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Kannan L, Syeda U. Overlapping Syndromes: Drug-Induced Vasculitis From Hydralazine With Positive Antinuclear Antibodies. Clin Med Insights Case Rep 2023; 16:11795476221146906. [PMID: 36643285 PMCID: PMC9837267 DOI: 10.1177/11795476221146906] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/05/2022] [Indexed: 01/12/2023] Open
Abstract
Hydralazine is an antihypertensive medication that has been associated with drug-associated autoimmune syndromes like interstitial lung disease, pauci-immune glomerulonephritis, and hypocomplementemia. Hydralazine-induced ANCA-associated vasculitis and hydralazine induced positive antinuclear antibodies are rare. Clinical manifestations range from arthralgia, petechiae, or rash to multiorgan involvement. When presented as pulmonary-renal syndrome, it can be rapidly progressive and fatal. Here, we describe a case of hydralazine-associated vasculitis with rapidly progressive glomerulonephritis and highlight the importance of early diagnosis and prompt treatment.
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Affiliation(s)
- Lakshmi Kannan
- Lakshmi Kannan, Department of Internal Medicine, Division of Nephrology, Pikeville Medical Center, Pikeville, KY 41501, USA.
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2
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Khosla AA, Saunders H, Helgeson S, Hikida H, Aslam N, Salem F, Albadri S, Baig H. The Utility of Bronchoscopy in Hydralazine-Induced ANCA-Associated Vasculitis. Case Rep Pulmonol 2023; 2023:1461011. [PMID: 37095760 PMCID: PMC10122576 DOI: 10.1155/2023/1461011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 04/26/2023] Open
Abstract
Hydralazine is a vasodilator used for the management of hypertension, heart failure, and hypertensive emergencies in pregnancy. It has been implicated in the causation of drug-induced lupus erythematosus (DLE) and rarely with ANCA-associated vasculitis (AAV), which may present as a pulmonary-renal syndrome and be rapidly fatal. Herein, we describe a case of hydralazine-associated AAV presenting as acute kidney injury with the use of early bronchoalveolar lavage (BAL) with serial aliquots to aid with diagnosis. Our case highlights how, in the correct clinical setting, BAL can act as a rapid diagnostic test to help guide quicker treatment to allow for better patient outcomes.
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Affiliation(s)
| | | | | | | | - Nabeel Aslam
- Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Fadi Salem
- Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Sam Albadri
- Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Hassan Baig
- Mayo Clinic Florida, Jacksonville, FL 32224, USA
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Abstract
PURPOSE OF REVIEW Drug-induced vasculitis (DIV) is a rare form of vasculitis related to the use of various drugs. DIV primarily affects small to medium size vessels, but it can potentially involve vessels of any size. Differentiating between primary systemic vasculitis and DIV can be challenging; however, it is crucial, so that the offending agent can be discontinued promptly. RECENT FINDINGS The clinical phenotype of DIV is protean and depends on the size of the affected vessels. It ranges from arthralgias, to an isolated cutaneous rash, to severe single or multi-organ involvement. While withdrawal of the offending drug is the most important step in management, a significant number of patients require immunosuppressive therapy for varying periods of time. DIV can affect any vascular bed size, leading to protean vasculitic syndromes. Increased awareness among general practitioners, specialty, and subspecialty physicians is crucial for early recognition, and withdrawal of drug for better outcomes.
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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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Dias CB, Jorge LB, Woronik V, Cavalcante LB, Yu L. IgA nephropathy in patients with serum anti-neutrophil cytoplasmic autoantibody (ANCA) positivity: case series. ACTA ACUST UNITED AC 2021; 44:42-47. [PMID: 34289006 PMCID: PMC8943862 DOI: 10.1590/2175-8239-jbn-2021-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/06/2021] [Indexed: 01/11/2023]
Abstract
Some cases of patients with IgA nephropathy diagnosed via kidney biopsy and antineutrophil cytoplasmic antibody (ANCA) positivity have been reported. This article describes a case series comprising patients with IgA nephropathy and ANCA positivity seen at a medical center in the city of São Paulo, Brazil, from 1996 to 2016. A total of 111 patients underwent diagnostic kidney biopsies for IgA nephropathy. Five were ANCA-positive at the time of diagnosis; their mean age was 45 ± 15.3 years and they were predominantly females with a mean proteinuria of 2.2 ± 0.9 g/day and a median serum creatinine level of 2.5 (2.0 - 8,6) mg/dL; all had hematuria. Four of the five were cANCA-positive (80%); all had normal serum C3 and C4 levels; and 80% were positive for ANA. One case presented an association with infection, but no associations were found with medication. One patient had granuloma and another had a collapsing lesion. This article describes the cases of five ANCA-positive patients (with predominantly cANCA positivity) submitted to diagnostic kidney biopsies for IgA nephropathy; one patient had a collapsing lesion, but progressed well.
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Affiliation(s)
- Cristiane Bitencourt Dias
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Fisiologia Renal, São Paulo, SP, Brasil
| | - Lectícia Barbosa Jorge
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Nefrologia, São Paulo, SP, Brasil
| | - Viktoria Woronik
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Fisiologia Renal, São Paulo, SP, Brasil
| | - Lívia Barreira Cavalcante
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Patologia, São Paulo, SP, Brasil
| | - Luis Yu
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Nefrologia, São Paulo, SP, Brasil
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Tu W, Fayman B, Ward SC, Mamoon Y, Bandagi SS. Hydralazine-Induced Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Asymptomatic and Renal-Restricted Presentation. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e931263. [PMID: 33993184 PMCID: PMC8141334 DOI: 10.12659/ajcr.931263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Patient: Female, 66-year-old Final Diagnosis: Hydralazine induced ANCA-associated vasculitis Symptoms: Asymptomatic Medication:— Clinical Procedure: — Specialty: Nephrology • Rheumatology
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Affiliation(s)
- Wan Tu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York City, NY, USA
| | - Barry Fayman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York City, NY, USA
| | - Stephen C Ward
- Department of Pathology and Laboratory Medicine, Icahn School of Medicine, The Mount Sinai Hospital, New York City, NY, USA
| | - Yusufal Mamoon
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York City, NY, USA
| | - Sabiha S Bandagi
- Department of Rheumatology, Icahn School of Medicine at Mount Sinai, Queens Hospital Center, New York City, NY, USA
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Tiong BK, Singh AS, Sarantopoulos GP, Kermani TA. Kaposi sarcoma in anti-neutrophil cytoplasmic antibody-associated vasculitis: a case-based review. Rheumatol Int 2021; 41:1357-1367. [PMID: 33620515 PMCID: PMC8164621 DOI: 10.1007/s00296-021-04810-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/06/2021] [Indexed: 12/19/2022]
Abstract
Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) are systemic necrotizing vasculitides associated with significant morbidity and mortality. Given the immunosuppression used to manage these conditions, it is important for clinicians to recognize complications, especially infectious ones, which may arise during treatment. Kaposi sarcoma (KS) is a lymphoangioproliferative neoplasm caused by human herpes virus 8 (HHV-8). Its cutaneous manifestations can mimic vasculitis. We describe a 77-year-old man with microscopic polyangiitis with pulmonary-renal syndrome treated with prednisone and intravenous cyclophosphamide who developed KS (HHV-8 positive) after 2 months of treatment. Cyclophosphamide was discontinued and prednisone gradually lowered with improvement and clinical stabilization of KS lesions. This comprehensive review includes all published cases of KS in patients with AAV, with a goal to summarize potential risk factors including the clinical characteristics of vasculitis, treatment and outcomes of patients with this rare complication of immunosuppressive therapy. We also expanded our literature review to KS in other forms of systemic vasculitis. Our case-based review emphasizes the importance of considering infectious complications of immunosuppressive therapy, especially glucocorticoids, and highlights the rare association of KS in systemic vasculitis.
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Affiliation(s)
- Benedict K Tiong
- Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA, 90404, USA.
| | - Arun S Singh
- Division of Hematology and Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - G Peter Sarantopoulos
- Department of Pathology and Laboratory Medicine, UCLA Medical Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Tanaz A Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California, Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA, 90404, USA
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Doughem K, Battisha A, Sheikh O, Konduru L, Madoukh B, Al-Sadawi M, Shaikh S. Hydralazine-Induced ANCA Associated Vasculitis (AAV) Presenting with Pulmonary-Renal Syndrome (PRS): A Case Report with Literature Review. Curr Cardiol Rev 2021; 17:182-187. [PMID: 32418528 PMCID: PMC8226194 DOI: 10.2174/1573403x16666200518092814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/29/2020] [Accepted: 03/23/2020] [Indexed: 01/26/2023] Open
Abstract
Hydralazine, an arterial vasodilator, is a widely used medication for the management of hypertension and heart failure, especially for patients who cannot tolerate the use of ACEIs or ARBs. It is generally well-tolerated and has a safe profile in pregnancy. However, hydralazine can induce immune-mediated side effects, such as hydralazine-induced lupus and less commonly hydralazine- induced ANCA vasculitis. The latter most commonly affects the kidneys with or without other organ involvement. There are several cases reported in the literature of hydralazine-induced ANCA associated vasculitis (AAV) that have pulmonary manifestations, also known as hydralazine- induced pulmonary-renal syndrome (PRS), a condition with a high risk of mortality. We are reporting a case of Hydralazine-induced ANCA associated glomerulonephritis with severe diffuse alveolar hemorrhage (DAH). In addition, we will review the current literature and discuss the importance of prompt diagnosis and early management to decrease mortality and morbidity associated with this serious condition.
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Affiliation(s)
- Karim Doughem
- Address correspondence to this author at University of Texas Health Science Center at Houston, Houston, TX 77030, United States; E-mail:
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Al-Abdouh A, Siyal AM, Seid H, Bekele A, Garcia P. Hydralazine-induced antineutrophil cytoplasmic antibody-associated vasculitis with pulmonary-renal syndrome: a case report. J Med Case Rep 2020; 14:47. [PMID: 32290867 PMCID: PMC7158156 DOI: 10.1186/s13256-020-02378-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 03/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background Hydralazine is a common vasodilator which has been used for the treatment of hypertension and heart failure. Hydralazine can induce antineutrophil cytoplasmic antibody-associated vasculitis due to its auto-immunogenic capability and one of the very rare presentations is pulmonary–renal syndrome. Case presentation We report a case of a 64-year-old African American woman, who presented to our emergency room with shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, leg swelling, fatigue, loss of appetite, cough with clear sputum, and lightheadedness. On admission, she developed acute hypoxic respiratory failure requiring intubation and acute renal failure requiring hemodialysis. A serologic workup was positive for antineutrophil cytoplasmic antibody, antinuclear antibody, anti-histone, anti-cardiolipin IgM, and anti-double-stranded DNA antibodies. A renal biopsy was done due to persistent deterioration in kidney function and demonstrated classic crescentic (pauci-immune) glomerulonephritis. Hydralazine was empirically discontinued early in the admission and she was started on corticosteroids and cyclophosphamide following biopsy results. She was clinically stable but remained dependent on hemodialysis after discharge. Conclusion Hydralazine-induced antineutrophil cytoplasmic antibody-associated vasculitis with pulmonary–renal syndrome is a rare occurrence. In the setting of hydralazine use, multiple positive antigens, and multisystem involvement, clinicians should consider this rare condition requiring prompt cessation of offending drug, early evaluation with biopsy, and contemplate empiric immunosuppressive therapy while biopsy confirmation is pending.
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Affiliation(s)
- Ahmad Al-Abdouh
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD, 21229, USA.
| | | | - Hanan Seid
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD, 21229, USA
| | - Ammer Bekele
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD, 21229, USA
| | - Pablo Garcia
- Section of Critical Care, Department of Medicine, Saint Agnes Hospital, Baltimore, MD, USA
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Ford JA, Monach PA. Disease heterogeneity in antineutrophil cytoplasmic antibody-associated vasculitis: implications for therapeutic approaches. THE LANCET. RHEUMATOLOGY 2019; 1:e247-e256. [PMID: 38229381 DOI: 10.1016/s2665-9913(19)30077-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/20/2019] [Accepted: 10/02/2019] [Indexed: 01/18/2024]
Abstract
In recent decades, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis has transformed from an almost uniformly fatal disease to a treatable form of primary systemic vasculitis. Substantial disease heterogeneity exists within ANCA-associated vasculitis and the increasing understanding of this heterogeneity has implications for guiding treatment decisions. Approaches to induction and maintenance therapy vary depending on disease severity, clinical manifestations, and patient-specific factors. In this narrative Review, we examine how disease heterogeneity in ANCA-associated vasculitis, with respect to disease severity, clinical presentations, and ANCA specificity, influences therapeutic decision making. Many questions regarding therapeutic strategies in ANCA-associated vasculitis remain unanswered, and these should guide future research in this complex group of diseases.
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Affiliation(s)
- Julia A Ford
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Paul A Monach
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Veterans Affairs Boston Healthcare System, Boston, MA, USA
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Timlin H, Wu M, Crespo-Bosque M, Geetha D, Ingolia A, Haque U, Towns MC, Grader-Beck T. Clinical Characteristics of Hydralazine-induced Lupus. Cureus 2019; 11:e4996. [PMID: 31497427 PMCID: PMC6707822 DOI: 10.7759/cureus.4996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 06/25/2019] [Indexed: 12/23/2022] Open
Abstract
Introduction The use of hydralazine has been associated with the development of lupus erythematosus and lupus-like syndromes. We performed this retrospective study to identify clinical characteristics of individuals who developed hydralazine-induced lupus. Material and methods We performed a single-center retrospective review of seven individuals who had a diagnosis of hydralazine-induced lupus by International Classification of Diseases, Ninth Revision (ICD9) code and were on hydralazine prior to their diagnosis. Clinical and laboratory data were obtained from a review of the medical record up to 12-month follow-up. Results Of the seven individuals with hydralazine-induced lupus, five were Caucasian (71%) and two were African-American. The mean age at the time of diagnosis was 62 years. Four (57%) were male. The majority of individuals were exposed to hydralazine for more than 12 months (83%). Four individuals had biopsy-proven lupus nephritis and four individuals had cardiopulmonary and skin involvement. Six patients were positive for antinuclear antibody (ANA) with a homogenous pattern, and five of those were positive for anti-histone antibody. Additionally, positive anti-double-stranded DNA (anti-dsDNA) antibody, anti-cardiolipin antibodies, low complements, positive lupus anticoagulant, and leukopenia were seen in 42% of our cohort. Of the five individuals in whom anti-myeloperoxidase (MPO) antibody was strongly positive, all had renal involvement defined by an elevated creatinine with three having biopsy-proven lupus nephritis. Three other individuals with MPO positivity had concurrent cardiopulmonary and skin involvement. Four individuals were positive for anti-proteinase 3 (PR3) antibody, three of whom were strongly positive with renal involvement defined by an elevated creatinine with two having biopsy-proven lupus nephritis. The level of anti-dsDNA antibody and anti-PR3 antibody normalized at three months while anti-MPO antibody took 12 months to normalize following cessation of hydralazine. When checked, low complement component 3 (C3) and anti-histone antibody persisted past 12 months. In addition to the withdrawal of hydralazine, six individuals were treated with hydroxychloroquine and five with mycophenolate mofetil. Three of four individuals with renal involvement received plasmapheresis and two received cyclophosphamide and hemodialysis. Conclusion Hydralazine can aggravate and unmask incipient lupus. Since the presentation can be varied, early recognition of symptoms is critical. Precautions should be taken before initiating this medication in individuals with certain risk factors. Once diagnosed, potential serological findings such as a positive anti-MPO/anti-PR3 antibody could predict more severe manifestations such as pulmonary-renal complications.
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Affiliation(s)
- Homa Timlin
- Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Michael Wu
- Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Duvuru Geetha
- Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ashley Ingolia
- Internal Medicine, North Oaks Health System, Hammond, USA
| | - Uzma Haque
- Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Marilyn C Towns
- Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Thomas Grader-Beck
- Rheumatology, The Johns Hopkins University School of Medicine, Baltimore, USA
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Baradhi KM. An intriguing case of anemia and renal failure. Proc (Bayl Univ Med Cent) 2019; 32:78-79. [DOI: 10.1080/08998280.2018.1540824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/21/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022] Open
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