Chloroquine induced utricaria—A detailed history helps

Sir,

We read with great interest a case report Chloroquine induced utricaria: A newer adverse effect by Balamurugesan, et al.[1] The authors have reported a case of young male diagnosed with malaria that developed utricaria. The appearance of utricaria was immediate after taking the first dose of Chloroquine. Here we add one more case who is a young boy developed utricaria after the first dose of Chloroquine.[2] This will further add in gaining further knowledge.

In addition, some important points in relation to this case and with the available literature on malaria and utricaria were detailed out. Since malaria is endemic in India, it is important always to make a good interpretation so that it will help the community in mass. Since Chloroquine is extensively used antimalarial drug, we should be cautious in all aspects of medication. So, in view of the important facts we made our search and found there are reports on malaria and utricaria that is highly needed to be discussed to come up with interpretation of the disease and drug [Table 1].

Table 1.

Case report and studies of utricaria in malaria

References	Symptoms	Diagnosis	Interpretation
Sharma V et al.[3]	Urticaria	Falciparum malaria	Oral Artesunate, Pyrimetamine sulphadoxine
Vaishnani JB[4]	Urticaria	Falciparum malaria	Parenteral dexamethasone and chlorpheneramine maleate +injection α-β arteether
Godse KV et al.[5]	Urticaria (10 Patients)	Falciparum and vivax malaria	The falciparum positive patients were treated with tablet quinine salt 600 mg three times a day for 7 days. Vivax positive patients with Chloroquine + primaquine.

The literature shows an incidence of malarial disease manifesting with urticaria was reported between 1.33 and 25.6%.[6,7,8] Several reports are seen from India.[9,10] Natarajan et al. postulated that deposition of malarial pigment in the reticuloendothelial system (RES) produces excessive IgE that triggers urticaria.[11] This presentation may also occur with a wide range of subclinical infection. A report of urticarioid manifested case with imported pernicious cerebral malaria was documented.[12] Talib et al. presented cases of malaria for their protean manifestations. In five patients out of thirteen presented for chronic urticaria with or without polyarticular arthritis and few other mimicked acute rheumatic arthritis with a case of pulmonary tuberculosis and two other developed apparent Chloroquine-resistant malaria.[13]

Hence, in an endemic area like India, the presentation of fever and urticaria should always give physicians and health care professionals a clue of underlying timely treatable malaria.

With this background and since drug is involved, we did a Naranjo probability scale and found to be scored “3” and shows the “possibility” only [Table 2].

Table 2.

Naranjo probability scale

Question	Yes	No	Do Not Know	Score
Are there previous conclusive reports on this reaction?	+1	0	0	1
Did the adverse event appear after the suspected drug was administered?	+2	-1	0	2
Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered?	+1	0	0	1
Did the adverse event reappear when the drug was re-administered?	+2	-1	0	0
Are there alternative causes (other than the drug) that could on their own have caused the reaction?	-1	+2	0	-1
Did the reaction reappear when a placebo was given?	-1	+1	0	0
Was the drug detected in blood (or other fluids) in concentrations known to be toxic?	+1	0	0	0
Was the reaction more severe when the dose was increased or less severe when the dose was decreased?	+1	0	0	0
Did the patient have a similar reaction to the same or similar drugs in any previous exposure?	+1	0	0	0
Was the adverse event confirmed by any objective evidence?	+1	0	0	0
				3

Regarding the case we feel strongly that the patient history in the past regarding any urticarial rash with fever might be advantageous to know. Also, if it is Chloroquine induced, the alternative drug used should be detailed out.

To conclude, we the physicians at the primary health care should be aware of both the aspects that will help us in decision making and to prevent untoward adverse reaction. It is also our mandate to notify the national pharmacovigilance program of India (PVPI) through respective ADR monitoring center or by mobile application.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.