1
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Bhatnagar M, Agaronov A, Sarkisyan E, Sotoudeh Deilamy I, Pepito D, Akhondi H. Overlapping drug-induced vasculitis, ANCA-associated vasculitis, and lupus nephritis caused by low-dose hydralazine. Int J Rheum Dis 2023; 26:2272-2277. [PMID: 37452463 DOI: 10.1111/1756-185x.14809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION We present a case of drug-induced vasculitis secondary to low-dose hydralazine with overlapping features of antineutrophil cytoplasmic antibody-associated vasculitis and drug-induced lupus nephritis. CASE PRESENTATION A 52-year-old Hispanic woman with a medical history of resistant hypertension treated with hydralazine 10 mg twice daily for 1 year presented with generalized weakness, dizziness, nausea, vomiting, and gross hematuria. There was fever, tachycardia, leukocytosis, lactic acidosis, hyperkalemia, renal failure, and anemia. Chest computed tomography and bronchoscopy revealed a left lower lobe infiltrate and diffuse alveolar hemorrhage. Serologic testing was positive for anti-double-stranded DNA, anti-Smith, lupus anticoagulant, anti-histone, anti-cardiolipin IgM antibodies, and antineutrophil cytoplasmic antibodies (myeloperoxidase and proteinase 3). A kidney biopsy revealed crescentic glomerulonephritis with an overlapping finding of membranous nephropathy. Broad-spectrum antibiotics, immunosuppressants, corticosteroids, and plasmapheresis were initiated. The patient survived but required continuous hemodialysis. CONCLUSIONS Although a few cases of simultaneous antibody-associated vasculitis and drug-induced lupus nephritis secondary to hydralazine use have been reported, this case is singular. Similar findings were previously reported with doses of 50-100 mg two to three times daily over 1-5 years. In our patient, a dose of only 10 mg twice daily for a year caused a severe disease presentation. This brings to light the combination of different vasculitides that can coexist and the potentially life-threatening adverse effects of low-dose hydralazine that should be kept in mind.
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Affiliation(s)
- M Bhatnagar
- Sunrise Health GME Consortium, Mountain View Hospital, Las Vegas, Nevada, USA
| | - A Agaronov
- College of Osteopathic Medicine, Touro University Nevada, Henderson, Nevada, USA
| | - E Sarkisyan
- College of Osteopathic Medicine, Touro University Nevada, Henderson, Nevada, USA
| | - I Sotoudeh Deilamy
- Sunrise Health GME Consortium, Mountain View Hospital, Las Vegas, Nevada, USA
| | - D Pepito
- Sunrise Health GME Consortium, Mountain View Hospital, Las Vegas, Nevada, USA
| | - H Akhondi
- Valley Health System, Las Vegas, Nevada, USA
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2
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Echevarria V, Pierre E, Quiros J, Eftekhari P. Hydralazine-Induced Anti-neutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis. Cureus 2023; 15:e47656. [PMID: 38021694 PMCID: PMC10667955 DOI: 10.7759/cureus.47656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis comprises several conditions involving vascular destruction that extends into tissue necrosis. There are several autoimmune and environmental causes implicated in the disease progression; among these is drug-induced vasculitis caused by hydralazine use. Hydralazine-induced vasculitis is an uncommon potential complication of the medication and can progress to multisystem involvement and eventually advance to end-organ damage and renal failure. Our patient presented with symptoms of lower extremity edema, dyspnea, and a nonproductive cough eventually resulting in the identification of hydralazine-induced ANCA-associated vasculitis with hypocomplementemia and positive anti-histone antibody. Due to the prevalence of hydralazine as a cardiac drug, physicians managing patients on the medication should have a high index of suspicion of the potential for vasculitis in order to promote prompt diagnosis and treatment of the ANCA-vasculitis.
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Affiliation(s)
- Victoria Echevarria
- Internal Medicine, American University of the Caribbean School of Medicine, Sint Maarten, SXM
| | - Ednord Pierre
- Internal Medicine, Broward Health Medical Center, Fort Lauderdale, USA
| | - Jorge Quiros
- Internal Medicine, Broward Health Medical Center, Fort Lauderdale, USA
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3
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Banbury S, Rauck C, Morgan EE, Arisi MF, Berk-Krauss J, Buckey T, Fadugba O, Rosenbach M. Diffuse hydralazine-associated vasculitis with pathergy: An overlapping picture of Sweet syndrome and bullous vasculitis. JAAD Case Rep 2023; 39:78-80. [PMID: 37664446 PMCID: PMC10468317 DOI: 10.1016/j.jdcr.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023] Open
Affiliation(s)
- Sara Banbury
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Corinne Rauck
- Department of Dermatology at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric E. Morgan
- Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria F. Arisi
- Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Juliana Berk-Krauss
- Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Timothy Buckey
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Olajumoke Fadugba
- Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology at University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Hydralazine-Associated Pulmonary-Renal Syndrome. Am J Ther 2022; 29:e667-e669. [PMID: 33538489 DOI: 10.1097/mjt.0000000000001313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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5
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Martin K, Deleveaux S, Cunningham M, Ramaswamy K, Thomas B, Lerma E, Madariaga H. The presentation, etiologies, pathophysiology, and treatment of pulmonary renal syndrome: A review of the literature. Dis Mon 2022; 68:101465. [PMID: 36008166 DOI: 10.1016/j.disamonth.2022.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Pulmonary renal syndrome (PRS) is a constellation of different disorders that cause both rapidly progressive glomerulonephritis and diffuse alveolar hemorrhage. While antineutrophil cytoplasmic antibody associated vasculitis and anti-glomerular basement membrane disease are the predominant causes of PRS, numerous other mechanisms have been shown to cause this syndrome, including thrombotic microangiopathies, drug exposures, and infections, among others. This syndrome has high morbidity and mortality, and early diagnosis and treatment is imperative to improve outcomes. Treatment generally involves glucocorticoids and immunosuppressive agents, but treatment targeted to the underlying disorder can improve outcomes and mitigate side effects. Familiarity with the wide range of possible causes of PRS can aid the clinician in workup, diagnosis and early initiation of treatment. This review provides a summary of the clinical presentation, etiologies, pathophysiology, and treatment of PRS.
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Affiliation(s)
| | | | | | | | - Beje Thomas
- Medstar Georgetown University Hospital, United States
| | - Edgar Lerma
- Advocate Christ Medical Center, United States
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6
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Hawn VS, Vo TA, Flomenbaum D, Gibralter RP. Hydralazine-induced vasculitis presenting with ocular manifestations. Am J Ophthalmol Case Rep 2022; 26:101515. [PMID: 35464686 PMCID: PMC9020102 DOI: 10.1016/j.ajoc.2022.101515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 03/08/2022] [Accepted: 04/01/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Vivian S. Hawn
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, NY, 10461, Bronx, USA
| | - Thomas A. Vo
- Department of Ophthalmology and Visual Sciences, Montefiore Medical Center, 111 East 210th Street, NY, 10467, Bronx, USA
| | - David Flomenbaum
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, NY, 10461, Bronx, USA
| | - Richard P. Gibralter
- Department of Ophthalmology and Visual Sciences, Montefiore Medical Center, 111 East 210th Street, NY, 10467, Bronx, USA
- Corresponding author. 3332 Rochambeau Avenue, Bronx, NY, 10467-2836, USA.
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7
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Warren K, Vu K, Shergill K, Watson B, Faris M. Rare complication of a commonly used antihypertensive agent: A case of hydralazine-induced ANCA-associated vasculitis presenting as rapidly progressive glomerulonephritis. Clin Case Rep 2022; 10:e05411. [PMID: 35154727 PMCID: PMC8819714 DOI: 10.1002/ccr3.5411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 01/13/2022] [Accepted: 01/18/2022] [Indexed: 12/28/2022] Open
Abstract
Hydralazine-induced ANCA-associated vasculitis is a rare clinical entity, with complications including rapidly progressive glomerulonephritis, pulmonary hemorrhage, and pulmonary-renal syndrome. We present this case to highlight the clinical features that support this challenging diagnosis and to emphasize the importance of prompt recognition and aggressive intervention given its significant morbidity and mortality.
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Affiliation(s)
- Kayle Warren
- Department of Internal MedicineGrand Strand Medical CenterMyrtle BeachSouth CarolinaUSA
| | - Khiem Vu
- Department of Internal MedicineGrand Strand Medical CenterMyrtle BeachSouth CarolinaUSA
| | - Karandeep Shergill
- Department of Internal MedicineGrand Strand Medical CenterMyrtle BeachSouth CarolinaUSA
| | - Brian Watson
- Department of Internal MedicineGrand Strand Medical CenterMyrtle BeachSouth CarolinaUSA
| | - Mohamed Faris
- Department of Internal MedicineGrand Strand Medical CenterMyrtle BeachSouth CarolinaUSA
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8
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Deshayes S, Dolladille C, Dumont A, Martin Silva N, Chretien B, De Boysson H, Alexandre J, Aouba A. A worldwide pharmacoepidemiological update of drug-associated ANCA-associated vasculitis at the time of targeted therapies. Arthritis Rheumatol 2021; 74:134-139. [PMID: 34164938 DOI: 10.1002/art.41902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/10/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The literature data supporting the role of a drug in the onset of drug-associated anti-neutrophil cytoplasmic antibody-associated vasculitis (DA-AAV) mainly rely on case reports or short series and implicate old treatments. The advent of new treatments may have modified the epidemiology of these adverse drug reactions (ADRs). We therefore aimed to update this list by using a pharmacovigilance-based data mining approach. METHODS We collected data on ADRs reported with the MedDRA preferred term "Anti-neutrophil cytoplasmic antibody positive vasculitis" up to November 2020 from the World Health Organization pharmacovigilance database (VigiBase® ). For each retrieved drug, a case/noncase analysis was performed, and disproportionate reporting was calculated by using the information component (IC). A positive IC025 value, which is the lower end of the 95% credibility interval, was considered significant. RESULTS A total of 483 deduplicated individual case safety reports of DA-AAV involving 15 drugs with an IC025 >0 were retrieved. DA-AAV occurred in 264 (71.2%, n=371) women, the median age at onset was 62 years [45-72], and the median time to onset between the introduction of the suspected drug and DA-AAV was 9 months [1-36]. DA-AAV occurrence was considered serious in 472 (97.7%, n=481) cases and fatal in 43 (8.9%) cases. The drugs associated with the highest disproportionate reporting were hydralazine, propylthiouracil, thiamazole, sofosbuvir, minocycline, carbimazole, mirabegron, and nintedanib. CONCLUSION This study strengthens the previously suspected association but also identifies 3 new drugs that may cause DA-AAV. Particular attention should be given to these drugs by prescribers and in experimental studies.
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Affiliation(s)
- Samuel Deshayes
- Department of Internal Medicine, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000, Caen, France.,Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, 14000, Caen, France
| | - Charles Dolladille
- Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, 14000, Caen, France.,Department of Pharmacology, CHU de Caen Normandie, 14000, Caen, France
| | - Anaël Dumont
- Department of Internal Medicine, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000, Caen, France
| | - Nicolas Martin Silva
- Department of Internal Medicine, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000, Caen, France
| | - Basile Chretien
- Department of Pharmacology, CHU de Caen Normandie, 14000, Caen, France
| | - Hubert De Boysson
- Department of Internal Medicine, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000, Caen, France.,Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, 14000, Caen, France
| | - Joachim Alexandre
- Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, 14000, Caen, France.,Department of Pharmacology, CHU de Caen Normandie, 14000, Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000, Caen, France.,Normandie Univ, UNICAEN, EA4650 SEILIRM, CHU de Caen Normandie, 14000, Caen, France
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9
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DiLorenzo AM, Pasieka HB, Cardis MA. An Edematous and Ulcerative Eruption With Nasolabial Sparing in an Older Woman. JAMA Dermatol 2021; 156:1127-1128. [PMID: 32845285 DOI: 10.1001/jamadermatol.2020.2420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ashley M DiLorenzo
- Medstar Washington Hospital Center, Georgetown University Hospital, Chevy Chase, Maryland
| | - Helena B Pasieka
- Medstar Washington Hospital Center, Georgetown University Hospital, Chevy Chase, Maryland
| | - Michael A Cardis
- Medstar Washington Hospital Center, Georgetown University Hospital, Chevy Chase, Maryland
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10
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Huo MX, Avelino ARM, Singh G. Severe cutaneous presentation of hydralazine-induced ANCA vasculitis without renal or pulmonary involvement, complicated by DIC. BMJ Case Rep 2021; 14:14/5/e238609. [PMID: 33975832 PMCID: PMC8118062 DOI: 10.1136/bcr-2020-238609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hydralazine is a common arterial vasodilator used in the management of congestive heart failure and hypertension. It can be associated with drug-induced lupus and less commonly antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV). Drug-induced AAV typically has a favourable long-term prognosis. It is not commonly associated with primary skin involvement, as most cases also have notable kidney and lung disease. Cases with isolated skin findings are rare. We present a rare case of a 60-year-old woman on long-term hydralazine who presented with AAV with primary skin and mucosal involvement, in the form of diffuse bullous and ulcerative lesions, which posed a diagnostic challenge. Her hospital course was marked by several complications including disseminated intravascular coagulation. She required intensive therapy with high-dose steroids, plasmapheresis and rituximab. She tolerated immunosuppression well and with multidisciplinary supportive care, she recovered well and was able to be discharged from the hospital.
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Affiliation(s)
- Mae Xintong Huo
- Internal Medicine, Albany Medical Center, Albany, New York, USA
| | | | - Gurpreet Singh
- Internal Medicine, Albany Medical Center, Albany, New York, USA
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11
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Santoriello D, Bomback AS, Kudose S, Batal I, Stokes MB, Canetta PA, Radhakrishnan J, Appel GB, D'Agati VD, Markowitz GS. Anti-neutrophil cytoplasmic antibody associated glomerulonephritis complicating treatment with hydralazine. Kidney Int 2021; 100:440-446. [PMID: 33857570 DOI: 10.1016/j.kint.2021.03.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/23/2021] [Accepted: 03/05/2021] [Indexed: 01/23/2023]
Abstract
Hydralazine, a widely used therapy for hypertension and heart failure, can elicit autoimmune disease, including anti-neutrophil cytoplasmic antibody associated glomerulonephritis (ANCA-GN). We identified 80 cases of ANCA-GN complicating treatment with hydralazine, accounting for 4.3% (80/1858 biopsies) of ANCA-GN diagnosed between 2006 and 2019. Over three-fourths of patients were on hydralazine for at least one year, with mean daily dose of approximately 250 mg/day. ANCA testing revealed p-ANCA/myeloperoxidase-ANCA seropositivity in 98%, including 39% with dual p-ANCA/myeloperoxidase-ANCA and cANCA/anti-protinase 3-ANCA positivity, often accompanied by anti-nuclear antibody (89%), anti-histone antibody (98%), and hypocomplementemia (58%). Kidney biopsy revealed necrotizing and crescentic glomerulonephritis, similar to primary ANCA-GN, but significantly less frequently pauci-immune (77 vs. 100%) and more commonly associated with mesangial hypercellularity (30 vs. 5%), electron dense deposits (62 vs. 20%), and endothelial tubuloreticular inclusions (11 vs. 0%); all significant differences. On follow-up, 42 of 51 patients received induction immunosuppression: 19 reached the combined end-points of kidney failure or death and 32 had mean creatinine of 1.49 mg/dL at last follow-up. Thus, hydralazine-associated ANCA-GN often exhibits overlapping clinical and pathologic features of mild immune complex glomerulonephritis resembling lupus nephritis. With discontinuation of hydralazine and immunosuppression, outcomes are similar to primary ANCA-GN.
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Affiliation(s)
- Dominick Santoriello
- Department of Pathology, Columbia University Irving Medical Center, New York, New York, USA.
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Satoru Kudose
- Department of Pathology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ibrahim Batal
- Department of Pathology, Columbia University Irving Medical Center, New York, New York, USA
| | - M Barry Stokes
- Department of Pathology, Columbia University Irving Medical Center, New York, New York, USA
| | - Pietro A Canetta
- Department of Pathology, Columbia University Irving Medical Center, New York, New York, USA
| | - Jai Radhakrishnan
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Gerald B Appel
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Vivette D D'Agati
- Department of Pathology, Columbia University Irving Medical Center, New York, New York, USA
| | - Glen S Markowitz
- Department of Pathology, Columbia University Irving Medical Center, New York, New York, USA
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12
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Diffuse Alveolar Hemorrhage Secondary to Hydralazine-Induced Antineutrophilic Cytoplasmic Antibody–Associated Vasculitis. Am J Ther 2020; 29:e603-e604. [DOI: 10.1097/mjt.0000000000001175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Skaljic M, Agarwal A, Smith RJ, Nguyen CV, Xu X, Shahane A, Degnan K, Greenblatt J, Rosenbach M. A hydralazine-induced triumvirate: Lupus, cutaneous vasculitis, and cryptococcoid Sweet syndrome. JAAD Case Rep 2019; 5:1006-1009. [PMID: 31720352 PMCID: PMC6838470 DOI: 10.1016/j.jdcr.2019.08.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Meliha Skaljic
- Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin Agarwal
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert J Smith
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cuong V Nguyen
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xiaowei Xu
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anupama Shahane
- Division of Rheumatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen Degnan
- Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeff Greenblatt
- Division of General Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Kang S, Cho MH, Hyun H, Kim JH, Ko JS, Kang HG, Cheong HI, Kim WS, Moon KC, Ha IS. A Pediatric Case of a D-Penicillamine Induced ANCA-associated Vasculitis Manifesting a Pulmonary-Renal Syndrome. J Korean Med Sci 2019; 34:e173. [PMID: 31222986 PMCID: PMC6589402 DOI: 10.3346/jkms.2019.34.e173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/03/2019] [Indexed: 12/15/2022] Open
Abstract
D-penicillamine has been reported to cause antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis presenting as rapidly progressive glomerulonephritis or pulmonary-renal syndrome mostly in adults. We report a pediatric case of D-penicillamine induced ANCA-associated vasculitis that manifests as a pulmonary-renal syndrome with a mild renal manifestation. A 13-year-old girl who has been taking D-penicillamine for five years under the diagnosis of Wilson disease visited the emergency room because of hemoptysis and dyspnea. She had diffuse pulmonary hemorrhage, microscopic hematuria, and proteinuria. Myeloperoxidase ANCA was positive, and a renal biopsy revealed pauci-immune crescentic glomerulonephritis. Under the diagnosis of D-penicillamine-induced ANCA-associated vasculitis, D-penicillamine was switched to trientine, and the patient was treated with plasmapheresis, glucocorticoid, cyclophosphamide, and mycophenolate mofetil. Pulmonary hemorrhage improved rapidly followed by the disappearance of the hematuria and proteinuria five months later.
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Affiliation(s)
- Sena Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Myung Hyun Cho
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyesun Hyun
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Ji Hyun Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
- Kidney Institute, Seoul National University Medical Research Center, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
- Kidney Institute, Seoul National University Medical Research Center, Seoul, Korea
| | - Woo Sun Kim
- Department of Radiology, Seoul National University Children's Hospital, Seoul, Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Il Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
- Kidney Institute, Seoul National University Medical Research Center, Seoul, Korea.
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15
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Tsai-Nguyen G, Modrykamien AM, Bredeweg A. Hereditary afibrinogenemia and pulmonary-renal hydralazine-induced vasculitis. Proc (Bayl Univ Med Cent) 2019; 32:397-398. [PMID: 31384199 DOI: 10.1080/08998280.2019.1619397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/11/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022] Open
Abstract
Combined pulmonary-renal hydralazine-induced vasculitis is rare, and hereditary afibrinogenemia is also rare. We present a case of a 62-year-old man with a history of hereditary afibrinogenemia who presented with hemoptysis and hematuria. Although he had prior episodes of hemoptysis that resolved with repletion of fibrinogen levels, a hydralazine-induced vasculitis was the ultimate cause of his recurrent hemoptysis and hematuria. Hydralazine was held and after transfusion with cryoprecipitate, he was treated with prednisone and rituximab.
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Affiliation(s)
- Ginger Tsai-Nguyen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Baylor University Medical CenterDallasTexas
| | - Ariel M Modrykamien
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Baylor University Medical CenterDallasTexas
| | - Arthur Bredeweg
- Department of Pathology, Baylor University Medical CenterDallasTexas
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16
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Espinosa MC, Ding B, Choi K, Cohen DN, Marcelli M, Ifoeze OW. A simultaneous presentation of drug-induced lupus with drug-induced ANCA vasculitis secondary to hydralazine use in a patient with sarcoidosis. Proc (Bayl Univ Med Cent) 2019; 32:231-234. [PMID: 31191136 DOI: 10.1080/08998280.2019.1570422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/04/2019] [Accepted: 01/10/2019] [Indexed: 10/27/2022] Open
Abstract
Frequently used in the management of hypertension and heart failure, hydralazine is associated with the development of adverse rheumatologic side effects. The authors highlight a unique case of drug-induced lupus and drug-induced anti-neutrophil cytoplasmic antibody (ANCA) vasculitis from hydralazine use in a 50-year-old man with sarcoidosis and hypertension.
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Affiliation(s)
| | - Belicia Ding
- School of Medicine, Baylor College of MedicineHoustonTexas
| | - Kati Choi
- Department of Medicine, Baylor College of MedicineHoustonTexas
| | - Daniel N Cohen
- Department of Pathology and Immunology, Baylor College of MedicineHoustonTexas
| | - Marco Marcelli
- Department of Medicine, Baylor College of MedicineHoustonTexas
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17
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Aeddula NR, Pathireddy S, Ansari A, Juran PJ. Hydralazine-associated antineutrophil cytoplasmic antibody vasculitis with pulmonary-renal syndrome. BMJ Case Rep 2018; 2018:bcr-2018-227161. [PMID: 30413463 PMCID: PMC6229221 DOI: 10.1136/bcr-2018-227161] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hydralazine, a vasodilator, is commonly used as an adjunctive treatment for moderate to severe hypertension, heart failure and hypertensive emergencies in pregnancy. Hydralazine-induced lupus was first described in 1953. Clinical presentation ranges from arthralgia, myalgia, petechiae, or rash to single or multiorgan involvement. An occurrence of systemic vasculitis is a rare complication. When presented as the pulmonary-renal syndrome, it could have a rapidly progressive course which can be fatal. Here, we describe a case of hydralazine-associated rapidly progressive glomerulonephritis and pulmonary haemorrhage. We use this case to review the current literature and discuss and highlight the importance of a high degree of clinical acumen, early diagnosis and prompt treatment for better clinical outcomes.
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Affiliation(s)
- Narothama Reddy Aeddula
- Nephrology, Deaconess Health System, Evansville, Indiana, USA.,Medicine, Indiana University School of Medicine, Evansville, Indiana, USA
| | - Samata Pathireddy
- Internal Medicine, Deaconess Health System, Evansville, Indiana, USA.,Medicine, Indiana University School of Medicine, Evansville, Indiana, USA
| | - Asif Ansari
- Nephrology, Permian Basin Kidney Center, Midland, Texas, USA
| | - Peter J Juran
- Nephrology, Deaconess Health System, Evansville, Indiana, USA.,Medicine, Indiana University School of Medicine, Evansville, Indiana, USA
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Abstract
PURPOSE OF REVIEW Rapid introduction of newly developed drugs in the absence of clear understanding of the pathophysiologic mechanisms behind drug-induced lupus erythematosus (DILE) can sometimes make DILE difficult to recognize in clinical practice. The purpose of this review is to summarize drugs most recently reported to be involved in DILE and discuss the current landscape of diverse mechanisms involved. RECENT FINDINGS A large number of proton pump inhibitor (PPI)-induced subacute cutaneous lupus erythematosus cases have been reported, suggesting a shift over time in the spectrum of drugs implicated in DILE. Twenty-two articles comprising 29 DILE case reports published within the last 2 years are summarized in this review, including 12 (41.4%) systemic DILE. Antitumor necrosis factor (anti-TNF) drugs were the most frequently (41.7%) reported to introduce systemic DILE in these cases. Chemotherapeutic drugs were the most common drug class (54.5%) involved in subacute cutaneous lupus erythematosus, with an observed higher incidence in female patients. Enhanced neutrophil extracellular trap (NET) formation induced by procainamide and hydralazine could be a new mechanism contributing to the pathogenesis of DILE. SUMMARY The list of drugs implicated in triggering DILE is expanding as new drugs with novel mechanisms of action are being developed. It is important to recognize culprit drugs that may induce lupus erythematosus, as discontinuation usually results in improvement of drug-induced manifestations. Characterizing the mechanisms involved might help better understand the cause of idiopathic autoimmunity.
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Affiliation(s)
- Ye He
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Dermatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Amr H. Sawalha
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Center for Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
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Zuckerman R, Patel M, Costanzo EJ, Dounis H, Haj RA, Seyedali S, Asif A. Hydralazine-associated adverse events: a report of two cases of hydralazine-induced ANCA vasculitis. ACTA ACUST UNITED AC 2018; 40:193-197. [PMID: 29738027 PMCID: PMC6533989 DOI: 10.1590/2175-8239-jbn-3858] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 08/13/2017] [Indexed: 11/25/2022]
Abstract
Hydralazine is a direct-acting vasodilator, which has been used in treatment for
hypertension (HTN) since the 1950s. While it is well known to cause drug-induced
lupus (DIL), recent reports are indicating the emergence of the drug-induced
anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (DIV). Herein,
we describe two patients (aged 57 and 87 years) who presented with severe acute
kidney injury (AKI), proteinuria, and hematuria. Both were receiving hydralazine
for the treatment of hypertension. ANCA serology was positive in both patients
along with anti-histone antibodies (commonly seen in drug-induced vasculitis).
Renal biopsy revealed classic crescentic (pauci-immune) glomerulonephritis in
these patients and hydralazine was discontinued. During the hospital course, the
57-year-old patient required dialysis therapy and was treated with steroids and
rituximab for the ANCA disease. Renal function improved and the patient was
discharged (off dialysis) with a serum creatinine of 3.6 mg/dL (baseline = 0.9
mg/dL). At a follow-up of 2 years, the patient remained off dialysis with
advanced chronic kidney disease (CKD) (stage IIIb). The 87-year-old patient had
severe AKI with serum creatinine at 10.41 mg/dL (baseline = 2.27 mg/dL). The
patient required hemodialysis and was treated with steroids, rituximab, and
plasmapheresis. Unfortunately, the patient developed catheter-induced bacteremia
and subsequently died of sepsis. Hydralazine can cause severe AKI resulting in
CKD or death. Given this extremely unfavorable adverse-event profile and the
widespread availability of alternative anti-hypertensive agents, the use of
hydralazine should be carefully considered.
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Affiliation(s)
| | | | | | - Harry Dounis
- Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Rany Al Haj
- Jersey Shore University Medical Center, Neptune, NJ, USA
| | | | - Arif Asif
- Jersey Shore University Medical Center, Neptune, NJ, USA
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20
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Kumar B, Strouse J, Swee M, Lenert P, Suneja M. Hydralazine-associated vasculitis: Overlapping features of drug-induced lupus and vasculitis. Semin Arthritis Rheum 2018. [PMID: 29519741 DOI: 10.1016/j.semarthrit.2018.01.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Hydralazine is an antihypertensive medication that has been associated with drug-induced lupus erythematosus (DIL) as well as ANCA-associated vasculitis (AAV). Although rare, early diagnosis is critical since drug cessation is the mainstay of therapy. This retrospective study aims to characterize the clinical, laboratory, and histopathologic features of this disease. METHODS Once approval was obtained from the Institutional Review Board at the University of Iowa, all patients carrying a diagnosis of vasculitis (ICD9 code: 447.6 or ICD10 code: I77.6, I80, L95, M30, or M31) and positive ANCA lab results over the past 15 years were identified. Age, gender, comorbid conditions, medications taken over the prior 6 months, laboratory data, including electrolytes, urine studies and serologies, chest x-rays, CT scans, and pathologic biopsy records were abstracted from the electronic medical record. RESULTS 323 cases of AAV were identified, of which 12 were exposed to hydralazine, all at the time of diagnosis. The average duration of hydralazine therapy was 22 months and mean cumulative dose was 146g. Patients were typically older (70.3 years old) with slight female preponderance (7 females). Eleven patients presented with dyspnea, fatigue, and unintentional weight loss. Five had polyarthralgias and 8 had lower extremity petechiae. All 12 patients were both ANA and ANCA positive. ANA titers ranged from 1:160 and 1:2560. Ten were of diffuse pattern while 2 were nucleolar. ANCA titers ranged from 1:320 to 1:2560. Eleven had a pANCA pattern while one had cANCA. All 12 patients were positive for histone and 11 were positive for myeloperoxidase antibodies. Eleven also had dsDNA antibodies, and 4 had anti-cardiolipin IgG or IgM antibodies. Nine patients were also hypocomplementemic (mean C3 level: 88.4mg/dL; mean C4 level: 16.5mg/dL). All patients had variable levels of proteinuria (1+ to 3+) and eleven had active urine sediment. Urine protein:creatinine ratios ranged from 0.2 to 1.7. Of the 6 patients who underwent kidney biopsy, all 6 showed pauci-immune crescentic glomerulonephritis. Seven patients had bilateral pulmonary interstitial infiltrates and four had pleural effusions on CT scan. Four had pericardial effusions as demonstrated by echocardiography. CONCLUSIONS Hydralazine-associated vasculitis is a drug-associated autoimmune syndrome that presents with interstitial lung disease, hypocomplementemia, and pauci-immune glomerulonephritis. Patients have elements of both DIL and DIV, as manifested by high ANA and ANCA titers as well as the presence of histone and MPO antibodies. Further research is needed to understand the etiopathogenesis of this condition.
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Affiliation(s)
- Bharat Kumar
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242.
| | - Jennifer Strouse
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
| | - Melissa Swee
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
| | - Petar Lenert
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
| | - Manish Suneja
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
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21
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Ranugha PSS, Betkerur J. Antihypertensives in dermatology Part II - Cutaneous adverse reactions to antihypertensives. Indian J Dermatol Venereol Leprol 2018; 84:137-147. [DOI: 10.4103/ijdvl.ijdvl_992_16] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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22
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Bomback AS. An Elderly Man with Fatigue, Dyspnea, and Kidney Failure. Clin J Am Soc Nephrol 2017; 12:836-838. [PMID: 28274994 PMCID: PMC5477222 DOI: 10.2215/cjn.13311216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Andrew S Bomback
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York
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23
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Abstract
Drugs are associated frequently with the development of various types of acute and chronic kidney diseases. Nephrotoxicity is associated most commonly with injury in the tubulointerstitial compartment manifested as either acute tubular injury or acute interstitial nephritis. A growing number of reports has also highlighted the potential for drug-induced glomerular disease, including direct cellular injury and immune-mediated injury. Recognition of drug-induced nephropathies and rapid discontinuation of the offending agents are critical to maximizing the likelihood of renal function recovery. This review will focus on the pathology and pathogenesis of drug-induced acute interstitial nephritis and drug-induced glomerular diseases.
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Affiliation(s)
- Paisit Paueksakon
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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24
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Abstract
The three common themes that underlie the induction and perpetuation of autoimmunity are genetic predisposition, environmental factors, and immune regulation. Environmental factors have gained much attention for their role in triggering autoimmunity, with increasing evidence of their influence as demonstrated by epidemiological studies, laboratory research, and animal studies. Environmental factors known to trigger and perpetuate autoimmunity include infections, gut microbiota, as well as physical and environmental agents. To address these issues, we will review major potential mechanisms that underlie autoimmunity including molecular mimicry, epitope spreading, bystander activation, polyclonal activation of B and T cells, infections, and autoinflammatory activation of innate immunity. The association of the gut microbiota on autoimmunity will be particularly highlighted by their interaction with pharmaceutical agents that may lead to organ-specific autoimmunity. Nonetheless, and we will emphasize this point, the precise mechanism of environmental influence on disease pathogenesis remains elusive.
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Affiliation(s)
- Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy.
| | - Patrick S C Leung
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani, 2, 35128, Padova, Italy
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California Davis, Davis, CA, USA
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25
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Devarapu SK, Lorenz G, Kulkarni OP, Anders HJ, Mulay SR. Cellular and Molecular Mechanisms of Autoimmunity and Lupus Nephritis. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2017; 332:43-154. [PMID: 28526137 DOI: 10.1016/bs.ircmb.2016.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Autoimmunity involves immune responses directed against self, which are a result of defective self/foreign distinction of the immune system, leading to proliferation of self-reactive lymphocytes, and is characterized by systemic, as well as tissue-specific, inflammation. Numerous mechanisms operate to ensure the immune tolerance to self-antigens. However, monogenetic defects or genetic variants that weaken immune tolerance render susceptibility to the loss of immune tolerance, which is further triggered by environmental factors. In this review, we discuss the phenomenon of immune tolerance, genetic and environmental factors that influence the immune tolerance, factors that induce autoimmunity such as epigenetic and transcription factors, neutrophil extracellular trap formation, extracellular vesicles, ion channels, and lipid mediators, as well as costimulatory or coinhibitory molecules that contribute to an autoimmune response. Further, we discuss the cellular and molecular mechanisms of autoimmune tissue injury and inflammation during systemic lupus erythematosus and lupus nephritis.
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Affiliation(s)
- S K Devarapu
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - G Lorenz
- Klinikum rechts der Isar, Abteilung für Nephrologie, Technische Universität München, Munich, Germany
| | | | - H-J Anders
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - S R Mulay
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany.
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26
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Jarrot PA, Chiche L, Hervier B, Daniel L, Vuiblet V, Bardin N, Bertin D, Terrier B, Amoura Z, Andrés E, Rondeau E, Hamidou M, Pennaforte JL, Halfon P, Daugas E, Dussol B, Puéchal X, Kaplanski G, Jourde-Chiche N. Systemic Lupus Erythematosus and Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Overlap Syndrome in Patients With Biopsy-Proven Glomerulonephritis. Medicine (Baltimore) 2016; 95:e3748. [PMID: 27258503 PMCID: PMC4900711 DOI: 10.1097/md.0000000000003748] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The aim of the study was to report the clinical, biological, and pathological characteristics of patients with glomerulonephritis (GN) secondary to systemic lupus erythematosus (SLE)/antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) overlap syndrome.A nationwide survey was conducted to identify cases of SLE/AAV overlap syndrome. Data were collected from SLE and AAV French research groups. Inclusion criteria were diagnosis of both SLE and AAV according to international classification criteria and biopsy-proven GN between 1995 and 2014. Additional cases were identified through a systematic literature review. A cohort of consecutive biopsy-proven GN was used to study the prevalence of overlapping antibodies and/or overlap syndrome.The national survey identified 8 cases of SLE/AAV overlap syndrome. All patients were female; median age was 40 years. AAV occurred before SLE (n = 3), after (n = 3), or concomitantly (n = 2). Six patients had rapidly progressive GN and 3/8 had alveolar hemorrhage. All patients had antinuclear antibodies (ANA); 7/8 had p-ANCA antimyeloperoxidase (MPO) antibodies. Renal biopsies showed lupus nephritis (LN) or pauci-immune GN. Remission was obtained in 4/8 patients. A literature review identified 31 additional cases with a similarly severe presentation. In the GN cohort, ANCA positivity was found in 30% of LN, ANA positivity in 52% of pauci-immune GN, with no correlation with pathological findings. The estimated prevalence for SLE/AAV overlap syndrome was 2/101 (2%).In patients with GN, SLE/AAV overlap syndrome may occur but with a low prevalence. Most patients have an aggressive renal presentation, with usually both ANA and anti-MPO antibodies. Further studies are needed to assess shared pathogenesis and therapeutic options.
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Affiliation(s)
- Pierre-Andre Jarrot
- From the Department of Internal Medicine and Clinical Immunology (PAJ, GK), AP-HM Hôpital de La Conception; Inserm UMR-S 1076 Vascular Research Center of Marseille (PAJ, GK, NJ-C), Aix-Marseille Université; Department of Internal Medicine (LC, PH), Hôpital Européen de Marseille, Marseille; Reference Center for Systemic Lupus Erythematosus (BH, ZA), Department of Internal Medicine, AP-HP Hôpital Pitie-Salpêtrière, Paris; Department of Pathology (LD), AP-HM Hôpital de La Timone, Aix-Marseille Université; Department of Pathology (VV), Paul Bouin Laboratory, Reims, France; Laboratory of Immunology (NB, DB), AP-HM Hôpital de la Conception, Aix-Marseille Université, Marseille; French Vasculitis Study Group (BT, XP), Department of Internal Medicine, National Reference Center for Necrotizing Vasculitis, AP-HP Hôpital Cochin, University Paris-Descartes; Department of Internal Medicine (EA), Hôpital Civil, Strasbourg; Department of Nephrology (ER), AP-HP Hôpital Tenon, Paris; Department of Internal Medicine (MH), Hôpital Hôtel-Dieu, Nantes; Department of Internal Medicine (J-LP), Hôpital Robert Debré, Reims Université, Reims; Groupe Coopératif sur le Lupus Rénal (ED), Department of Nephrology, AP-HP Hôpital Bichat, Paris; and Department of Nephrology (BD, NJ-C), AP-HM Hôpital Conception, Aix-Marseille Université, Marseille, France
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27
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Grau RG. Drug-Induced Vasculitis: New Insights and a Changing Lineup of Suspects. Curr Rheumatol Rep 2015; 17:71. [DOI: 10.1007/s11926-015-0545-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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28
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Dharmarajan TS, Dharmarajan L. Tolerability of Antihypertensive Medications in Older Adults. Drugs Aging 2015; 32:773-96. [DOI: 10.1007/s40266-015-0296-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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29
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Hogan JJ, Markowitz GS, Radhakrishnan J. Drug-induced glomerular disease: immune-mediated injury. Clin J Am Soc Nephrol 2015; 10:1300-10. [PMID: 26092827 DOI: 10.2215/cjn.01910215] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Jonathan J Hogan
- Department of Medicine, Division of Nephrology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | | | - Jai Radhakrishnan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
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30
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Spinasse LB, Santos AR, Suffys PN, Muxfeldt ES, Salles GF. Different phenotypes of the NAT2 gene influences hydralazine antihypertensive response in patients with resistant hypertension. Pharmacogenomics 2015; 15:169-78. [PMID: 24444407 DOI: 10.2217/pgs.13.202] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Hydralazine, a vasodilator used in resistant hypertension (RH) treatment is metabolized by an acetylation reaction mediated by N-acetyltransferase 2, the activity of which depends on NAT2 polymorphisms. Our aim was to evaluate whether different acetylation phenotypes influenced the antihypertensive effect of hydralazine in patients with RH. PATIENTS & METHODS DNA samples from 169 RH patients using hydralazine were genotyped by sequencing the NAT2 coding region, and acetylation phenotypes were defined. RESULTS Sixty-five patients (38.5%) were intermediate, 60 (35.5%) slow and 21 (12.4%) fast acetylators. Twenty-three (13.6%) patients were indeterminate. Upon association analysis, only slow acetylators had significant blood pressure reductions after hydralazine use, with mean 24-h systolic and diastolic blood pressure reductions of 9.2 and 5.5 mmHg. Four patients presented hydralazine adverse effects resulting in drug withdrawal, three of them were slow acetylators. CONCLUSION The slow acetylation phenotype, determined by polymorphisms within NAT2, influenced both the antihypertensive and adverse effects of hydralazine in RH.
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Affiliation(s)
- Lizania Borges Spinasse
- Laboratory of Molecular Biology Applied to Mycobacteria - Oswaldo Cruz Institute - Fiocruz, Av. Brazil 4365, CEP: 21040-360, Manguinhos, Rio de Janeiro, Brazil
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31
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Alvarado Cárdenas M, Marín Sánchez A, Lima Ruiz J. [Statins and autoimmunity]. Med Clin (Barc) 2015; 145:399-403. [PMID: 25662717 DOI: 10.1016/j.medcli.2014.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 11/27/2014] [Indexed: 02/05/2023]
Abstract
Statins are the most widely used drugs for both primary and secondary prevention of cardiovascular diseases and those associated with atherosclerosis. About 25 million people are on statin therapy in the world. Although they are well tolerated by most patients and have a safety profile, some patients have muscle level alterations. The biological effects associated with these drugs are known as pleiotropic; they are of such interest and diversity that explains, in part, some of the actions of statins, especially in relation to inflammation and the immune system. Some patients have certain immune disorders that can turn into an undesirable clinical expression. Recent studies have shown that they can trigger autoimmune phenomena. Pathologies have been described in which these agents act as triggers such as immune-mediated necrotizing myopathy or indirectly in dermatomyositis or autoimmune hepatitis, among others. Given the high number of people being treated with statins, we believe that this is a clinically relevant problem and therefore worthy of study.
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Affiliation(s)
| | | | - Joan Lima Ruiz
- Servicio de Medicina Interna, Hospital Vall d'Hebron, Barcelona, España
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32
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Trojan horses: drug culprits associated with antineutrophil cytoplasmic autoantibody (ANCA) vasculitis. Curr Opin Rheumatol 2014; 26:42-9. [PMID: 24276086 DOI: 10.1097/bor.0000000000000014] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antineutrophil cytoplasmic autoantibody (ANCA) vasculitis is a systemic autoimmune disease resulting in small-vessel inflammation caused by pathogenic autoantibodies directed against proteinase 3 or myeloperoxidase. Legal drug culprits have been implicated as causative agents in secondary forms of disease, and a recent burst of reports also implicate levamisole-adulterated cocaine as a culprit. RECENT FINDINGS Here, we briefly discuss all drug culprits associated with ANCA vasculitis and then focus on clinical, serologic, therapeutic and mechanistic aspects of four main drug culprits receiving attention of late, namely hydralazine, minocycline, propylthiouracil (PTU) and levamisole-adulterated cocaine. SUMMARY Hydralazine, minocycline, propylthiouracil and levamisole-adulterated cocaine use should be closely considered in any patient where ANCA vasculitis is entertained given the wide use of these drugs in the community. Furthermore, medical practitioners should test urine for the presence of cocaine in any patient with presumed ANCA vasculitis, and if positive, then urine should also be tested for levamisole. Clinical features can be severe requiring not only drug cessation and supportive care, but also immunosuppression, plasma exchange in severe cases and dialysis as needed. Clinical trial investigators should strongly consider excluding patients with drug-induced forms of disease and mechanistic inroads are greatly needed in these secondary forms of disease to help elucidate the underlying cause and pathogenesis of ANCA vasculitis.
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33
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Xiao X, Chang C. Diagnosis and classification of drug-induced autoimmunity (DIA). J Autoimmun 2014; 48-49:66-72. [PMID: 24456934 DOI: 10.1016/j.jaut.2014.01.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 11/13/2013] [Indexed: 12/17/2022]
Abstract
Since sulfadiazine associated lupus-like symptoms were first described in 1945, certain drugs have been reported to interfere with the immune system and induce a series of autoimmune diseases (named drug-induced autoimmunity, DIA), exemplified by systemic lupus erythematosus (SLE). Among the drugs, procainamide and hydralazine are considered to be associated with the highest risk for developing lupus, while quinidine has a moderate risk, and all other drugs have low or very low risk. More recently, drug-induced lupus has been associated with the use of newer biological modulators, such as tumor necrosis factor (TNF)-alpha inhibitors and cytokines. In addition to lupus, other major autoimmune diseases, including vasculitis and arthritis, have also been associated with drugs. Because resolution of symptoms generally occurs after cessation of the offending drugs, early diagnosis is crucial for treatment strategy and improvement of prognosis. Unfortunately, it is difficult to establish standardized criteria for DIA diagnosis. Diagnosis of DIA requires identification of a temporal relationship between drug administration and the onset of symptoms, but the relative risk with respect to dose and duration for each drug has rarely been determined. DIA is affected by multiple genetic and environmental factors, leading to difficulties in establishing a list of global clinical features that are characteristic of most or all DIA patients. Moreover, the distinction between authentic DIA and unmasking of a latent autoimmune disease also poses challenges. In this review, we summarize the highly variable clinical features and laboratory findings of DIA, with an emphasis on the diagnostic criteria.
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Affiliation(s)
- Xiao Xiao
- Shanghai Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Institute of Digestive Disease, 145 Shandong Middle Road, Shanghai 200001, China
| | - Christopher Chang
- Division of Allergy, Asthma and Immunology, Thomas Jefferson University, Wilmington, DE 19803, USA.
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34
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Barrett CMF, Troxell ML, Larsen CP, Houghton DC. Membranous glomerulonephritis with crescents. Int Urol Nephrol 2013; 46:963-71. [PMID: 24217802 DOI: 10.1007/s11255-013-0593-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 10/22/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE The coexistence of membranous glomerulonephritis (MGN) and necrotizing and crescentic glomerulonephritis (NCGN) is an unusual finding in a renal biopsy except in lupus nephritis. Little is known about whether these lesions are causally related in any clinical setting. METHODS We reviewed the pathology, presentation, and clinical course of 13 non-lupus patients with combined MGN and NCGN in native kidney biopsies (nine females, four males; median age 69 years), with particular attention to evidence of secondary MGN. Additional IgG subclass and phospholipase A2 receptor (PLA2R) immunofluorescence studies were conducted in seven cases. RESULTS Eight biopsies were pauci-immune other than the capillary wall deposits of MGN; one patient had a non-lupus immune complex disease, and four had mesangial deposits, including one with rare subendothelial deposits. None had anti-glomerular basement membrane disease. IgG4 was dominant or codominant in the capillary wall deposits in three cases and virtually absent in four; PLA2R was positive in two cases, and negative in five. Seven patients were judged to have secondary MGN, including five of eight ANCA+ patients. Twelve patients were treated with combinations of steroids, cyclophosphamide, rituximab, followed by durable response in seven and relentless progression to end stage renal disease in four. CONCLUSIONS Secondary MGN occurs with higher frequency in ANCA-positive NCGN than in the general MGN population. A causal relationship between MGN and NCGN was not established in any patient, but circumstances suggest a common cause in several, including immune complex disease, drug reaction and paraneoplastic syndrome.
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Affiliation(s)
- Caroline M F Barrett
- Department of Pathology, Oregon Health and Science University, L471, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
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Keasberry J, Frazier J, Isbel NM, Van Eps CL, Oliver K, Mudge DW. Hydralazine-induced anti-neutrophil cytoplasmic antibody-positive renal vasculitis presenting with a vasculitic syndrome, acute nephritis and a puzzling skin rash: a case report. J Med Case Rep 2013; 7:20. [PMID: 23316942 PMCID: PMC3565908 DOI: 10.1186/1752-1947-7-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 12/04/2012] [Indexed: 11/10/2022] Open
Abstract
Introduction Anti-neutrophil cytoplasmic antibody-associated vasculitis has been associated with many drugs and it is a relatively rare side effect of the antihypertensive drug hydralazine. The diagnosis and management of patients who have anti-neutrophil cytoplasmic antibody-associated vasculitis may be challenging because of its relative infrequency, variability of clinical expression and changing nomenclature. The spectrum of anti-neutrophil cytoplasmic antibody-associated vasculitis is wide and can be fatal. This case documents a 62-year-old woman who presented with hydralazine-induced anti-neutrophil cytoplasmic antibody-positive renal vasculitis with a puzzling cutaneous rash. Case presentation We report a rare case of hydralazine-induced anti-neutrophil cytoplasmic antibody-associated vasculitis in a 62-year-old Caucasian woman who presented with a vasculitic syndrome with a sore throat, mouth ulcers and otalgia after several months of constitutional symptoms. She then proceeded to develop a rash over her right lower limb. Clinically, the rash had features to suggest Sweet’s syndrome, but also had some appearances consistent with embolic phenomena and did not have the appearance of palpable purpure usually associated with cutaneous vasculitis. Differential diagnoses were hydralazine-associated Sweet’s syndrome, streptococcal-induced cutaneous eruption or an unrelated contact dermatitis. A midstream urine sample detected glomerular blood cells in the setting of anti-neutrophil cytoplasmic antibody-positive renal vasculitis and Streptococcus pyogenes bacteremia. A renal biopsy revealed a pauci-immune, focally necrotizing glomerulonephritis with small crescents. Her skin biopsy revealed a heavy neutrophil infiltrate involving the full thickness of the dermis with no evidence of a leucocytoclastic vasculitis, but was non-specific. She was initially commenced on intravenous lincomycin for her bloodstream infection and subsequently commenced on immunosuppression after cessation of hydralazine. The patient was subsequently discharged from hospital after a rapid clinical improvement. Conclusion Hydralazine-induced anti-neutrophil cytoplasmic antibody-positive renal vasculitis is a rare adverse effect and can present with a severe vasculitic syndrome with multiple organ involvement. Features of this association include the presence of high titres of anti-myeloperoxidase-anti-neutrophil cytoplasmic antibody with multi-antigenicity, positive anti-histone antibodies and the lack of immunoglobulin and complement deposition histopathogically. A rash that is characteristic of Sweet’s syndrome has also been described as an association. Prompt cessation of hydralazine may be sufficient to reverse disease activity but immunosuppression may be needed for definite treatment.
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Affiliation(s)
- Justin Keasberry
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia.
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Abstract
Drug-induced lupus erythematosus differs in its manifestation from drug-induced vasculitis. The former is associated with characteristic symptoms that improve following discontinuation, whereas the latter is predominantly an antineutrophil cytoplasmic antibody (ANCA) positive small vessel vasculitis involving the kidneys, skin, and lungs. We present a case of advanced disease in an elderly Caucasian woman requiring corticosteroids, and immunosuppressive therapy, who was on hydralazine for >2 years.
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Chang C, Gershwin ME. Drug-induced lupus erythematosus: incidence, management and prevention. Drug Saf 2011; 34:357-74. [PMID: 21513360 DOI: 10.2165/11588500-000000000-00000] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The generation of autoantibodies and autoimmune diseases such as systemic lupus erythematosus has been associated with the use of certain drugs in humans. Early reports suggested that procainamide and hydralazine were associated with the highest risk of developing lupus, quinidine with a moderate risk and all other drugs were considered low or very low risk. More recently, drug-induced lupus has been associated with the use of the newer biological modulators such as tumour necrosis factor (TNF)-α inhibitors and interferons. The clinical features and laboratory findings of TNFα inhibitor-induced lupus are different from that of traditional drug-induced lupus or idiopathic lupus, and standardized criteria for the diagnosis of drug-induced lupus have not been established. The mechanism(s) responsible for the development of drug-induced lupus may vary depending on the drug or even on the patient. Besides lupus, other autoimmune diseases have been associated with drugs or toxins. Diagnosis of drug-induced lupus requires identification of a temporal relationship between drug administration and symptom development, and in traditional drug-induced lupus there must be no pre-existing lupus. Resolution of symptoms generally occurs after cessation of the drug. In this review, we will discuss those drugs that are more commonly associated with drug-induced lupus, with an emphasis on the new biologicals and the difficulty of making the diagnosis of drug-induced lupus against a backdrop of the autoimmune diseases that these drugs are used to treat. Stimulation of the immune system by these drugs to cause autoimmunity may in fact be associated with an increased effectiveness in treating the pathology for which they are prescribed, leading to the dilemma of deciding which is worse, the original disease or the adverse effect of the drug. Optimistically, one must hope that ongoing research in drug development and in pharmacogenetics will help to treat patients with the maximum effectiveness while minimizing side effects. Vigilance and early diagnosis are critical. The purpose of this review is to summarize the most recent developments in our understanding of the incidence, pathogenesis, diagnosis and treatment of drug-induced lupus.
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Affiliation(s)
- Christopher Chang
- Division of Allergy, Asthma and Immunology, Nemours A.I. Dupont Childrens Hospital, Thomas Jefferson University, Wilmington, Delaware, USA
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