Hydralazine-induced lupus syndrome presenting with large pericardial effusion

When Chest Pain Reveals More: A Case of Hydrochlorothiazide-Induced Systemic Lupus Erythematosus

BACKGROUND Drug induced lupus erythematosus is considered an autoimmune entity which is precipitated by medications. Hydrochlorothiazide has been recognized to cause subacute cutaneous lupus erythematosus, but very few cases of systemic drug induced lupus systemic erythematosus have been reported. CASE REPORT A 57-year-old Caucasian male with a past medical history of hypertension and hyperlipidemia presented with recurrent fevers, chest pain, and dyspnea. Initial evaluation revealed diffuse ST elevations, small pericardial effusion, anemia, and leukopenia. He was initially treated with nonsteroidal anti-inflammatory drugs and prednisone for pericarditis. Six months later, he reported fatigue, arthralgias, morning stiffness, weight loss, fevers, and night sweats. Laboratory tests revealed persistent anemia and leukopenia. Extensive workup, including bone marrow biopsy and infectious evaluations, was negative. Autoimmune workup, however, revealed positive antihistone and antichromatin antibodies despite negative antinuclear antibody. A diagnosis of drug induced lupus secondary to hydrochlorothiazide was made. The medication was stopped, and prednisone was initiated resulting in marked improvement in his symptoms and hematologic abnormalities. CONCLUSIONS This report is one of the few known cases of systemic lupus erythematosus most likely induced by hydrochlorothiazide. Based on our finding, hydrochlorothiazide should be considered a possible offending agent when a patient presents with symptoms suspicious of drug induced lupus.

Antinuclear antibody-negative lupus? An ominous presentation of hydralazine-induced lupus syndrome

Up to 10% of systemic lupus erythematosus (SLE) cases are drug-induced; hence, they are called drug-induced lupus syndrome (DILS). Antinuclear antibody (ANA) should be present to diagnose SLE and DILS. ANA-negative lupus is very rare; therefore, it presents a diagnostic challenge. In the medical literature, two cases of ANA-negative hydralazine-induced lupus syndrome (HILS) have been described within the last year. Here, we present the third such case of HILS with negative ANA serology in a patient who developed considerable pericardial effusion. The association between ANA-negative HILS and pericardial effusion warrants future research.

ANA-Negative Hydralazine-Induced Pericardial Effusion

This case describes a patient with pericardial effusion as a phenomenon of the drug-induced lupus erythematosus (DILE) syndrome due to hydralazine. The relevance of this case report lies in the fact that although hydralazine has been a known causative agent of DILE, its presentation may involve a negative anti-nuclear antibody (ANA) study. Pericardial effusion is a documented adverse effect as a result of hydralazine use. It is typically common to screen for DILE with the serum ANA test prior to proceeding to more costly and specific tests (i.e., anti-histone antibody). As per our literature review, this is the second case of hydralazine causing DILE with a negative ANA. As in our case, although the screening serum ANA is the initial next best step for suspicion of DILE by hydralazine, it is important to consider the diagnosis without ANA positivity.

Hydralazine Induced Lupus Syndrome Presenting with Recurrent Pericardial Effusion and a Negative Antinuclear Antibody

Drug induced lupus erythematosus (DIL or DILE) is an autoimmune disorder caused by chronic use of certain drugs. We report a unique case of hydralazine induced lupus syndrome (HILS) with a negative antinuclear antibody in a female patient who was on hydralazine for a period of 1.5–2 years and developed recurrent pericardial effusion as a result of it. Initially her condition was managed with a pericardial window. The recurrence of a massive pericardial effusion necessitated a right hemipericardiectomy. After hydralazine was stopped, she never had any further episodes of pericardial effusion or tamponade.