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Bettacchioli E, Foulquier JB, Chevet B, Cornec-Le Gall E, Hanrotel C, Lanfranco L, de Moreuil C, Lambert Y, Dueymes M, Foulquier N, Cornec D. Dual MPO/PR3 ANCA positivity and vasculitis: insights from a 7-cases study and an AI-powered literature review. Rheumatology (Oxford) 2024; 63:2557-2568. [PMID: 38552316 DOI: 10.1093/rheumatology/keae170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/21/2024] [Indexed: 09/05/2024] Open
Abstract
OBJECTIVES Anti-neutrophil cytoplasm antibodies (ANCA)-associated vasculitides (AAV) are rare conditions characterized by inflammatory cell infiltration in small blood vessels, leading to tissue necrosis. While most patients with AAV present antibodies against either myeloperoxidase (MPO) or proteinase 3 (PR3), rare cases of dual positivity for both antibodies (DP-ANCA) have been reported, and their impact on the clinical picture remains unclear. The goal of this study was to investigate the clinical implications, phenotypic profiles and outcomes of patients with DP-ANCA. METHODS A retrospective screening for DP-ANCA cases was conducted at Brest University Hospital's immunology laboratory (France), analysing ANCA results from March 2013 to March 2022. Clinical, biological, imaging, and histological data were collected for each DP-ANCA case. Additionally, a comprehensive literature review on DP-ANCA was performed, combining an artificial intelligence (AI)-based search using BIBOT software with a manual PUBMED database search. RESULTS The report of our cases over the last 9 years and those from the literature yielded 103 described cases of patients with DP-ANCA. We identified four distinct phenotypic profiles: (i) idiopathic AAV (∼30%); (ii) drug-induced AAV (∼25%); (iii) autoimmune disease associated with a low risk of developing vasculitis (∼20%); and (iv) immune-disrupting comorbidities (infections, cancers, etc) not associated with AAV (∼25%). CONCLUSION This analysis of over a hundred DP-ANCA cases suggests substantial diversity in clinical and immunopathological presentations. Approximatively 50% of DP-ANCA patients develop AAV, either as drug-induced or idiopathic forms, while the remaining 50%, characterized by pre-existing dysimmune conditions, demonstrates a remarkably low vasculitis risk. These findings underscore the complex nature of DP-ANCA, its variable impact on patient health, and the necessity for personalized diagnostic and management approaches in these cases.
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Affiliation(s)
- Eléonore Bettacchioli
- Immunology and Immunotherapy Laboratory, CHU de Brest, Brest, France
- LBAI Inserm UMR 1227, Univ Brest, Brest, France
| | | | | | - Emilie Cornec-Le Gall
- Nephrology Department, CHU de Brest, Brest, France
- GGB Inserm UMR 1078, Univ Brest, Brest, France
| | | | | | - Claire de Moreuil
- Internal Medicine Department, CHU de Brest, Brest, France
- GETBO Inserm UMR 1304, Univ Brest, Brest, France
| | - Yannick Lambert
- Internal Medicine Department, Morlaix Hospital Centre, Morlaix, France
| | - Maryvonne Dueymes
- Immunology and Immunotherapy Laboratory, CHU de Brest, Brest, France
- LBAI Inserm UMR 1227, Univ Brest, Brest, France
| | | | - Divi Cornec
- LBAI Inserm UMR 1227, Univ Brest, Brest, France
- Rheumatology Department, CHU de Brest, Brest, France
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Acharya I, Weisman DS, Smith LW, Arend LJ. Diagnostic dilemma: drug-induced vasculitis versus systemic vasculitis. Drug Ther Bull 2024:dtb.2024.e254736rep. [PMID: 38857951 DOI: 10.1136/dtb.2024.e254736rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Affiliation(s)
- Indira Acharya
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - David S Weisman
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Lanaya Williams Smith
- Department of Internal Medicine, MedStar Good Samaritan Hospital, Baltimore, Maryland, USA
| | - Lois Johanna Arend
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
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Xu W, Chen M, Liu S, Su Y, Zhang Y. Transient pulmonary and gastric bleeding after iopamidol administration in a patient with marginal zone lymphoma: a case report. BMC Pulm Med 2024; 24:198. [PMID: 38649880 PMCID: PMC11036599 DOI: 10.1186/s12890-024-02993-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 04/02/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Iopamidol is a non-ionic, water-soluble iodine contrast agent that is considered safe for intravenous or intra-arterial administration and is widely used both in the general population and in patients undergoing oncological treatment. While adverse reactions to iopamidol have been documented, to date, no pulmonary and gastric hemorrhages induced by iopamidol have been reported in oncology patients. We report the first case of this complication. CASE PRESENTATION We report the case of a 60-year-old woman with marginal zone lymphoma who was receiving antineoplastic therapy. As part of the investigation for the condition, she underwent chest enhancement CT with iopamidol. Shortly thereafter(within five minutes), she experienced hemoptysis and hematemesis. She was intubated and admitted to the intensive care unit. Pre- and post-contrast images demonstrated the course of the hemorrhage. Flexible bronchoscopy and gastroscopy on the following day showed no active bleeding, and the patient recovered completely after antiallergy treatment. We speculate that contrast-induced hypersensitivity was the most likely cause of the transient pulmonary and gastric bleeding. CONCLUSION Although rare, the complications of iopamidol, which may cause allergic reactions in the lungs and stomach, should be considered.
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Affiliation(s)
- Weixian Xu
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, 6 Qinren Road, Chancheng District, 528000, Foshan City, Guangdong Province, China
| | - Miaozhen Chen
- Foshan Clinical Medical School of Guangzhou University of Chinese Medicine, 3 Sanyou South Road, Chancheng District, 528000, Foshan City, Guangdong Province, China
| | - Songtao Liu
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, 6 Qinren Road, Chancheng District, 528000, Foshan City, Guangdong Province, China
| | - Yi Su
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, 6 Qinren Road, Chancheng District, 528000, Foshan City, Guangdong Province, China
| | - Yunhai Zhang
- The Eighth Clinical Medical College of Guangzhou University of Chinese Medicine, 6 Qinren Road, Chancheng District, 528000, Foshan City, Guangdong Province, China.
- Department of Critical Care Medicine, Foshan Hospital of Traditional Chinese Medicine, 6 Qinren Road, Chancheng District, 528000, Foshan City, Guangdong Province, China.
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Galip N, Ankay N, Bundak R. Vasculitis-like Palpable Purpuric Rash Induced by Decapeptyl in a Pediatric Patient Diagnosed Central Precocious Puberty. J Clin Res Pediatr Endocrinol 2023; 15:307-311. [PMID: 34763385 PMCID: PMC10448555 DOI: 10.4274/jcrpe.galenos.2021.2021.0205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/04/2021] [Indexed: 12/01/2022] Open
Abstract
Central precocious puberty (CPP) is defined as the appearance of secondary sexual signs in girls younger than eight years of age or the onset of menarche before the age of 10 years. Gonadotropin-releasing hormone analogs (GnRHa) are the most effective therapy in CPP. Drug-induced hypersensitivity vasculitis is an inflammation of blood vessels, which may be due to the use of a number of pharmacologic agents. This case report describes drug-induced vasculitis in a girl being treated with Decapeptyl. A 7.25 year-old girl was admitted to Pediatric Endocrinology outpatients with premature breast development. She was diagnosed with CPP on the basis of physical examination and laboratory findings and tripoteline acetate (Decapeptyl®) treatment was initiated. She experienced multiple widespread skin rashes and mild abdominal pain with high temperature eight hours after the second dose of Decapeptyl. She was admitted to hospital with the diagnosis of drug-induced vasculitis and a single dose of intravenous methyl-prednisolone (1 mg/kg) and oral cetirizine was given. Her blood and urine analysis revealed no other organ involvement, other than skin. On the third day, the purpuric lesions began to resolve and had completely disappeared by the sixth day. Her treatment for CPP was switched to Depot Leuprolide acetate and she continued her treatment for two years uneventfully. To the best of our knowledge, this is the first report of a child with CPP experiencing drug-induced vasculitis due to tripotelin injection. Effective treatment may be continued by switching to an alternative gonadotropin releasing hormone analog.
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Affiliation(s)
- Nilüfer Galip
- University of Kyrenia, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Allergy and Clinical Immunology, Kyrenia, North Cyprus
| | - Nermin Ankay
- Dr. Burhan Nalbantoğlu State Hospital, Clinic of Pediatrics, Nicosia, North Cyprus
| | - Rüveyde Bundak
- University of Kyrenia, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, Kyrenia, North Cyprus
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Acharya I, Weisman DS, Smith LW, Arend LJ. Diagnostic dilemma: drug-induced vasculitis versus systemic vasculitis. BMJ Case Rep 2023; 16:e254736. [PMID: 37429646 PMCID: PMC10335510 DOI: 10.1136/bcr-2023-254736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
Drug-induced vasculitis can rarely cause inflammation and necrosis of blood vessel walls of both kidney and lung tissue. Diagnosis is challenging because of the lack of difference between systemic and drug-induced vasculitis in clinical presentation, immunological workup and pathological findings. Tissue biopsy guides diagnosis and treatment. Pathological findings must be correlated with clinical information to arrive at a presumed diagnosis of drug-induced vasculitis. We present a patient with hydralazine-induced antineutrophil cytoplasmic antibodies-positive vasculitis with a pulmonary-renal syndrome manifesting as pauci-immune glomerulonephritis and alveolar haemorrhage.
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Affiliation(s)
- Indira Acharya
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - David S Weisman
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Lanaya Williams Smith
- Department of Internal Medicine, MedStar Good Samaritan Hospital, Baltimore, Maryland, USA
| | - Lois Johanna Arend
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
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Iijima Y, Kobayashi Y, Uchida Y, Tsutsui T, Kakizaki Y, Naganuma T, Tsukamoto K, Oyama T, Miyashita Y. A case report of granulomatous polyangiitis complicated by tuberculous lymphadenitis. Medicine (Baltimore) 2018; 97:e12430. [PMID: 30412059 PMCID: PMC6221664 DOI: 10.1097/md.0000000000012430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
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.
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Affiliation(s)
- Yuki Iijima
- Lung Cancer and Respiratory Disease Center, Yamanashi Central Hospital
| | - Yoichi Kobayashi
- Lung Cancer and Respiratory Disease Center, Yamanashi Central Hospital
| | - Yoshinori Uchida
- Lung Cancer and Respiratory Disease Center, Yamanashi Central Hospital
| | - Toshiharu Tsutsui
- Lung Cancer and Respiratory Disease Center, Yamanashi Central Hospital
| | - Yumiko Kakizaki
- Lung Cancer and Respiratory Disease Center, Yamanashi Central Hospital
| | | | | | - Toshio Oyama
- Pathology, Yamanashi Central Hospital, Kofu City, Yamanashi, Japan
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Morgado B, Madeira C, Pinto J, Pestana J. Leukocytoclastic Vasculitis with Systemic Involvement Associated with Ciprofloxacin Therapy: Case Report and Review of the Literature. Cureus 2016; 8:e900. [PMID: 28070469 PMCID: PMC5208583 DOI: 10.7759/cureus.900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A 71-year-old woman presented with constitutional signs and lower extremity palpable purpura after being prescribed a four-day course of 500 mg of ciprofloxacin two times daily for a gastrointestinal infection. She was admitted for inpatient treatment. During the third hospital day, she presented with an episode of abundant hematemesis while her skin lesions remained unchanged. Upper endoscopy revealed multiple lesions consistent with vasculitis and histological examination of the skin biopsy disclosed a leukocytoclastic vasculitis. The patient was successfully treated with prednisone following ciprofloxacin discontinuation. Complete resolution of the lesions on drug withdrawal strongly suggested drug toxicity, which was further supported by a score of 8 in the Naranjo Adverse Drug Reaction Probability Scale. Awareness that the development of skin and gastrointestinal lesions following administration of ciprofloxacin may be a manifestation of ciprofloxacin-induced vasculitis can help early detection, treatment, and lead to an overall good prognosis.
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Affiliation(s)
- Bruno Morgado
- Department of Biomedical Sciences and Medicine, University of Algarve
| | | | - Joana Pinto
- Department of Biomedical Sciences and Medicine, University of Algarve
| | - Joana Pestana
- Department of Internal Medicine, Hospital Centre of Algarve
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ANCA Associated Vasculitis and Renal Failure Related to Propylthiouracil and Hyperthyroidism Induced Cholestasis in the Same Case. Case Rep Nephrol 2014; 2014:762528. [PMID: 25506446 PMCID: PMC4258370 DOI: 10.1155/2014/762528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 10/15/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction. Liver involvement due to hyperthyroidism and also ANCA positive vasculitis related renal failure cases were reported separately several times before. However, to our knowledge, these two complications together in the same case had never been observed before. Case Presentation. The case of an ANCA positive 71-year-old Caucasian male with renal failure and lung involvement, subclinical hyperthyroidism, and intrahepatic cholestatic jaundice was presented in this paper. After exclusion of all of the other possibilities, cholestatic hepatitis was explained by subclinical hyperthyroidism; renal failure and lung involvement were interpreted as ANCA related vasculitis which might be a side effect of propylthiouracil use. Conclusion. The coexistence of these rare conditions in the same patient deserves emphasis and it is worth reporting. This case demonstrates that following the clinical course of the patient is essential after prescribing any medications to see whether any complication occurs or not. If the complications of this case were noticed earlier, it would be possible to treat and to prevent the permanent damages.
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9
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Wakabayashi K, Kadowaki T. [A case of alveolar hemorrhage 35 years after propylthiouracil treatment]. Nihon Ronen Igakkai Zasshi 2012; 49:612-616. [PMID: 23459653 DOI: 10.3143/geriatrics.49.612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
A 69-year-old woman had received oral treatment of propylthiouracil (PTU) under a diagnosis of hyperthyroidism for 35 years. In the first 10 days of January 2009, she noticed the development of a cough. In February of the same year, she consulted a clinic with bloody sputum. Chest X-ray films revealed diffuse infiltration in both lungs, and she came to our hospital for further examination. An alveolar hemorrhage was identified by bronchial alveolar lavage testing. Because the cough was relieved by stopping PTU administration and there has been no relapse during 2-year follow-up, this case was diagnosed as PTU-induced diffuse alveolar hemorrhage. Her myeloperoxidase (MPO) -anti-neutrophil cytoplasmic antibody (ANCA) level was 55 EU, suggesting ANCA-associated angitis. However, as a drug lymphocyte stimulation test to PTU was also positive and her MPO-ANCA level was not elevated, the onset mechanism of this case was unclear.
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Affiliation(s)
- Kiryo Wakabayashi
- Department of Pulmonary Medicine, National Hospital Organization Matsue Medical Center
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10
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Pietszkowski NC, Carvalho GAD, Souza HND, Werka CR, Borazo LA, Graf H, Carvalho MD. [Antineutrophil cytoplasmic antibody (Anca)-associated autoimmune disease induced by propylthiouracil]. ACTA ACUST UNITED AC 2008; 51:136-41. [PMID: 17435868 DOI: 10.1590/s0004-27302007000100022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Accepted: 06/23/2006] [Indexed: 11/22/2022]
Abstract
Antithyroid drugs sometimes cause severe complications. Propylthiouracil (PTU) can be associated to ANCA positive vasculitis, most often related to myeloperoxidase subtype (ANCA-MPO). Our objective is to describe a female patient with Graves' disease, who developed PTU induced-autoimmune disease, with cutaneous, pulmonary, and renal lesions, associated with ANCA. Histopathological examination revealed diffuse pulmonary hemorrhage, and focal segmental glomerulosclerosis at the kidney biopsy. She was treated with systemic corticosteroid therapy and cyclophosphamide, with clinical improvement. This case highlights the need for greater awareness of this relatively rare adverse effect of propylthiouracil.
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Kang AY, Baek YH, Sohn YJ, Lee SK, Son CH, Kim K, Yang DK. Diffuse alveolar hemorrhage associated with antineutrophil cytoplasmic antibody levels in a pregnant woman taking propylthiouracil. Korean J Intern Med 2006; 21:240-3. [PMID: 17249506 PMCID: PMC3891029 DOI: 10.3904/kjim.2006.21.4.240] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Propylthiouracil (PTU) is known to be a potential cause of antineutrophil cytoplasmic antibody (ANCA) positive small vessel vasculitis, resulting in glomerulonephritis and diffuse alveolar hemorrhage (DAH). Herein, we describe a 25-year-old pregnant woman who developed a perinulcear ANCA (p-ANCA) and myeloperoxidase ANCA (MPO-ANCA) positive DAH during PTU therapy. The patient improved after corticosteroid therapy and discontinuation of the PTU. Methimazole was prescribed in spite of the risk of recurrence of DAH because of the pregnancy. The patient is currently free from pulmonary problems. Our case shows that the alternative agent, methimazole, can be used to treat hyperthyroidism in a pregnant patient with PTU associated DAH.
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Affiliation(s)
- Ah Young Kang
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Yang Hyun Baek
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - You Jung Sohn
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Soo-Keol Lee
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Choon Hee Son
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - KyeongHee Kim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Doo Kyung Yang
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
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Kawasaki S, Nakamura H, Honda E, Iwanaga N, Kawakami A, Ida H, Origuchi T, Honda S, Tsuchihashi Y, Yoshimine H, Eguchi K. Tacrolimus as a reinforcement therapy for a patient with MPO-ANCA-associated diffuse alveolar hemorrhage. Clin Rheumatol 2006; 26:1211-4. [PMID: 16900300 DOI: 10.1007/s10067-006-0355-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Revised: 05/24/2006] [Accepted: 05/24/2006] [Indexed: 11/29/2022]
Abstract
A 67-year-old woman, suffering from continuous hemoptysis, was admitted to our hospital where she was managed with mechanical ventilation. Computed tomography of the chest demonstrated bilateral massive alveolar hemorrhage without evidence of infectious disease. She was diagnosed with anti-myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA)-associated diffuse alveolar hemorrhage because a high titer of MPO-ANCA was found in the serum. Plasmapheresis as well as methylprednisolone pulse therapy were initiated, followed by intravenous administration of cyclophosphamide. Tacrolimus was employed for the maintenance therapy, and the oral prednisolone dosage could successfully be tapered without recurrence, along with the decrement of the titer of MPO-ANCA.
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Affiliation(s)
- Satoko Kawasaki
- The First Department of Internal Medicine, Graduate School of Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto, Nagasaki City, Nagasaki 852-8501, Japan
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13
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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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14
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Yu F, Zhao MH, Zhang YK, Zhang Y, Wang HY. Anti-endothelial cell antibodies (AECA) in patients with propylthiouracil (PTU)-induced ANCA positive vasculitis are associated with disease activity. Clin Exp Immunol 2005; 139:569-74. [PMID: 15730404 PMCID: PMC1809319 DOI: 10.1111/j.1365-2249.2005.02725.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2004] [Indexed: 11/26/2022] Open
Abstract
Increasing evidence has demonstrated that propylthiouracil (PTU) could induce ANCA positive vasculitis. However, our previous work has suggested that only one-fifth of the PTU-induced ANCA positive patients had clinical vasculitis and so the mechanism is not clear. Anti-endothelial cell antibodies (AECA) have been implicated in the pathogenesis of various vasculitides, including primary ANCA positive systemic vasculitis. The purpose of this study is to investigate the prevalence of AECA and their possible role in the pathogenesis of patients with PTU-induced ANCA positive vasculitis. Sera from 11 patients with PTU-induced ANCA positive vasculitis at both active and quiescent phases, and sera from 10 patients with PTU-induced ANCA but without clinical vasculitis, were studied. Sera from 30 healthy blood donors were collected as normal controls. Soluble proteins from 1% Triton-100 extracted in vitro cultured human umbilical vein endothelial cells were used as antigens and an immunoblotting technique was performed to determine the presence of AECA, and their specific target antigens were identified. In patients with PTU-induced ANCA positive vasculitis, 10 of the 11 patients in an active phase of disease were serum IgG-AECA positive and six protein bands of endothelial antigens could be blotted (61 kD, 69 kD, 77 kD, 85 kD, 91 kD and 97 kD). However, in the quiescent phase, seven of the 10 positive sera turned negative. None of the ANCA positive but vasculitis negative patients or normal controls were AECA positive. In conclusion, AECA could be found in sera from patients with PTU-induced ANCA positive vasculitis and were associated more closely with vasculitic disease activity.
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Affiliation(s)
- F Yu
- Institutes Renal Division and Institute of Nephrology, Peking University First Hospital, Beijing, China
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15
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Abstract
PURPOSE OF REVIEW Much of our education about endocrine disorders focuses on their diagnosis and treatment. Although the musculoskeletal manifestations of endocrine disorders are well documented, they are often overlooked. This review will discuss new developments regarding those rheumatic manifestations. RECENT FINDINGS Diabetic research is investigating connective tissue alterations in hand syndromes. A recent review elucidated the natural history of diabetic muscle infarction. Research has identified factors that stimulate osteoblast activity in diffuse idiopathic skeletal hyperostosis and bone loss in diabetics. Accumulating evidence documents thyroid disease coexisting with connective tissue disorders. Reports document cases of vasculitis occurring after propylthiouracil treatment. Finally, data clarifies the effects of thyroid dysfunction, hyperparathyroidism, acromegaly and hypercortisolism on bone. SUMMARY Current research mainly relates to the effects of endocrine disorders on bone. As we advance our understanding of mechanisms that lead to rheumatic disorders in endocrine disease, we will improve our ability to treat them.
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Affiliation(s)
- Dana Jacobs-Kosmin
- Division of Rheumatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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