Quinine


Quinine is the main alkaloid derived from cinchona bark. It is used in medicine mainly as an antimalarial drug but also as an antipyretic and analgesic easily available in many over-the-counter preparations (treatment of leg cramps).
 
Incidence
Anaphylaxis is uncommon.
 
Thrombocytopenia is more frequent (1/1000 to 1/3500).
 
Clinical manifestations
Anaphylactic shock, fever.
 
Eczematous eruption (photoallergic), lichenoid photosensitivity, contact dermatitis (hair lotions), fixed drug eruption, allergic vasculitis, rash.
 
Agranulocytosis, thrombocytopenia, hemolytic uremic syndrome, disseminated intravascular coagulation.
 
Diagnostic methods
Cutaneous testing.
 
Intradermal skin-tests: positive 1/1000 in one case of anaphylaxis.
 
Patch-tests (quinine 1% pet).
 
Photo-patch tests.
 
 
 
Serologic methods
 
Quinine dependent neutrophil antibodies IgG, IgM (immuno-fluorescence, agglutination).
 
Quinine dependent platelet antibodies IgG, IgM (immuno-fluorescence).
 
Quinine dependent erythrocyte antibodies (antiglobulin test).
 
Specific IgE
 
Positive RAST and RAST-inhibition in one case of anaphylaxis.
 
Oral provocation test: positive in one case of anaphylaxis.
 
Mechanisms
IgE-mediated hypersensitivity: few cases with positive cutaneous tests and specific IgE.
 
Cytotoxicity: thrombocytopenia, anemia, leukopenia.
 
Delayed cell-mediated hypersensitivity: contact dermatitis.
 
Management
Cross-sensitivity between quinine and quinidine (photoallergy)
 
Quinine should be available one prescription only.
 
Warning of quinine potential harmful effects should be printed on all over the counter preparations and on bottles of tonic-water.

References

  1. Maguire R.B, Stronsek D.F, Campbell A.C, "Recurrent pancytopenia, coagulopathy and renal failure associated with multiple quinine-dependent antibodies", Ann. Intern. Med., 1993 ; 119: 215-7
  2. Aster R.H, "Quinine sensitivity: a new cause of the hemolytic uremic syndrome", Ann. Intern. Med, 1993 ; 119: 243-4
  3. Ljunggren B, Hindsen M, Isaksson M, "Systemic quinine photosensitivity with photoepicutaneous cross-reactivity to quinidine", Contact. Dermatitis., 1992 ; 26: 1-4
  4. Pin I, Dor P.H, Vervloet D, Senft M, Charpin J, "Hypersensibilité immédiate à la quinine", Presse Med., 1985 ; 14 (17): 967-9.

As in all diagnostic testing, the diagnosis is made by the physican based on both test results and the patient history.