Case report and review of minocycline-induced cutaneous polyarteritis nodosa

A Spotlight on Drug-Induced Vasculitis

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.

Remission of Angiographically Confirmed Minocycline-induced Renal Polyarteritis Nodosa: A Case Report and Literature Review

A 23-year-old man presented with severe hypertension. Based on his history of minocycline treatment for over three years and clinical symptoms, such as myalgias and renovascular hypertension with multiple intrarenal aneurysms, he was diagnosed with minocycline-induced renal polyarteritis nodosa (PAN). After minocycline treatment cessation and management of the hypertension, his blood pressure, renin-aldosterone levels, and urinary protein levels gradually improved. Seven and a half years later, repeated angiography found that the aneurysms had resolved. This is the first report in English describing a case of minocycline-induced renal PAN that was reversed functionally and morphologically without steroids or immunosuppressive drugs.

Localized Forms of Vasculitis

Purpose of Review

To provide an updated review on epidemiology, clinical manifestations, diagnostic assessment, treatment, and prognosis of localized vasculitis, following the 2012 Revised International Chapel Hill Consensus Conference Nomenclature on single-organ vasculitis.

Recent Findings

Localized, single-organ vasculitides encompass a group of rare conditions in which there is no evidence of concomitant systemic vasculitis. Most data on this topic derives from case reports and small case series. Although some aspects of these diseases, such as clinical manifestations and histologic findings, have already been extensively investigated, there is still a lack of robust data concerning the pathogenesis, epidemiology, and treatment.

Summary

Localized vasculitides may have a wide range of clinical features depending on the organ affected. The inflammatory process may have a multifocal/diffuse or unifocal distribution. Diagnosis is usually based on histopathology findings and exclusion of systemic vasculitis, which may frequently pose a challenge. Further research on treatment is warranted.

Contribution of HLA-DRB1 * 09: 01 allele to development of minocycline induced antineutrophil cytoplasmic antibody (ANCA)-associated cutaneous vasculitis: report of two cases

We report two cases of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) that developed after long-term oral administration of minocycline and consider the contribution of human leukocyte antigen (HLA)-DRB 1 * 09: 01 allele to its development. Case 1; A 47-year-old man receiving minocycline for palmoplantar pustulosis for 24 months developed fever, arthralgia, and irregular livedo on the bilateral lower legs. Skin biopsy demonstrated vasculitis, while a blood test showed positivity of myeloperoxidase (MPO)-ANCA. Discontinuation of minocycline and oral administration of prednisolone relieved the symptoms promptly. Case 2; A 53-year-old woman developed reddish-brown livedo reticularis with tenderness on the bilateral lower legs after administration of minocycline to treat palmoplantar pustulosis for 24 months. Although skin biopsy did not demonstrate vasculitis, a blood test showed MPO-ANCA positivity. Cessation of minocycline resulted in rapid improvement of the cutaneous lesions and constitutional symptoms. We diagnosed both cases as having Drug-associated ANCA-associated Vasculitis (DAV) caused by minocycline according to the diagnostic criteria proposed by Cluver et al. Further examination revealed the presence of HLA-DRB1 * 09:01 allele in both cases. This allele has been implicated in the genetic background of idiopathic microscopic polyangiitis (MPA) in the Japanese population. Our finding suggests a relationship between the development of MPO-ANCA or DAV caused by minocycline and HLA-DRB1 * 09:01 allele, but will have to confirmed by further studies with larger numbers of patients.

A Case of Diffuse Alveolar Hemorrhage Associated with High-Titer of MPO-ANCA Demonstrating Cytoplasmic Staining Pattern

Diffuse alveolar hemorrhage (DAH) is a life-threatening complication of ANCA-associated vasculitis (AAV) that requires urgent recognition and treatment. A presumptive diagnosis is often rendered without histopathology if concordant positivity of ANCA by indirect immunofluorescence (IIF) and ELISA assays, i.e., P-ANCA+/myeloperoxidase (MPO) Ab+ or C-ANCA+/proteinase-3 (PR3) Ab+, is documented in the context of pulmonary-renal syndrome or rapidly progressive glomerulonephritis. In this respect, the discordance between IIF and ELISA assays poses a diagnostic challenge in the absence of convincing histopathology and involves the risks of delaying the implementation of timely immunosuppressive therapy. Here, we report a 74-year-old woman who developed DAH and was found to have a high titer of MPO-ANCA exhibiting cytoplasmic staining on IIF, i.e., MPO-C-ANCA. The literature suggests that the availability of distinct epitopes on the MPO molecule dictates the perinuclear versus cytoplasmic staining pattern, which potentially explains the discordance between ELISA and IIF assays. Her DAH was controlled in association with seven sessions of plasmapheresis, methylprednisolone 1 gram daily for 3 days followed by 1 mg/kg/day, and rituximab. This case exemplifies the importance of consideration of pretest probability of suspected diagnosis that would realize a plausible interpretation of seemingly inconsistent serological profile and its effective incorporation into the diagnostic reasoning.

The color of skin: purple diseases of the skin, nails, and mucosa

The color purple can be seen in several types of eruptions including inflammatory dermatoses like lichen planus, infectious dermatoses like ecthyma gangrenosum, neoplasms like Kaposi sarcoma, and vasculitis and vasculopathy. The current review focuses on the clinical appearance, pathophysiology, and treatment of several vasculitides and vasculopathies including capillaritis, cutaneous small-vessel vasculitis, immunoglobulin A (IgA) vasculitis, cryoglobulinemia, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis, polyarteritis nodosum, warfarin-induced skin necrosis, heparin-induced thrombocytopenia, purpura fulminans, antiphospholipid antibody syndrome, calciphylaxis, levamisole-induced vasculopathy, and thrombotic thrombocytopenic purpura. Dermatologists play a central role in treating patients with cutaneous vasculitis and vasculopathy and may have the opportunity to facilitate identification of systemic disease by diagnosing cutaneous vasculitis and vasculopathy.

Cutaneous Polyarteritis Nodosa: Uncommon and Rare Form of Cutaneous Vasculitis

Cutaneous polyarteritis nodosa (CPAN) is a variant of polyarteritis nodosa that is limited primarily to the skin. It is a chronic recurrent disorder characterized by the presence of nodular lesions with or without ulceration on the distal third of the lower limbs. Nodular vasculitis and thrombophlebitis can be clinically or pathologically mistaken for CPAN. We present a case of a 51-year-old woman with painful nodules on the lower limbs. Some of the nodules were ulcerated. Histopathological examination of a nodule on deep incisional biopsy revealed fibrinoid necrosis of a medium-sized artery in the subcutis along with perivascular mixed infiltrate. The patient did not have any symptoms or signs of internal organ involvement. The possible etiological factor has not been detected. The patient was treated with oral prednisone 0.5 mg/kg/day and dapson 150 mg/day. Over the one-year follow-up the lesions showed regression, with one minimal relapse which resolved after the short course of oral prednisone.

A case report of granulomatous polyangiitis complicated by tuberculous lymphadenitis

RATIONAL

Granulomatous polyangiitis (GPA) is a type of vasculitis involving medium and small arteries, typically affecting the upper and lower respiratory tract with coexisting glomerulonephritis. GPA is also characterized by necrotizing granulomatous inflammation and the presence of antineutrophil cytoplasm antibodies (ANCA). So far, various infections have lead to elevation of titers of serum ANCA, making it difficult to diagnose.

PATIENT CONCERNS

We report a 50-year-old woman who was diagnosed as tuberculous lymphadenitis. During the treatment by anti-tuberculosis (TB) drugs, rapidly progressive renal failure and pleurisy had appeared with elevated titer of PR3-ANCA. Renal biopsy revealed crescentic glomerulonephritis.

DIAGNOSIS

Renal biopsy revealed crescentic glomerulonephritis and diagnosis of GPA was made.

INTERVENTIONS

Steroid therapy had been started with continuation of anti-TB drugs.

OUTCOMES

Renal dysfunction had gradually recovered and pleurisy had disappeared with decreasing titer of PR3-ANCA.

LESSONS

This is the first report of GPA complicated by TB infection. When we encounter a case with rapidly progressive renal failure during the TB infection, complication of GPA should be suspected as 1 of the different diagnosis.

Case Report of Empagliflozin-Induced Cutaneous Polyarteritis Nodosa

Polyarteritis nodosa (PAN) is a rare vasculitis affecting medium-sized vessels. Cutaneous PAN is a clinical variant, and we report the first case of empagliflozin-induced cutaneous PAN in a 69-year-old man. After starting empagliflozin, the patient presented with tender subcutaneous nodules on his legs, which showed a medium-sized vessel vasculitis on histopathology. Upon cessation of this medication, he had full resolution of these nodules. This case illustrates that empagliflozin can induce cutaneous PAN, and further attention to this medication's association with cutaneous PAN is warranted.

Lymphocytic Thrombophilic Arteritis: A Possible Association with Minocycline

We describe a case of lymphocytic thrombophilic arteritis in a 15-year-old girl who had previously taken minocycline for a year. Cutaneous polyarteritis nodosa and lymphocytic thrombophilic arteritis share many features and may both be triggered by minocycline. There may be a long latency between drug exposure to minocycline and development of disease.

Pyogenic Arthritis, Pyoderma Gangrenosum, Acne, Suppurative Hidradenitis (PA-PASH) Syndrome: An Atypical Presentation of a Rare Syndrome

Patient: Male, 44

Final Diagnosis: PAPASH syndrome

Symptoms: Recurrent skin ulcers • diarrhea • inflammatory arthritis

Medication: Prednisone • anti-tumor necrosis factor

Clinical Procedure: N/A

Specialty: Rheumatology

Epidemiological, clinical and laboratory profiles of cutaneous polyarteritis nodosa patients: Report of 22 cases and literature review

Cutaneous polyarteritis nodosa (CPAN) is a rare disease that affects small and middle caliber vessels of the deep dermis and subcutaneous tissue and its etiopathology remains yet to be understood.

METHODS

Retrospective review of twenty two cases diagnosed as CPAN and confirmed by skin biopsy over the last 11 years was evaluated in our department.

RESULTS

We found predominance in white woman, mean age of 39.4 years, showing no comorbidities in most of our sample. Mean follow-up time was 58 months. The most frequent cutaneous manifestations were ulcers, livedo racemosa, subcutaneous nodules, atrophie blanche lesions and purpuras; with lower limb involvement in all cases, however other areas were also involved. The main regional symptoms were pain and paresthesia, while systemic complaints were absent in the majority of cases. Mononeuritis multiplex was identified in a quarter of our sample. Most of the laboratory findings were non-specific. There was evidence for previous contact with Mycobacterium tuberculosis in 46.1% of cases which were tested for purified protein derivative (PPD) test. In our patients the disease course was benign and without complications, and systemic polyarteritis nodosa did not develop in any patient.

CONCLUSIONS

An extensive work-up including laboratory tests on autoimmunity and thrombophilic factors and investigation of infectious diseases, especially previous contact with tuberculosis agent, should be part of the CPAN investigation.

Testicular Pain Associated With Minocycline Use

Two males ages 16 and 23 years presented with new testicular pain while taking minocycline. Both patients experienced resolution of their symptoms only after minocycline discontinuation. Testicular pain with minocycline use has been previously described, however only in the setting of systemic autoimmune reactions (which were absent here). These cases represent probable rare adverse reactions to minocycline. For patients taking minocycline who experience otherwise unexplained testicular pain, a trial discontinuation of this medication should be considered.

Minocycline-induced polyarteritis nodosa-like vasculitis presenting as brainstem stroke

Minocycline use has been associated with the development of autoimmune disorders, including drug-induced vasculitis. Previously published reports suggest that clinical manifestations are limited to cutaneous, constitutional, or musculoskeletal symptoms. To our knowledge there has been only one reported patient with ischemic stroke in the setting of minocycline-induced vasculitis. We describe a 26-year-old woman, with no vascular risk factors, who had an ischemic pontine stroke in the setting of biopsy-proven minocycline-induced polyarteritis nodosa-like vasculitis. Discontinuation of minocycline resulted in resolution of the vasculitis, and she has not had any recurrent ischemic events. This report shows that ischemic strokes may occur as a result of minocycline-induced vasculitis. While this is likely a rare association, recognition is important given the widespread use of minocycline and the potential for devastating consequences in a young population. Consequently, drug-induced vasculitis should be considered in patients with an ischemic stroke taking minocycline.

ANA (+) ANCA (+) systemic vasculitis associated with the use of minocycline: case-based review

Minocycline is a synthetic tetracycline-derived antibiotic with significant anti-inflammatory properties that may benefit patients with rheumatoid arthritis. Surprisingly, chronic exposure to minocycline can also cause a breach in immunologic tolerance resulting in a variety of autoimmune syndromes such as drug-induced lupus or autoimmune hepatitis. Vasculitis, most commonly resembling cutaneous polyarteritis nodosa, has also been seen in patients taking this drug. Herein, we present a case of biopsy-proven systemic vasculitis presenting as an ANA (+) ANCA (+) polyarteritis nodosa-like syndrome in a male patient who was taking minocycline for his acne for approximately 2 years. Patient initially presented with constitutional symptoms such as profound weight loss and fatigue, along with myalgias, oligoarticular arthritis, and livedo reticularis. About 2 months later, he developed a severe left testicular pain. Biopsy showed vasculitis complicated with the infarction of the left testis. Angiography revealed microaneurysms in the renal and splenic circulation. Stopping the offending drug, along with the short course of prednisone and hydroxychloroquine, resulted in prompt resolution of his symptoms. We additionally present a comprehensive review of biopsy-proven cases of vasculitis associated with chronic minocycline treatment focusing on its pathogenesis and clinical manifestations.

Minocycline-induced renal polyarteritis nodosa

Minocycline is a bacteriostatic, long-acting, lipid-soluble tetracycline that is generally well tolerated, but has been associated with polyarteritis nodosa (PAN). This is a case report of a 21-year-old woman presented to her primary care physician with several months of fatigue, mylagias, weight loss and intermittent severe bi-temporal headaches without changes in vision. Her medications included an Ortho-Tri-Cyclen Lo and Minocycline, which she started 2 years prior for acne. On presentation, she was tachycardic and severely hypertensive. Initial laboratory evaluation showed hyponatraemia and hypokalaemia as well as elevation of inflammatory markers. Autoimmune work-up was positive for perinuclear antineutrophil cytoplasmic antibodies. Renal arteriogram was characteristic of PAN and along with her other symptoms, she fulfilled the necessary criteria of American College of Rheumatology for diagnosis of PAN. Minocycline as a possible causative agent was discontinued since it was reported to cause cutaneous PAN in the literature. Cyclophosphamide and prednisone were initiated for treatment of her vasulculitis. Her symptoms and hypertension improved over the next several months. This is the first report of the minocycline-induced renal PAN.

Polyarteritis nodosa-like vasculitis in association with minocycline use: a single-center case series

OBJECTIVE

To describe the clinical features, treatment, and outcomes of polyarteritis nodosa (PAN)-like vasculitis in association with minocycline therapy.

METHODS

We identified all subjects ≥18 years old with PAN-like vasculitis in the context of minocycline use seen at our institution between January 1995 and October 2010. Cases of hepatitis B-associated PAN were excluded. PAN was defined based on angiographic findings or tissue biopsy. Minocycline use was defined as medication use at the time of onset of first symptom.

RESULTS

We identified 9 patients (5 females; 56%) with a median age of 30 (range 18 to 55) years. Four patients (44%) had isolated cutaneous disease, while 5 cases (56%) had systemic involvement including renal artery microaneurysms (2 patients), cholecystitis (1 patient), mononeuritis multiplex (2 patients), and mesenteric vasculitis (1 patient). Median duration of minocycline use was 2 (range 1 to 4) years. Three patients had a positive antinuclear antibody with negative extractable nuclear antigen antibodies. All patients had positive antineutrophil cytoplasmic antibody in a perinuclear pattern but specificity to myeloperoxidase was observed in 2 patients (22%). Diagnosis was confirmed by histopathology in 6 patients (67%) and angiography in 3 patients (33%). Minocycline was discontinued in all cases. Further immunosuppressive therapy was added in 6 cases (67%).

CONCLUSIONS

Cutaneous, as well as systemic, PAN-like vasculitis may occur in association with minocycline use. Clinicians should consider the possibility of drug-induced vasculitis, especially in cases of medium-vessel vasculitis with atypical antineutrophil cytoplasmic antibody serologies or in patients with negative hepatitis B testing.

ANCA-associated vasculitis in systemic sclerosis report of 3 cases

The aim of the study was to describe the occurrence of anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) in systemic sclerosis (SSc) patients. SSc patients who developed biopsy-proven AAV were identified. Their clinical manifestations, autoantibodies, presentation with vasculitis, treatment and outcome were described and compared with previously reported patients with these two conditions. Of 985 patients, 3 were identified. All patients had interstitial lung disease, and all presented with acute renal failure, proteinuria and hematuria, and were P-ANCA- and anti-Scl-70-positive. One required hemodialysis. Two were hypertensive; additionally, one patient had sinusitis, and another had monoarthritis and a macular rash. All were treated with high-dose corticosteroids and responded to therapy and attained remission at 6 months. At 1 year, one patient died of pneumonia. ANCA-associated vasculitis is a rare but serious finding in SSc patients. Positive anti-Scl-70 antibody is found commonly in these patients. Different treatment modalities are effective. Serious infections can complicate therapy and lead to death.

Vasculitic neuropathy associated with minocycline use

INTRODUCTION

Minocycline is an antibiotic used for the treatment of acne. It has been associated with several autoimmune syndromes, including drug-induced lupus, autoimmune hepatitis, and vasculitis.

METHOD AND RESULTS

We report a case of a 28-year-old previously healthy woman who developed a left sciatic mononeuropathy 2 weeks after starting minocycline for acne. Magnetic resonance imaging studies supported the localization. A biopsy of the left sural nerve revealed acute nerve large arteriole necrotizing vasculitis. Her condition improved after the withdrawal of minocycline and a course of treatment with methylprednisolone.

CONCLUSION

This case provides further evidence that minocycline may induce a nonsystemic necrotizing vasculitis.

Cutaneous polyarteritis nodosa: a comprehensive review

Cutaneous polyarteritis nodosa is a rare form of vasculitis relating to small-to-medium-sized arteries. Its etiology is unknown. Clinical manifestations include tender subcutaneous nodules, livedo reticularis, cutaneous ulcers and necrosis. Although it is distinct from systemic polyarteritris nodosa in that it lacks significant internal organ involvement, extra-cutaneous manifestations may be evident. Commonly encountered symptoms include fever, malaise, myalgias, arthralgias, and paresthesias. Exclusion of systemic polyarteritis nodosa is essential in diagnosis. The clinical course is chronic with remissions, relapses, and a favorable prognosis. Mild cases may resolve with nonsteroidal anti-inflammatory drugs. If more severe, treatment with systemic corticosteroids generally achieves adequate response; however, adjunctive therapy is often necessary to allow reduction in steroid dosage.

Minocycline in acne vulgaris: benefits and risks

Minocycline is a semi-synthetic, second-generation tetracycline. It was introduced in 1972 and has both antibacterial and anti-inflammatory properties. Minocycline is used for a variety of infectious diseases and in acne. Even today, new indications beyond the antibacterial indications are being investigated such as its use in neurologic diseases. Formerly, minocycline was thought to have a superior efficacy in the treatment of inflammatory acne, especially with respect to antibacterial-resistant Propionibacterium acnes. A thorough review of the literature, however, shows that minocycline is not more effective in acne than other tetracyclines. Compared with first-generation tetracyclines, minocycline has a better pharmacokinetic profile, and compared with doxycycline it is not phototoxic. However, minocycline has an increased risk of severe adverse effects compared with other tetracyclines. It may induce hypersensitivity reactions affecting the liver, lung, kidneys, or multiple organs (Drug Reaction with Eosinophilia and Systemic Symptoms [DRESS] syndrome) in the first weeks of treatment and, with long-term treatment, may cause autoimmune reactions (systemic lupus erythematosus, autoimmune hepatitis). In addition, CNS symptoms, such as dizziness, are more frequent compared with other tetracyclines. Long-term treatment may induce hyperpigmentation of the skin or other organs. Resistance of P. acnes to minocycline also occurs, dependent on the prescribing behavior. Considering the aspects of efficacy, its adverse effect profile, resistance, price, and alternatives, minocycline is no longer considered the first-line antibacterial in the treatment of acne.

[Case of minocycline-induced vasculitic neuropathy]

A 70-year-old woman was admitted to our hospital because of fever, numbness in her extremities and right drop foot. Because her hip prosthesis had loosened as a result of infection, she had been taking 100 mg of minocycline orally for eight months. Three months before admission, she had had melena several times and body weight loss and pyrexia developed. A month before admission, asymmetrical paresthesia and numbness appeared in her extremities and finally right drop foot developed. Laboratory tests showed elevated C-reactive protein and positive anti-nuclear antibody. Abnormalities found in nerve conduction study were compatible with mononeuritis multiplex. Sural nerve biopsy revealed an occluded medium-size artery in the epineurium and axonal degeneration in the nerve fascicles, confirming the diagnosis of vasculitic neuropathy. These manifestations met the American Congress Rheumatology criteria for polyarteritis nodosa. However, her clinical conditions markedly improved after discontinuing minocycline and therefore she was diagnosed as having minocycline-induced vasculitic neuropathy. Although minocycline-induced vasculitis is a well known adverse effect of the drug, peripheral neuropathy with biopsy findings has rarely been reported. Drug induced-vasculitis is important as a differential diagnosis for mononeuritis multiplex because the symptoms can be improved by the discontinuation of an offending drug.

Minocycline-Induced Cutaneous Polyarteritis Nodosa

Minocycline is a tetracycline derivative with multiple clinical uses including the treatment of various infections, acne vulgaris, and rosacea. Numerous adverse events have been reported ranging from minor complaints such as nausea, to serious life-threatening toxicities such as acute renal failure, hepatotoxicity, and systemic lupus erythematosus. We report the case of an 18-year-old female patient who developed minocycline-induced cutaneous polyarteritis nodosa after taking minocycline for acne vulgaris. The vasculitis resolved after discontinuation of the minocycline without need for corticosteroids. This case is the eighth biopsy-confirmed case of minocycline-induced polyarteritis nodosa. Although minocycline is an effective medication with a wide variety of clinical uses, clinicians must be aware of its potential side effects including autoimmune-related disorders such as polyarteritis nodosa or systemic lupus erythematosus.

Update on Cutaneous Vasculitis

Vasculitis presents with a range of clinical manifestations, many of which affect the skin. Diagnosing and classifying vasculitis can prove challenging. Particularly given the lack of unified criteria that are both useful as a research tool and clinically relevant. Also, vasculitis may be secondary to a wide range of conditions, making the prompt recognition and treatment of associated disorders essential for appropriate patient management. This article will highlight the classification, pathogenesis, clinical presentation, diagnosis, evaluation, and treatment of the cutaneous vasculitides.

Minocycline-induced vasculitis fulfilling the criteria of polyarteritis nodosa

A 47-year-old man who had been taking minocycline for palmoplantar pustulosis developed fever, myalgias, polyneuropathy, and testicular pain, with elevated C-reactive protein (CRP). Neither myeloperoxidase- nor proteinase-3-antineutrophil cytoplasmic antibody was positive. These manifestations met the American College of Rheumatology 1990 criteria for the classification of polyarteritis nodosa. Stopping minocycline led to amelioration of symptoms and normalization of CRP level. To our knowledge, this is the second case of minocycline-induced vasculitis satisfying the criteria. Differential diagnosis for drug-induced disease is invaluable even for patients with classical polyarteritis nodosa.