This case demonstrates the importance of rapid recognition and treatment of hydroxychloroquine poisoning. We anticipate that clinicians may be asked to recognize and manage this toxidrome in increasing frequency as attention on hydroxychloroquine as potential pharmacotherapy for COVID-19 disease may be popularized, despite an increasing concern on the increased mortality associated with this treatment.

Various world leaders have repeatedly touted the use of hydroxychloroquine to manage COVID-19 disease despite the lack of rigorous clinical trial data to support its use.

Personal anecdotes from world leaders may have the untoward effect of promoting the use of hydroxychloroquine in the treatment and prevention of COVID-19.

In addition to the association of hydroxychloroquine use in the context of the COVID-19 pandemic, it is important to recognize unique sources of chloroquine exposure like aquarium cleaners (chloroquine phosphate) and initiate prompt treatment for individuals who present with findings consistent with toxicity.

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