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Moosa SA, Mendez CM, Sanchez Z, Cabrera LM, Ishtiaq S. Granulomatosis With Polyangiitis in Untreated Graves' Disease: A Rare Event. Cureus 2022; 14:e29742. [PMID: 36340518 PMCID: PMC9621745 DOI: 10.7759/cureus.29742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
Abstract
Antithyroid medications can cause antineutrophil cytoplasmic antibody (ANCA) vasculitis. However, no literature in English describes the coexistence of granulomatosis with polyangiitis (GPA) and untreated Graves' disease. We present a 19-year-old female with thyroid storm and additional complaints of cough, hemoptysis, nasal discharges, polyarthralgia, and skin lesions. Imaging showed peri-hilar cavities and acute-on-chronic sinusitis. Elevated cytoplasmic pattern antineutrophil cytoplasmic antibody (C-ANCA) and anti-proteinase-3 antibody levels plus histopathology of the nasal and skin biopsies suggested GPA. Propranolol, methimazole, and potassium-iodide resolved the thyroid storm. Induction therapy (steroids, rituximab) for GPA provided relief of chronic symptoms stressing the importance of early recognition and swift initiation of treatment.
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Affiliation(s)
- Syed Ahmad Moosa
- Internal Medicine, St. John's Episcopal Hospital, New York, USA
- Research, Bangladesh Medical Association of North America, New York, USA
| | | | - Zuleyka Sanchez
- Internal Medicine, St John's Episcopal Hospital, New York, USA
| | | | - Sameera Ishtiaq
- Internal Medicine, St. John's Episcopal Hospital, New York, USA
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2
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Miletić M, Stojanović M, Stojković M, Nedeljković-Beleslin B, Tančić-Gajić M, Ćirić J, Žarković M. Granulomatosis with polyangiitis: Possible endocrine manifestations. MEDICINSKI GLASNIK SPECIJALNE BOLNICE ZA BOLESTI ŠTITASTE ŽLEZDE I BOLESTI METABOLIZMA 2022. [DOI: 10.5937/mgiszm2287028m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a necrotizing vasculitis of small and medium-sized blood vessels characterized by diffuse inflammation of vascular structures and perivascular and extravascular granulomatosis. In its systemic form, GPA predominantly affects the ear, nose and throat, with lung and kidney involvement with typically rapidly progressive necrotizing glomerulonephritis with extracapillary crescents, while the absence of kidney damage at the time of diagnosis is defined as a limited form of GPA with a more favorable prognosis (1, 2). Antineutrophil cytoplasmic antibodies (c-ANCA) with specificity for proteinase 3 (PR3) represent a biochemical diagnostic criterion. They are detected in 90% of generalized forms and in about 50% of limited forms of granulomatosis with polyangiitis (1, 2). In the absence of treatment, GPA is a disease of progressive evolution. Systemic corticosteroid therapy and immunosuppressive therapy significantly changed the prognostic aspect of the disease. Only a few sporadic observations have been published on endocrine disorders associated with GPA. We present a case of a man, 39 years old, with Wegener's granulomatosis who developed autoimmune thyroiditis 8 years after the initial diagnosis.
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Alidoost M, Cheng J, Alpert DR. Propylthiouracil-Induced Anti-Neutrophil Cytoplasmic Antibody Vasculitis Presenting with Red Eye Followed by Pulmonary Hemorrhage: Diagnostic and Management Considerations. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e925200. [PMID: 33293503 PMCID: PMC7733149 DOI: 10.12659/ajcr.925200] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Patient: Female, 34-year-old Final Diagnosis: Vascuitis Symptoms: Hemoptysis Medication:— Clinical Procedure: — Specialty: Rheumatology
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Affiliation(s)
- Marjan Alidoost
- Department of Internal Medicine, Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Jennifer Cheng
- Department of Endocrinology, Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Deborah R Alpert
- Department of Rheumatology, Hackensack Meridian Health, Jersey Shore University Medical Center, Neptune, NJ, USA
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4
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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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Abstract
We herein report the case of a 38-year-old Japanese woman with antithyroid arthritis syndrome who experienced severe migratory polyarthritis after the initiation of thiamazole therapy. The patient's symptoms promptly disappeared without any sequelae after the withdrawal of the drug. Antithyroid arthritis syndrome is poorly characterized, and the findings from our literature review indicate that this syndrome exhibits serological features that are distinct from those of antithyroid agent-induced vasculitis syndrome. The absence of autoantibodies, especially anti-neutrophil cytoplasmic antibodies, may help characterize and diagnose antithyroid arthritis syndrome. Furthermore, physicians' awareness of this syndrome is essential for its diagnosis in clinical practice.
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Affiliation(s)
- Kazuhiko Takaya
- Division of Diabetes and Endocrinology, Japanese Red Cross Medical Center, Japan
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Mukae H, Furusyo N, Murata M, Ogawa E, Kainuma M, Shimizu M, Ihara T, Hayashi J. A case of granulomatosis with polyangiitis preceded by subacute thyroiditis. Clin Case Rep 2015; 3:139-44. [PMID: 25838901 PMCID: PMC4377243 DOI: 10.1002/ccr3.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/17/2014] [Accepted: 10/25/2014] [Indexed: 11/11/2022] Open
Abstract
Granulomatosis with polyangiitis can be a complication of thyroid disease, not only autoimmune disease but also subacute thyroiditis.
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Affiliation(s)
- Haru Mukae
- Department of General Internal Medicine Kyushu University Hospital Fukuoka Japan
| | - Norihiro Furusyo
- Department of General Internal Medicine Kyushu University Hospital Fukuoka Japan
| | - Masayuki Murata
- Department of General Internal Medicine Kyushu University Hospital Fukuoka Japan
| | - Eiichi Ogawa
- Department of General Internal Medicine Kyushu University Hospital Fukuoka Japan
| | - Mosaburo Kainuma
- Department of General Internal Medicine Kyushu University Hospital Fukuoka Japan
| | - Motohiro Shimizu
- Department of General Internal Medicine Kyushu University Hospital Fukuoka Japan
| | - Takeshi Ihara
- Department of General Internal Medicine Kyushu University Hospital Fukuoka Japan
| | - Jun Hayashi
- Department of General Internal Medicine Kyushu University Hospital Fukuoka Japan
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Yokogawa N, Vivino FB. Hydralazine-induced autoimmune disease: comparison to idiopathic lupus and ANCA-positive vasculitis. Mod Rheumatol 2014. [DOI: 10.3109/s10165-009-0168-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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8
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Increased IgG4-Positive Plasma Cells in Granulomatosis with Polyangiitis: A Diagnostic Pitfall of IgG4-Related Disease. Int J Rheumatol 2012; 2012:121702. [PMID: 22577389 PMCID: PMC3332209 DOI: 10.1155/2012/121702] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 02/15/2012] [Accepted: 02/16/2012] [Indexed: 12/24/2022] Open
Abstract
Granulomatosis with polyangiitis (Wegener's) (GPA) may mimic IgG4-related disease (IgG4-RD) on histologic examination of some biopsies, especially those from head and neck sites. IgG4 immunostain is often performed in this context for differential diagnosis with IgG4-RD. However, the prevalence of IgG4+ cells in GPA has not been explored. We examined the IgG4+ cells in 26 cases confirmed as GPA by a thorough clinical and pathologic assessment. Twenty-six biopsies consisted of 14 sinonasal/oral cavity/nasopharynx, 7 orbit/periorbital, 3 lung/pleura, 1 iliac fossa/kidney, and 1 dura specimens. Eight of 26 (31%) biopsies revealed increased IgG4+ cells (>30/HPF and >40% in IgG4+/IgG+ ratio). The IgG4+ cells and IgG4+/IgG+ ratio ranged 37–137/hpf and 44–83%, respectively. Eight biopsies with increased IgG4+ cells were from sinonasal (n = 4) or orbital/periorbital (n = 4) sites. In conclusion, increased IgG4+ cells are not uncommonly seen in sinonasal or orbital/periorbital biopsies of GPA, which could pose as a diagnostic pitfall.
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10
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Mesalamine-Induced Multiple Pulmonary Cavitary Nodules Associated With Cytoplasmic Antineutrophil Cytoplasmic Antibody (c-ANCA). J Clin Rheumatol 2009; 15:256-7. [DOI: 10.1097/rhu.0b013e3181b1900f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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11
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Yokogawa N, Vivino FB. Hydralazine-induced autoimmune disease: comparison to idiopathic lupus and ANCA-positive vasculitis. Mod Rheumatol 2009; 19:338-47. [PMID: 19424772 DOI: 10.1007/s10165-009-0168-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 03/04/2009] [Indexed: 11/29/2022]
Abstract
We report two cases of hydralazine-induced vasculitis with rare complications: pulmonary renal syndrome and digital gangrene. We also review 68 published cases of hydralazine-induced vasculitis. Hydralazine-induced vasculitis mimics idiopathic antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis. However, it also produces other autoantibodies, such as antinuclear antibodies, antihistone antibodies, anti-dsDNA antibodies, and antiphospholipid antibodies. Patients with hydralazine-induced vasculitis typically have a more severe course than those with hydralazine-induced lupus, predominantly due to renal vasculitis, and require a more aggressive treatment.
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Affiliation(s)
- Naoto Yokogawa
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA.
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Churg-Strauss Syndrome following PTU Treatment. Int J Rheumatol 2009; 2009:504105. [PMID: 20107567 PMCID: PMC2809019 DOI: 10.1155/2009/504105] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Accepted: 02/16/2009] [Indexed: 11/17/2022] Open
Abstract
Propylthiouracil (PTU) is a frequently prescribed drug in the treatment of hyperthyroidism. The use of PTU is, however, accompanied by numerous potentially serious side effects including vasculitis. PTU-related vasculitides can present as haematuria, pulmonary haemorrhage, or cutaneous lesion together with aspecific symptoms such as fever, myalgia, arthralgia, and fatigue. Cerebral involvement is seldom observed. We present a 49-year-old female with Graves' disease and asthma, who developed paresis of the proximal extremities, eosinophilia, pulmonary, and cutaneous lesions following treatment with PTU. A cerebral vasculitis consistent with Churg-Strauss syndrome (CSS) was suspected. Although cerebral involvement is seldom observed with PTU treatment, cerebral vasculitis should be considered in patients developing CNS symptoms.
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Mor A, Pillinger MH, Wortmann RL, Mitnick HJ. Drug-induced arthritic and connective tissue disorders. Semin Arthritis Rheum 2007; 38:249-64. [PMID: 18166218 DOI: 10.1016/j.semarthrit.2007.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Revised: 10/01/2007] [Accepted: 10/21/2007] [Indexed: 12/15/2022]
Abstract
OBJECTIVES All pharmacologic agents have the potential for both benefit and toxicity. Among the more interesting and important adverse consequences of drug therapy are a range of joint and connective tissue complaints that may mimic or reproduce primary rheumatologic diseases. In this article, we review the literature on commonly used drugs reported to induce arthritis and/or connective tissue-based diseases. We assess the strength of the reported associations, discuss diagnostic features and treatment implications, and consider possible mechanisms for drug-induced genesis of rheumatic conditions. METHODS We reviewed the Medline database from 1987 to 2006 to identify drug-induced arthritic and connective-tissue disease syndromes, utilizing 48 search terms. A qualitative review was performed after the articles were abstracted and the relevant information was organized. RESULTS Three hundred fifty-seven articles of possible relevance were identified. Two hundred eleven publications were included in the final analysis (case series and reports, clinical trials, and reviews). Many drugs were identified as mimicking existing rheumatic conditions, including both well-established small molecules (eg, sulfasalazine) and recently introduced biologic agents (eg, antitumor necrosis factor agents). The most commonly reported drug-induced rheumatic conditions were lupus-like syndromes. Arthritis and vasculitis were also often reported. CONCLUSIONS Drug-induced rheumatic syndromes are manifold and offer the clinician an opportunity to define an illness that may remit with discontinuation of the offending agent. Early diagnosis and withdrawal of the drug may prevent unnecessary morbidity and disability.
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Affiliation(s)
- Adam Mor
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY 10003, USA.
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de Lind van Wijngaarden RAF, van Rijn L, Hagen EC, Watts RA, Gregorini G, Tervaert JWC, Mahr AD, Niles JL, de Heer E, Bruijn JA, Bajema IM. Hypotheses on the etiology of antineutrophil cytoplasmic autoantibody associated vasculitis: the cause is hidden, but the result is known. Clin J Am Soc Nephrol 2007; 3:237-52. [PMID: 18077783 DOI: 10.2215/cjn.03550807] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The first description of what is now known as antineutrophil cytoplasmic autoantibody-associated necrotizing vasculitis appeared more than 140 yr ago. Since then, many aspects of the pathogenic pathway have been elucidated, indicating the involvement of antineutrophil cytoplasmic autoantibodies, but why antineutrophil cytoplasmic autoantibodies are produced in the first place remains unknown. Over the years, many hypotheses have emerged addressing the etiology of antineutrophil cytoplasmic antibody production, but no exclusive factor or set of factors can so far be held responsible. Herein is reviewed the most influential hypotheses regarding the causes of antineutrophil cytoplasmic antibody-associated vasculitis with the aim of placing in an epidemiologic background the different hypotheses that are centered on environmental and genetic influences.
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15
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Pillinger MH, Staud R. Propylthiouracil and Antineutrophil Cytoplasmic Antibody Associated Vasculitis: The Detective Finds a Clue. Semin Arthritis Rheum 2006; 36:1-3. [PMID: 16887462 DOI: 10.1016/j.semarthrit.2006.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2006] [Accepted: 04/23/2006] [Indexed: 11/28/2022]
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Aloush V, Litinsky I, Caspi D, Elkayam O. Propylthiouracil-Induced Autoimmune Syndromes: Two Distinct Clinical Presentations with Different Course and Management. Semin Arthritis Rheum 2006; 36:4-9. [PMID: 16887463 DOI: 10.1016/j.semarthrit.2006.03.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To report 4 cases of propythiouracil (PTU)-induced lupus or vasculitis and to review the literature on that subject. METHODS We describe the clinical presentation, course, and outcome of 4 patients and review the medical literature registered in the Medline PubMed database from 1966 to 2004 by using the keywords: Graves, thyrotoxicosis, propylthiouracil, lupus, vasculitis, arthritis, rash, ANA, and ANCA. Cases were classified into drug-induced lupus (DIL) or vasculitis using accepted definitions and evaluated with emphasis on gender, age, origin, duration of treatment, delay in diagnosis, clinical and serological features, and outcome. RESULTS We described our 4 patients and analyzed 42 well-documented cases of DIL- and PTU-induced vasculitis (30 had vasculitis and 12 fulfilled the classification criteria of DIL). Patients with vasculitis were significantly older (mean 43 versus 22 years) and had a longer duration of treatment in comparison with DIL (35 versus 24 weeks). Musculoskeletal symptoms were prominent in DIL, while renal and pulmonary involvement was found in a significantly higher proportion of PTU-induced vasculitis. ANA, anti-DNA, and anti-histone were predominantly found in DIL, while p-ANCA was found in a similar proportion of patients in both groups. c-ANCA was detected only in patients with vasculitis. All patients with DIL completely recovered (most after stopping PTU), while about 50% of PTU-induced vasculitis needed steroids or immunosuppressive drugs, including cyclophosphamide and plasmapheresis. CONCLUSIONS Most of the cases of PTU-induced autoimmune phenomena are due to vasculitis. Despite the common presence of p-ANCA in both DIL- and PTU-induced vasculitis, substantial differences in demographic, clinical, and outcome features of these entities allow an accurate diagnosis and consequent management.
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Affiliation(s)
- Valerie Aloush
- Trainee in Rheumatology, Department of Rheumatology, Tel Aviv Medical Center and the Sackler Faculty of Medicine, University of Tel Aviv, Tel Aviv, Israel
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Sève P, Stankovic K, Michalet V, Vial T, Scoazec JY, Broussolle C. Carbimazole induced eosinophilic granulomatous vasculitis localized to the stomach. J Intern Med 2005; 258:191-5. [PMID: 16018796 DOI: 10.1111/j.1365-2796.2005.01525.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Vasculitis associated with anti-neutrophil cytoplasmic antibodies has been reported in patients treated with anti-thyroid drugs and especially propylthiouracil. We report here a case of granulomatous eosinophilic vasculitis mimicking gastric neoplasm and peripheral eosinophilia in a 27-year-old man who was treated with carbimazole for 5 months for Graves' disease. Clinical and morphologic features resolved within 2 months after stopping the drug, suggesting a causative role for the drug. To our knowledge, this is the first biopsy-proven granulomatous eosinophilic vasculitis associated with this drug.
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Affiliation(s)
- P Sève
- Department of Internal Medicine, Hôtel Dieu, 1 place de l'Hôpital, Lyon Cedex 02, France
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Bonaci-Nikolic B, Nikolic MM, Andrejevic S, Zoric S, Bukilica M. Antineutrophil cytoplasmic antibody (ANCA)-associated autoimmune diseases induced by antithyroid drugs: comparison with idiopathic ANCA vasculitides. Arthritis Res Ther 2005; 7:R1072-81. [PMID: 16207324 PMCID: PMC1257438 DOI: 10.1186/ar1789] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2005] [Revised: 06/14/2005] [Accepted: 06/22/2005] [Indexed: 11/15/2022] Open
Abstract
Clinical and serological profiles of idiopathic and drug-induced autoimmune diseases can be very similar. We compared data from idiopathic and antithyroid drug (ATD)-induced antineutrophil cytoplasmic antibody (ANCA)-positive patients. From 1993 to 2003, 2474 patients were tested for ANCA in the Laboratory for Allergy and Clinical Immunology in Belgrade. Out of 2474 patients, 72 (2.9%) were anti-proteinase 3 (PR3)- or anti-myeloperoxidase (MPO)-positive and their clinical and serological data were analyzed. The first group consisted of ANCA-associated idiopathic systemic vasculitis (ISV) diagnosed in 56/72 patients: 29 Wegener's granulomatosis (WG), 23 microscopic polyangiitis (MPA) and four Churg-Strauss syndrome. The second group consisted of 16/72 patients who became ANCA-positive during ATD therapy (12 receiving propylthiouracil and four receiving methimazole). We determined ANCA and antinuclear (ANA) antibodies by indirect immunofluorescence; PR3-ANCA, MPO-ANCA, anticardiolipin (aCL) and antihistone antibodies (AHA) by ELISA; and cryoglobulins by precipitation. Complement components C3 and C4, alpha-1 antitrypsin (α1 AT) and C reactive protein (CR-P) were measured by nephelometry. Renal lesions were present in 3/16 (18.8%) ATD-treated patients and in 42/56 (75%) ISV patients (p <0.001). Skin lesions occurred in 10/16 (62.5%) ATD-treated patients and 14/56 (25%) ISV patients (p <0.01). ATD-treated patients more frequently had MPO-ANCA, ANA, AHA, aCL, cryoglobulins and low C4 (p <0.01). ISV patients more frequently had low α1 AT (p = 0.059) and high CR-P (p <0.001). Of 16 ATD-treated patients, four had drug-induced ANCA vasculitis (three MPA and one WG), while 12 had lupus-like disease (LLD). Of 56 ISV patients, 13 died and eight developed terminal renal failure (TRF). There was no lethality in the ATD-treated group, but 1/16 with methimazole-induced MPA developed pulmonary-renal syndrome with progression to TRF. ANCA-positive ISV had a more severe course in comparison with ATD-induced ANCA-positive diseases. Clinically and serologically ANCA-positive ATD-treated patients can be divided into two groups: the first consisting of patients with drug-induced WG or MPA which resemble ISV and the second consisting of patients with LLD. Different serological profiles could help in the differential diagnosis and adequate therapeutic approach to ANCA-positive ATD-treated patients with symptoms of systemic disease.
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Affiliation(s)
- Branka Bonaci-Nikolic
- Institute of Allergy and Clinical Immunology, Clinical Centre of Serbia, Belgrade, Serbia and Montenegro
| | - Milos M Nikolic
- Institute of Dermatology, Clinical Centre of Serbia, Belgrade, Serbia and Montenegro
| | - Sladjana Andrejevic
- Institute of Allergy and Clinical Immunology, Clinical Centre of Serbia, Belgrade, Serbia and Montenegro
| | - Svetlana Zoric
- Institute of Endocrinology, Clinical Centre of Serbia, Belgrade, Serbia and Montenegro
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Pirot AL, Goldsmith D, Pascasio J, Beck SE. Pulmonary capillaritis with hemorrhage due to propylthiouracil therapy in a child. Pediatr Pulmonol 2005; 39:88-92. [PMID: 15532087 DOI: 10.1002/ppul.20072] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We report on a case of pulmonary capillaritis with diffuse alveolar hemorrhage in a child due to propylthiouracil (PTU). PTU treatment is a rare cause of pulmonary capillaritis in adults; we report on the first case in a pediatric patient. The treatment of pulmonary capillaritis often requires corticosteroid therapy, other immunosuppressive medications, or withdrawal of the causative agent. Our patient recovered completely after treatment with a limited course of corticosteroids and removal of PTU.
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Affiliation(s)
- Anayansi Lasso Pirot
- Department of Pediatrics, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania 19134, USA
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20
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Vanek C, Samuels MH. Central nervous system vasculitis caused by propylthiouracil therapy: a case report and literature review. Thyroid 2005; 15:80-4. [PMID: 15687828 DOI: 10.1089/thy.2005.15.80] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Antineutrophil cytoplasmic antibodies (ANCA) are associated with vasculitis, including vasculitis induced by drugs such as the thionamides. The affected organ systems in thionamide-induced vasculitis have been primarily renal, musculoskeletal, and dermatologic. We describe the first case of thionamide-induced central nervous system vasculitis presenting as confusion, with complete resolution after discontinuation of propylthiouracil. We review the literature and summarize 42 additional cases of thionamide-induced ANCA-positive vasculitis since 1992. Propylthiouracil was responsible in 93% of cases and the predominant ANCA pattern on immunofluorescent staining was perinuclear (p-ANCA). Clinical improvement occurred after drug discontinuation in 93%, steroid therapy was used in some cases. The mean duration of treatment with thionamides was 35 months prior to presentation. Long-term medical treatment with thionamides for hyperthyroidism may increase the risk of this severe side effect.
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Affiliation(s)
- C Vanek
- Oregon Health and Science University, Divison of Endocrinology, Diabetes, and Clinical Nutrition, Portland, OR 97239-3098, USA
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21
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Stone JH. Limited versus severe Wegener's granulomatosis: baseline data on patients in the Wegener's granulomatosis etanercept trial. ARTHRITIS AND RHEUMATISM 2003; 48:2299-309. [PMID: 12905485 DOI: 10.1002/art.11075] [Citation(s) in RCA: 301] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To report baseline data on 180 patients with Wegener's granulomatosis (WG) enrolled in the WG Etanercept Trial (WGET), and to examine demographic and clinical differences between patients with limited disease and those with severe disease. METHODS Definitions of limited and severe disease were agreed upon by consensus of the investigators at a pretrial meeting and were incorporated into the protocol as a stratification criterion. These data were applied prospectively to the WGET patient cohort, based on clinical features and the intention to treat patients according to disease activity. Data related to disease onset, date of diagnosis, clinical features, antineutrophil cytoplasmic antibody assays, tissue biopsy findings, and other medical history were collected on a baseline medical history form. Physician-investigators from each center participated in the development of this form, and all were certified in its use prior to the start of the trial. Selected data on patients who were screened for the trial but were not enrolled were also collected. RESULTS Several significant differences between the limited and severe disease subsets were observed. Patients with limited disease were nearly a decade younger at disease onset compared with patients with severe disease. Thirty-three percent of patients with severe disease were women, compared with 58% of those with limited disease. Despite their younger age at symptom onset, patients with limited disease tended to have longer disease duration, a greater likelihood of experiencing exacerbation of previous disease following a period of remission, and a higher prevalence of destructive upper respiratory tract disorders at the time of enrollment (e.g., saddle-nose deformity). Patients with limited WG were less likely than those with severe disease to have antibodies to either proteinase 3 or myeloperoxidase. Patients with severe disease had a higher likelihood of previous thyroid disease, particularly either Graves' disease or Hashimoto thyroiditis, suggesting the possibility of different pathogenetic factors within these disease subsets. Other observed differences between these subsets, such as the greater frequency of alveolar hemorrhage in the severe disease group, were related to the a priori definitions of limited and severe disease. CONCLUSION There are significant differences between patients with limited WG and those with severe WG with regard to sex, age, the likelihood of recurrent disease, the risk of damage in certain organ systems, and, possibly, etiologic factors. These differences (and perhaps other differences that are currently unrecognized) in patient subsets may have implications for mechanisms of pathogenesis, prognosis, response to treatment, and the design of future clinical investigations.
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Affiliation(s)
- John H Stone
- Johns Hopkins Vasculitis Center, 5501 Hopkins Bayview Circle, JHAAC 1B.23, Baltimore, MD 21223, USA.
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Abstract
Therapeutic agents from virtually every pharmacological class have been implicated in the development of drug-induced vasculitis. Clinical manifestations range from small vessel hypersensitivity vasculitis and leukocytoclastic vasculitis to clinical syndromes indistinguishable from classical systemic forms of vasculitis such as Wegener's granulomatosis, polyarteritis nodosa and Churg-Strauss syndrome (CSS). The exact pathogenic mechanisms involved remain to be elucidated; but both cell-mediated and humoral immunity appear to play important roles. Affected individuals may present with cutaneous involvement alone or life-threatening systemic involvement, which may result in severe and sometimes fatal illness. Since clinical presentation as well as serological and pathological parameters is identical to idiopathic forms of vasculitis, a high index of suspicion is necessary to accurately and expeditiously diagnose drug-induced vasculitis. Withdrawal of the offending agent alone is often sufficient to induce prompt resolution of clinical manifestations, obviating the need for systemic corticosteroids or more powerful forms of immunosuppression.
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Affiliation(s)
- Mittie K Doyle
- Tulane University Health Sciences Center, Department of Medicine, Section of Clinical Immunology, Allergy & Rheumatology, 1700 Perdido Street, SL-57 New Orleans, LA 70112, USA.
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Tieulie N, Huong DLT, Andreu M, Wechsler B, Mercadal L, Beaufils H, Diermert MC, Piette JC. [ANCA associated glomerulonephritis related to benzylthiouracil]. Rev Med Interne 2002; 23:853-6. [PMID: 12428489 DOI: 10.1016/s0248-8663(02)00694-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA) have been reported in patients suffering from Graves' disease treated with anti-thyroid drugs and especially propylthiouracil (PTU). EXEGESIS We report a case of Graves' disease treated with benzylthiouracil (Basdène). This therapy was complicated by acute renal insufficiency due to crescentic glomerulonephritis associated with pANCA. After benzylthiouracil withdrawal and under corticosteroids, renal insufficiency, biological inflammation and pANCA levels decreased. CONCLUSION Similar vasculitis associated with pANCA secondary to anti-thyroid drugs, especially propylthiouracil, were described. This suggests a causal relation between drug and vasculitis. To our best knowledge, it is the first case of vasculitis secondary to benzylthiouracil.
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Affiliation(s)
- N Tieulie
- Service de médecine interne, groupe hospitalier Pitié-Salpêtrière, 47, boulevard de l'Hôpital, 75651 Paris, France
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25
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Abstract
Many therapeutic agents, including recently introduced biologic response modifiers, can induce a variety of vasculitic manifestations ranging from small vessel hypersensitivity vasculitis and leukocytoclastic vasculitis to distinct vasculitic syndromes such as Wegener's granulomatosis, polyarteritis nodosa, and Churg Strauss syndrome. The pathogenic mechanisms remain to be defined and appear to be multifactorial, with cell-mediated and humural immune mechanisms playing important roles. Clinical presentation varies in severity from mild to severe and even fatal illness, can be self-limiting, or follows a more chronic protracted course. There are no significant differences in clinical presentation, serologic abnormalities, and pathologic findings with the idiopathic forms of vasculitis. However, it is extremely important to identify the offending drug because the discontinuation of the drug is often followed by a rapid improvement of the underlying vasculitic disorder.
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Affiliation(s)
- Marta Lucia Cuellar
- Section of Allergy, Immunology and Rheumatology, Department of Medicine, Tulane University Medical Center, 1700 Perdido Street-SL57, New Orleans, LA, 70112-2822, USA.
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Gil I, Porto J, Fernandes B, Gonçalo M, Carvalho L, Vieira J, Moura J. Granulomatose de Wegener – Forma limitada. REVISTA PORTUGUESA DE PNEUMOLOGIA 2002. [DOI: 10.1016/s0873-2159(15)30744-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
DIV is a relatively common cause of inflammatory vasculitis. Drugs from almost every pharmacologic class have been implicated in causing vasculitis in sporadic cases. The level of certainty and quality of evidence for these associations between specific agents and vasculitis vary greatly. The clinical manifestations of DIV range from single organ involvement (most commonly, skin) to life-threatening multiorgan disease. The recently described subset of cases of DIV associated with positive tests for ANCA are an interesting subset of DIV. The diagnosis of DIV is usually one of exclusion. The treatment of DIV is dependent on the severity of disease activity but should always include withdrawal of the suspected drug. If no agent can be implicated, as many drugs as feasible should be discontinued. The necessity of prescribing glucocorticoids or immunosuppressive agents depends on the disease severity and other case-specific information. Increasing understanding of the pathophysiologic characteristics of all inflammatory vasculitides should lead to better diagnostic and therapeutic approaches to DIV.
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Affiliation(s)
- P A Merkel
- Arthritis Center, Boston University School of Medicine, and Rheumatology Section, Boston University Medical Center, Boston, Massachusetts, USA.
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Seligman VA, Bolton PB, Sanchez HC, Fye KH. Propylthiouracil-Induced Microscopic Polyangiitis. J Clin Rheumatol 2001; 7:170-4. [PMID: 17039123 DOI: 10.1097/00124743-200106000-00007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of propylthiouracil (PTU) has been associated with various forms of vasculitis. We herein describe the case of a patient with Grave's disease who, after years of PTU therapy, developed a necrotizing vasculitis with anti-serine protease-3 antibodies. Despite treatment with corticosteroids and cyclophosphamide, the patient died of intra-alveolar hemorrhage secondary to her vasculitis. Based on the vessel size involved, the organ distribution of pathologic findings, and lack of granulomas, autopsy findings were felt to be more consistent with microscopic polyangiitis (MPA) than with her original clinical diagnosis of Wegener's granulomatosis. Her case satisfied both clinical and pathologic criteria for MPA. An MPA diagnosis is important to consider in similar clinical presentations because therapy may just need to be early withdrawal of an inciting drug, such as PTU, and the initiation of corticosteroids without cytotoxic therapy.
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Affiliation(s)
- V A Seligman
- Department of Medicine and Pathology, University of California, San Francisco, CA 94143, USA
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Sato H, Hattori M, Fujieda M, Sugihara S, Inomata H, Hoshi M, Miyamoto S. High prevalence of antineutrophil cytoplasmic antibody positivity in childhood onset Graves' disease treated with propylthiouracil. J Clin Endocrinol Metab 2000; 85:4270-3. [PMID: 11095466 DOI: 10.1210/jcem.85.11.7000] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Propylthiouracil (PTU)-induced antineutrophil cytoplasmic antibody (ANCA)-related vasculitis and nephritis were recently reported in about 30 patients with hyperthyroidism. The objective of this study was to clarify the prevalence of ANCA and the relationship between ANCA and thyroid antibodies in children with Graves' disease. Titers of myeloperoxidase (MPO)-ANCA in sera of 51 patients with childhood onset Graves' disease (16 before treatment, 25 and 10 treated with PTU and methimazole, respectively) were measured by enzyme-linked immunosolvent assay. Antithyroglobulin antibodies (TGAbs) and antithyroperoxidase antibodies (TPOAbs) were also measured by RIA in 25 PTU-treated patients. No patients had clinical manifestations of vasculitis and nephritis. MPO-ANCA was positive in 6.7% of patients before treatment and in 64.0% of those treated with PTU and in none of those treated with methimazole. MPO-ANCA had a significantly positive correlation with TGAbs (P < 0.05) and no significant correlation with TPOAbs. These findings show the high prevalence of the MPO-ANCA positivity in PTU-treated childhood onset Graves' disease, suggesting that PTU may not be preferred as the first line for the treatment of children with Graves' disease. The significant correlation between MPO-ANCA and TGAbs indicates that the severity of Graves' disease may be a factor responsible for the MPO-ANCA positivity. The cross-reactivity between MPO-ANCA and TPOAbs may not play a role in the high prevalence of MPO-ANCA in the patients exposed to PTU.
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Affiliation(s)
- H Sato
- Divisions of Endocrinology, Chiba Children's Hospital, Japan
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Collins MT, Remaley AT, Csako G, Pucino F, Skarulis MC, Balow JE, Sarlis NJ. Increased levothyroxine requirements presenting as "inappropriate" TSH secretion syndrome in a patient with nephrotic syndrome. J Endocrinol Invest 2000; 23:383-92. [PMID: 10908166 DOI: 10.1007/bf03343742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patients with primary thyroid failure on levothyroxine (LT4) replacement who develop nephrotic syndrome (NS) may rarely present with an increase in LT4 requirements. In this report, we describe a patient with thyroid failure following radioactive iodine ablation for Graves' disease who required an escalation of LT4 doses following the onset of NS. The case presented with disproportionately elevated TSH levels in the presence of normal (or slightly subnormal) thyroid hormone levels, thus, masquerading as a state of "inappropriate" TSH secretion. This pattern of extreme dysregulation in thyroid function indices due to urinary loss of thyroid hormones has not been previously described in NS, and, therefore, extends the spectrum of endocrine manifestations of NS.
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Affiliation(s)
- M T Collins
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland, USA
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Malek AM, Higashida RT, Halbach VV, Dowd CF, Phatouros CC, Lempert TE, Meyers PM, Smith WS, Stoney R. Patient presentation, angiographic features, and treatment of strangulation-induced bilateral dissection of the cervical internal carotid artery. Report of three cases. J Neurosurg 2000; 92:481-7. [PMID: 10701540 DOI: 10.3171/jns.2000.92.3.0481] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Domestic violence leading to strangulation by an abusive spouse can cause carotid artery dissection. This phenomenon is rare and has been described in only three previous instances. The authors present their management strategies in three additional cases. Three young women aged 24 to 43 years were victims of manual strangulation committed by their spouses 3 months to 1 year before presentation. Two of the patients suffered delayed cerebral infarctions before presentation and angiography demonstrated focal, mirror-image severe residual stenoses in the high-cervical internal carotid artery (ICA), which were characteristic of a healed chronic dissection; there was no evidence of fibromuscular dysplasia. One of these patients underwent unilateral percutaneous angioplasty with stent placement, and the other underwent bilateral percutaneous angioplasty. Both patients have recovered from their strokes and remain clinically stable at 8 and 20 months posttreatment, respectively. The third patient presented with bilateral ischemic frontal watershed infarctions resulting from an occluded left ICA and a severely narrowed right ICA. Given the extent of the established infarctions, this case was managed with a long-term regimen of anticoagulation medications, and the patient remains neurologically impaired. These cases illustrate the susceptibility of the manually compressed ICA to traumatic injury as a result of domestic violence. They identify bilateral symmetrical ICA dissection as a consistent finding and the real danger of delayed stroke as a consequence of strangulation. Endovascular therapy in which percutaneous angioplasty and/or stent placement are used can be useful in treating residual focal stenoses to improve cerebral perfusion and to lower the risk of embolic or ischemic stroke.
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Affiliation(s)
- A M Malek
- Department of Radiology, University of California, San Francisco, USA.
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Duffy M. Advances in diagnosis, treatment, and management of orbital and periocular Wegener's granulomatosis. Curr Opin Ophthalmol 1999; 10:352-7. [PMID: 10621551 DOI: 10.1097/00055735-199910000-00013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ophthalmologists are often in a position to diagnose Wegener's granulomatosis and prevent significant morbidity. The past 2 years have seen advances in diagnosis and management strategies for this condition. Orbital magnetic resonance imaging and histologic profiles have been better characterized. Perhaps the greatest advance has been the recognition of promising therapeutic alternatives to the current standard cytotoxic protocol. Trimethoprim-sulfamethoxazole or methotrexate may be valuable in selected patients with limited forms of Wegener's granulomatosis. Finally, new insights into the mechanisms of disease activation and tissue injury may lead to better treatment and long-term prognosis.
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Affiliation(s)
- M Duffy
- Department of Ophthalmology & Visual Sciences, University of Illinois Eye & Ear Infirmary, Chicago 60612, USA.
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