Quinine-induced disseminated intravascular coagulation: case report and review of the literature

Objective: To describe the clinical course of quinine-induced disseminated intravascular coagulation (DIC) and review all previous cases reported in the medical literature. Design: Case report/literature review. Setting: University teaching hospital medical ICU. Patients: One patient in whom thrombocytopenia, coagulopathy, intravascular hemolysis, DIC, and acute renal failure temporally followed the ingestion of quinine. Data sources: We conducted a computerized free-text MEDLINE database search from 1969 to 2000 using the keywords quinine and thrombocytopenia, quinine and hemolytic-uremic syndrome, and quinine and disseminated intravascular coagulation. Study selection: All reported cases and reviews of quinine-induced thrombocytopenia, hemolytic-uremic syndrome (HUS), and DIC were reviewed. DIC was distinguished from quinine-induced thrombocytopenia or quinine-induced HUS based on the presence of abnormal clotting times, elevated fibrin degradation products, and/or elevated D-dimer levels. Data synthesis: Fifteen previous patients were found to meet the criteria for DIC temporally related to the recent ingestion of quinine. The clinical course and laboratory abnormalities documented for each case are reviewed. Conclusions: Quinine-induced DIC is a distinct clinical entity, which may present as unexplained thrombocytopenia, coagulopathy, or renal failure. In susceptible patients, the immune response to quinine may result in the production of not only anti-platelet antibodies but also antibodies against leukocytes, erythrocytes, and endothelial cells. Furthermore, the varying patterns and specificities of antibody production in an individual patient may result in a spectrum of clinical disease from mild, transient thrombocytopenia to overt intravascular hemolysis, renal failure, coagulopathy, and DIC. Early recognition of quinine-induced DIC is paramount, as this diagnosis affords a better prognosis than other adult forms of HUS or DIC.