Hydroxychloroquine-induced generalized myopathy in a patient with lupus tumidus: a case report

Alice Verdelli; Daniela Massi; Vincenza Maio; Gabriele Cavazza; Alberto Corrà; Elena Biancamaria Mariotti; Lavinia Quintarelli; Valentina Ruffo Di Calabria; Cristina Aimo; Emiliano Antiga; Marzia Caproni

doi:10.4081/dr.2023.9771

Authors

Alice Verdelli
alice.verdelli@hotmail.it
Rare Dermatological Diseases Unit, Department of Health Sciences, Toscana Centro Local Health Unit, Florence; European Reference Network Skin Member, Italy.
Daniela Massi Section of Pathology, Department of Health Sciences, University of Florence, Italy.
Vincenza Maio Section of Pathology, Department of Health Sciences, University of Florence, Italy.
Gabriele Cavazza Section of Dermatology, Department of Health Sciences, University of Florence, Italy. https://orcid.org/0009-0007-9373-0705
Alberto Corrà 1Rare Dermatological Diseases Unit, Department of Health Sciences, Toscana Centro Local Health Unit, Florence; European Reference Network Skin Member, Italy. https://orcid.org/0000-0003-0903-4998
Elena Biancamaria Mariotti Section of Dermatology, Department of Health Sciences, University of Florence, Italy.
Lavinia Quintarelli Rare Dermatological Diseases Unit, Department of Health Sciences, Toscana Centro Local Health Unit, Florence; European Reference Network Skin Member, Italy. https://orcid.org/0000-0002-9228-8042
Valentina Ruffo Di Calabria Section of Dermatology, Department of Health Sciences, University of Florence, Italy. https://orcid.org/0000-0003-0307-6636
Cristina Aimo Section of Dermatology, Department of Health Sciences, University of Florence, Italy.
Emiliano Antiga Section of Dermatology, Department of Health Sciences, University of Florence, Italy. https://orcid.org/0000-0001-7787-4433
Marzia Caproni Rare Dermatological Diseases Unit, Department of Health Sciences, Toscana Centro Local Health Unit, Florence; European Reference Network Skin Member; Section of Dermatology, Department of Health Sciences, University of Florence, Italy. https://orcid.org/0000-0002-7471-3471

A subtype of cutaneous lupus erythematosus known as lupus erythematosus tumidus (LET) is characterized by sun-exposed areas that typically display urticaria-like papules and plaques. For LET, systemic therapy with antimalarials – particularly hydroxychloroquine (HCQ) – is the first line of treatment. Even though the safety profile of these medications appears to be high, there have been very few reports of side effects in the literature, including hemolytic anemia, retinal toxicity, maculopapular rash, gastrointestinal disturbance, and blue-gray discoloration of the skin or mucous membranes. Here, we report a unique instance of a 46- year-old LET smoker who, following HCQ treatment, developed a generalized myopathy.

Patsinakidis N, Kautz O, Gibbs BF, Raap U. Lupus erythematosus tumidus: clinical perspectives. Clin Cosmet Investig Dermatol 2019;12:707-19.

Filotico R, Mastrandrea V. Cutaneous lupus erythematosus: clinico-pathologic correlation. G Ital Dermatol Venereol 2018;153:216-29.

Kuhn A, Aberer E, Bata-Csörgő Z, et al. S2k guideline for treatment of cutaneous lupus erythematosus- guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 2017;31:389-404.

Verdelli A, Corrà A, Mariotti EB, et al. An update on the management of refractory cutaneous lupus erythematosus. Front Med (Lausanne) 2022;9:941003.

Fiehn C, Ness T, Weseloh C, et al. Safety management of the treatment with antimalarial drugs in rheumatology. Interdisciplinary recommendations based on a systematic literature search. Z Rheumatol 2020;79:186-94.

Khosa S, Khanlou N, Khosa GS, Mishra SK. Hydroxychloroquine-induced autophagic vacuolar myopathy with mitochondrial abnormalities. Neuropathology 2018;38:646-52.

Doughty CT, Amato AA. Toxic myopathies. Continuum (Minneap Minn) 2019;25:1712-31

Kwon JB, Kleiner A, Ishida K, et al. Hydroxychloroquine-induced myopathy. J Clin Rheumatol 2010;16:28-31.

Kalajian AH, Callen JP. Myopathy Induced by antimalarial agents: the relevance of screening muscle enzyme levels. Arch Dermatol 2009;145:597-600.

Verdelli A, Coi A, Marzano AV, et al. Autoantibody profile and clinical patterns in 619 Italian patients with cutaneous lupus erythematosus. J Eur Acad Dermatol Venereol 2019;33:742-52.

Böckle BC, Sepp NT. Smoking is highly associated with discoid lupus erythematosus and lupus erythematosus tumidus: analysis of 405 patients. Lupus 2015;24:669-74.

Verdelli, A., Massi, D., Maio, V., Cavazza, G., Corrà, A., Mariotti, E. B., Quintarelli, L., Ruffo Di Calabria, V., Aimo, C., Antiga, E., & Caproni, M. (2023). Hydroxychloroquine-induced generalized myopathy in a patient with lupus tumidus: a case report. Dermatology Reports, 16(2). https://doi.org/10.4081/dr.2023.9771