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Cambodian Literature: From Angkor to Year Zero and Beyond

Photo: Sharon May, “Bayon, Cambodia” (2009)

It has been forty years since the black-clad Khmer Rouge marched into Phnom Penh during the Khmer New Year of April 1975 and evacuated the city, sending its inhabitants on foot to work and starve in labor camps in the countryside, initiating “Year Zero.” Literature, art, and religion were abolished. The Khmer language itself was changed. The ability to read and write, knowledge of a foreign language, even the wearing of eyeglasses, could get one killed. During the regime, between 1975 and ’79, nearly two million people—out of a population of only seven million—died of starvation, disease, torture, and execution. According to one estimate, less than one percent of intellectuals survived. Most estimate about ten percent of artists survived; the same applies to books. Out of six hundred librarians, only three remained. During the Khmer Rouge period the Buddhist monasteries—traditional repositories of learning and literature—were ransacked and converted to prisons. The National Library was used to raise pigs. In the words of activist Vannath Chea, “The arts are like women: the first to be degraded in poverty and war.”

Cambodia is a small heart-shaped country—about the size of the US state of Washington—set in between Thailand, Laos, Vietnam, and the Gulf of Thailand. In the northwest lies the great lake of the Tonle Sap, on whose edges rise the magnificent temples of Angkor. This civilization flourished between the ninth and fifteenth centuries, and recent archeological mapping has revealed that Angkor was in fact the largest pre-industrial city in the world. In 1863, Cambodia became a protectorate of France; it gained independence in 1953, only to become inadvertently caught up in the American war in Vietnam. The US heavily bombed Cambodia in the 1960s and ’70s, before the Khmer Rouge took over in 1975.

While Cambodia is famous for the “killing fields” of the Khmer Rouge and for the temples of Angkor, it is less known for its writing. Nevertheless, Cambodia possesses a rich literature—both oral and written—and had a thriving community of writers before the war. This issue includes examples of this material, rarely translated into English, from the Angkor era through the Khmer Rouge regime and afterward.

The earliest recorded writings in Cambodia are stone inscriptions in Sanskrit, dating back to the fifth century. We are fortunate to have a translation of one of these inscriptions, composed at the pinnacle of the Angkor era by Queen Indradevi, celebrated as one of Cambodia’s first known female poets. Her poem (c. 1190–1200 AD) was carved into the Great Stele of Phimeanakas. Indradevi’s words are brought to life by translator Trent Walker, who chants the queen’s Sanskrit in Khmer style.

By the fourteenth century, Khmer had replaced Sanskrit as the official language. Classical Khmer represents the metaphysical union between Indian Brahmin and native Khmer of Cambodia’s creation myths. It combines the multisyllabic vocabulary of Pali and Sanskrit with the largely monosyllabic, highly alliterative and onomatopoeic native vocabulary. Classical Khmer poetry has about fifty forms, using complex meters and intricate rhyme schemes.

The epics, composed in thousands of stanzas, could take days to chant. These classics were recorded between the fourteenth to nineteenth centuries. The most famous epic poem in Cambodia is the Reamker , the Cambodian version of the Indian Ramayana, which has been recited, sung, and danced in various forms for centuries. Other epic poems include Lpoek Angkor Vat (The Story of Angkor Wat), which celebrates the Angkor temples; the Jataka tales, stories of the former lives of the Buddha; and the Tum Teav, based on a seventeenth-century tragic love story, considered Cambodia’s Romeo and Juliet. The classic tale of separated lovers would become the subject of many of Cambodia’s later modern novels.

Modern Cambodian literature began to emerge in the early nineteenth century. Khmer poet and scholar Ukñā Suttantaprījā Ind (1859–1924) was a pivotal figure. His poem  Journey to Angkor Wat describes his travels to attend King Sisowath’s arrival at the Angkor temples in 1909. The manuscript represents a transitional period in literature, between “tradition” and “modernity.” Possibly commissioned by the King, it was discovered posthumously, and the first edition was published by the Buddhist Institute. In the excerpt translated here, the poet’s recounting of the river journey becomes a meditation on life, desire, and impermanence.

The Buddhist Institute, which printed Ukñā Suttantaprījā Ind’s famous Gatilok and other literature, became the nation’s first publisher in the early 1900s. Khmer-language newspapers and journals first appeared in the 1920s, although the first Khmer-owned and operated newspaper, Naggaravatta (Angkor Wat) did not appear until 1937. The first Khmer modern novel also appeared in the 1930s. A new Khmer term was invented for the novel, pralomlok, which means a story that is written to seduce the hearts of human beings. Many of these early works featured ill-fated lovers and contained moral and social critique. As was common for the era in Southeast Asia, and for writers such as Dickens and Tolstoy earlier in Europe, most novels were first serialized in newspapers or journals. Among the early novels still read today are The Waters of Tonle Sap by Kim Hak, The Tale of Sophat by Rim Kim, The Rose of Pailin by Nhok Them, and Wilted Flower by Nou Hach. Literature became linked with national identity, as quoted in the journal Kambuja Surya , “If its writing disappears, the nation vanishes.”

Following Cambodia’s independence in the mid-twentieth century, literacy, education and publication expanded. Songwriting became a literary form. This was the heyday of Cambodian rock and roll, the “golden” voice of Sinn Sisamouth, and a vibrant, sophisticated community of writers and intellectuals, fluent in both Khmer and French, who were creating new Khmer literature and national consciousness. This literary community was also threatened by censorship, disappearances, assassinations, the closing down of publications, and the war that was spilling over from neighboring Vietnam. After the 1970 coup, which deposed Prince Sihanouk, civil war ensued between the Khmer Republic and the Khmer Rouge.

Kham Pun Kimny, featured in this issue, wrote about urban and political life in a surreal, satirical style during this tumultuous time. He was one of the first writers Soth Polin hired for his newspaper Nokor Thom . “Crazy for Wandering” comes from Kham Pun Kimny’s collection, Control Yourself: Don’t Cry, Don’t Laugh—Philosophies of the Strange and Absurd. Not long after the book’s publication, he disappeared.

On April 17, 1975, less than four decades after the publication of Cambodia’s first novel, the flourishing of Cambodian literature and scholarship abruptly ended with the Khmer Rouge takeover. Writing of a personal nature was completely prohibited. To dare to write risked one’s life. The diary of Oum Sophany is one of the few personal accounts known to have been written while the Khmer Rouge were in power. Laura Jean McKay’s essay, “The Keeper,” featured in this issue, tells the story of Oum Sophany and quotes passages from her remarkable diary.

On January 7, 1979, Vietnamese-backed troops ousted the Khmer Rouge. The handful of artists and writers who survived found themselves in a shattered country. The nation’s infrastructure had been destroyed, and the land seeded with mines and unexploded ordnance. There was widespread poverty and illiteracy. In addition, writers faced censorship, years of lost education, and a lack of printing presses; spare parts, ink, and even paper were hard to come by.

Considering all this, it is surprising that anyone wrote at all. But people did, among them Oum Sophany. Almost as soon as the Khmer Rouge regime ended, a new literature began to appear: novels were handwritten, often in pencil, on the cheap graph-lined paper of student notebooks, then photocopied or recopied by hand and rented out by the day at market stalls. Many memoirs also have been published over the decades, both inside and outside of Cambodia.

As for the former generation of writers, we are fortunate to have the work of three who survived the war and continue to write: U Sam Oeur, Kong Bunchheoun, and Soth Polin.

U Sam Oeur began singing poems as a child while herding water buffalo and received his MFA from the Iowa Writers’ Workshop in 1968, after which he returned to Cambodia. He survived the Khmer Rouge years by feigning illiteracy and pretending at times to be deaf and dumb. “I could not speak,” he says. “Even though people asked, Are you deaf? Are you mute? I always shook my head. There were no words. Just work and work. No talking. No looking at anyone. No looking at the sky, nothing.” He translated Walt Whitman’s Leaves of Grass into Khmer and is one of the first Cambodian poets to write in free verse. He believed this break from the rigid structures of classical Khmer poetry was necessary in order to convey the sorrow of the war. Even so, he still chants his poetry in traditional Khmer style. In this issue he is featured chanting with rap artist praCh in a unique poetic collaboration. His prose piece, “Silkworms,” recalls a time in his youth when he helped his mother raise silkworms during the Japanese occupation of Cambodia from 1942 to 1943.

Kong Bunchheoun, born in Battambang province, began his long writing career as a novelist, playwright, poet, and lyricist in the 1950s in Phnom Penh. He escaped execution during the Khmer Rouge time thanks to a cadre who had read his novels and testified to his “profound sense of social justice.” He continues to be one of Cambodia’s most prolific writers. “The Shade of the Tenth Coconut Tree” is among the many songs he wrote for Sinn Sisamouth in the 1970s inspired by the Sangkae River.

Cambodia’s strong oral tradition of poetry and storytelling is carried on today by traditional artists such as the bluesy, improvisational chapey master Kong Nay, known as the Ray Charles of Cambodia, and by a younger generation of spoken-word and rap artists, among them praCh. Called “Cambodia’s first rap star” by Newsweek, praCh was born in Cambodian refugee camps at the end of the war. In the tracks featured in this issue, he collaborates with Master Kong Nay and poet U Sam Oeur. 

Soth Polin learned to read and write from his great-grandfather, the poet Nou Kan, and began writing novels, short stories and philosophical tales in the 1960s. He survived the Khmer Rouge because he had fled for refuge to Paris after a friend’s assassination in 1974; he lived in France for a decade before going to the U.S. “When you lose your country, you lose everything,” he said. “If you are a writer, you no longer have the echo of your readers.” In France, he survived by driving a taxi. He published one novel in French, The Anarchist , an excerpt of which is featured in this issue.

The devastation of the Khmer Rouge period continues to impact writers today. Writers still must contend with high illiteracy rates, lack of availability of books, lack of mentors, scarcity of publishers and the absence of a central publication distribution network. Some have turned to online publishing. Many self-publish their work, through photocopies or on Facebook and blogs. Others write video scripts and song lyrics. Government-sponsored literary prizes and nongovernmental organizations provide some support. The Nou Hach Literary Project publishes Nou Hach Literary Journal, conducts literary awards, and holds creative-writing workshops and conferences. PEN Cambodia also supports writers through workshops and publication. 

The Center for Khmer Studies is instrumental in Khmer scholarship. The Documentation Center of Cambodia (DC-Cam), under the direction of Youk Chhang, has gathered hundreds of thousands of documents, photos, films, and interviews, as well as published several books, including translations of world literature into Khmer, and the famous Tum Teav into English.

In addition, an increasing number of Cambodian filmmakers are making their mark, foremost among them award-winning Rithy Panh, who helped create the Bophana Center in Phnom Penh, which preserves Cambodia’s film, photographic and audio history. Named for Rithy Panh’s film Bophana: A Cambodian Tragedy , which tells the story of the forbidden love letters of Hout Bophana and Ly Sitha, the center also trains Cambodian filmmakers, many of whom have won awards in their own right. 

The resilience of Cambodian writers, past and present, cannot be overstated. The loss of family, friends, mentors, education, country, home—even of paper, printing presses, and ink—none have stopped Cambodians from pursuing the illusive, seductive and demanding vocation of writing. “I hope our art continues. I think it will survive,” Soth Polin says. “There will be another generation of writers. But right now, what we have lost is indescribable. Khun Srun, Hak Chhay Hok, Chou Thani, Kem Sat . . . They are gone . . . What we have lost is not reconstructable. An epoch is finished. So when we have literature again, it will be a new literature.” 

Some of the material in this essay was drawn from “In the Shadow of Angkor: A Search for Cambodian Literature” and author interviews that first appeared in In the Shadow of Angkor: Contemporary Writing from Cambodia (Manoa: An International Journal/University of Hawai‘i Press, 2004). 

© Sharon May. All rights reserved.

Sharon May researched the Khmer Rouge regime for Columbia…

Sky of the Lost Moon

The keeper: oum sophany, the anarchist.

Cambodian Literature: An Introduction

• Trent Walker
• University of Hawai'i Press
• Volume 33, Number 2, 2021/Volume 34, Number 1, 2022
• pp. xxv-xxxii
• 10.1353/man.2021.0013
• View Citation

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The Price We Paid: The Troubled History of Cambodian Literature

Cambodian literature is something of a unique creation, born from a tragic national history and a culture of oral storytelling. Vincent Wood explores the history of Cambodia’s literature and the struggles faced by Khmer writers in the twentieth century.

Historically, only a small portion of Cambodia ’s population was literate and so large parts of the storytelling traditions of the country are oral and based in local folklore. These stories are heavily influenced by the predominant religions of Buddhism and Hinduism and also reflect the cultural influence of nearby India. The oldest example of such oral stories is the Reamker, a Cambodian version of the Indian epic Ramayana which is traditionally staged theatrically with dance alongside the verses. For most of Cambodia’s history, written literature was, for the most part, restricted to the royal courts or Buddhist monasteries of the country. In 1863 Cambodia became a protectorate of France , bringing new literary attitudes and technologies to the country; by 1908 the first book in Khmer was printed in Phnom Penh. This allowed a new flowering of Cambodian literature and by 1954 the Khmer Writers’ Association had been set up in order to promote writing, as well as introduce new themes and direction to literature. However, the Khmer Rouge ‘s seizure of power in 1975 and their subsequent social engineering policies would have a devastating effect on Khmer literature. The Khmer Rouge wanted to eliminate anyone suspected of ‘involvement with free market activities’, which led to the persecution and mass-killing of those it deemed to be ‘intellectuals’; often simply anyone with an education, or even just those that wore glasses. As a result, organisations like the Khmer Writers’ Association were rapidly dissolved. Following the defeat and deposition of the Khmer Rouge, in 1979, writers were freed from stigma and persecution, and the Khmer Writers’ Association was re-established in 1993. Free to express themselves, many wrote about the brutal ordeals that had to be suffered under the communist dictatorship, among them Vatey Seng, who wrote The Price We Paid , and Navy Phim, who wrote Reflections of a Khmer Soul . These novels were part of the healing process of the writers themselves, but also that of the psyche of an entire nation.

Tararith Kho is one of the few Cambodian authors to have made a name for himself both within his own country and internationally. Outside of Cambodia, his poetry about growing up in a totalitarian society and witnessing the atrocities of the Killing Fields is growing in popularity, and in 2012 he became a Scholars at Risk fellow at Harvard . His books and poetry anthologies include Lesson of Life, Culture Should Not Stay Alone , Regretful , Red Print and Khmer Nigeria Poetry . Other recent literature is still predominantly focused on big issues plaguing the country, such as Somaly Mam ’s The Road of Lost Innocence . The book is a memoir about Mam’s childhood and adolescence as a prisoner of the sex trade in Cambodia, and helps to raise awareness of the extent of the trafficking to this day. Along with several other authors, Mam has managed to make some money through translated versions of her work, but in general, Cambodians writing in Khmer still struggle to make a decent income from their work, stifling the production of literature. Mam herself is now actively engaged in philanthropy, using some of this money to support anti-trafficking groups. In a country where many writers were wiped out or fled for fear of persecution, it is these few — writing about their experiences and the trials of their nation — that are breathing a new life into the literature of Cambodia. It has been a long and arduous struggle for those who yearn to tell their stories, one not yet entirely over, but with people like Mam and Kho leading the way there is still hope for a brighter literary future for this troubled country. By Vincent JS Wood

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Dealing with the Khmer Rouge History in Cambodia

• First Online: 22 October 2022

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• SungYong Lee 3  

Part of the book series: Rethinking Political Violence ((RPV))

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This chapter offers background information about the central research subject. It firstly gives a brief overview of the impact of KR rule on people’s lives. Instead of providing a comprehensive and detailed examination of KR’s policies, this section pays attention to describing the policy areas and operational features that people recall as having had the most devastating influences on them. Some of these issues include the party’s unprofessional mismanagement, its attempt to control people through terror, and the attempts to dismantle Cambodia’s fundamental community system. This chapter then introduces how the programmes and politics to deal with the KR history have evolved since 1979 primarily through the central government, the Extraordinary Chamber in the Courts of Cambodia, and a number of civil society actors. Finally, this chapter introduces the social and political factors that have laid an important foundation for everyday reconciliation practices: national security conditions, the policies set by the political authority, national economic conditions, and cultural and religious beliefs within local communities.

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Although the number of people killed under the DK regime is still disputed, many sources generally agree with an approximation of between 1.5 million and 2 million. For instance, the Cambodian Genocide Program at Yale University suggests that 1.7 million died (CGP, n.d.), while Short ( 2005 ) argues that the number of victims should be estimated at 1.5 million. Kiernan ( 1993 , 2002 ) and Heder ( 1999 ) also agree with a figure of between 1.5 and 1.7 million deaths.

Sangha denotes Buddhist order or community that usually consists of monks and nuns but occasionally includes lay practitioners.

Agger, I. (2015). Calming the mind: Healing after mass atrocity in Cambodia. Transcultural Psychiatry, 52 (4), 543–560. https://doi.org/10.1177/1363461514568336

Article   Google Scholar  

Bennett, C. (2015). Living with the dead in the killing fields of Cambodia (Doctoral thesis). University of Kent.

Google Scholar  

Bennett, C. (2018). Karma after democratic Kampuchea: Justice outside the Khmer Rouge tribunal. Genocide Studies and Prevention: An International Journal, 12 (3), 68–82. https://doi.org/10.5038/1911-9933.12.3.1567

Bultmann, D. (2018). The social order of postconflict transformation in Cambodia . Rowman and Littlefield.

Chandler, D. (2008). Cambodia deals with its past: Collective memory, demonisation and induced amnesia. Totalitarian Movements and Political Religions, 9 (2–3), 355–369. https://doi.org/10.1080/14690760802094933

Chhair, S., & Ung, L. (2016/2017). Economic history of industrialization in Cambodia: Learning to complete (Working Paper No. 7). United Nations University-World Institute for Development Economics Research (UNU-WIDER). https://www.brookings.edu/wp-content/uploads/2016/07/L2C_WP7_Chhair-and-Ung-v2-1.pdf

DC-CAM. (n.d.). Documentation . Documentation Center of Cambodia (DC-CAM). http://dccam.org/documentation

ECCC. (n.d.). Public affairs outreach figures 2009–2017 . Extraordinary Chambers in the Courts of Cambodia (ECCC). https://www.eccc.gov.kh/sites/default/files/Outreach%20statestics%20as%20of%20September%202017.pdf

Gidley, R. (2019). Illiberal transitional justice and the extraordinary chambers in the courts of Cambodia . Palgrave Macmillan.

Book   Google Scholar  

Guillou, A. Y. (2012). An alternative memory of the Khmer Rouge genocide: The dead of the mass graves and the land guardian spirits [teak ta]. South East Asia Research, 20 (2), 207–226. https://doi.org/10.5367/sear.2012.0102

Harris, I. (2013). Buddhism in a dark age: Cambodian monks under Pol Pot . University of Hawai’i Press.

Heder, S. (1999). Pol Pot at bay: People’s war and the breakdown of the 1991 Paris Agreements (Doctoral thesis). School of Oriental and African Studies, University of London.

Hinton, A. (2011). ‘Beyond suffering’—Genocidal terror under the Khmer Rouge: A view from the work of May Ebihara. In J. A. Marston (Ed.), Anthropology and community in Cambodia: Reflections on the work of May Ebihara (pp. 59–78). Monash University Press.

Hughes, C. (2003). The political economy of Cambodia’s transition, 1991–2001 . Routledge.

Kent, A. (2003). Recovery of the collective spirit: The role of the revival of Buddhism in Cambodia (Working Paper No. 8). Department of Social Anthropology, Gothenburg University.

Kent, A. (2008). Peace, power and pagodas in present-day Cambodia. Contemporary Buddhism, 9 (1), 77–97. https://doi.org/10.1080/14639940802312717

Keyes, C. (1990). Cultural survival quarterly magazine: Buddhism and revolution in Cambodia. Cultural Survival. Retrieved November 16, 2018, from https://www.culturalsurvival.org/publications/cultural-survival-quarterly/buddhism-and-revolution-cambodia

Kiernan, B. (1993). Genocide and democracy in Cambodia: The Khmer Rouge, the United Nations and the international community . Yale University Press.

Kiernan, B. (2002). The Pol Pot regime: Race, power, and genocide in Cambodia under the Khmer Rouge, 1975–79 . Yale University Press.

Lee, S. (2021). Understanding everyday peace in Cambodia: Plurality, subtlety, and connectivity. Journal of Peacebuilding & Development, 16 (1), 24–38. https://doi.org/10.1177/1542316620974371

Manning, P. (2015). Reconciliation and perpetrator memories in Cambodia. International Journal of Transitional Justice, 9 (3), 386–406. https://doi.org/10.1093/ijtj/ijv015

Manning, P., Ly, S.-K., & Ser, S. (2018, May 16). Changing the story: Whose stories and why?. University of Leeds . https://changingthestory.leeds.ac.uk/2018/05/16/changing-the-story-whose-stories-and-why/

Pham, P. N., Balthazard, M., Gibbons, N., & Vinck, P. (2019). Perspectives on memory, forgiveness and reconciliation in Cambodia’s post-Khmer Rouge society. International Review of the Red Cross, 101 (910), 125–149. https://doi.org/10.1017/S1816383119000213

Short, P. (2005). Pol pot: The history of a nightmare . John Murray Publishers.

So, F. (2010). An oral history of Cham Muslim women, in Cambodia under the Khmer Rouge (KR) regime (Doctoral thesis). Ohio University.

Soeung, B., & Lee, S. (2017). The revitalisation of Buddhist peace activism in post-war Cambodia. Conflict, Security & Development, 17 (2), 141–161. https://doi.org/10.1080/14678802.2017.1300356

The Cambodian Genocide Program (CGP). (n.d.). The CGP 1994–2019 . Cambodian Genocide Program, Yale University. Retrieved July 3, 2022, from https://gsp.yale.edu/case-studies/cambodian-genocide-program

Tully, J. (2005). A short history of Cambodia: From empire to survival . Allen & Unwin.

Williams, T., Bernath, J., Tann, V., & Kum, S. (2018). Justice and reconciliation for the victims of the Khmer Rouge?: Victim participation in Cambodia’s transitional Justice process . Centre for Conflict Studies, Centre for the Study of Humanitarian Law & Swisspeace.

Zucker, E. M. (2011). Trust and distrust in a highland Khmer community after thirty years of war. In J. A. Marston (Ed.), Anthropology and community in Cambodia: Reflections on the work of May Ebihara (pp. 79–103). Monash University Press.

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Lee, S. (2022). Dealing with the Khmer Rouge History in Cambodia. In: Everyday Reconciliation in Post-Khmer Rouge Cambodia. Rethinking Political Violence. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-031-13987-1_2

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Full Thesis: Cambodia's Foreign Policy and China's Influence during the Khmer Rouge Era

The paper posits that China is a significant factor influencing Pol Pot’s foreign policy decisions and implementation. In the attainment of national interests for absolute independence and self-reliance at the emergence of external and internal security threats, Pol Pot, the most influential Khmer Rouge leader, could not survive without China’s strong support. Thus, he needs to form whatever policies that have to be consistent with what China wants otherwise his regime might end up losing the latter’s support. In this aspect, the more strictly he complies with those policies, the more likely his regime heavily depends on China. In sum up, this case precisely divulges the regime failure as a result of the stagnant policy enforcement and prodigious dependence on only one external actor, China, who is reluctant to offer more help when Pol Pot refuses to obey its advice.

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The paper posits that China is a significant factor having remarkable influence on Pol Pot’s foreign policy decisions and implementation.

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As the US-China trade war appears to be further escalating, Cambodia should rethink its foreign policy towards China and the West. While Cambodia’s ties with China have substantially improved with time, its relations with the West have reached a new low in the last few years. Its fluctuating relationship with the United States seems to be less amicable, if not worse.

Chandara Khun

China was recently described by the Prime Minister Hun Sen as Cambodia‟s “most trusted friend”. This claim might be proved by a flood of China‟s aid as well as her sharp growing trade and investments in the last decade, which put China the biggest donor and the largest investor. However, Cambodia-China relations stretch much longer than what we see at the present and might be even more complex in the old days. Hence, I begin to examine how their connections have developed over time, especially at each cross section of the Cold War and the post-Cold War periods. Then, I will study closely what made these two countries approach each other and became the strategic partners in Southeast Asia by classifying each party‟s interests into economic and strategic characteristics. This classification might, on one hand, project a clear picture of Cambodia‟s unequal status in the relations, and, on the other hand, illustrate its growing independence from China‟s influence. After all, the paper discusses how this bilateral relationship might have the implication on Cambodia‟s domestic politics and vice versa .From Cambodia‟s perspectives, I argues that their current relations might widen the economic inequality and make the situations of human rights worse in Cambodia so this pair of consequences would, in turn, have domino effects on their future relations through the declining strategic interests of Cambodia‟s government, particularly from the post-national election 2013 onwards.

Capriciously, China appears to shift its policy towards Hun Sen and the Cambodian People’s Party in the wake of Phnom Penh tussle on July 5 and 6, 1997. At a short notice, Cambodia under the leadership of Hun Sen discernibly has burgeoned relations with Beijing emphatically. Some even suggest this bilateral relation has reached its peak in the last few years. Concurrently, the relations between Phnom Penh and Washington remain strained, despite strenuous efforts aimed for diplomatic revitalization since the mid1990s. It is perceptible that Cambodia has undertaken foreign policy that apparently takes side with Beijing, rather than the Washington between 1997 and 2013. While economic interests have been attributed to this move, this paper aims to explore motivations that exhort Cambodia to be more supportive to China, rather than the United States during the unfolded period. The findings of the thesis postulates that five catalysts serve as the motivating forces, including the personality perception, and background of the Prime Minister Hun Sen, the influences of the bureaucrats and Cambodian interests groups, Cambodia’s contexts between 1997 and 2013, different intensities of economic interdependence and exchange visits between Cambodia and the two countries.

Cambodia is in a strategically challenging position. It has close relations with two rival countries – Vietnam and China. In recent years, Cambodia has found itself in a difficult situation caused by the dispute between China and Vietnam over the South China Sea issues and the challenges concerning the Mekong River. These geopolitical challenges have left little room for Cambodia to maneuver its foreign policy. Considering the ongoing strategic rivalry between Beijing and Hanoi, Phnom Penh has to carefully manage its foreign relations to balance between these two countries, both of which are its close friends. Failing to walk the diplomatic and geopolitical tightrope effectively poses significant economic and security risks for Cambodia.

Andrew Wickersham

Between 1945 and 1970 the United States Department of State consistently misjudged the ideology of Cambodia’s Prince Norodom Sihanouk. This same confusion permeates academic literature as well. David Chandler identifies Sihanouk as a leftist, Chinese puppet, while Michael Vickery, stresses his right-wing tendencies and dependence on the United States. Neither conception represents an accurate characterization of Norodom Sihanouk. Consistent with traditional Cambodian understandings of kingship, Sihanouk’s ideology can best be described as conservative Buddhist nationalism. In an attempt to maintain true national sovereignty, he remained consistently committed to a policy of non-alignment. The prince viewed domestic policy through a similar framework, attempting to hold a middle course between pro-American Khmer Blues against the communist Khmer Rouge. This delicate balance became increasingly untenable as the Vietnam War escalated. Ultimately, the State Department’s miscalculation o...

Asia Research Institute working paper 200, May 2013

Martin Stuart-Fox , Trude Jacobsen

Dr. Juan R. Céspedes, Ph.D.

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• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarize yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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CASE REPORT article

Hydroxychloroquine-induced hyperpigmentation of the skin and bull’s-eye maculopathy in rheumatic patients: a case report and literature review.

• 1 Guizhou University of Traditional Chinese Medicine, Guiyang, China
• 2 Department of Rheumatology and Immunology, Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China

Hydroxychloroquine (HCQ) is used as a traditional disease-modifying antirheumatic drugs (DMARDs), for the treatment of autoimmune diseases such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). However, it can cause serious adverse reactions, including hyperpigmentation of the skin and bull’s-eye macular lesions. Here, we present a case of HCQ-induced hyperpigmentation of the skin and bull’s-eye macular lesions in a patient who received HCQ for RA. A 65-year-old female patient developed blurred vision and hyperpigmentation of multiple areas of skin over the body for one month after 3 years of HCQ treatment for RA. Based on clinical presentation, ophthalmological examination and dermatopathological biopsy, a diagnosis of drug-induced cutaneous hyperpigmentation and bullous maculopathy of the right eye was made. After discontinuation of HCQ and treatment with iguratimod tablets, the hyperpigmentation of the patient ‘s skin was gradually reduced, and the symptoms of blurred vision were not significantly improved. We also reviewed the available literature on HCQ-induced cutaneous hyperpigmentation and bull’s-eye macular lesions and described the clinical features of HCQ-induced cutaneous hyperpigmentation and bull’s-eye macular lesions. In conclusion, clinicians should be aware of early cutaneous symptoms and HCQ-associated ophthalmotoxicity in patients with rheumatic diseases on HCQ sulphate and should actively monitor patients, have them undergo regular ophthalmological examinations and give appropriate treatment to prevent exacerbation of symptoms.

Introduction

Hydroxychloroquine (HCQ) is a 4-aminoquinoline antimalarial drug. It is commonly used as a sulfate, namely HCQ sulfate. Its antimalarial effect is the same as that of chloroquine, but its toxicity is only half that of chloroquine. In addition, HCQ sulfate also has anti-inflammatory, immunomodulatory and anticoagulant effects ( 1 – 4 ), so it is widely used in clinical treatment of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjögren’s syndrome, skin diseases, etc., and the adverse reactions are gradually increasing ( 5 , 6 ). There are fewer reports on HCQ-induced hyperpigmentation of the skin and macular lesions in the bull’s eye. This article analyses the literature related to HCQ sulfate-induced hyperpigmentation of the skin and macular lesions in the bull’s eye in conjunction with the literature review by taking a case of HCQ sulfate-induced hyperpigmentation and macular lesions in the bull’s eye as an example in order to warn the clinic to fully understand the adverse effects of HCQ.

Case report

We assessed a 65-year-old female patient with RA in December 2023 who had been diagnosed with RA 10 years earlier and was now feeling pain in both shoulders, wrists, and finger joints of both hands with mild limitation of movement. The patient was treated with HCQ (400mg/d) and low-dose prednisolone (5 mg/d) for 3 years. The patient had no other comorbidities or medications, and for the past month felt blurred vision and noticed a darkening of the skin color. Our physical examination revealed excessive skin pigmentation in many parts of the body, especially in the head and face, neck, upper limbs and lower limbs ( Figure 1 ). The patient attributed this to chronic ultraviolet light exposure.

Figure 1 Hyperpigmentation of head, face, neck, upper limbs and lower limbs.

We performed relevant laboratory tests on the patient, which showed an elevated erythrocyte sedimentation rate of 61.00 mm/h (normal, 0-20 mm/L), an elevated rheumatoid factor of 43.15 IL/ml (normal, 0-20 IL/ml), and an elevated anti-cyclic citrullinated peptide antibody of > 500.00 U/mL (normal, 0-20 U/mL). We performed an ophthalmological examination of the patient because he had symptoms of blurred vision and because studies have shown that HCQ can cause retinopathy ( 7 , 8 ). The visual field examination results showed that the visual field of the right eye showed a visual field defect outside the range of 45° above and 25° on the nasal side, and the light sensitivity of the remaining visual field decreased significantly. Compared with the dark spots around the physiological blind spots of the left eye, the photosensitivity decreased widely outside the range of 40°, and the photosensitivity decreased scattered within the range of 40°. Therefore, we performed optical coherence tomography (OCT) ( Figure 2 ) and fundus screening ( Figures 3A-D ) on the patient. The results of OCT examination showed that the retinal pigment epithelium (RPE) layer in the macular area of the right eye was disordered and uneven, and irregular mass uplift was seen. The reflection of the ellipsoid zone and the IS/OS layer was interrupted and discontinuous. The RPE layer on the temporal side of the macular showed localized choroidal depression. The macular morphology was irregular, and the thickness of the macular fovea was significantly thinner ( Figure 2A ). However, the results of OCT of the left eye did not show any significant abnormality ( Figure 2B ). The results of fundus screening showed that the right eye had a round-like lesion in the macular area, about 2.5*3PD in size. The lesion was uneven yellow-white, and the center was dark brown. In conjunction with the OCT findings, a bull’s eye macular lesion was considered.

Figure 2 (A) OCT results of the right eye; (B) OCT results of the left eye.

Figure 3 (A) Right anterior segment findings; (B) Right eye fundus screening results; (C) Left anterior segment findings; (D) Left eye fundus screening results.

From the results of the ophthalmologic examination, our patient was not considered for the diagnosis of age-related macular degeneration (AMD), which is characterized by the accumulation of extracellular deposits and the progressive degeneration of photoreceptors and adjacent tissues ( 9 – 12 ). The prevalence increases gradually with age and usually affects vision for a short period of time, even leading to blindness ( 13 , 14 ). In AMD, the damage is concentrated in the central portion of the retina, known as the macula. One of the features of AMD is the scattered or confluent areas of degeneration of RPE cells and overlying photoreceptors in the photoreceptors of the photoreceptors, which depend on the RPE for trophic support. Although our patient’s OCT results showed disturbed and uneven RPE reflection seen in the retina of the macular area of the right eye. However, there was no significant abnormality in the left eye OCT results. Another feature of AMD is the formation of choroidal neovascularization, in which immature blood vessels grow from the choroid below toward the outer retina. These immature blood vessels leak fluid below or inside the retina ( 10 ). In contrast, our patient’s funduscopic findings showed no vasculopathy. So we consider that this macular lesion is not so much related to aging as it is to the use of HCQ.

In addition, we performed a skin biopsy on the patient. HE staining ( Figure 4A ) showed excessive keratinization of the epidermal mesh basket, a significant increase in melanin in the basal layer, sparse lymphocyte and tissue cell infiltration around the blood vessels in the superficial dermis, and a few melanocytes and melanin granules were seen locally, considering drug-induced pigmentation. Therefore, it can be differentiated from skin pigmentation caused by exposure to ultraviolet light ( 15 ). Fontana-Masson staining ( Figure 4B ) showed a significant increase in melanin in the basal layer of the epidermis and a few melanin granules in the superficial dermis. Prussian blue staining and silver hexamine staining were negative ( Figures 4C, D ). Five items of direct immunofluorescence ( Figure 5 ) C3, IgG, IgM, IgA and Fib were all negative.

Figure 4 (A) HE staining; (B) Fontana-Masson staining; (C) Prussian blue staining; (D) silver hexamine staining.

Figure 5 Direct immunofluorescence staining.

According to the patient ‘s medical history and examination results, we believe that the patient ‘s long-term use of HCQ in the treatment of RA, resulting in hyperpigmentation of the skin and bull’s-eye maculopathy. Therefore, we decided to discontinue HCQ and replace it with iguratimod tablets (50mg/d) and prednisone acetate tablets (5mg/d) to control the disease. It is important to note that iguratimod is only used in China and Japan for the treatment of RA and has been shown to be effective ( 16 – 18 ). Since then, we followed up the patient for three months. After discontinuation of HCQ and treatment with iguratimod tablets, the hyperpigmentation of the patient ‘s skin was gradually reduced, and the symptoms of blurred vision were not significantly improved.

Literature retrieval

Based on the patient’s clinical presentation and ophthalmologic findings, we reviewed similar cases reported in PubMed, Embase, Web of Science and other databases from the establishment of the database to December 2023. We used “hydroxychloroquine”, “plaquenil”, “case study”, “case report”, “bull’s-eye maculopathy” and “hyperpigmentation” as the search terms to filter out the eligible literature and extract the relevant information of the cases. From the results of our literature search, a total of 181 articles were retrieved from the literature related to hyperpigmentation of the skin. After screening, 18 articles were obtained, the total number of cases was 20, female patients were more than male patients, distributed in different countries or regions, the primary disease was mainly RA or SLE, the color of skin pigmentation was mainly blue/gray, and the site of skin pigmentation was mainly on the face, the upper limbs or the lower limbs, and the daily dosage of HCQ was mainly 400mg, and the skin pigmentation of the over-pigmented skin of the majority of the patients could be gradually subsided after stopping the HCQ. Table 1 shows the detailed clinical features of these cases. A total of 46 articles were retrieved from the literature related to macular degeneration of the bull’s eye. After screening 11 valid literature were obtained, the total number of cases was 13, all were female patients, the daily dose of HCQ was 200-1200mg and the approximate cumulative dose was 438-2920g, and most of the patients’ solution was to stop HCQ therapy. Table 2 shows the detailed clinical features of these cases.

Table 1 Reported cases of hyperpigmentation of HCQ.

Table 2 Reported Adverse Ocular Region Effects of HCQ.

Hyperpigmentation of skin induced by HCQ

Hyperpigmentation of the skin caused by antimalarial treatment has been reported since the Second World War ( 48 ). However, the associated skin hyperpigmentation due to HCQ seems to be uncommon compared to other antimalarials such as chloroquine ( 28 , 49 ). One study showed that the onset of HCQ-associated skin hyperpigmentation ranged from 3 months to 22 years after the start of treatment, with a median of 6.1 years ( 50 ). In our reported case, the patient developed hyperpigmentation of the skin about 3 years after the start of treatment, and the treatment was to discontinue HCQs and to control the RA with iguratimod tablets, which led to a gradual reduction of the patient’s skin hyperpigmentation over several months ( 22 , 25 ). Although there is evidence that both melanin and iron deposition can be present in the dermis in HCQ-induced hyperpigmented skin lesions ( 50 ), the exact mechanism is unknown ( 30 ). Our patients completed the relevant pathological examination. Fontana-Masson staining ( Figure 4B ) showed a significant increase in melanin in the basal layer of the epidermis and a few melanin granules in the superficial layer of the dermis. Prussian blue staining was negative ( Figure 4C ). Therefore, we describe the pathological features of some cases ( Table 3 ). In terms of treatment, most of the investigators took the approach of discontinuing HCQ treatment to prevent further exacerbation of HCQ-induced hyperpigmentation of the skin. Most patients were able to reduce their hyperpigmentation after discontinuing HCQ treatment.

Table 3 Pathological features of some cases.

Retinal toxicity due to HCQ

Long-term treatment with HCQ can lead to retinal toxicity ( 51 ). This retinal change is typically characterized by a thinning of the photoreceptor layer, starting with a paracentral sulcus ring and progressing over time to a “bull’s-eye” maculopathy, caused by pericentral atrophy and retention of the central sulcus ( 52 ). Some researchers have suggested that HCQ may be associated with bilateral retinopathy involving not only the macula but also the peripheral retina ( 39 ). The relationship between HCQ-related skin pigmentation and ocular toxicity is currently unknown ( 28 ); However, there is a need for regular ophthalmological follow-ups so that the patient’s eye condition can be understood ( 30 ). Our patient developed vision loss after 36 months of HCQ treatment, with a cumulative dose of about 438 g. Ophthalmological examination revealed macular lesions in the right eye. Table 2 describes some of the published information on similar cases, and the case we reported is similar to those reported in the literature. In terms of treatment, most of the investigators took to discontinuing HCQ treatment to prevent further worsening of the ocular adverse effects caused by HCQ. However, patients who have developed bull’s-eye macular degeneration are difficult to rehabilitate ( 41 ). In terms of ophthalmic examination, Fung et al. ( 40 ) suggest that OCT may be a useful, non-invasive clinical assessment if a patient presents with new visual changes associated with HCQ. In addition, OCT findings of diffuse retinal atrophy or increased reflectivity around the macular central pucker can support the port suspected diagnosis of HCQ-associated retinal toxicity.

In conclusion, HCQ can cause adverse reactions such as hyperpigmentation of the skin and macular degeneration of the bull’s eye, clinicians should be aware of early cutaneous symptoms and HCQ-associated ophthalmotoxicity in patients with rheumatic diseases on HCQ sulphate and should actively monitor patients, have them undergo regular ophthalmological examinations and give appropriate treatment to prevent exacerbation of symptoms.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by Ethics Committee of the Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

J-PP: Writing – original draft, Writing – review & editing. X-YY: Writing – original draft. FL: Writing – original draft. X-MY: Writing – original draft. HX: Writing – original draft. W-KM: Writing – original draft. X-MY: Writing – original draft, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. The study was funded by the National Natural Science Foundation of China, 82160869, 82374494; Guizhou Provincial Key Technology R&D Program, Qiankehe Support [2021] General 006; Guizhou Provincial Basic Research Program(Natural Science) Qiankehe Basic-ZK[2023] General 412; Guizhou Kehe Academic New Seedling[2023-36]; Guizhou University of Traditional Chinese Medicine National and Provincial Scientific and Technological Innovation Talent Teams Cultivation Project, Guizhou University of Traditional Chinese Medicine TD He Zi [2022]004.

Acknowledgments

We appreciate Yuzheng Yang (Organization: Guizhou University of Traditional Chinese Medicine, Guiyang, China) for organizing the data, Yuheng Shi and Shasha Du (Organization: Ophthalmology Department, Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China) for performing the ophthalmologic examinations, and all authors for their cooperation.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

1. Al-Bari MA. Chloroquine analogues in drug discovery: new directions of uses, mechanisms of actions and toxic manifestations from malaria to multifarious diseases. J Antimicrob Chemother . (2015) 70:1608–21. doi: 10.1093/jac/dkv018

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Bai L, Li H, Li J, Song J, Zhou Y, Liu B, et al. Immunosuppressive effect of artemisinin and hydroxychloroquine combination therapy on IgA nephropathy via regulating the differentiation of CD4+ T cell subsets in rats. Int Immunopharmacol . (2019) 70:313–23. doi: 10.1016/j.intimp.2019.02.056

3. Chandler LC, Yusuf IH, McClements ME, Barnard AR, MacLaren RE, Xue K. Immunomodulatory effects of hydroxychloroquine and chloroquine in viral infections and their potential application in retinal gene therapy. Int J Mol Sci . (2020) 21:1. doi: 10.3390/ijms21144972

4. Richard SA, Kampo S, Hechavarria ME, Sackey M, Buunaaim ADB, Kuugbee ED, et al. Elucidating the pivotal immunomodulatory and anti-inflammatory potentials of chloroquine and hydroxychloroquine. J Immunol Res . (2020) 2020:4582612. doi: 10.1155/2020/4582612

5. Nirk EL, Reggiori F, Mauthe M. Hydroxychloroquine in rheumatic autoimmune disorders and beyond. EMBO Mol Med . (2020) 12:e12476. doi: 10.15252/emmm.202012476

6. Schrezenmeier E, Dörner T. Mechanisms of action of hydroxychloroquine and chloroquine: implications for rheumatology. Nat Rev Rheumatol . (2020) 16:155–66. doi: 10.1038/s41584-020-0372-x

7. Alveyn E, Galloway J. When should we start screening for hydroxychloroquine retinopathy? Rheumatol (Oxford England) . (2022) 61:3097–8. doi: 10.1093/rheumatology/keac043

CrossRef Full Text | Google Scholar

8. Proano C, Kimball GP. Hydroxychloroquine retinal toxicity. New Engl J Med . (2019) 380:e27. doi: 10.1056/NEJMicm1304542

9. Fleckenstein M, Keenan TDL, Guymer RH, Chakravarthy U, Schmitz-Valckenberg S, Klaver CC, et al. Age-related macular degeneration. Nat Rev Dis Primers . (2021) 7:31. doi: 10.1038/s41572-021-00265-2

10. Ambati J, Fowler BJ. Mechanisms of age-related macular degeneration. Neuron . (2012) 75:26–39. doi: 10.1016/j.neuron.2012.06.018

11. Chirco KR, Potempa LA. C-reactive protein as a mediator of complement activation and inflammatory signaling in age-related macular degeneration. Front Immunol . (2018) 9:539. doi: 10.3389/fimmu.2018.00539

12. Clark SJ, McHarg S, Tilakaratna V, Brace N, Bishop PN. Bruch's membrane compartmentalizes complement regulation in the eye with implications for therapeutic design in age-related macular degeneration. Front Immunol . (2017) 8:1778. doi: 10.3389/fimmu.2017.01778

13. Friedman DS, O'Colmain BJ, Muñoz B, Tomany SC, McCarty C, de Jong PT, et al. Prevalence of age-related macular degeneration in the United States. Arch Ophthalmol (Chicago Ill 1960) . (2004) 122:564–72. doi: 10.1001/archopht.122.4.564

14. Wong TY, Chakravarthy U, Klein R, Mitchell P, Zlateva G, Buggage R, et al. The natural history and prognosis of neovascular age-related macular degeneration: a systematic review of the literature and meta-analysis. Ophthalmology . (2008) 115:116–26. doi: 10.1016/j.ophtha.2007.03.008

15. D'Orazio J, Jarrett S, Amaro-Ortiz A, Scott T. UV radiation and the skin. Int J Mol Sci . (2013) 14:12222–48. doi: 10.3390/ijms140612222

16. Hu CJ, Zhang L, Zhou S, Jiang N, Zhao JL, Wang Q, et al. Effectiveness of iguratimod as monotherapy or combined therapy in patients with rheumatoid arthritis: a systematic review and meta-analysis of RCTs. J orthopaedic Surg Res . (2021) 16:457. doi: 10.1186/s13018-021-02603-2

17. Tanaka K, Yamaguchi T, Hara M. Iguratimod for the treatment of rheumatoid arthritis in Japan. Expert Rev Clin Immunol . (2015) 11:565–73. doi: 10.1586/1744666x.2015.1027151

18. Xie S, Li S, Tian J, Li F. Iguratimod as a new drug for rheumatoid arthritis: current landscape. Front Pharmacol . (2020) 11:73. doi: 10.3389/fphar.2020.00073

19. True DG, Bryant LR, Harris MD, Bernert RA. Clinical images: Hydroxychloroquine-associated mucocutaneous hyperpigmentation. Arthritis rheumatism . (2002) 46:1698. doi: 10.1002/art.10278

20. Millard TP, Kirk A, Ratnavel R. Cutaneous hyperpigmentation during therapy with hydroxychloroquine. Clin Exp Dermatol . (2004) 29:92–3. doi: 10.1111/j.1365-2230.2004.01412.x

21. Reynaert S, Setterfield J, Black MM. Hydroxychloroquine-induced pigmentation in two patients with systemic lupus erythematosus. J Eur Acad Dermatol Venereology . (2006) 20:487–8. doi: 10.1111/j.1468-3083.2006.01494.x

22. Amichai B, Gat A, Grunwald MH. Cutaneous hyperpigmentation during therapy with hydroxychloroquine. J Clin Rheumatol . (2007) 13:113. doi: 10.1097/01.rhu.0000260649.36417.09

23. Melikoglu MA, Melikoglu M, Gurbuz U, Budak BS, Kacar C. Hydroxychloroquine-induced hyperpigmentation: a case report. J Clin Pharm Ther . (2008) 33:699–701. doi: 10.1111/jcp.2008.33.issue-6

24. Puri PK, Lountzis NI, Tyler W, Ferringer T. Hydroxychloroquine-induced hyperpigmentation: the staining pattern. J cutaneous Pathol . (2008) 35:1134–7. doi: 10.1111/j.1600-0560.2008.01004.x

25. Rood MJ, Vermeer MH, Huizinga TW. Hyperpigmentation of the skin due to hydroxychloroquine. Scandinavian J Rheumatol . (2008) 37:158. doi: 10.1080/03009740701769735

26. Morrison LK, Nordlund JJ, Heffernan MP. Persistent cutaneous hyperpigmentation due to hydroxychloroquinone one year after therapy discontinuation. Dermatol Online J . (2009) 15:15. doi: 10.5070/D32T07Q0NW

27. Cho EB, Kim BC, Park EJ, Kwon IH, Cho HJ, Kim KH, et al. Hydroxychloroquine-induced hyperpigmentation. J Dermatol . (2012) 39:859–60. doi: 10.1111/j.1346-8138.2012.01591.x

28. Mir A, Boyd KP, Meehan SA, McLellan B. Hydroxycholoroquine-induced hyperpigmentation. Dermatol Online J . (2013) 19:20723. doi: 10.5070/D31912020723

29. Cohen PR. Hydroxychloroquine-associated hyperpigmentation mimicking elder abuse. Dermatol Ther . (2013) 3:203–10. doi: 10.1007/s13555-013-0032-z

30. Tracy CL, Blakey B, Parker G, Roebuck J. Hydroxychloroquine-induced hyperpigmentation. J Clin Rheumatol . (2013) 19:292. doi: 10.1097/RHU.0b013e31829d547b

31. Sawalha AH. Hydroxychloroquine-induced hyperpigmentation of the skin. J Rheumatol . (2015) 42:135–6. doi: 10.3899/jrheum.140995

32. Coulombe J, Boccara O. Hydroxychloroquine-related skin discoloration. CMAJ Can Med Assoc J . (2017) 189:E212. doi: 10.1503/cmaj.150622

33. Ivo R, Lopes CA, Reis R. Woman in grey: hydroxychloroquine-induced hyperpigmentation. BMJ Case Rep . (2018) 11:1. doi: 10.1136/bcr-2018-227305

34. Thakur V, Dalla A, Kumar S, Kumaran MS, Aggarwal D, Radotra BD. Hydroxychloroquine induced cutaneous pigmentation: a unique pattern. Postgraduate Med J . (2019) 95:169–70. doi: 10.1136/postgradmedj-2018-136377

35. Tosios KI, Kalogirou EM, Sklavounou A. Drug-associated hyperpigmentation of the oral mucosa: report of four cases. Oral surgery Oral medicine Oral Pathol Oral Radiol . (2018) 125:e54–66. doi: 10.1016/j.oooo.2017.10.006

36. Tekgöz E, Akıncıoğlu E, Çınar M, Yılmaz S. A case of exogenous ochronosis associated with hydroxychloroquine. Eur J Rheumatol . (2018) 5:206–8. doi: 10.5152/eurjrheum.2018.17190

37. Shearer RV, Dubois EL. Ocular changes induced by long-term hydroxychloroquine (plaquenil) therapy. Am J Ophthalmol . (1967) 64:245–52. doi: 10.1016/0002-9394(67)92518-4

38. Johnson MW, Vine AK. Hydroxychloroquine therapy in massive total doses without retinal toxicity. Am J Ophthalmol . (1987) 104:139–44. doi: 10.1016/0002-9394(87)90005-5

39. Weiner A, Sandberg MA, Gaudio AR, Kini MM, Berson EL. Hydroxychloroquine retinopathy. Am J Ophthalmol . (1991) 112:528–34. doi: 10.1016/s0002-9394(14)76853-9

40. Fung AE, Samy CN, Rosenfeld PJ. Optical coherence tomography findings in hydroxychloroquine and chloroquine-associated maculopathy. Retinal cases Brief Rep . (2007) 1:128–30. doi: 10.1097/01.iae.0000226540.61840.d7

41. Salu P, Uvijls A, van den Brande P, Leroy BP. Normalization of generalized retinal function and progression of maculopathy after cessation of therapy in a case of severe hydroxychloroquine retinopathy with 19 years follow-up. Documenta ophthalmologica Adv Ophthalmol . (2010) 120:251–64. doi: 10.1007/s10633-010-9220-7

42. Phillips BN, Chun DW. Hydroxychloroquine retinopathy after short-term therapy. Retinal Cases Brief Rep . (2014) 8:67–9. doi: 10.1097/icb.0000000000000006

43. Wong KL, Pautler SE, Browning DJ. Near-infrared reflectance bull's eye maculopathy as an early indication of hydroxychloroquine toxicity. Clin Ophthalmol (Auckland NZ) . (2015) 9:521–5. doi: 10.2147/opth.S76963

44. Brandao LM, Palmowski-Wolfe AM. A possible early sign of hydroxychloroquine macular toxicity. Documenta Ophthalmologica Adv Ophthalmol . (2016) 132:75–81. doi: 10.1007/s10633-015-9521-y

45. Modi YS, Singh RP. Bull's-eye maculopathy associated with hydroxychloroquine. New Engl J Med . (2019) 380:1656. doi: 10.1056/NEJMicm1412167

46. Pellerano F, Chahín G, Niurka Leonor M, Stern H. Hydroxychloroquine-induced bull's eye maculopathy. Lancet Rheumatol . (2020) 2:e120. doi: 10.1016/s2665-9913(19)30040-2

47. Ameen Ismail A, Sadek SH, Hatata RM. Early onset monocular hydroxychloroquine maculopathy in a systemic lupus erythematosus patient with history of central retinal artery occlusion: a case report. BMC Ophthalmol . (2022) 22:434. doi: 10.1186/s12886-022-02657-8

48. Lippard VW, Kauer GL Jr. Pigmentation of the palate and subungual tissues associated with suppressive quinacrine hydrochloride therapy. Am J Trop Med hygiene . (1945) 25:469–71. doi: 10.4269/ajtmh.1945.s1-25.469

49. Skare T, Ribeiro CF, Souza FH, Haendchen L, Jordão JM. Antimalarial cutaneous side effects: a study in 209 users. Cutaneous Ocular Toxicol . (2011) 30:45–9. doi: 10.3109/15569527.2010.521225

50. Jallouli M, Francès C, Piette JC, Huong du LT, Moguelet P, Factor C, et al. Hydroxychloroquine-induced pigmentation in patients with systemic lupus erythematosus: a case-control study. JAMA Dermatol . (2013) 149:935–40. doi: 10.1001/jamadermatol.2013.709

51. Melles RB, Marmor MF. The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA Ophthalmol . (2014) 132:1453–60. doi: 10.1001/jamaophthalmol.2014.3459

52. Hallali G, Seyed Z, Maillard AV, Drine K, Lamour L, Faure C, et al. Extreme interocular asymmetry in an atypical case of a hydroxychloroquine-related retinopathy. Medicina (Kaunas Lithuania) . (2022) 58:1. doi: 10.3390/medicina58070967

Keywords: hydroxychloroquine, adverse drug reaction, hyperpigmentation of the skin, bull’s-eye maculopathy, literature review, autoimmune disease

Citation: Peng J-p, Yang X-y, Luo F, Yuan X-m, Xiong H, Ma W-k and Yao X-m (2024) Hydroxychloroquine-induced hyperpigmentation of the skin and bull’s-eye maculopathy in rheumatic patients: a case report and literature review. Front. Immunol. 15:1383343. doi: 10.3389/fimmu.2024.1383343

Received: 07 February 2024; Accepted: 27 March 2024; Published: 10 April 2024.

Reviewed by:

Copyright © 2024 Peng, Yang, Luo, Yuan, Xiong, Ma and Yao. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Xue-ming Yao, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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