POSSIBLY THIAZIDE-INDUCED RENAL NECROTISING VASCULITIS

Prevalence of Churg-Strauss syndrome, vasculitis, eosinophilia and associated conditions: retrospective analysis of 58 prescription-event monitoring cohort studies

PURPOSE

Churg-Strauss syndrome is characterised by hypereosinophilia, systemic vasculitis and asthma. The cause is usually unknown, but there have been reports of an association with particular drugs, including anti-asthma drugs. Our aim was to estimate the prevalence of Churg-Strauss syndrome and related conditions in post-marketing safety studies of new anti-asthma drugs.

METHODS

We accessed the prescription-event monitoring (PEM) database of the Drug Safety Research Unit (DSRU). This database currently has information on 622 294 patients observed during 58 completed PEM studies of individual drugs, including 35 799 patients in studies of new anti-asthma drugs.

RESULTS

Overall, four cases of Churg-Strauss syndrome were identified during these studies, giving a period prevalence rate of 6.8 (95% confidence limits [CL]: 1.8-17.3) per million patient-years of observation. The period prevalence of Churg-Strauss syndrome was significantly greater in the PEM cohorts of anti-asthma drugs (64.4 million patient-years of observation; 95% CL: 13.3-188.1), than the other PEM drug cohorts (1.8 per million patient-years of observation; 95% CL: 0.05-10.2) (rate ratio: 35.1; 95% CL: 2.8-1839.9; p=0.002).

CONCLUSION

Our data provide estimates of the prevalence of Churg-Strauss syndrome and related conditions in cohorts of asthmatic patients, which may be useful during the pharmacovigilance of new asthma drugs, including the new leukotriene receptor antagonists.

Leukotriene antagonists and the Churg-Strauss syndrome

BACKGROUND AND OBJECTIVES

Leukotriene antagonists (LTAs), or antileukotrienes, are a new group of anti-inflammatory drugs used for the treatment of asthma. They might substitute for or allow tapering of corticosteroids in asthmatic patients. These drugs have been associated with the development of Churg-Strauss syndrome (CSS), a rare form of vasculitic angiitis. It is unclear whether the development of CSS is a direct drug effect or an unmasking of a preexisting condition on withdrawal of steroids for asthma. We present a case of CSS in a patient treated with montelukast and review the literature to analyze the association between LTAs and the development of CSS.

METHOD

We reviewed the literature using MEDLINE from February 1966 to October 2000. To the cases identified, we present an additional case of a patient who underwent a diagnostic lung biopsy.

RESULTS

Twenty-two case reports of patients receiving LTAs who developed CSS were identified. The onset of CSS occurred 2 days to 10 months after starting treatment with LTAs. All patients had received inhaled or oral steroids for asthma. The interval between the last oral corticosteroid treatment and CSS onset ranged from 3 days to 8 months.

CONCLUSIONS

To date, there is no compelling evidence that the development of CSS in asthmatic patients receiving LTAs results from a direct drug effect. Rather, it appears that tapering of corticosteroids in these patients unmasks the multiorgan manifestations of the disease. We believe that the use of LTAs should not be influenced by the apparent increase in the incidence of CSS and that these are still safe drugs for asthma.

Cutaneous and systemic manifestations of drug-induced vasculitis

OBJECTIVE

To evaluate the literature for published cases of drug-induced vasculitis with cutaneous and/or systemic manifestations.

DATA SOURCES

The MEDLINE database was searched from 1965 to December 1999 for articles focusing on drugs and vasculitis, using various search terminologies (e.g., Churg-Strauss syndrome, Goodpasture's syndrome, Henoch-Schönlein purpura, various drugs suspected to induce vasculitis). Cases were included when they met the established criteria as described in the methodology.

DATA SYNTHESIS

Drugs found to be most frequently associated with vasculitis were propylthiouracil, hydralazine, colony-stimulating factors, allopurinol, cefaclor, minocycline, D-penicillamine, phenytoin, isotretinoin, and methotrexate. The interval between the first exposure and appearance of symptoms was reported to be extremely variable (hours to years). Vasculitis has occurred after drug dosage increases and after rechallenge with the suspected drug. In the majority of cases, vasculitis has resolved after discontinuing the drug. Patients with more severe, often life-threatening, manifestations have required treatment with corticosteroids, plasmapheresis, hemodialysis, or cyclophosphamide. Death was the result in 10% of all published cases, with a predominance in patients in whom multiple organ systems were involved.

CONCLUSIONS

Clinicians need to be suspect of drug-induced vasculitis to enable prompt diagnosis and treatment. This should improve patient outcomes based on the data referenced for this article.

Churg-Strauss syndrome

OBJECTIVES

This article discusses the clinical manifestations and treatment protocols of Churg-Strauss syndrome (CSS). A review of the definition, pathophysiology, and prognosis of CSS is included, as well as more recent evidence of the presumed association between antileukotriene antagonists and CSS.

DATA SOURCES

Relevant articles in the medical literature derived from searching the MEDLINE database (1966 to present) with key terms Churg-Strauss syndrome, allergic granulomatosis, and allergic granulomatous angiitis. Sources included review articles, meta-analyses, randomized control trials, case reports, case series, and seminal articles, the majority of which had been published within the past decade.

STUDY SELECTION

Studies that described the clinical manifestations, pathophysiology, etiology, treatment, or prognosis of CSS.

RESULTS

CSS is a systemic vasculitic disorder with multiorgan involvement and diverse presentations.

CONCLUSIONS

Recognition of the multiorgan manifestations of CSS is crucial to clinical management. Whether a causal relationship exists between antileukotriene antagonists and onset of CSS remains unclear.

Thiazide-induced kidney damage with circulating antibodies against myeloperoxidase and cardiolipin

A 79-year-old man developed a renal insufficiency while on thiazide. Extrarenal symptoms were absent. Screening for antibodies revealed high titre for anti-myeloperoxidase and anti-cardiolipin antibodies, but no other antibodies were present. After withdrawal of the drug the progression of renal insufficiency ceased. Four months later the both antibodies had disappeared. We conclude, that antibodies against granulocytes will become a valuable diagnostic tool in diagnosing drug-induced vasculitis.

Nephrotic syndrome and immune complex glomerulonephritis associated with chlorpropamide therapy

Therapeutic drugs are well-recognized as a cause of the nephrotic syndrome in humans. However, documentation of the renal histopathologic features is lacking or incomplete in many cases. Even when accurate histopathologic information is available, there is little evidence to support a specific pathogenetic mechanism of renal injury in the vast majority of cases. We describe a patient with diabetes who had hepatitis and dermatitis in association with the use of chlorpropamide. In addition to these well-described toxic reactions to this drug, the nephrotic syndrome developed. Renal biopsy revealed the presence of a proliferative glomerulonephritis that was shown to be of an immune complex nature on immunofluorescence and electronmicroscopic study. Serial serum complement levels and circulating immune complex levels were consistent with an immunologically mediated reaction. Repeated renal biopsy documented resolution of the renal changes. Thus, in this patient, a drug-induced nephrotic syndrome was associated with a proliferative glomerulonephritis, probably due to the formation of immune complexes.

Acute interstitial nephritis associated with thiazide diuretics. Clinical and pathologic observations in three cases

Renal failure insidiously developed in three patients treated with a combination of hydrochlorothiazide and triamterene five to 10 weeks after commencing therapy. All had normal renal function prior to therapy and none had preexisting renal disease. Two of the patients had eosinophilia and two had a fever. One patient was oliguric. Renal biopsy demonstrated acute interstitial nephritis histologically. Direct immunofluorescence did not disclose evidence of either immune complex or antitubular basement membrane antibody deposition. Withdrawal of the drug led to remarkable improvement with renal function returning to normal in two patients and near normal in the third. The sequence of events and the histologic findings strongly suggest that the acute interstitial nephritis was due to a drug-induced hypersensitivity reaction. Although hydrochlorothiazide appears to be the drug responsible for the reaction, certain observations suggest a possible potentiating role for triamterene.

[Toxic nephropathies (author's transl)]

Direct tubular damage, hypersensitivity reaction, metabolically mediated kidney disturbances, and chronic nephropathies are important sequelae of several drugs or their metabolites. In this review the drug-induced kidney disease is discussed from a clinical, histological, and pathogenetic point of view. The knowledge of possible nephrotoxic reactions and their underlying toxins are essential for prevention of this kidney disease.

Drug induced interstitial nephritis, hepatitis and exfoliative dermatitis

Acute interstitial nephritis associated with hepatitis, exfoliative dermatitis, fever and eosinophilia is uncommon. The syndrome has been described previously in association with phenindione administration, leptospirosis and heavy metal poisoning. Four cases are described, two of which were due to phenindione sensitivity. The other two patients had been exposed to a number of toxins including allopurinol, frusemide, chlorothiazide and methyldopa so that the exact aetiological agent is unclear. Interstitial nephritis should be considered as a cause of acute renal failure in patients with other features of drug hypersensitivity.