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Sun XJ, Li ZY, Chen M. Pathogenesis of anti-neutrophil cytoplasmic antibody-associated vasculitis. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:11-21. [PMID: 37138650 PMCID: PMC10150877 DOI: 10.2478/rir-2023-0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 02/08/2023] [Indexed: 05/05/2023]
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) encompasses a group of potentially life-threatening disorders characterized by necrotizing small vessel vasculitis with positive serum ANCA. To date, the pathogenesis of AAV has not been fully elucidated, but remarkable progress has been achieved in the past few decades. In this review, we summarize the mechanism of AAV. The pathogenesis of AAV involves various factors. ANCA, neutrophils, and the complement system play key roles in disease initiation and progression, forming a feedback amplification loop leading to vasculitic injury. Neutrophils activated by ANCA undergo respiratory burst and degranulation, as well as releasing neutrophils extracellular traps (NETs), thus causing damage to vascular endothelial cells. Activated neutrophils could further activate the alternative complement pathway, leading to the generation of complement 5a (C5a), which amplifies the inflammatory response by priming neutrophils for ANCA-mediated overactivation. Neutrophils stimulated with C5a and ANCA could also activate the coagulation system, generate thrombin, and subsequently cause platelet activation. These events in turn augment complement alternative pathway activation. Moreover, disturbed B-cell and T-cell immune homeostasis is also involved in disease development. In-depth investigation in pathogenesis of AAV might help to offer more effective targeted therapies.
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Affiliation(s)
- Xiao-Jing Sun
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing100034, China
- Peking University Institute of Nephrology, Beijing100034, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing100034, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing100034, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing100034, China
| | - Zhi-Ying Li
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing100034, China
- Peking University Institute of Nephrology, Beijing100034, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing100034, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing100034, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing100034, China
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing100034, China
- Peking University Institute of Nephrology, Beijing100034, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing100034, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing100034, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing100034, China
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Salvadori M, Tsalouchos A. Genetic Associations and Environmental Exposures in the Aetiopathogenesis of Anti-Neutrophil Cytoplasmic Antibody- Associated Vasculitis: An Updated Review. EUROPEAN MEDICAL JOURNAL 2018. [DOI: 10.33590/emj/10311700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) represents a heterogeneous group of rare diseases characterised by necrotising inflammation of the small blood vessels and the presence of ANCA with specificity for proteinase-3 or myeloperoxidase. Genetic susceptibility along with malignancy, drug exposure, and environmental exposures to infectious agents and silica are involved in disease progression. To date, growing evidence has revealed that ANCA specificity defines homogeneous groups of patients more effectively than clinical diagnosis, since proteinase-3 ANCA and myeloperoxidase-ANCA are linked with different genetic backgrounds and epidemiologies. This review presents current and updated knowledge on the central aetiopathogenic role of genetic associations and environmental exposures in AAV; discusses the main mechanisms of ANCA immunogenesis; and highlights the value of ANCA specificity for future classification criteria.
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Affiliation(s)
- Maurizio Salvadori
- Renal Unit, Department of Transplantation, Careggi University Hospital, Florence, Italy
| | - Aris Tsalouchos
- Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia, Italy
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Chen B, Yang X, Sun S, Guo W, Li X, Zhang L, Guo Z, Han J, Li N. Propylthiouracil-Induced Vasculitis With Alveolar Hemorrhage Confirmed by Clinical, Laboratory, Computed Tomography, and Bronchoscopy Findings: A Case Report and Literature Review. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016; 18:e23320. [PMID: 27257510 PMCID: PMC4888935 DOI: 10.5812/ircmj.23320] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 04/05/2015] [Accepted: 05/23/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Propylthiouracil (PTU) is commonly used to treat hyperthyroidism and can induce antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Although this is a rare side effect, ANCA-associated vasculitis can progress to severe disease if its diagnosis and treatment are delayed, leading to a poor prognosis. CASE PRESENTATION A 43-year-old woman with Graves' disease developed pulmonary vasculitis and diffuse alveolar hemorrhage (DAH) associated with ANCA against myeloperoxidase and proteinase-3 that was confirmed by computed tomography (CT) and bronchoscopy and treated with PTU. The symptoms and signs of alveolar hemorrhage were rapidly resolved after PTU withdrawal and treatment with corticosteroids. After 6 months of follow-up, the patient maintained complete ANCA-negative clinical remission status, as confirmed by normal CT and bronchoscopy findings. To our knowledge, this is the first documented case of bronchoscopic comparison of PTU-induced DAH before and after steroid treatment. CONCLUSIONS Patients treated with PTU should be closely monitored and followed up, even if the drug has been used for several years. When patients develop progressive dyspnea with alveolar opacities on chest imaging that cannot be explained otherwise, alveolar hemorrhage should be an important differential diagnosis while investigating the case. Early diagnosis and prompt discontinuation of the PTU treatment are essential for improving patient outcomes.
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Affiliation(s)
- Bo Chen
- Department of Radiologic Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoqing Yang
- Department of Internal Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shihai Sun
- Department of Surgery, Taian Second Chinese Medicine Hospital, Taian, Shandong, China
| | - Weina Guo
- Department of Rheumatologic Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaosheng Li
- Department of Radiologic Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lei Zhang
- Department of Radiologic Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhongliang Guo
- Department of Internal Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jie Han
- Department of Rheumatologic Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Corresponding Authors: Jie Han, Department of Rheumatologic Medicine, Shanghai East Hospital, Tongji University School of Medicine, No.150 Ji Mo Road, Shanghai 200120, China. Tel: +86-2161569573, Fax: +86-2161569538, E-mail: ; Ning Li, Department of Rheumatologic Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China. Tel: +86-2161569573, Fax: +86-2161569538, E-mail:
| | - Ning Li
- Department of Rheumatologic Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Corresponding Authors: Jie Han, Department of Rheumatologic Medicine, Shanghai East Hospital, Tongji University School of Medicine, No.150 Ji Mo Road, Shanghai 200120, China. Tel: +86-2161569573, Fax: +86-2161569538, E-mail: ; Ning Li, Department of Rheumatologic Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China. Tel: +86-2161569573, Fax: +86-2161569538, E-mail:
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Paiaulla S, Venkategowda PM, Rao SM, Balaraju B. Propylthiouracil-induced autoimmune disease. Indian J Crit Care Med 2015; 19:484-6. [PMID: 26321810 PMCID: PMC4548420 DOI: 10.4103/0972-5229.162471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hyperthyroidism is a condition characterized by excessive production of thyroid hormones. Propylthiouracil (PTU) is commonly used as first line drug in the management of hyperthyroidism. This is a case report of 24-year-old female, a known case of hyperthyroidism since 4 years, who came with a history of fever and myalgia since 3 days and dyspnea with coughing out of blood since 1 day. Patient was taking PTU (100 mg per day) since 4 years for hyperthyroidism. Patient was immediately intubated for type-II respiratory failure. Diagnosed to be having PTU-induced autoimmune disease. PTU was stopped and treated with methylprednisolone and cyclophosphamide. Clinical features improved over a period of 8 days and discharged home successfully. Having a high suspicion for the onset of autoimmune disease in hyperthyroidism patients who are on PTU therapy and timely treatment with immunosuppressants and supportive care along with the withdrawal of the drug can make a difference in morbidity and mortality.
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Affiliation(s)
- Santosh Paiaulla
- Department of Critical Care Medicine, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, Telangana, India
| | - Pradeep Marur Venkategowda
- Department of Critical Care Medicine, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, Telangana, India
| | - S Manimala Rao
- Department of Critical Care Medicine, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, Telangana, India
| | - Banda Balaraju
- Department of Critical Care Medicine, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, Telangana, India
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ANCA Associated Vasculitis and Renal Failure Related to Propylthiouracil and Hyperthyroidism Induced Cholestasis in the Same Case. Case Rep Nephrol 2014; 2014:762528. [PMID: 25506446 PMCID: PMC4258370 DOI: 10.1155/2014/762528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 10/15/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction. Liver involvement due to hyperthyroidism and also ANCA positive vasculitis related renal failure cases were reported separately several times before. However, to our knowledge, these two complications together in the same case had never been observed before. Case Presentation. The case of an ANCA positive 71-year-old Caucasian male with renal failure and lung involvement, subclinical hyperthyroidism, and intrahepatic cholestatic jaundice was presented in this paper. After exclusion of all of the other possibilities, cholestatic hepatitis was explained by subclinical hyperthyroidism; renal failure and lung involvement were interpreted as ANCA related vasculitis which might be a side effect of propylthiouracil use. Conclusion. The coexistence of these rare conditions in the same patient deserves emphasis and it is worth reporting. This case demonstrates that following the clinical course of the patient is essential after prescribing any medications to see whether any complication occurs or not. If the complications of this case were noticed earlier, it would be possible to treat and to prevent the permanent damages.
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Gorgan M, Bockorny B, Lawlor M, Volpe J, Fiel-Gan M. Pulmonary hemorrhage with capillaritis secondary to mycophenolate mofetil in a heart-transplant patient. Arch Pathol Lab Med 2013; 137:1684-7. [PMID: 24168511 DOI: 10.5858/arpa.2012-0460-cr] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Immunosuppressive drugs are an integral part of therapy in organ transplantation. However, they are not without side effects, and although rare, these agents should be considered in the differential diagnosis of pulmonary complications in patients receiving transplants. We present a case of a patient who developed acute respiratory failure 7 days after orthotopic heart transplantation and who had been on both mycophenolate mofetil (MMF) and tacrolimus agents. Lung biopsy revealed features of pulmonary hemorrhage with capillaritis. Considered as a possible etiology, MMF was withdrawn. There was immediate improvement of the patient's symptoms. The temporal relationship between MMF exposure and onset of pulmonary symptoms in the absence of other possible etiologies strongly suggests a causal relationship. Previously published reports of pulmonary toxicity from MMF included interstitial fibrosis. To the best of our knowledge, this is the first reported case of pulmonary hemorrhage with capillaritis because of administration of MMF.
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Affiliation(s)
- Maria Gorgan
- From the Departments of Pathology (Drs Gorgan and Fiel-Gan), Radiology (Dr Volpe), Infectious Diseases (Dr Lawlor), and Internal Medicine (Dr Bockorny), Hartford Hospital, Hartford, Connecticut
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MacVittie K, Halámek J, Privman V, Katz E. A bioinspired associative memory system based on enzymatic cascades. Chem Commun (Camb) 2013; 49:6962-4. [DOI: 10.1039/c3cc43272f] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Tetikkurt C, Yuruyen M, Tetikkurt S, Bayar N, Ozdemir I. Propylthiouracil-induced lupus-like or vasculitis syndrome. Multidiscip Respir Med 2012; 7:14. [PMID: 22958435 PMCID: PMC3436642 DOI: 10.1186/2049-6958-7-14] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 06/25/2012] [Indexed: 11/10/2022] Open
Abstract
A 27 year old female with Graves’ disease presented with fever, exertional dyspnea and polyarthralgia. Erythema nodosum had occured three months earlier. The patient declared irregular use of propylthiouracil (PTU) for the last 8 months. Neutropenia and microscopic hematuria developed in the second week of admission. Chest X-ray showed inhomogenous pulmonary opacities, left pleural effusion and cardiomegaly. Computed tomography (CT) revealed multiple subpleural nodules, left pleural effusion, pericardial effusion, enlarged mediastinal and axillary lymph nodes. Bronchoalveolar lavage (BAL) cytology demonstrated hemosiderin laden macrophages. Histopathologic examination of the transbronchial biopsy specimen revealed a nonspecific inflammation. Serum was positive for ANA, P-ANCA, MPO-ANCA, PR3-ANCA and negative for anti-ds-DNA, C-ANCA, C3, C4 and anti-histone antibody. All symptoms resolved in two months after PTU withdrawal and starting steroid treatment. The same clinical manifestations recurred when the patient used PTU erronously one month after discharge. This is a case of PTU induced-autoimmune disease in whom the accurate distinction between drug-induced-lupus (DIL) and vasculitis was not possible due to the significant overlap of clinical and laboratory findings causing a significant diagnostic challenge for the chest physician.
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Affiliation(s)
- Cuneyt Tetikkurt
- Pulmonary Diseases Department, Cerrahpasa Medical Faculty, Istanbul University, Tanzimat sokak Serkan Apt, No 8/16 Caddebostan, Istanbul, 34728, Turkey.
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Chen M, Gao Y, Guo XH, Zhao MH. Propylthiouracil-induced antineutrophil cytoplasmic antibody-associated vasculitis. Nat Rev Nephrol 2012; 8:476-83. [PMID: 22664738 DOI: 10.1038/nrneph.2012.108] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) refers to a group of potentially life-threatening autoimmune diseases. A recent development in this field is the recognition that certain drugs can induce AAV. Among these agents, the drug most often implicated in causing disease is the commonly used antithyroid agent propylthiouracil (PTU). This Review provides an update on PTU-induced AAV. Clinical characteristics of PTU-induced AAV are similar to that of primary AAV, but usually have a milder course and better prognosis, provided early cessation of the disease-causing drug. PTU-induced ANCAs usually react to several components of myeloid granules, which is helpful in differentiating PTU-induced AAV from primary AAV. Early cessation of PTU is crucial in the treatment of PTU-induced AAV. The duration of immunosuppressive therapy might be shorter than in primary AAV, depending on the severity of organ damage, and maintenance therapy is not always necessary.
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Affiliation(s)
- Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Xicheng District, Beijing 100034, China
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Morais P, Baudrier T, Mota A, Cunha AP, Alves M, Neves C, Capela J, Sá-Couto P, Azevedo F. Antineutrophil cytoplasmic antibody (ANCA)-positive cutaneous leukocytoclastic vasculitis induced by propylthiouracil confirmed by positive patch test: a case report and review of the literature. Cutan Ocul Toxicol 2010; 30:147-53. [DOI: 10.3109/15569527.2010.533318] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Chen M, Kallenberg CGM. ANCA-associated vasculitides--advances in pathogenesis and treatment. Nat Rev Rheumatol 2010; 6:653-64. [PMID: 20924413 DOI: 10.1038/nrrheum.2010.158] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) include Wegener granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome and renal-limited vasculitis. This Review highlights the progress that has been made in our understanding of AAV pathogenesis and discusses new developments in the treatment of these diseases. Evidence from clinical studies, and both in vitro and in vivo experiments, supports a pathogenic role for ANCAs in the development of AAV; evidence is stronger for myeloperoxidase-ANCAs than for proteinase-3-ANCAs. Neutrophils, complement and effector T cells are also involved in AAV pathogenesis. With respect to treatment of AAV, glucocorticoids, cyclophosphamide and other conventional therapies are commonly used to induce remission in generalized disease. Pulse intravenous cyclophosphamide is equivalent in efficacy to oral cyclophosphamide but seems to be associated with less adverse effects. Nevertheless, alternatives to cyclophosphamide therapy have been investigated, such as the use of methotrexate as a less-toxic alternative to cyclophosphamide to induce remission in non-organ-threatening or non-life-threatening AAV. Furthermore, rituximab is equally as effective as cyclophosphamide for induction of remission in AAV and might become the standard of therapy in the near future. Controlled trials in which specific immune effector cells and molecules are being therapeutically targeted have been initiated or are currently being planned.
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Affiliation(s)
- Min Chen
- Renal Division, Peking University First Hospital, Beijing 100034, China
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Chen M, Kallenberg CG. The environment, geoepidemiology and ANCA-associated vasculitides. Autoimmun Rev 2010; 9:A293-8. [DOI: 10.1016/j.autrev.2009.10.008] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Sarzi-Puttini P, Atzeni F, Capsoni F, Lubrano E, Doria A. RETRACTED: Drug-induced lupus erythematosus. Autoimmunity 2009; 38:507-18. [PMID: 16373256 DOI: 10.1080/08916930500285857] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Drug-induced lupus is a syndrome which share symptoms and laboratory characteristics with idiopathic systemic lupus erythematosus (SLE). The terms drug-induced lupus (DIL) and drug-induced lupus erythematosus (DILE) are preferred, but other ones are also used-drug-related lupus, lupus-like syndrome and lupus erythematosus medicamentosus. The first case of DILE was reported in 1945 and associated with sulfadiazine. In 1953, it was reported that DILE was related to the use of hydralazine. More than 80 drugs have been associated with DILE. The average age of patients with DILE is nearly twice that of patients with idiopathic SLE. Approximately half the patients with drug-induced SLE are women, compared with 90% of patients with idiopathic SLE. Similarly to idiopathic lupus, DILE can be divided into systemic, sub-acute cutaneous and chronic cutaneous lupus. The syndrome is characterised by arthralgia, myalgia, pleurisy, rash and fever in association with antinuclear antibodies in the serum. The clinical and laboratory manifestations of drug-induced SLE are similar to those of idiopathic SLE, but central nervous system and renal involvement are rare in DILE. Recognition of DILE is important because it usually reverts within a few weeks after stopping the drug. This review discusses the general issues in DILE, such as pathogenic mechanisms, clinical forms and diagnostic criteria, and provides more detailed information for some of the most recent implicated drugs: minocycline, statins, anti-TNF-alpha agents.
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Affiliation(s)
- Piercarlo Sarzi-Puttini
- Department of Rheumatology, Rheumatology Unit, L Sacco University Hospital, via GB Grassi 74, Milan 20157, Italy.
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GAO YING, ZHAO MINGHUI. Review article: Drug-induced anti-neutrophil cytoplasmic antibody-associated vasculitis. Nephrology (Carlton) 2009; 14:33-41. [DOI: 10.1111/j.1440-1797.2009.01100.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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El-Fakih R, Chehab BM, Shaver T. Thionamide-induced vasculitis: a case of alveolar haemorrhage secondary to propylthiouracil. J Intern Med 2008; 264:610-2. [PMID: 18624905 DOI: 10.1111/j.1365-2796.2008.01990.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chen M, Xia B, Chen B, Guo Q, Li J, Ye M, Hu Z. N-acetyltransferase 2 slow acetylator genotype associated with adverse effects of sulphasalazine in the treatment of inflammatory bowel disease. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21:155-8. [PMID: 17377643 PMCID: PMC2657682 DOI: 10.1155/2007/976804] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM N-acetyltransferase 2 (NAT2) is an important enzyme catalyzing N-acetylation of sulfasalazine (SASP). The aim of the present study was to investigate associations of the genotypes of NAT2 with inflammatory bowel disease (IBD), and with adverse effects of SASP, which is used as the first-line treatment of IBD. PATIENTS AND METHODS The wildtype allele (NAT2*4) and three variant alleles (NAT2*5B, NAT2*6A and NAT*7B) of the NAT2 gene were determined in 101 patients with IBD (84 patients with ulcerative colitis and 17 patients with Crohn's disease) and 109 healthy controls by the polymerase chain reaction-restriction fragment length polymorphism method. Sixty-eight patients with IBD treated with SASP were followed, and their adverse reactions were recorded. RESULTS Eleven patients (16%) experienced adverse effects from SASP, including nine cases of sulfapyridine (SP) dose-related adverse effects and two cases of hypersensitivity (skin rash). Patients with the slow acetylator genotypes without the NAT2*4 allele experienced adverse effects more frequently (36%) than those with the fast acetylator genotypes with at least one NAT2*4 allele (11%), but the results were not significantly different (OR of 0.26, 95% CI 0.065 to 1.004; P=0.051). However, those with the slow acetylator genotypes experienced more SP dose-related adverse effects than those with the fast acetylator genotypes (36% versus 8%, OR of 0.17, 95% CI 0.039 to 0.749; P=0.019). CONCLUSIONS The NAT2 gene polymorphism was not associated with susceptibility to IBD in Chinese populations, but the NAT2 slow acetylator genotypes were significantly associated with SP dose-related adverse effects of SASP in the treatment of IBD.
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Affiliation(s)
- Min Chen
- Research Center of Digestive Diseases, School of Medicine, Wuhan University, Wuhan, People’s Republic of China
| | - Bing Xia
- Research Center of Digestive Diseases, School of Medicine, Wuhan University, Wuhan, People’s Republic of China
- Key Laboratory of Allergy and Immune-Related Diseases, School of Medicine, Wuhan University, Wuhan, People’s Republic of China
- Departments of Internal Medicine and Geriatrics, Wuhan University Zhongnan Hospital, Wuhan, People’s Republic of China
- Correspondence and reprints: Dr Bing Xia, Departments of Internal Medicine and Geriatrics, Wuhan University Zhongnan Hospital, Donghu Road 169, Wuhan 430071, Hubei Province, People’s Republic of China. Telephone 86-27-67812985, fax 86-27-87307622, e-mail
| | - Bixiao Chen
- Key Laboratory of Allergy and Immune-Related Diseases, School of Medicine, Wuhan University, Wuhan, People’s Republic of China
| | - Qiusha Guo
- Key Laboratory of Allergy and Immune-Related Diseases, School of Medicine, Wuhan University, Wuhan, People’s Republic of China
| | - Jin Li
- Research Center of Digestive Diseases, School of Medicine, Wuhan University, Wuhan, People’s Republic of China
| | - Mei Ye
- Departments of Internal Medicine and Geriatrics, Wuhan University Zhongnan Hospital, Wuhan, People’s Republic of China
| | - Zhengguo Hu
- Departments of Internal Medicine and Geriatrics, Wuhan University Zhongnan Hospital, Wuhan, People’s Republic of China
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Kang AY, Baek YH, Sohn YJ, Lee SK, Son CH, Kim K, Yang DK. Diffuse alveolar hemorrhage associated with antineutrophil cytoplasmic antibody levels in a pregnant woman taking propylthiouracil. Korean J Intern Med 2006; 21:240-3. [PMID: 17249506 PMCID: PMC3891029 DOI: 10.3904/kjim.2006.21.4.240] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Propylthiouracil (PTU) is known to be a potential cause of antineutrophil cytoplasmic antibody (ANCA) positive small vessel vasculitis, resulting in glomerulonephritis and diffuse alveolar hemorrhage (DAH). Herein, we describe a 25-year-old pregnant woman who developed a perinulcear ANCA (p-ANCA) and myeloperoxidase ANCA (MPO-ANCA) positive DAH during PTU therapy. The patient improved after corticosteroid therapy and discontinuation of the PTU. Methimazole was prescribed in spite of the risk of recurrence of DAH because of the pregnancy. The patient is currently free from pulmonary problems. Our case shows that the alternative agent, methimazole, can be used to treat hyperthyroidism in a pregnant patient with PTU associated DAH.
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Affiliation(s)
- Ah Young Kang
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Yang Hyun Baek
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - You Jung Sohn
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Soo-Keol Lee
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Choon Hee Son
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - KyeongHee Kim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Doo Kyung Yang
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
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Fenniche S, Dhaoui A, Ammar FB, Benmously R, Marrak H, Mokhtar I. Acebutolol-Induced Subacute Cutaneous Lupus Erythematosus. Skin Pharmacol Physiol 2005; 18:230-3. [PMID: 16015021 DOI: 10.1159/000086668] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2004] [Accepted: 01/06/2005] [Indexed: 11/19/2022]
Abstract
Beta-blocking medications are rarely associated with drug-induced lupus erythematosus syndrome and have never been incriminated as a cause of subacute lupus erythematosus (SCLE). We present herein the first case of SCLE induced by acebutolol. A 57-year-old woman presented with a 1-month history of a cutaneous eruption of the photo-exposed areas. One month ago, the patient had started a treatment with oral acebutolol to cure a hypertension of 1-year evolution. Physical examination revealed erythematous scaly annular plaques, involving the face, arms and trunk. Immunologic serology findings revealed a positive titer of antinuclear antibodies up to 1/1,280 with positivity of antihistone and Ro/SSA antibodies. Acebutolol was stopped, and the lesions cleared completely 4 months later. Literature data, along with our case, suggest a link between acebutolol therapy and the onset of a lupus syndrome. Although this is the first report of acebutolol-induced SCLE, we should be aware of this occurrence, and avoidance of acebutolol is recommended in patients with stigmata of lupus erythematosus.
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Affiliation(s)
- S Fenniche
- Dermatology Department, Habib Thameur Hospital, Tunis, Tunisia.
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Hoffmann TK, von Schmiedeberg S, Wulferink M, Thier R, Bier H, Ruzicka T, Lehmann P. Dapson-induzierte Agranulozytose. Hautarzt 2005; 56:673-7. [PMID: 15999287 DOI: 10.1007/s00105-004-0877-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A 34-year-old female patient with a three year history of generalized granuloma annulare was treated systemically with dapsone (DADPS). Six weeks after the onset of treatment, the patient developed an extensive tonsillitis of the base of the tongue with fever and malaise. Routine laboratory work showed a leukocytopenia with agranulocytosis. Further investigation revealed a marked decrease of the enzyme activity of N-acetyltransferase 2, which plays an important role in dapsone metabolism. Treatment included the cessation of dapsone, antibiotic coverage, and G-CSF leading to the rapid improvement of symptoms and normalization of leukocyte counts. Dapsone-induced angina agranulocytotica is a rare event and is interpreted as an idiosyncratic reaction. Depending on genetic polymorphisms of various enzymes, dapsone can be metabolized to immunologically or toxicologically relevant intermediates. Because of the risk of severe hematologic reactions, dapsone should only be employed for solid indications and with appropriate monitoring.
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Affiliation(s)
- T K Hoffmann
- Hals-Nasen-Ohren-Klinik, Heinrich-Heine-Universität Düsseldorf.
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Abstract
Among the numerous idiopathic immune-mediated diseases that can be drug-induced, such as pemphigus, psoriasis, lichen, etc, drug-induced lupus is the most widely commented upon and investigated. The terms drug-induced lupus (DIL) and drug-induced lupus erythematosus (DILE) are preferred, but other ones are also used--drug-related lupus, lupus-like syndrome, and lupus erythematosus medicamentosus. This review discusses the general issues in DILE, such as pathogenic mechanisms, clinical forms, and diagnostic criteria, and provides more detailed information for some of the implicated drugs: minocycline, statins, terbinafine, etc.
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Affiliation(s)
- Dimitar Antonov
- Department of Dermatology and Venereology, Sofia Faculty of Medicine, Sofia, Bulgaria.
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Yamashita M, Inokuma S, Matsumura N. Sweet's syndrome associated with propylthiouracil-induced antineutrophil cytoplasmic antibody. Mod Rheumatol 2004; 14:327-30. [PMID: 24387655 DOI: 10.3109/s10165-004-0319-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract A 44-year-old woman had tender erythematous nodules in both the upper and lower extremities, headache, and fever during the course of propylthiouracil therapy for Graves' disease. Serologic tests showed high titers of antineutrophil cytoplasmic antibody (ANCA) against myeloperoxidase (MPO). A skin biopsy showed neutrophilic dermatitis consistent with Sweet's syndrome. After the cessation of propylthiouracil therapy and the administration of steroids, all her symptoms disappeared and the titer of antineutrophil cytoplasmic antibody against myeloperoxidase decreased. A causal relationship between propylthiouracil (PTU) therapy and Sweet's syndrome is suggested.
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Affiliation(s)
- Masahiro Yamashita
- Department of Internal Medicine, Saka General Hospital , 16-5 Nishikicho, Shiogama 985-8506 , Japan
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22
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Gao Y, Zhao MH, Guo XH, Xin G, Gao Y, Wang HY. The prevalence and target antigens of antithyroid drugs induced antineutrophil cytoplasmic antibodies (ANCA) in Chinese patients with hyperthyroidism. Endocr Res 2004; 30:205-13. [PMID: 15473130 DOI: 10.1081/erc-120037729] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Antithyroid drugs such as propylthiouracil (PTU) and methimazole (MMI) are common medications in Chinese patients with hyperthyroidism and PTU-induced antineutrophil cytoplasmic antibody (ANCA) positive vasculitis has been reported. The current cross-sectional study aimed to investigate the prevalence and the target antigens of ANCA in Chinese patients with hyperthyroidism pre- and post-antithyroid medication therapy. METHODS Sera from 216 patients with hyperthyroidism in our hospital were collected from January to July in 2002. Patients were divided into four groups: untreated (n = 34); treated with PTU (n = 62); treated with MMI (n = 77); and treated with both PTU and MMI (n = 43). Indirect immunofluorescence (IIF) assay was used to detect ANCA and ANA. Antigen-specific ELISAs were used to detect antigen specificities. The known antigens included myeloperoxidase (MPO), proteinase 3 (PR3), human leukocyte elastase (HLE), lactoferrin, bactericidal/permeability-increasing protein (BPI), cathepsin G and azurocidin. RESULTS 33/216 sera were IIF positive, 20 of the 33 samples were ANCA positive, 11 samples were ANA positive, and two samples were both P-ANCA and ANA positive. The prevalence of positive ANCA in patients receiving PTU (14/62, 22.6%) was significantly higher than that of untreated patients (1/34, 2.9%) and patients treated with MMI (0/77, 0), P < 0.017. Of the 22 IIF-ANCA positive samples, 12 (54.5%) sera recognized lactoferrin, seven (31.8%) sera recognized HLE, four sera recognized MPO and azurocidin respectively, three sera recognized PR3 and cathepsin G respectively, and one serum recognized BPI. Six of the 22 (27.3%) patients with ANCA positive had clinical evidence of vasculitis. All patients with MPO-ANCA and two of the three patients with PR3-ANCA had clinical vasculitis. CONCLUSION PTU is associated with the production of ANCA in patients with hyperthyroidism. PTU-induced ANCA are due to polyclonal activation of B cells. Anti-MPO and anti-PR3 antibodies may associate the occurrence of clinical vasculitis.
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Affiliation(s)
- Ying Gao
- Department of Nephrology, Peking University First Hospital, Beijing, PR China
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23
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Yamauchi K, Sata M, Machiya JI, Osaka D, Wada T, Abe S, Otake K, Kubota I. Antineutrophil cytoplasmic antibody positive alveolar haemorrhage during propylthiouracil therapy for hyperthyroidism. Respirology 2003; 8:532-5. [PMID: 14708556 DOI: 10.1046/j.1440-1843.2003.00499.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recently, propylthiouracil (PTU) has been thought to be one of the possible causes of antineutrophil cytoplasmic antibody (ANCA)-associated small vessel vasculitis syndrome, resulting in glomerulonephritis and, infrequently, diffuse alveolar haemorrhage (DAH). The mechanism of ANCA-positive vasculitis during PTU therapy is still unknown. Herein, we describe the case of a 59-year-old woman who developed myeloperoxidase (MPO)- and proteinase 3 (PR3)-ANCA positive DAH, without any other organ system involvement, during PTU therapy. Diminution and discontinuation of PTU resulted in a positive response. To our knowledge, this is the first documentation of both MPO- and PR3-ANCA-positive DAH, without systemic manifestations, developing during PTU therapy.
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Affiliation(s)
- Keiko Yamauchi
- First Department of Internal Medicine, Yamagata University School of Medicine, Yamagata, Japan
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Helfgott SM, Smith RN. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 21-2002. A 21-year-old man with arthritis during treatment for hyperthyroidism. N Engl J Med 2002; 347:122-30. [PMID: 12110741 DOI: 10.1056/nejmcpc020104] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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ten Holder SM, Joy MS, Falk RJ. Cutaneous and systemic manifestations of drug-induced vasculitis. Ann Pharmacother 2002; 36:130-47. [PMID: 11816242 DOI: 10.1345/aph.1a124] [Citation(s) in RCA: 128] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Sandra M ten Holder
- Division of Nephrology and Hypertension, School of Medicine, University of North Carolina, CB #7155, 348 MacNider Bldg., Chapel Hill, NC 27599-7155, USA
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von Schmiedeberg S, Fritsche E, Rönnau AC, Specker C, Golka K, Richter-Hintz D, Schuppe HC, Lehmann P, Ruzicka T, Esser C, Abel J, Gleichmann E. Polymorphisms of the xenobiotic-metabolizing enzymes CYP1A1 and NAT-2 in systemic sclerosis and lupus erythematosus. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1999; 455:147-52. [PMID: 10599336 DOI: 10.1007/978-1-4615-4857-7_21] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The etiology of systemic autoimmune diseases, such as systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) is still unknown. In several cases, however, xenobiotics (i.e. drugs and occupational agents) were identified as etiologic agents and associations with certain polymorphic alleles of xenobiotic-metabolizing enzymes have been reported. Cytochrome P4501A1 (CYP1A1) and N-acetyltransferase 2 (NAT-2) are xenobiotic-metabolizing enzymes of phase 1- and phase 2-metabolism, respectively. CYP1A1 may activate drugs and other chemicals to reactive metabolites. NAT-2 is the most important enzyme in acetylation of aromatic amines, and thus may be responsible for detoxification of many of these compounds. Two polymorphisms of the human CYP1A1 gene, a point mutation in the 3' flanking region of the gene (Msp1) and a mutation in exon 7 leading to an isoleucine-valine-exchange in the heme-binding region of the enzyme, have been described and may lead to a higher basal and inducible enzyme activity. With respect to NAT-2, several alleles which combine for the two phenotypes "fast" and "slow" acetylators have been described. We analyzed the gene frequencies of the CYP1A1 polymorphisms and the phenotypes of NAT-2 in patients suffering from idiopathic SLE or SSc. CYP1A1 polymorphisms were analyzed in genomic DNA by PCR, whereas NAT-2 phenotypes were measured by the caffeine method. For CYP1A1 polymorphisms, 106 patients have been typed until now. The SLE group (n = 68) exhibited a significant increase (p < 0.05) in the mutant Val-allele (OR = 2.59) when compared to controls (n = 184). However, no significant differences in allele frequencies for MspI in the SLE group and for both CYP1A1 polymorphisms in the SSc group could be observed. Regarding the NAT-2 phenotype, patients suffering from SLE (n = 88) 75% and SSc (n = 26) 80.2%, respectively, were slow acetylators compared to 55% slow acetylators in the healthy German population (p < 0.05). The observed increased frequencies of the CYP1A1 mutant Val-allele and the slow actylator phenotype in idiopathic autoimmune disease support our concept that in slow acetylators non-acetylated xenobiotics may accumulate and are subsequently metabolized by other enzymes into reactive intermediates. Thus, enhanced formation of reactive metabolites could alter self-proteins presented to the immune system thus stimulating autoreactive T cells which induce autoimmunity.
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Affiliation(s)
- S von Schmiedeberg
- Department of Dermatology, Heinrich-Heine-University Düsseldorf, Germany
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Dhillon SS, Singh D, Doe N, Qadri AM, Ricciardi S, Schwarz MI. Diffuse alveolar hemorrhage and pulmonary capillaritis due to propylthiouracil. Chest 1999; 116:1485-8. [PMID: 10559122 DOI: 10.1378/chest.116.5.1485] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Propylthiouracil (PTU) has recently been observed to be associated with antineutrophil cytoplasmic antibody (ANCA)-positive small vessel vasculitis, resulting in crescentic glomerulonephritis and, infrequently, diffuse alveolar hemorrhage (DAH). We describe a case of a 23-year-old pregnant woman who developed a perinuclear ANCA and antimyeloperoxidase-positive small vessel vasculitis manifesting as DAH and crescentic glomerulonephritis after she began taking PTU. An open lung biopsy was consistent with pulmonary capillaritis. She responded to corticosteroid therapy and discontinuation of PTU. DAH can be caused by pulmonary capillaritis, bland hemorrhage, or diffuse alveolar damage. To our knowledge, this represents the first documentation of an underlying pulmonary capillaritis in a case of PTU-induced DAH.
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Affiliation(s)
- S S Dhillon
- Saint Elizabeth Health Center, Youngstown, OH 44501-1970, USA.
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Affiliation(s)
- K D Pramatarov
- Department of Dermatology, Medical University-Sofia, Bulgaria
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