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Cinchonism

Cinchonism is an adverse reaction to the antiprotozoal drug quinine, manifested by headaches, auditory and visual deficits, as well as tinnitus. The diagnosis is made by confirming recent use of this agent during patient history. Treatment depends on the severity of symptoms and may necessitate hemodialysis in severe cases.


Presentation

Various side-effects of quinine use exist, but cinchonism includes nausea, vomiting and tinnitus as constitutive features [7]. Flushing, marked visual and auditory abnormalities, as well as abdominal pain and hypersensitivity reactions (ranging from urticaria to bronchospasm and anaphylactic shock) may be encountered [4].

Tachycardia
  • TERM Fall '12 PROFESSOR Dr.AngelaOlmstead TAGS Cardiology, adverse effects, Atrial fibrillation, Cardiac electrophysiology, ventricular tachycardia Sign up to access 24/7 study resources for your classes What students are saying As a current student on[coursehero.com]
  • Cardiovascular: Hypotension, sinus tachycardia, QRS widening, prolongation of the PR and QT intervals. Wide-complex tachycardias and torsades de points. Usually occur within 8 hours of overdose and resolve once blood concentrations of quinine fall.[lifeinthefastlane.com]
Myopathy
  • However, inactivation of these enzymes can also cause abnormal accumulation of glycogen and phospholipids in lysosomes, causing toxic myopathy. It is possible this action is the root cause of cinchonism.[en.wikipedia.org]
  • However switching off these enzymes can also cause abnormal accumulation of glycogen and phospholipids in lysosomes, causing a toxic myopathy . It is possible this is the root cause of cinchonism. Notes Dawson, T. A. (1995).[ipfs.io]
  • It reduces inflammation, which makes antimalarial drugs useful for treating arthritis , but it can also cause a form of muscle disease generally categorized as myopathy.[wisegeek.com]
  • However switching off these enzymes can also cause abnormal accumulation of glycogen and phospholipids in lysosomes, causing a toxic myopathy . It is possible this is the root cause of cinchonism.[dictionnaire.sensagent.leparisien.fr]
Purpura
  • Quinine-induced immune thrombocytopenic purpura followed by hemolytic uremic syndrome. Am J Kidney Dis 1999;33(1):133–7. PubMed Google Scholar 7. Crum NF, Gable P. Quinine-induced hemolytic-syndrome. 2000;93(7)3:726–8. Google Scholar 8.[link.springer.com]
Withdrawn
  • Most symptoms of cinchonism (except in severe cases) are reversible and disappear once quinine is withdrawn.[en.wikipedia.org]
  • Most symptoms of cinchonism (except in severe cases) are reversible and disappear once quinine is withdrawn. Read more at Wikipedia.org[the-medical-dictionary.com]
Headache
  • Cinchonism is an adverse reaction to the antiprotozoal drug quinine, manifested by headaches, auditory and visual deficits, as well as tinnitus. The diagnosis is made by confirming recent use of this agent during patient history.[symptoma.com]
  • Cinchonism is characterized by hearing loss, headache, tinnitus, and signs of cerebral congestion. See also quinine .[medical-dictionary.thefreedictionary.com]
  • […] cinchonism * * * cin·cho·nism 'siŋ-kə-.niz-əm, 'sin-chə- n a disorder due to excessive or prolonged use of cinchona or its alkaloids and marked by temporary deafness, ringing in the ears, headache, dizziness, and rash * * * n. poisoning caused by an overdose[medicine.academic.ru]
  • Pathol. poisoning by any of the cinchona alkaloids, characterized by headache, deafness, and ringing in the ears. [1855 60; CINCHON(A) ISM] * * * … Universalium cinchonism — Poisoning by cinchona, quinine, or quinidine; characterized by tinnitus, headache[translate.academic.ru]
Insomnia
  • Mon, 19 Dec 2011 Headaches, tinnitus, ichy rash, twiching muscles, insomnia, I would like to know if these symtoms will go away. I used this drug for about six years I have been off the drug now for about six weeks.[patientsville.com]

Workup

If patient history reveals history of quinine use, the diagnosis should be made immediately, whereas electrocardiography (ECG) and determination or renal function through measurement of blood urea nitrogen (BUN) and creatinine is recommended to assess the state of the cardiovascular system.

Hyponatremia
  • None of the randomized patients had hypomagnesemia, hyponatremia, or hypokalemia in the initial laboratory determinations. [Figure 2 ILLUSTRATION OMITTED] TABLE 1 Patients' Characteristics (n 45) (*) Range 28 to 87 years.[the-medical-dictionary.com]

Treatment

Treatment of cinchonism is mainly in the form of dose reduction or cessation of quinine use, but patients in whom other manifestations of quinine toxicity (for ex. severe central nervous system and renal impairment) can be severe or even life-threatening [4], hemodialysis may be option, with a goal of prompt removing of the drug from circulation [5].

Prognosis

Depending on the dose ingested and severity of symptoms, the prognosis may range from self-limiting complaints to life-threatening organ failure [5]. For this reason, a prompt diagnosis is vital to ensure a quick recovery and to prevent further complications.

Etiology

Cinchonism is an entity describing an adverse reaction to quinine, which is derived from the bark of the cinchona tree in South America, hence the term cinchonism [2].

Epidemiology

The exact rates of cinchonism remain unknown. A significant risk factor for this condition, however, is seen in patients with long QT syndrome, renal disease, myasthenia gravis, optic neuritis and G6PD, suggesting that this drug should be contraindicated in these patients [6].

Sex distribution
Age distribution

Pathophysiology

The exact mechanism of action of quinine is yet to be determined and which mechanisms lead to the development of cinchonism remains unknown [7].

Prevention

Proper patient monitoring and dose tapering can significantly reduce the risk of cinchonism [8].

Summary

Cinchonism is a clinical syndrome associated with ingestion of quinine, an antiprotozoal drug that exerts various effects in the body [1]. Quinine is derived from the bark of the cinchona tree that grows in the Andes, South America and its synthetic production started during the 20th century to combat malarial disease [2]. Although the mechanism of action of quinine still remains incompletely understood, analgesic, antipyretic and antiinflammatory properties have been described [3]. This drug (and its stereoisomer quinidine) is very efficient against Plasmodium vivax and ovale species, but not Plasmodium falciparum and it is one of the main drugs against babesiosis [4]. Unfortunately, various side-effects have been observed at regular dosages, one of them being cinchonism, which is characterized by tinnitus, headaches, both auditory and visual deficits and anaphylactic shock in rare cases [5]. The diagnosis is relatively easy to make, whereas treatment may include discontinuation of the drug, dose tapering or hemodialysis [5]. To reduce the risk of cinchonism, quinine should be avoided in patients suffering from cardiac (most importantly long QT syndrome) or renal disease, myasthenia gravis, optic neuritis or glucose-6-phosphate deficiency (G6PD) [1] [6], as a more severe reaction to the drug is observed under such circumstances.

Patient Information

Cinchonism is a medical term that is used to describe the appearance of specific symptoms as a result of quinine toxicity. Quinine is a drug derived from the bark of the cinchona tree that grows in the Andes in South America (hence the term cinchonism) and it is primarily used as an antiparasitic agent in treatment of malaria and babesiosis. Its exact mechanism of action remains unknown, but it can cause various adverse affects. Visual and auditory disturbances, tinnitus, headaches, nausea and vomiting are main features of cinchonism, whereas patients with a severe reaction to the drug can develop anaphylaxis (a profound, life-threatening allergic reaction to the drug). The diagnosis should be made as soon as the use of quinine is discovered during patient history taking and discontinuation of the drug (or dose reduction) is sufficient in the majority of cases. To reduce the risk of cinchonism, quinine should never be administered to patients suffering from renal disease, cardiac abnormalities such as long QT syndrome, myasthenia gravis, optic neuritis or glucose-6-phosphate deficiency (G6PD).

References

Article

  1. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.
  2. Howard MA, Hibbard AB, Terrell DR, Medina PJ, Vesely SK, George JN. Quinine allergy causing acute severe systemic illness: report of 4 patients manifesting multiple hematologic, renal, and hepatic abnormalities. Proc (Bayl Univ Med Cent). 2003;16(1):21-26.
  3. Bateman DN, Dyson EH. Quinine toxicity. Adverse Drug React Acute Poisoning Rev. 1986;5(4):215-233.
  4. Katzung, BG, Masters SB, Trevor AJ. Basic & Clinical pharmacology. New York, NY: McGraw-Hill; 2012.
  5. Goldenberg AM, Wexler LF. Quinine overdose: review of toxicity and treatment. Clin Cardiol. 1988;11(10):716-718.
  6. Gilbert DN, Chambers HF, Eliopoulos GN, Saag MS. The Sanford Guide to Antimicrobial Therapy 2015. 45th ed. Antimicrobial Therapy, Inc, Sperryville, VA; 2015.
  7. Barrocas AM, Cymet T. Cinchonism in a patient taking Quinine for leg cramps. Compr Ther. 2007;33(3):162-163.
  8. Vieira JL, Midio AF. Drug monitoring of quinine in men with nonsevere falciparum malaria: study in the Amazon region of Brazil. Ther Drug Monit. 2001;23(6):612-615.

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Last updated: 2017-08-09 17:48