felt “unusually tired” and that walking was a great effort. She had rested the following day iu an effort to recover from her fatigue. Past History.-The patient’s past history was essentially negative. She admitted to having taken various self-medications, including vitamins, calcium, and iodine. The latter *Chief. Periodontia Section, Veterans Administration Center, Wood, Wis.. and Assistant Professor, Department of Oral Medicine, Marquette University School of Dentistry, Milwaukee, WiS. 401

was ljeing l>y

a

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family

history was negat.ivc and ~loiicontril,ul~~r~. UMcal EzunGnation.-The first ohserration at tht! tinw of oxaolioetiou was that of numerous, obvious petechiao on the face which woultl not ),lan(?h up011 prcwurc. The patient admitt,od having init.iatlly Jwticed thtase upon rising. Further c?xamination rcvoaled petechiae of the scalp, neck, arms, and Irgs. with an area of ec*c?hymosis above the loft ankle. The latter apparently was in tho wJll(! h:atioJl as the previolJsty mcJltiollc~d “lump ” :lnd could Jlot bo attributed to any known traulna.

Fig. l.-Intraoral

view at time of initial

examination.

Oral examination revealed a mass of blood covering the gingivae and teeth in the maxillary left cuspid, premolar, and molar region (Fig. 1). 1n addition, there were localized areaa of spontaneous bleeding from the gingival crevices. Purpuric lesions were scattered throughout the oral mucosa, with larger, dark purplish, bullous vascular lesions in the floor of the mouth and on the mucosa of the lower lip. The oral st.ructures were otherwise in an excellent state of health clinically. A Rumpel-Leede test for capillary fragility was strongly positive. Laboratory Data.-On the basis of the clinical findings, a hematologic work-up was red blood count, 4,750,OOO; white blood count, requested. Laboratory reports were as follows: 5,300 with a normal differential; hemoglobin, 14.9; coagulation time, 12 minutes 30 seconds; prothrombin time, 100 per cent. The platelet count, however, WM 20,000. (There was, subsequently, no clot retraction within the following 24 hours.) A diagnosis of thrombocytopenic purpura was made, and an emergency consultat.ion was held with the hematologist. Hematology Consultation.-Physical examination revealed petechiae to be present over the whole body, with another area of ecchymosis on the left thigh. The spleen and liver were not palpable. A heart murmur was noted, however. Tt was at this time that the patient admitted having had periodic “palpitations of the heart” since approximately March, 1960.

Volume 17 Number 3

THROMBOCYTOPENIC

PURPURA

FOLLOWING

QUINIDINE

403

Her private physician had prescribed a daily dose of one tablet (0.2 Gm.) of quinidine sulfate, which she continued to take for a week or two. She took no further medication until about 6 days prior to being seen on consultation. One tablet daily had been taken for 4 consecutive days, and during the following 2 days a total of three tablets had been taken. The patient’s private physician was contacted, and arrangements were made for immediate admission to the hospital as a precautionary measure to help prevent possible serious internal hemorrhage. Hospital Cozc7se and Treatment.-History and physical examination upon admission to the hospital were essentially as noted above. A laboratory work-up revealed the following additional data: urinalysis, normal with the exception of 6 to 8 red blood cells per highpower field; VDRL, nonreactive; bleeding time, 30 seconds; and 4+ occult blood. The physician’s orders were as follows: (1) bed rest; (2) Co-Deltra, 10 mg. orally every 8 hours for three doses, then 5 mg. four times daily for four doses and 3 mg. t,hree times daily for three doses; (3) no quinidine or quinidinecontaining medications; (4) daily cornplet,e blood count, platelet count., and bleeding and clotting time.

250,000 m ai = 204000 2 b I50,000 ii s J l00.000 a 50,000 o!

0

Fig. Z.-Platelet

I

10

I

20

count versus

I

I

1

I

I

1

30

40

I

I

50

60

70

60

90

100

time following

discontinuance

oP ouinidine

I

1

110 120 therapy.

The following day, Nov. 29, 1960, no spontaneous bleeding was noted. The platelet count had risen to 50,000. The Co-Deltra was decreased to 5 mg. every 12 hous on November 30 and to 5 mg. daily with a 4 day supply when the patient was discharged on December 2. The platelet count at the time of discharge was 110,000, with only faint evidence of petechiae clinically. Posthospitdimtion Cozlrse.-An apparently complete and uneventful recovery was report.ed. Follow-up platelet counts were as follows: 165,000 on December 8, 270,000 on December 19, 260,000 on January 19, and 290,000 on March 15. Fig. 2 presents a graphic illustration of platelet count versus time. It will be noted that there was a continuous rise in the platelet count from the initial laboratory report on Nov. 28, 1960, until the normal level was reached. DISCUSSION

Thrombocytopenic purpura due to drug hypersensitivity represents one of many hemorrhagic diseases to which the dentist must be alert. The initial symptom observed by the patient frequently is that of spontaneous gingival and/or mucosal bleeding. Therefore, the dentist. is often consubed initially in the belief that the condition is primarily of a localized nature rat.her than a syst.emic condition.

404

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REFERENCES Drugs: Their Naturcn, .\at ion and Us