COVID-19 Infection Despite Hydroxychloroquine Use

Saumil Doshi MD, Nicole White MD, Glenn Wortmann MD, Shraddha Rayamajhi MD

Infectious Diseases Section, Washington Hospital Center, USA

Case Reports NEJM360

Case 1
Date of Presentation : 3/24/2020
Case Presentation: A 79 year old male with h/o RA who was taking hydroxychloroquine 200 mg BID initially presented with several days of anorexia and cough. Patient was afebrile on presentation with oxygen saturation of 97% on RA, CXR showed patchy right upper lobe opacity. He was discharged from ED on levofloxacin with plans for outpatient f/u. The patient returned after 2 days with worsened myalgia, cough, SOB. NP swab revealed presence of SARS-CoV-2 as detected by a PCR assay.
Labs: WBC: 3100, Absolute lymphocyte count:1800, Plt: 156,000, Cr:1.13, AST:35, ALT:27, CRP:55.7, troponin: <0.017, LDH:244, CK:74, Rapid flu: negative
Treatment and outcome: Hydroxychloroquine was continued and azithromycin was added for potential added benefit. The patient gradually improved and was discharged home after 3 days.

Case 2
Date of Presentation: 3/26/2020
Case Presentation: A 29 year old female with h/o SLE well controlled on hydroxychloroquine 200 mg BID and daily prednisone 5 mg daily, presented to urgent care with 3 days of fever and cough. A chest X ray was consistent with pneumonia. Her symptoms did not improve and she presented to ED 3 days later where the NP swab revealed presence of SARS-CoV-2 by PCR assay.
Labs: WBC 6600, Absolute lymphocyte count:500, Hct: 37.3%, Plt: 172,000, cr; 0.69, AST:24, ALT:27, CRP:120, Troponin:<0.017, LDH:175, CK:42, Ferritin:659, Rapid flu:negative
Treatment and outcome: Continued on hydroxychloroquine and azithromycin was added. Her clinical condition remains tenuous at the time of this report

Lessons learnt: Although in vitro data suggests chloroquine and hydroxychloroquine have efficacy against SARS-CoV-2, robust clinical data is lacking and our experience with the two described patients demonstrated that chronic use of hydroxychloroquine does not preclude infection. Whether either drug provides any protection against infection or ameliorates the disease course requires larger studies.