array:24 [
  "pii" => "S2173574317300576"
  "issn" => "21735743"
  "doi" => "10.1016/j.reumae.2017.04.001"
  "estado" => "S300"
  "fechaPublicacion" => "2017-09-01"
  "aid" => "922"
  "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología"
  "copyrightAnyo" => "2016"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "crp"
  "cita" => "Reumatol Clin. 2017;13:294-6"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 1052
    "formatos" => array:3 [
      "EPUB" => 63
      "HTML" => 759
      "PDF" => 230
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S1699258X16300249"
      "issn" => "1699258X"
      "doi" => "10.1016/j.reuma.2016.04.008"
      "estado" => "S300"
      "fechaPublicacion" => "2017-09-01"
      "aid" => "922"
      "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología"
      "documento" => "simple-article"
      "crossmark" => 1
      "subdocumento" => "crp"
      "cita" => "Reumatol Clin. 2017;13:294-6"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 6013
        "formatos" => array:3 [
          "EPUB" => 234
          "HTML" => 4511
          "PDF" => 1268
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Caso cl&#237;nico</span>"
        "titulo" => "Trombocitopenia recurrente inducida por hidroxicloroquina en ausencia de actividad del lupus eritematoso sist&#233;mico"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "294"
            "paginaFinal" => "296"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Relapsed hydroxychloroquine induced thrombocytopenia in a systemic lupus erythematosus patient"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0005"
            "etiqueta" => "Figura 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr1.jpeg"
                "Alto" => 578
                "Ancho" => 1524
                "Tamanyo" => 71593
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Evolutivo de cifras plaquetarias en relaci&#243;n a exposici&#243;n con HCQ&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Vanesa Ant&#243;n V&#225;zquez, Luis Pascual, H&#233;ctor Corominas, Isabel Gim&#233;nez Torrecilla"
            "autores" => array:4 [
              0 => array:2 [
                "nombre" => "Vanesa"
                "apellidos" => "Ant&#243;n V&#225;zquez"
              ]
              1 => array:2 [
                "nombre" => "Luis"
                "apellidos" => "Pascual"
              ]
              2 => array:2 [
                "nombre" => "H&#233;ctor"
                "apellidos" => "Corominas"
              ]
              3 => array:2 [
                "nombre" => "Isabel"
                "apellidos" => "Gim&#233;nez Torrecilla"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2173574317300576"
          "doi" => "10.1016/j.reumae.2017.04.001"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574317300576?idApp=UINPBA00004M"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X16300249?idApp=UINPBA00004M"
      "url" => "/1699258X/0000001300000005/v1_201708130010/S1699258X16300249/v1_201708130010/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2173574317300394"
    "issn" => "21735743"
    "doi" => "10.1016/j.reumae.2016.04.008"
    "estado" => "S300"
    "fechaPublicacion" => "2017-09-01"
    "aid" => "915"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Reumatolog&#237;a y Colegio Mexicano de Reumatolog&#237;a"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "cita" => "Reumatol Clin. 2017;13:297-8"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 889
      "formatos" => array:3 [
        "EPUB" => 72
        "HTML" => 625
        "PDF" => 192
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
      "titulo" => "Leukocytoclastic Vasculitis and Infection&#46; Report of a Case"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "297"
          "paginaFinal" => "298"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Vasculitis leucocitocl&#225;stica e infecci&#243;n&#46; A prop&#243;sito de un caso"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Fig&#46; 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 673
              "Ancho" => 1500
              "Tamanyo" => 100367
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Vesiculobullous form of cutaneous leukocytoclastic vasculitis&#46; &#40;A&#41; Prior to antibiotic therapy&#46; &#40;B&#41; After antibiotic therapy&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Mar&#237;a Jose Moreno Mart&#237;nez, Deseada Palma S&#225;nchez, Elena Pe&#241;as Mart&#237;nez, Ana Haro Mart&#237;nez, Marta Mayor Gonz&#225;lez"
          "autores" => array:5 [
            0 => array:2 [
              "nombre" => "Mar&#237;a Jose"
              "apellidos" => "Moreno Mart&#237;nez"
            ]
            1 => array:2 [
              "nombre" => "Deseada"
              "apellidos" => "Palma S&#225;nchez"
            ]
            2 => array:2 [
              "nombre" => "Elena"
              "apellidos" => "Pe&#241;as Mart&#237;nez"
            ]
            3 => array:2 [
              "nombre" => "Ana"
              "apellidos" => "Haro Mart&#237;nez"
            ]
            4 => array:2 [
              "nombre" => "Marta"
              "apellidos" => "Mayor Gonz&#225;lez"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S1699258X16300146"
        "doi" => "10.1016/j.reuma.2016.04.002"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X16300146?idApp=UINPBA00004M"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574317300394?idApp=UINPBA00004M"
    "url" => "/21735743/0000001300000005/v1_201708230012/S2173574317300394/v1_201708230012/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S217357431730103X"
    "issn" => "21735743"
    "doi" => "10.1016/j.reumae.2016.05.014"
    "estado" => "S300"
    "fechaPublicacion" => "2017-09-01"
    "aid" => "941"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46; and Sociedad Espa&#241;ola de Reumatolog&#237;a y Colegio Mexicano de Reumatolog&#237;a"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "ssu"
    "cita" => "Reumatol Clin. 2017;13:287-93"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 660
      "formatos" => array:3 [
        "EPUB" => 52
        "HTML" => 449
        "PDF" => 159
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Review Article</span>"
      "titulo" => "Biosimilars&#58; A New Scenario in Biologic Therapies"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "287"
          "paginaFinal" => "293"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "F&#225;rmacos biosimilares&#58; un nuevo escenario en las terapias biol&#243;gicas"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Fig&#46; 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 1566
              "Ancho" => 3082
              "Tamanyo" => 257185
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Variability in the safety of biological products beyond the content of the active ingredient&#46; ATC&#44; anatomical therapeutic chemical&#59; INN&#44; international nonproprietary name&#46; &#42;The examples are provided for illustrative purposes&#46; It should be remembered that Remsima and Inflectra are the same product&#46; Modification from Vermeer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">48</span></a></p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Jos&#233; M&#46; Serra L&#243;pez-Matencio, Alberto Morell Baladr&#243;n, Santos Casta&#241;eda"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "Jos&#233; M&#46;"
              "apellidos" => "Serra L&#243;pez-Matencio"
            ]
            1 => array:2 [
              "nombre" => "Alberto"
              "apellidos" => "Morell Baladr&#243;n"
            ]
            2 => array:2 [
              "nombre" => "Santos"
              "apellidos" => "Casta&#241;eda"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S1699258X16300572"
        "doi" => "10.1016/j.reuma.2016.05.013"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1699258X16300572?idApp=UINPBA00004M"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357431730103X?idApp=UINPBA00004M"
    "url" => "/21735743/0000001300000005/v1_201708230012/S217357431730103X/v1_201708230012/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>"
    "titulo" => "Relapsed Hydroxychloroquine Induced Thrombocytopenia in Systemic Lupus Erythematosus Patient"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "294"
        "paginaFinal" => "296"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Vanesa Ant&#243;n V&#225;zquez, Luis Pascual, H&#233;ctor Corominas Macias, Isabel Gim&#233;nez Torrecilla"
        "autores" => array:4 [
          0 => array:4 [
            "nombre" => "Vanesa Ant&#243;n"
            "apellidos" => "V&#225;zquez"
            "email" => array:1 [
              0 => "vanesa&#46;anton&#46;v&#64;gmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Luis"
            "apellidos" => "Pascual"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "H&#233;ctor"
            "apellidos" => "Corominas Macias"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Isabel"
            "apellidos" => "Gim&#233;nez Torrecilla"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "Servicio de Medicina Interna&#44; Hospital Mois&#232;s Broggi&#44; Sant Joan Desp&#237;&#44; Barcelona&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Reumatolog&#237;a&#44; Hospital Mois&#232;s Broggi&#44; Sant Joan Desp&#237;&#44; Barcelona&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Servicio de Nefrolog&#237;a&#44; Hospital Mois&#232;s Broggi&#44; Sant Joan Desp&#237;&#44; Barcelona&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Trombocitopenia recurrente inducida por hidroxicloroquina en ausencia de actividad del lupus eritematoso sist&#233;mico"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 578
            "Ancho" => 1524
            "Tamanyo" => 71373
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Changes in platelet counts in relation to exposure to hydroxychloroquine &#40;HCQ&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The potential causes of thrombocytopenia are numerous and&#44; depending on the mechanism of action&#44; can be classified into 2 large groups&#58; &#40;1&#41; immune-mediated&#8212;secondary to autoimmune diseases&#44; idiopathic thrombocytopenic purpura&#44; infections&#44; immunodeficiencies and drug-induced&#59; and &#40;2&#41; nonimmune-mediated&#8212;drug-induced&#44; bone marrow diseases and congenital&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 27-year-old man who had been diagnosed with systemic lupus erythematosus &#40;SLE&#41; 5 years earlier&#44; as a result of an episode of immune thrombocytopenia and primary peritonitis&#46; The diagnosis revealed antinuclear antibodies &#40;ANA&#41; at a titer of 1&#58;320&#44; negative results for anti-double strand &#40;ds&#41; DNA antibodies&#44; normal levels of complement component C3 and C4&#44; and a systemic lupus erythematosus disease activity index &#40;SLEDAI&#41; of 11&#46; Despite treatment with immunosuppressive agents and maintenance with mycophenolate sodium &#40;360<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41; and hydroxychloroquine &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; the patient developed class II lupus nephritis with an activity index of 1&#47;12 and of chronicity of 0&#47;12&#46; Renal biopsy was performed in June 2011&#58; light microscopic study of 10 glomeruli showed moderate focal and segmental mesangial hypercellularity&#44; although there were no lesions indicative of necrotic activity&#44; karyorrhexis&#44; crescents or fuchsinophilic deposits&#46; Cellularity was preserved and there was no tubulointerstitial fibrosis or atrophy&#46; Immunofluorescence of 4 glomeruli was positive&#44; with a pure mesangial glomerular pattern&#46; Some paramesangial deposits were focally and segmentally isolated&#46; There was no evidence of parietal deposits&#46; Tests revealed IgG&#8722;&#47;&#43;&#44; IgA&#43;&#43;&#44; C3&#43;&#43;&#44; C1q&#8722;&#47;&#43;&#44; Kappa&#43;&#47;&#43; and Lambda&#43;&#47;&#43;&#46; Negative findings in vessels&#44; interstitium and tubules&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">He had a proteinuria of 5<span class="elsevierStyleHsp" style=""></span>g&#47;day detected in May 2015 and was admitted to the hospital for another renal biopsy&#46; During his hospital stay&#44; he was found to have asymptomatic thrombocytopenia&#44; 4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>cells&#47;L&#44; with no signs of cellular atypia&#44; negative results on tests for antiplatelet and antihistone antibodies and a SLEDAI of 9&#46; He began to take corticosteroids at a dose of 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg body weight &#40;bw&#41;&#47;day&#44; with a diagnosis of autoimmune thrombocytopenia&#46; Immunosuppressive therapy was maintained&#44; and hydroxychloroquine&#44; which was not prescribed&#44; was discontinued&#46; After 48<span class="elsevierStyleHsp" style=""></span>h&#44; he had a rapid platelet recovery&#44; reaching 195<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>cells&#47;L&#46; This enabled the performance of the renal biopsy&#44; which revealed a progression of the lupus nephritis&#44; from class II to class V &#40;membranous glomerulonephritis&#41;&#46; Renal biopsy was repeated in July 2015&#46; Light microscopic study ruled out the presence of lesions indicative of proliferative glomerulonephritis&#59; there was no tubulointerstitial fibrosis and immunofluorescence of 5 glomeruli showed a generalized&#44; diffuse glomerular parietal pattern&#58; IgG&#43;&#43;&#43;&#44; IgA&#43;&#43;&#44; IgM&#43;&#47;&#8722;&#44; C3&#43;&#43;&#43;&#44; C1q&#43;&#44; Kappa&#43;&#43;&#43; and Lambda&#43;&#43;&#43;&#46; Findings in vessels&#44; interstitium and tubules were negative&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">At discharge&#44; a different physician again prescribed combined therapy with mycophenolate and hydroxychloroquine &#40;200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#46; The patient was readmitted 72<span class="elsevierStyleHsp" style=""></span>h after discharge due to a new episode of severe thrombocytopenia&#44; with no signs of lupus activity &#40;negative test for anti-dsDNA antibodies and normal C3 and C4 levels&#41;&#46; He began to take corticosteroids again &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg bw&#47;day&#41;&#44; without platelet recovery&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the rapid cause-and-effect relationship between hydroxychloroquine and thrombocytopenia&#44; the drug was discontinued intentionally&#46; Within 72<span class="elsevierStyleHsp" style=""></span>h&#44; the platelet count reached 200<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>cells&#47;L &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">During follow-up&#44; after 1 month&#44; the total platelet count was 250<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span><span class="elsevierStyleHsp" style=""></span>cells&#47;L and&#44; in analyses performed 3 and 6 months later&#44; there had been no decrease &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; He began to take tacrolimus because of the progression of nephritis&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Drug-induced thrombocytopenia is based on the accelerated destruction of platelets that can occur via 2 different mechanisms&#58; due to direct toxicity acting on the bone marrow or due to peripheral destruction by means of a mechanism that may or may not be immune-mediated by specific antibodies that react with the drug&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The drugs that have been most frequently related to the development of thrombocytopenia are cinchona alkaloids &#40;quinine&#47;quinidine&#41;&#44; sulfonamides&#44; nonsteroidal anti-inflammatory drugs&#44; diuretics&#44; anticonvulsants&#44; tuberculostatic drugs and heparins&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnosis of drug-induced thrombocytopenia is established by exclusion&#44; by interrupting administration of the drug and by the detection of drug-dependent antibodies&#46; The temporal relationship between the administration of the treatment and the development of thrombocytopenia is highly important&#44; as is recurrence after re-exposure to the drug&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> In our patient&#44; the discontinuance of the medication was used as a method of exclusion&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Reaching the definitive diagnosis in the case we report was complex&#44; given that the first manifestation of SLE in our patient was thrombocytopenia&#46; There is a form of clinical presentation in SLE consisting of chronic thrombocytopenia with a slight response to corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Thus&#44; the initial diagnostic suspicion focused on the exacerbation of the lupus activity&#44; in a patient in whom&#44; moreover&#44; the disease had progressed to renal involvement&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Hydroxychloroquine is an antimalarial drug employed in the treatment of lupus and other rheumatic diseases&#46; A number of retrospective studies have shown the efficacy of hydroxychloroquine in the treatment of the autoimmune thrombocytopenia associated with SLE&#46; The authors recommend that the medication not to be discontinued&#44; even in advanced stages of lupus nephritis&#46; Nevertheless&#44; the secondary effects of that drug include thrombocytopenia&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> although it is not a common adverse effect&#44; given that there are only isolated cases reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#8211;10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Finally&#44; we consider this case to be of clinical and practical interest&#44; because the cause of the thrombocytopenia was related to hydroxychloroquine and not to the lupus activity&#44; which at all times was clinically and serologically inactive&#44; despite the severity of the thrombocytopenia&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical Disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of Interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:3 [
          "identificador" => "xres884938"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec871138"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres884939"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec871137"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case Report"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conclusion"
        ]
        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Ethical Disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflicts of Interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-03-04"
    "fechaAceptado" => "2016-04-18"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec871138"
          "palabras" => array:3 [
            0 => "Hydroxychloroquine"
            1 => "Thrombocytopenia"
            2 => "Systemic lupus erythematosus"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec871137"
          "palabras" => array:3 [
            0 => "Hidroxicloroquina"
            1 => "Trombocitopenia"
            2 => "Lupus eritematoso sist&#233;mico"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hydroxychloroquine is used in the long-term therapy of systemic lupus erythematosus &#40;SLE&#41;&#46; Although considered to be a safe treatment&#44; side effects have been documented&#46; An uncommon side effect is thrombocytopenia&#46; In order to establish the diagnosis of thrombocytopenia secondary to Hydroxychloroquine&#44; non-pharmacological causes must be ruled out and it is necessary to determine a recurrence after re-exposure to the drug&#46; We present one case of severe thrombocytopenia occurring in a patient with SLE undergoing treatment with Hydroxychloroquine&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La hidroxicloroquina es un f&#225;rmaco antimal&#225;rico&#44; empleado como terapia a largo plazo en el lupus eritematoso sist&#233;mico &#40;LES&#41;&#46; A pesar de considerarse un tratamiento seguro&#44; existen efectos adversos descritos&#46; Uno muy infrecuente es la trombocitopenia&#46; Para establecer el diagn&#243;stico de trombocitopenia causada por hidroxicloroquina es necesario descartar otras causas no farmacol&#243;gicas y objetivar la recurrencia tras la reexposici&#243;n al f&#225;rmaco&#46; Presentamos un caso de trombocitopenia severa en un paciente con LES durante el tratamiento con hidroxicloroquina&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; V&#225;zquez VA&#44; Pascual L&#44; Corominas Macias H&#44; Gim&#233;nez Torrecilla I&#46; Trombocitopenia recurrente inducida por hidroxicloroquina en ausencia de actividad del lupus eritematoso sist&#233;mico&#46; Reumatol Clin&#46; 2017&#59;13&#58;294&#8211;296&#46;</p>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 578
            "Ancho" => 1524
            "Tamanyo" => 71373
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Changes in platelet counts in relation to exposure to hydroxychloroquine &#40;HCQ&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Platelets&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hemoglobin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Leukocytes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Lymphocytes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anti-DNA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">C3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">C4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Baseline&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">175<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">141<span class="elsevierStyleHsp" style=""></span>g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;6<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HCQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">140<span class="elsevierStyleHsp" style=""></span>g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">STOP HCQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">195<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">154<span class="elsevierStyleHsp" style=""></span>g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;8<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;7<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HCQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">153<span class="elsevierStyleHsp" style=""></span>g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;8<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">STOP HCQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">148<span class="elsevierStyleHsp" style=""></span>g&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;5<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1494223.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Platelet Count&#44; White Blood Cells&#44; Red Blood Cells&#44; Anti-DNA and Complement According to Exposure to and Interruption of Hydroxychloroquine &#40;HCQ&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:10 [
            0 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "International consensus report on the investigation and management of primary immune thrombocytopenia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Provan"
                            1 => "R&#46; Stasi"
                            2 => "A&#46;C&#46; Newland"
                            3 => "V&#46;S&#46; Blanchette"
                            4 => "P&#46; Bolton-Maggs"
                            5 => "J&#46;B&#46; Bussel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1182/blood-2009-06-225565"
                      "Revista" => array:6 [
                        "tituloSerie" => "Blood"
                        "fecha" => "2010"
                        "volumen" => "115"
                        "paginaInicial" => "168"
                        "paginaFinal" => "186"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19846889"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Drug induced immune thrombocytopenia&#58; pathogenesis&#44; diagnosis and management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46;H&#46; Aster"
                            1 => "B&#46;R&#46; Curtis"
                            2 => "J&#46;G&#46; McFarland"
                            3 => "D&#46;W&#46; Bougie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1538-7836.2009.03360.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Thromb Haemost"
                        "fecha" => "2009"
                        "volumen" => "7"
                        "paginaInicial" => "911"
                        "paginaFinal" => "918"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19344362"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Drug-induced immune thrombocytopenia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;H&#46; Aster"
                            1 => "D&#46;W&#46; Bougie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMra066469"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2007"
                        "volumen" => "357"
                        "paginaInicial" => "580"
                        "paginaFinal" => "587"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17687133"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Drug-induced thrombocytopenia&#58; a population study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;J&#46; Ten Berg"
                            1 => "A&#46; Huisman"
                            2 => "P&#46;C&#46; Souverein"
                            3 => "A&#46;F&#46; Achinen"
                            4 => "A&#46;C&#46; Egberts"
                            5 => "W&#46;W&#46; van Solinge"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Drug Saf"
                        "fecha" => "2006"
                        "volumen" => "29"
                        "paginaInicial" => "713"
                        "paginaFinal" => "721"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16872245"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Incidencia de trombocitopenia inducida por f&#225;rmacos en pacientes hospitalizados"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46; Seco-Melantuche"
                            1 => "O&#46; Delgado-S&#225;nchez"
                            2 => "L&#46; &#193;lvarez-Arroyo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7399/FH.2013.37.1.42"
                      "Revista" => array:6 [
                        "tituloSerie" => "Farm Hosp"
                        "fecha" => "2013"
                        "volumen" => "37"
                        "paginaInicial" => "27"
                        "paginaFinal" => "34"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23461497"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Haematological manifestations of systemic lupus erythematosus"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46; Keeling"
                            1 => "D&#46; Isenber"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Blood Rev"
                        "fecha" => "1993"
                        "volumen" => "7"
                        "paginaInicial" => "199"
                        "paginaFinal" => "207"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8130682"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Haematological side-effects of some anti-rheumatic drugs"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46;O&#46; Nieweg"
                            1 => "H&#46;G&#46; Bouma"
                            2 => "K&#46; Devries"
                            3 => "A&#46; Jansz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "1963"
                        "volumen" => "22"
                        "paginaInicial" => "440"
                        "paginaFinal" => "443"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14087256"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A case of thrombocytopenia associated with the use of hydroxychloroquine following open heart surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46; Demir"
                            1 => "F&#46; &#214;cal"
                            2 => "M&#46; Abanoz"
                            3 => "H&#46; Dermenci"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ijscr.2014.11.052"
                      "Revista" => array:7 [
                        "tituloSerie" => "Int J Surg Case Rep"
                        "fecha" => "2014"
                        "volumen" => "5"
                        "paginaInicial" => "1282"
                        "paginaFinal" => "1284"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25460494"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0378512215006714"
                          "estado" => "S300"
                          "issn" => "03785122"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Thrombopenia secondary to hydroxichloroquine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "L&#46; Caminal"
                            1 => "A&#46; Gonz&#225;lez"
                            2 => "J&#46; Ferro"
                            3 => "R&#46; Susano"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "An Med Interna"
                        "fecha" => "1994"
                        "volumen" => "11"
                        "paginaInicial" => "310"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7918951"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Thrombocytopenia due to aurothioglucose&#44; sulphasalazine&#44; andhydroxychloroquine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;J&#46; Wijnands"
                            1 => "W&#46;A&#46; Allebes"
                            2 => "A&#46;M&#46; Boerbooms"
                            3 => "L&#46;B&#46; van de Putte"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "1990"
                        "volumen" => "49"
                        "paginaInicial" => "798"
                        "paginaFinal" => "800"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1978639"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/21735743/0000001300000005/v1_201708230012/S2173574317300576/v1_201708230012/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "67860"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Case reports"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001300000005/v1_201708230012/S2173574317300576/v1_201708230012/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574317300576?idApp=UINPBA00004M"
]
Share
Journal Information
Vol. 13. Issue 5.
Pages 294-296 (September - October 2017)
Visits
11344
Vol. 13. Issue 5.
Pages 294-296 (September - October 2017)
Case Report
Full text access
Relapsed Hydroxychloroquine Induced Thrombocytopenia in Systemic Lupus Erythematosus Patient
Trombocitopenia recurrente inducida por hidroxicloroquina en ausencia de actividad del lupus eritematoso sistémico
Visits
11344
Vanesa Antón Vázqueza,
Corresponding author
vanesa.anton.v@gmail.com

Corresponding author.
, Luis Pascuala, Héctor Corominas Maciasb, Isabel Giménez Torrecillac
a Servicio de Medicina Interna, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain
b Servicio de Reumatología, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain
c Servicio de Nefrología, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain
This item has received
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (1)
Tables (1)
Table 1. Platelet Count, White Blood Cells, Red Blood Cells, Anti-DNA and Complement According to Exposure to and Interruption of Hydroxychloroquine (HCQ).
Abstract

Hydroxychloroquine is used in the long-term therapy of systemic lupus erythematosus (SLE). Although considered to be a safe treatment, side effects have been documented. An uncommon side effect is thrombocytopenia. In order to establish the diagnosis of thrombocytopenia secondary to Hydroxychloroquine, non-pharmacological causes must be ruled out and it is necessary to determine a recurrence after re-exposure to the drug. We present one case of severe thrombocytopenia occurring in a patient with SLE undergoing treatment with Hydroxychloroquine.

Keywords:
Hydroxychloroquine
Thrombocytopenia
Systemic lupus erythematosus
Resumen

La hidroxicloroquina es un fármaco antimalárico, empleado como terapia a largo plazo en el lupus eritematoso sistémico (LES). A pesar de considerarse un tratamiento seguro, existen efectos adversos descritos. Uno muy infrecuente es la trombocitopenia. Para establecer el diagnóstico de trombocitopenia causada por hidroxicloroquina es necesario descartar otras causas no farmacológicas y objetivar la recurrencia tras la reexposición al fármaco. Presentamos un caso de trombocitopenia severa en un paciente con LES durante el tratamiento con hidroxicloroquina.

Palabras clave:
Hidroxicloroquina
Trombocitopenia
Lupus eritematoso sistémico
Full Text
Introduction

The potential causes of thrombocytopenia are numerous and, depending on the mechanism of action, can be classified into 2 large groups: (1) immune-mediated—secondary to autoimmune diseases, idiopathic thrombocytopenic purpura, infections, immunodeficiencies and drug-induced; and (2) nonimmune-mediated—drug-induced, bone marrow diseases and congenital.1

Case Report

The patient was a 27-year-old man who had been diagnosed with systemic lupus erythematosus (SLE) 5 years earlier, as a result of an episode of immune thrombocytopenia and primary peritonitis. The diagnosis revealed antinuclear antibodies (ANA) at a titer of 1:320, negative results for anti-double strand (ds) DNA antibodies, normal levels of complement component C3 and C4, and a systemic lupus erythematosus disease activity index (SLEDAI) of 11. Despite treatment with immunosuppressive agents and maintenance with mycophenolate sodium (360mg/12h) and hydroxychloroquine (200mg/day), the patient developed class II lupus nephritis with an activity index of 1/12 and of chronicity of 0/12. Renal biopsy was performed in June 2011: light microscopic study of 10 glomeruli showed moderate focal and segmental mesangial hypercellularity, although there were no lesions indicative of necrotic activity, karyorrhexis, crescents or fuchsinophilic deposits. Cellularity was preserved and there was no tubulointerstitial fibrosis or atrophy. Immunofluorescence of 4 glomeruli was positive, with a pure mesangial glomerular pattern. Some paramesangial deposits were focally and segmentally isolated. There was no evidence of parietal deposits. Tests revealed IgG−/+, IgA++, C3++, C1q−/+, Kappa+/+ and Lambda+/+. Negative findings in vessels, interstitium and tubules.

He had a proteinuria of 5g/day detected in May 2015 and was admitted to the hospital for another renal biopsy. During his hospital stay, he was found to have asymptomatic thrombocytopenia, 4×109cells/L, with no signs of cellular atypia, negative results on tests for antiplatelet and antihistone antibodies and a SLEDAI of 9. He began to take corticosteroids at a dose of 1mg/kg body weight (bw)/day, with a diagnosis of autoimmune thrombocytopenia. Immunosuppressive therapy was maintained, and hydroxychloroquine, which was not prescribed, was discontinued. After 48h, he had a rapid platelet recovery, reaching 195×109cells/L. This enabled the performance of the renal biopsy, which revealed a progression of the lupus nephritis, from class II to class V (membranous glomerulonephritis). Renal biopsy was repeated in July 2015. Light microscopic study ruled out the presence of lesions indicative of proliferative glomerulonephritis; there was no tubulointerstitial fibrosis and immunofluorescence of 5 glomeruli showed a generalized, diffuse glomerular parietal pattern: IgG+++, IgA++, IgM+/−, C3+++, C1q+, Kappa+++ and Lambda+++. Findings in vessels, interstitium and tubules were negative.

At discharge, a different physician again prescribed combined therapy with mycophenolate and hydroxychloroquine (200mg/day). The patient was readmitted 72h after discharge due to a new episode of severe thrombocytopenia, with no signs of lupus activity (negative test for anti-dsDNA antibodies and normal C3 and C4 levels). He began to take corticosteroids again (1mg/kg bw/day), without platelet recovery.

Given the rapid cause-and-effect relationship between hydroxychloroquine and thrombocytopenia, the drug was discontinued intentionally. Within 72h, the platelet count reached 200×109cells/L (Table 1).

Table 1.

Platelet Count, White Blood Cells, Red Blood Cells, Anti-DNA and Complement According to Exposure to and Interruption of Hydroxychloroquine (HCQ).

  Platelets  Hemoglobin  Leukocytes  Lymphocytes  Anti-DNA  C3  C4 
Baseline  175×109/L  141g/L  9.2×109/L  1.6×109/L  Negative  0.9  0.15 
HCQ  4×109/L  140g/L  9.4×109/L  2×109/L  Negative  1.3  0.13 
STOP HCQ  195×109/L  154g/L  8.8×109/L  1.7×109/L  Negative  1.5  0.22 
HCQ  5×109/L  153g/L  10×109/L  1.8×109/L  Negative  1.1  0.19 
STOP HCQ  250×109/L  148g/L  9.5×109/L  1.5×109/L  Negative  1.0  0.2 

During follow-up, after 1 month, the total platelet count was 250×109cells/L and, in analyses performed 3 and 6 months later, there had been no decrease (Fig. 1). He began to take tacrolimus because of the progression of nephritis.

Fig. 1.

Changes in platelet counts in relation to exposure to hydroxychloroquine (HCQ).

(0.07MB).
Discussion

Drug-induced thrombocytopenia is based on the accelerated destruction of platelets that can occur via 2 different mechanisms: due to direct toxicity acting on the bone marrow or due to peripheral destruction by means of a mechanism that may or may not be immune-mediated by specific antibodies that react with the drug.2,3

The drugs that have been most frequently related to the development of thrombocytopenia are cinchona alkaloids (quinine/quinidine), sulfonamides, nonsteroidal anti-inflammatory drugs, diuretics, anticonvulsants, tuberculostatic drugs and heparins.3,4

The diagnosis of drug-induced thrombocytopenia is established by exclusion, by interrupting administration of the drug and by the detection of drug-dependent antibodies. The temporal relationship between the administration of the treatment and the development of thrombocytopenia is highly important, as is recurrence after re-exposure to the drug.4,5 In our patient, the discontinuance of the medication was used as a method of exclusion.

Reaching the definitive diagnosis in the case we report was complex, given that the first manifestation of SLE in our patient was thrombocytopenia. There is a form of clinical presentation in SLE consisting of chronic thrombocytopenia with a slight response to corticosteroids.6 Thus, the initial diagnostic suspicion focused on the exacerbation of the lupus activity, in a patient in whom, moreover, the disease had progressed to renal involvement.

Hydroxychloroquine is an antimalarial drug employed in the treatment of lupus and other rheumatic diseases. A number of retrospective studies have shown the efficacy of hydroxychloroquine in the treatment of the autoimmune thrombocytopenia associated with SLE. The authors recommend that the medication not to be discontinued, even in advanced stages of lupus nephritis. Nevertheless, the secondary effects of that drug include thrombocytopenia,7 although it is not a common adverse effect, given that there are only isolated cases reported in the literature.8–10

Conclusion

Finally, we consider this case to be of clinical and practical interest, because the cause of the thrombocytopenia was related to hydroxychloroquine and not to the lupus activity, which at all times was clinically and serologically inactive, despite the severity of the thrombocytopenia.

Ethical DisclosuresProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.

Conflicts of Interest

The authors declare they have no conflicts of interest.

References
[1]
D. Provan, R. Stasi, A.C. Newland, V.S. Blanchette, P. Bolton-Maggs, J.B. Bussel, et al.
International consensus report on the investigation and management of primary immune thrombocytopenia.
[2]
R.H. Aster, B.R. Curtis, J.G. McFarland, D.W. Bougie.
Drug induced immune thrombocytopenia: pathogenesis, diagnosis and management.
J Thromb Haemost, 7 (2009), pp. 911-918
[3]
R.H. Aster, D.W. Bougie.
Drug-induced immune thrombocytopenia.
N Engl J Med, 357 (2007), pp. 580-587
[4]
M.J. Ten Berg, A. Huisman, P.C. Souverein, A.F. Achinen, A.C. Egberts, W.W. van Solinge.
Drug-induced thrombocytopenia: a population study.
Drug Saf, 29 (2006), pp. 713-721
[5]
R. Seco-Melantuche, O. Delgado-Sánchez, L. Álvarez-Arroyo.
Incidencia de trombocitopenia inducida por fármacos en pacientes hospitalizados.
Farm Hosp, 37 (2013), pp. 27-34
[6]
D. Keeling, D. Isenber.
Haematological manifestations of systemic lupus erythematosus.
Blood Rev, 7 (1993), pp. 199-207
[7]
H.O. Nieweg, H.G. Bouma, K. Devries, A. Jansz.
Haematological side-effects of some anti-rheumatic drugs.
Ann Rheum Dis, 22 (1963), pp. 440-443
[8]
D. Demir, F. Öcal, M. Abanoz, H. Dermenci.
A case of thrombocytopenia associated with the use of hydroxychloroquine following open heart surgery.
Int J Surg Case Rep, 5 (2014), pp. 1282-1284
[9]
L. Caminal, A. González, J. Ferro, R. Susano.
Thrombopenia secondary to hydroxichloroquine.
An Med Interna, 11 (1994), pp. 310
[10]
M.J. Wijnands, W.A. Allebes, A.M. Boerbooms, L.B. van de Putte.
Thrombocytopenia due to aurothioglucose, sulphasalazine, andhydroxychloroquine.
Ann Rheum Dis, 49 (1990), pp. 798-800

Please cite this article as: Vázquez VA, Pascual L, Corominas Macias H, Giménez Torrecilla I. Trombocitopenia recurrente inducida por hidroxicloroquina en ausencia de actividad del lupus eritematoso sistémico. Reumatol Clin. 2017;13:294–296.

Copyright © 2016. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
Download PDF
Idiomas
Reumatología Clínica (English Edition)
Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?