A 35-year-old woman presented to the emergency department with vomiting, diarrhea and abdominal pain after drinking vodka and tonic at an office party. She was diagnosed with acute gastroenteritis and discharged. She returned two days later with worsening kidney function and symptoms. Further evaluation revealed thrombotic microangiopathy (TMA). A prior similar illness 16 months ago was reviewed, suggesting quinine-induced TMA from the tonic component of the vodka and tonic drink. The patient was treated with plasma exchange, hemodialysis and steroids.

1. After the Party’s Over
James N. George, M.D., Jordan M. Morton, M.D., Nathan
W. Liles, M.D., M.P.H., and Carla M. Nester, M.D. N Engl J
Med 2017; 376:74-80January 5, 2017DOI:
10.1056/NEJMcps1606z
Journal Club Presentation
Presented by
Dr. Ahmed Shahed
RMO (Green Unit)
Medicine Department
HFRCMCH

2. (1) Chills, myalgias, nausea, and abdominal cramping.
(2) That night she had a fever (temperature, 38.9°C
[102°F])
(3) Explosive nonbloody diarrhea, frequent vomiting,
and abdominal and low back pain.
The temperature was 37.6°C (99.6°F), Blood pressure
153/51 mm Hg, and heart rate 67 beats per minute. The
physical examination was normal except for mild
abdominal and back tenderness.
While driving home from an evening office party in the autumn of
2009, a 35-year-old woman had a sudden onset of

3. (1) Hb level of 13.8 g /dl.
(2) WBC count of 18,400 /cumm, with 63%
neutrophils and 27% band neutrophils.
(3) Platelet count of 132,000/cu mm
(4) A urine sample could not be obtained.
(5) A stool specimen was cultured for
routine pathogen

4. The presumed diagnosis was acute
gastroenteritis.
The patient was treated with intravenous fluids
and ondansetron and was instructed to see her
primary care physician within the next 3 to 5
days.

5. • Cholecystitis
• Cholangitis.
• Pancreatitis.

6. The patient’s evaluation in the emergency department did not take
into account additional laboratory data obtained that morning
(1) Blood urea nitrogen level of 17 mg/dl (6.1 mmol per liter)
(2) Creatinine 2.6 mg/dl (230 μmol per liter)
(3) Alanine aminotransferase 52 U/l (normal range, 12 to 48),
(4) Aspartate aminotransferase 248 U/l (normal range, 8 - 41)
(5) Bilirubin 3.5 mg /dl (60 μmol per liter)
Direct and indirect bilirubin levels were not measured.

7. • Hospital admission ?
• What would be the other
possibilities?
1. Acute Kidney Injury with
hepatic insufficiency.
a. RPGN/ Drug or Toxin
induced with
b. Hepatitis- Alcohol/Viral/
Idiosyncratic drug reaction.

8. The patient returned to the emergency department 2 days after
her first visit.
The vomiting and diarrhea had subsided, but
she had not urinated since her illness began.
Her back pain persisted. She had no fever or
rash. She reported no excessive alcohol use or
drug abuse.
The blood pressure was 146/88 mm Hg.

9. (1) Hb level 11.6 g/dl, WBC count 14,900/cumm with 67% neutrophils
and 6% band neutrophils, platelet count 54,000/cumm of blood.
(2) Creatinine level 9.3 mg/dl (822 μmol per liter)
(3) Alanine aminotransferase level 274 U/l
(4) Aspartate aminotransferase level 350 U/l
(5) Total bilirubin level 1.0 mg/dl(17 μmol per liter), INR 1.0
(6) Activated partial-thromboplastin time 28 seconds.
(7) Fibrinogen level 549 mg/dl (normal range, 150 to 450 mg/dl).
(7) A stool culture was negative for routine pathogens.
(8) Computed tomography (CT) of the patient’s abdomen and pelvis
(performed without the administration of contrast material) was normal.

10. • DIC
• TMA (MAHA)
(a) TTP
(b) Shiga toxin induced
HUS
• RPGN
(a) SLE
(b) Scleroderma renal
crisis

11. On evaluation at the hospital,
(1) Mild asthma and occasional headaches.
(2)Drug history- rizatriptan and ibuprofen (taken as needed for
headaches) and montelukast (taken daily).
(3) She had no history of Raynaud’s phenomenon and
reported no history of rashes, arthralgias, or other
manifestations suggestive of SLE.
(4) There was no family history of kidney disease. She had been
working regularly until the onset of this illness.
(1) She was afebrile.
(2) Her blood pressure was 154/98 mm Hg.
(3) The remainder of her physical examination was normal,
except for bilateral flank tenderness.

12. (1) Hb- 10.7g/dl. WBC-10,400/cumm with N= 83%
Platelet count 42,000/cumm.
(2) Creatinine level 10.7 mg/dl (946 μmol/l)
(3) Alanine aminotransferase 183 U per liter,
(4) Aspartate aminotransferase 174 U per/l,
(5) Lactate dehydrogenase 2402 U/l.
(6) PBF- showed many large polychromatophilic red cells
(reticulocytes) and many fragmented red cells (schistocytes).
(8) A direct antiglobulin test (Coombs’ test) was negative.

13. • Microagiopathic hemolytic anaemia,
thrombocytopenia and AKI.

14. In recalling the precise moment when the severe
symptoms had begun as
She was driving home from the
office party, she said, “It was like a
lightning strike.” She reported that
she did not use herbal remedies,
quinine pills, or illegal drugs.

15. • An immune-mediated adverse drug reaction TMA
a. Quinine
b. Ciprofloxacin
c. Gemcitabine
d. Oxaliplatin.

16. Further exploration of past medical history (16 months earlier)
The patient was questioned about ingestion of gin and tonic. She said
she had never had this drink. However, she then recalled that she had
drunk vodka and tonic (“but only a sip”) just before she left the party.
On further questioning, she recalled that the last time she had drunk
vodka and tonic before that night was 16 months earlier, at a wedding
party.
She had had chills, fever, vomiting, severe headache, and posterior
neck pain within an hour after consuming this drink, and she had
been taken to an emergency department. A subsequent review of the
records from that emergency department revealed that meningitis
had been suspected
Spinal fluid and CT of the head were both normal. The hemoglobin
level was 12.9 g per deciliter, the platelet count 227,000 per cubic
millimeter, and the creatinine level 1.7 mg per deciliter (150 μmol per
liter). No diagnosis was established. By 6 months after that episode
(10 months before the current illness), the creatinine level had
returned to normal (0.7 mg per deciliter [62 μmol per liter]).

17. • Quinine provides strong clinical evidence for
quinine-induced TMA

18. • ADAMTS13 (a disintegrin and metalloproteinase with a
thrombospondin type 1 motif, member 13) activity of 100% was
reported several days later. The platelet count subsequently
normalized.
• Quinine-dependent antibodies that were reactive with both
platelets and neutrophils were identified in the patient’s serum on
testing at the BloodCenter of Wisconsin.

19. Final Diagnosis
• Thrombotic microangiopathy
(TMA) Quinine dependent.
• Rx
a. Plasma exchange.
b. Hemodialysis.
c. Methylprednisolone.
d. Eculizumab.

20. Tonic Drinks and Water.