Systemic lupus erythematosus-like syndrome with focal proliferative glomerulonephritis during D-penicillamine therapy

Herbal medication triggering lupus nephritis - a case report

Background

Herbal medication is widely used in our region as a mode of alternative medicine. Its contents and combinations are often modified to suit the needs of different populations. These products are said to boost the immune system and may serve as a protective measure against many diseases including Systemic Lupus Erythematosus (SLE). Some even lay claims to be able to cure SLE. Although they are not without side effects, these medications are still preferred due to their widespread availability and affordability, compared to modern medications. However, to date, there have been no reported cases in which these traditional medications can trigger a lupus-like reaction, moreover one involving the kidneys.

Case presentation

We report a patient who developed overt lupus nephritis after consuming a course of herbal supplement. Her renal status did not improve upon cessation of the offending drug, and she required immunosuppressive therapy. After one cycle of IV cyclophosphamide, we managed to get the patient into remission - she is now on tapering doses of steroids.

Conclusion

We wish to highlight the possibility of consumption of herbal medication and the emergence of drug-induced lupus nephritis. A thorough anamnesis and high index of suspicion of drug-induced lupus nephritis is warranted when a patient on supplements presents with urinary abnormalities.

Drug-induced glomerular disease: immune-mediated injury

Drug-induced autoimmune disease was initially described decades ago, with reports of vasculitis and a lupus-like syndrome in patients taking hydralazine, procainamide, and sulfadiazine. Over the years, multiple other agents have been linked to immune-mediated glomerular disease, often with associated autoantibody formation. Certain clinical and laboratory features may distinguish these entities from their idiopathic counterparts, and making this distinction is important in the diagnosis and management of these patients. Here, drug-induced, ANCA-associated vasculitis, drug-induced lupus, and drug-associated membranous nephropathy are reviewed.

Drug-induced lupus: Including anti-tumour necrosis factor and interferon induced

Drug-induced lupus erythematosus is defined as a syndrome with clinical and serological features similar to systemic lupus erythematosus that is temporally related to continuous drug exposure and which resolves after discontinuation of this drug. More than 90 drugs, including biological modulators such as tumour necrosis factor-α inhibitors and interferons, have been identified as likely ‘culprits’. While there are no standard diagnostic criteria for drug-induced lupus erythematosus, guidelines that can help to distinguish drug-induced lupus erythematosus from systemic lupus erythematosus have been proposed and several different patterns of drug-induced lupus erythematosus are emerging. Distinguishing drug-induced lupus erythematosus from systemic lupus erythematosus is important because the prognosis of drug-induced lupus erythematosus is usually good when the drug is withdrawn. This review discusses the differences between drug-induced lupus erythematosus and systemic lupus erythematosus, the mechanisms of action of drug-induced lupus erythematosus and drugs that are usually associated with drug-induced lupus erythematosus, with particular focus on the biological treatments.

D-penicillamine-induced glomerulonephritis with crescent formation: Remission following drug discontinuation

We report a 71-year-old female who presented with rheumatoid arthritis complicated by proteinuria. She had been receiving D-penicillamine (D-Pc) for two years prior to presentation. A urinalysis showed proteinuria and hematuria which disappeared within 3 months after D-Pc was stopped. The renal histological findings showed focal proliferative glomerulonephritis with crescent formation. A total of 10 cases of D-Pc-induced glomerulonephritis with crescent formation without alveolar hemorrhage have previously been reported in the literature. To the best of our knowledge, this is the first case report in which the patient did not require any treatment.

Cystinosis and lupus erythematosus: coincidence or causation

A 14-year-old boy with known stable cystinosis, treated with cysteamine since infancy, presented with a deterioration of renal function with haematuria in conjunction with a nodular rash, arthralgia, leucopenia, hypocomplementaemia and raised antinuclear antibodies. He was diagnosed with spontaneous onset of systemic lupus erythematosus (SLE), and his renal biopsy was consistent with lupus nephritis. It is unusual for patients with one severe disease to develop another disease process completely unrelated to their original condition, but it can occur. However, other distinct variants of lupus have been described, including drug-induced lupus (DIL), which have features that over-lap with SLE. The potential differential diagnosis of the SLE as a form of DIL in association with cysteamine is discussed.

[Drug-induced lupus]

Drug-induced lupus (DIL) is syndrome characterised by the occurrence of lupus-like symptoms and serological findings, following exposure to certain drugs. A substantial number of drugs can induce the positivity of antinuclear antibodies (ANA) but the diagnosis of DIL cannot be done in the absence of clinical features. Most patients with DIL have constitutional symptoms, arthralgia or occasionally arthritis, myalgias, fever and weight loss. These features may take weeks or months to develop and use to be mild with renal and central nervous system happening very rarely. ANA are always positive. They are mainly anti-histone proteins. Antibodies to ds-DNA are a rare finding and would tend to favour a diagnosis of idiopathic SLE. They have been associated with the use of tumour necrosis factor inhibitors (ant-TNF) and minocycline. Some drugs can induce particular symptoms o serological abnormalities and the diagnosis may be more difficult. It is the case of minocycline-induced lupus, which uses to affect young women with anti-ds-DNA and p-ANCA antibodies positive and negative anti-histone antibodies. Treatment with anti-TNF alpha is frequently associated with the development of ANA and anti-DNA. The incidence of ANA positive varies between 23-57% and anti-DNA between 9-33%. However, only a small number of patients will develop DIL or vasculitis. Resolution or marked improvement of the symptoms generally occurs within 2-5 weeks of the drugs withdrawal although some patients may require non-steroid anti-inflammatory drug or low dose steroid. Immunosuppressive drugs may be needed in severe cases with renal or neurological involvement. Some patients remain ANA positive for long periods of time. No treatment is necessary for ANA positive in the absence of clinical features.

Drug-induced lupus

Drug-induced lupus (DIL) is a rare adverse reaction to a large variety of drugs with features resembling those of idiopathic systemic lupus erythematosus (SLE). It usually develops only after months and, quite commonly, years of treatment with the offending agent, although latencies of days or weeks have been described in some instances. There are some indications that the risk of DIL can increase with higher daily and cumulative doses and with longer duration of therapy. There are no definitive and commonly accepted diagnostic criteria for DIL, but the following guidelines have been proposed: (a) sufficient and continuing exposure to a specific drug, (b) at least one symptom compatible with SLE, (c) no history suggestive of SLE before starting the drug, and (d) resolution of symptoms within weeks (sometimes months) after discontinuation of the putative offending agent. In addition, it is frequently suggested that the presence of ANA is required for the diagnosis of DIL. However, negative ANA test results should not automatically preclude such a diagnosis, particularly if a patient has other autoantibodies associated with SLE/DIL.