Hydroxychloroquine Induced Cardiomyopathy

Hydroxychloroquine (HCQ) is one of the immunomodulatory medications used in treatment of autoimmune diseases. Rarely, HCQ can cause serious complications, such as cardiotoxicity. We present a rare case of HCQ-induced cardiomyopathy. 60-year-old female patient with a medical history of SLE on chronic HCQ therapy for 28 years, preexisting non-ischemic cardiomyopathy and heart failure with reduced ejection fraction for 7 years, and complete heart block status post pacemaker insertion presented with acute chest pain and severe weight loss. Patient underwent coronary angiogram that showed normal coronaries and right-sided heart catheterization that showed acute heart failure. Echocardiogram showed LVEF of 30% with global hypokinesis. Patient was started on dobutamine with an improvement of her symptoms. As HCQ-induced cardiomyopathy was suspected, patient underwent an endomyocardial biopsy that revealed a pathognomonic finding of myocyte vacuolization, consistent with HCQ-induced cardiomyopathy. HCQ was discontinued immediately. However, patient was a poor candidate for heart transplantation and durable mechanical circulatory support due to severe malnutrition secondary to end-stage heart failure. Patient accepted hospice care and passed away peacefully. This case highlights the need for high index of clinical suspicion, careful medication reconciliation for patients with non-ischemic cardiomyopathy, and tissue biopsy with careful histopathological examination to diagnose this rare complication.