Quinine Induced Thrombotic Microangiopathy (TMA)

Quinine is the most common cause of Drug induced thrombotic microangiopathy (DITMA), being the offending drug in 33% of cases. We present a case of DITMA after only a single dose of quinine with no previous history of quinine exposure treated successfully with plasma exchange (PEX), oral corticosteroid followed by mycophenolatemofetil (MMF). The diagnosis was made by the close temporal relationship of exposure of quinine to the onset of TMA and exclusion of other causes of TMA including aHUS, TTP, SLE. DITMA from quinine can be triggered either by a single ingestion occurring many months or up to 10 years in some case reports. Our case presented with a prolonged PT has previously been reported and makes the distinction from DIC more challenging. The patient was managed with regular hemodialysis and PEX. Although the role of PEX is uncertain in Quinine induced DITMA-in this case PEX was associated with improving hematological parameters, rising platelet counts, resolution of hemolysis on the blood film and a gradual improvement in renal function. This case highlights the need for a careful drug history in patients who present with TMA and provides evidence for the potential value of PEX in this condition. Although quinine antibody levels are not widely available, the use of immunosuppression with MMF to control the disease, through suppression and removal of quinine-dependent antibody production is supported. The evolution of Specialist Centers for TMA may help to concentrate experience in managing such acute case presentations and allow future research.