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Massicotte-Azarniouch D, Herrera CA, Jennette JC, Falk RJ, Free ME. Mechanisms of vascular damage in ANCA vasculitis. Semin Immunopathol 2022; 44:325-345. [PMID: 35254509 PMCID: PMC9064952 DOI: 10.1007/s00281-022-00920-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/02/2022] [Indexed: 12/12/2022]
Abstract
The discovery of anti-neutrophil cytoplasmic antibodies (ANCA) and their antigenic targets, myeloperoxidase (MPO) and proteinase 3 (PR3), has led to further understanding as to the pathophysiologic processes that underlie vascular and tissue damage in ANCA vasculitis. ANCA trigger neutrophil activation leading to vascular damage in ANCA vasculitis. However, decades of study have determined that neutrophil activation alone is not sufficient to cause disease. Inflammatory stimuli are drivers of ANCA autoantigen expression and ANCA production. Certain infections or bacterial peptides may be crucial players in the initial steps of ANCA immunopathogenesis. Genetic and epigenetic alterations of gene encoding for MPO and PR3 provide additional disturbances to the immune homeostasis which provide a substrate for pathogenic ANCA formation from an adaptive immune system predisposed to autoreactivity. Promoted by inflammatory cytokines, ANCA binding leads to neutrophil activation, a process characterized by conformational changes, production and release of cytotoxic substances, and alternative complement pathway activation, thus creating an intense inflammatory milieu. This cascade of events perpetuates a vicious cycle of further inflammatory cell recruitment and activation, culminating in tissue necrosis. Our understanding of the pathogenic process in ANCA vasculitis paves the way for the development of therapies targeting crucial steps in this process. The greater appreciation of the role for complement, monocytes, and the adaptive immune system has already led to novel complement blockers and is poised to lead to further innovations which will allow for tailored antigen- or cell-specific immunotherapy targeting the autoimmune process without exposure to undue risks or toxicities.
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Affiliation(s)
- David Massicotte-Azarniouch
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Carolina A Herrera
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ronald J Falk
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Meghan E Free
- Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
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Davidson KR, Ha DM, Schwarz MI, Chan ED. Bronchoalveolar lavage as a diagnostic procedure: a review of known cellular and molecular findings in various lung diseases. J Thorac Dis 2020; 12:4991-5019. [PMID: 33145073 PMCID: PMC7578496 DOI: 10.21037/jtd-20-651] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Bronchoalveolar lavage (BAL) is a commonly used procedure in the evaluation of lung disease as it allows for sampling of the lower respiratory tract. In many circumstances, BAL differential cell counts have been reported to be typical of specific lung disorders. In addition, more specific diagnostic tests including molecular assays such as polymerase chain reaction (PCR) or enzyme-linked immunosorbent assay, special cytopathologic stains, or particular microscopic findings have been described as part of BAL fluid analysis. This review focuses on common cellular and molecular findings of BAL in a wide range of lung diseases. Since the performance of the first lung irrigation in 1927, BAL has become a common and important diagnostic tool. While some pulmonary disorders have a highly characteristic signature of BAL findings, BAL results alone often lack specificity and require interpretation along with other clinical and radiographic details. Development of new diagnostic assays is certain to reinforce the utility of BAL in the future. Our review of the BAL literature is intended to serve as a resource to assist clinicians in the care of patients with lung disorders.
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Affiliation(s)
- Kevin R Davidson
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Duc M Ha
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Marvin I Schwarz
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Edward D Chan
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,National Jewish Health, Denver, Colorado, USA
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3
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Alba MA, Jennette JC, Falk RJ. Pathogenesis of ANCA-Associated Pulmonary Vasculitis. Semin Respir Crit Care Med 2018; 39:413-424. [PMID: 30404109 DOI: 10.1055/s-0038-1673386] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Antineutrophil cytoplasmic antibodies (ANCAs) are autoantibodies specific for antigens located in the cytoplasmic granules of neutrophils and lysosomes of monocytes. ANCAs are associated with a spectrum of necrotizing vasculitis that includes granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis. Pulmonary vasculitis and related extravascular inflammation and fibrosis are frequent components of ANCA vasculitis. In this review, we detail the factors that have been associated with the origin of the ANCA autoimmune response and summarize the most relevant clinical observations, in vitro evidence, and animal studies strongly indicating the pathogenic potential of ANCA. In addition, we describe the putative sequence of pathogenic mechanisms driven by ANCA-induced activation of neutrophils that result in small vessel necrotizing vasculitis and extravascular granulomatous necrotizing inflammation.
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Affiliation(s)
- Marco A Alba
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ronald J Falk
- University of North Carolina Kidney Center, Chapel Hill, North Carolina.,UNC Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Propylthiouracil-Associated Leukocytoclastic Necrotizing Cutaneous Vasculitis: A Case Report and Review of the Literature. J Burn Care Res 2018; 38:e678-e685. [PMID: 27893578 DOI: 10.1097/bcr.0000000000000464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The purpose of this case report and review of the literature is to provide an exploration of the clinical symptoms, diagnosis, prevention, and management of propylthiouracil (PTU)-associated vasculitis in the intensive care setting. A PubMed search of the available literature was conducted using the MeSH search terms "propylthiouracil" and "vasculitis." The literature search returned 121 articles. Twenty-five were excluded because they were not in English. Fifty-nine case reports or case studies describing PTU-associated vasculitis were included. Data extracted from each case study included patient age, sex, autoimmune markers, laboratory tests, length of time on PTU, treatment for vasculitis, and patient outcomes. The authors reviewed 128 cases of PTU-associated vasculitis. The majority were women (8.8:1 F:M ratio), and the most common presenting symptoms were rash (51.6%), fever (46.9%), and arthralgia (43.8%). In addition to discontinuing PTU, the most common treatment was steroids (71.9%). Eight patients (6.3%) progressed to end-stage renal disease; two (1.6%) required intubation for respiratory failure; and five (3.9%) died of various organ systems failure related to vasculitis development. A high index of suspicion for vasculitis should be maintained, especially when presented with skin manifestations in the presence of PTU therapy. Screening with myeloperoxidase-antinuclear cytoplasmic antibodies is most sensitive. Positive screening should prompt a thorough clinical investigation. In cases of severe skin manifestations, the focus should be on aggressive wound care. Our case report is unique, not only in the size and extent of cutaneous involvement, but also as the first description of mortality secondary to cutaneous manifestations.
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Abstract
A 39-year-old man treated with dasatinib for chronic myelogenous leukaemia presented to our hospital with haemoptysis, coughing, and dyspnoea. Chest radiography and computed tomography revealed ground-glass opacities and a crazy-paving pattern. Bronchoalveolar lavage was not performed due to serious hypoxemia and bleeding. Significant bleeding from the peripheral bronchi led to a diagnosis of an alveolar haemorrhage. Dasatinib-induced alveolar haemorrhaging was suspected based on the clinical findings. His condition improved immediately after dasatinib withdrawal and initiation of steroid therapy. Reports of alveolar haemorrhaging induced by dasatinib are rare. As such, this is considered an important case.
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Affiliation(s)
- Yoritake Sakoda
- Department of Respiratory Medicine, St. Mary's Hospital, Japan
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Ferreira C, Costa T, Marques AV. Diffuse alveolar haemorrhage secondary to propylthiouracil-induced vasculitis. BMJ Case Rep 2015; 2015:bcr-2014-208289. [PMID: 25661751 DOI: 10.1136/bcr-2014-208289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Propylthiouracil is a drug used to treat hyperthyroidism. It can cause several side effects including pulmonary disorders that, although rare, can be severe. The authors describe the case of a woman treated with propylthiouracil who developed diffuse alveolar haemorrhage with severe respiratory failure and anaemia, which improved with discontinuation of the antithyroid drug and on starting systemic corticosteroid therapy.
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Affiliation(s)
- Catarina Ferreira
- Pulmonology Department, Centro Hospitalar e Universitário de Coimbra-Hospital Geral, Coimbra, Portugal
| | - Teresa Costa
- Pulmonology Department, Centro Hospitalar e Universitário de Coimbra-Hospital Geral, Coimbra, Portugal
| | - Ana Vieira Marques
- Intensive Care Unit, Centro Hospitalar e Universitário de Coimbra-Hospital Geral, Coimbra, Portugal
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Kurimoto R, Sekine I, Iwasawa S, Sakaida E, Tada Y, Tatsumi K, Takahashi Y, Nakatani Y, Imai C, Takiguchi Y. Alveolar hemorrhage associated with pemetrexed administration. Intern Med 2015; 54:833-6. [PMID: 25832952 DOI: 10.2169/internalmedicine.54.3414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein describe a 67-year-old man with advanced adenocarcinoma of the lung who developed an alveolar hemorrhage (AH) associated with pemetrexed. He received four courses of pemetrexed therapy with carboplatin and seven courses of pemetrexed maintenance therapy. One week after the last pemetrexed administration, the patient developed hemoptysis with deteriorating dyspnea and anemia. Chest images showed diffuse ground-glass attenuation. The diagnosis of AH was based on findings of bloody bronchoalveolar lavage (BAL) fluid, hemosiderin-laden macrophages in the BAL fluid, and a transbronchial lung biopsy sample. This report is the first to describe AH associated with pemetrexed.
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Affiliation(s)
- Ryota Kurimoto
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Japan
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Gorgan M, Bockorny B, Lawlor M, Volpe J, Fiel-Gan M. Pulmonary hemorrhage with capillaritis secondary to mycophenolate mofetil in a heart-transplant patient. Arch Pathol Lab Med 2013; 137:1684-7. [PMID: 24168511 DOI: 10.5858/arpa.2012-0460-cr] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Immunosuppressive drugs are an integral part of therapy in organ transplantation. However, they are not without side effects, and although rare, these agents should be considered in the differential diagnosis of pulmonary complications in patients receiving transplants. We present a case of a patient who developed acute respiratory failure 7 days after orthotopic heart transplantation and who had been on both mycophenolate mofetil (MMF) and tacrolimus agents. Lung biopsy revealed features of pulmonary hemorrhage with capillaritis. Considered as a possible etiology, MMF was withdrawn. There was immediate improvement of the patient's symptoms. The temporal relationship between MMF exposure and onset of pulmonary symptoms in the absence of other possible etiologies strongly suggests a causal relationship. Previously published reports of pulmonary toxicity from MMF included interstitial fibrosis. To the best of our knowledge, this is the first reported case of pulmonary hemorrhage with capillaritis because of administration of MMF.
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Affiliation(s)
- Maria Gorgan
- From the Departments of Pathology (Drs Gorgan and Fiel-Gan), Radiology (Dr Volpe), Infectious Diseases (Dr Lawlor), and Internal Medicine (Dr Bockorny), Hartford Hospital, Hartford, Connecticut
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Kimura M, Seki T, Ozawa H, Ishihara T, Komatsu M, Tajiri S, Yanagi H, Nishina M, Noh JY, Fukagawa M, Takagi A. The onset of antineutrophil cytoplasmic antibody-associated vasculitis immediately after methimazole was switched to propylthiouracil in a woman with Graves' disease who wished to become pregnant. Endocr J 2013; 60:383-8. [PMID: 23154533 DOI: 10.1507/endocrj.ej12-0212] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Propylthiouracil (PTU) is recommended as a first-line antithyroid drug (ATD) during first trimester organogenesis in pregnancy because recent evidence suggests that methimazole (MMI) may be associated with congenital anomalies. However, PTU more commonly causes myeloperoxidase (MPO)-antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis, which usually occurs during prolonged treatment, compared with MMI. We report a case of MPO-ANCA-associated vasculitis in a 35-year-old woman with Graves'disease. Although her thyroid function could be maintained euthyroid by MMI, her ATD was switched to PTU because she wished to become pregnant. The patient presented with flu-like symptoms 8 days after starting PTU and developed hemoptysis and dyspnea at 22 days. Her MPO-ANCA titer was 21 ELISA units (EUs) before PTU treatment but increased to 259 EUs at 22 days after PTU treatment. Her clinical condition improved with the discontinuation of PTU and with immunosuppressive therapy. This case indicated that MPO-ANCA vasculitis occurred within several weeks after the initiation of PTU and that this side effect could be caused by the change from MMI to PTU. Thus, our clinical observation suggests that patients treated with PTU should be carefully monitored for MPO-ANCA titers and variable manifestations of MPO-ANCA-associated vasculitis regardless of the period of administration.
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Affiliation(s)
- Moritsugu Kimura
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Kanagawa 259-1193, Japan.
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Abstract
INTRODUCTION This review addresses the pulmonary manifestations of the vasculitides, with a focus on diagnostic modalities. Haemorrhagic presentations (usually associated with nephritis: the pulmonary-renal syndrome) are the most common vasculitic cause of early death. AREAS COVERED The diagnostic modalities in the pulmonary vasculitides are reviewed, with a focus on primary systemic vasculitis. A literature search of original research and review articles on pulmonary vasculitides was undertaken using the PubMed database. EXPERT OPINION Small-vessel anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, especially granulomatosis with polyangiitis (Wegener's granulomatosis) are the most frequent causes of pulmonary vasculitis and typically present as nodules, alveolar infiltrates (haemorrhagic or not), cavities or tracheobronchial stenosis. Lung involvement is less common in large-vessel vasculitis when pulmonary vascular abnormalities can be seen. No single test is pathogonomonic and diagnosis requires integration of clinical, laboratory, imaging and histological findings. Treatment follows similar regimens to other vasculitic presentations, with glucocorticoids in conjunction with immunosuppressive agents, and management of intercurrent sepsis and the increased risk of cardiovascular and thromboembolic events. Prompt diagnosis and intensive treatment of pulmonary vasculitis is essential to improve early mortality and long-term outcomes.
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Affiliation(s)
- Alina Casian
- Addenbrooke's Hospital, Vasculitis and Lupus Clinic , Cambridge , UK
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Chen M, Gao Y, Guo XH, Zhao MH. Propylthiouracil-induced antineutrophil cytoplasmic antibody-associated vasculitis. Nat Rev Nephrol 2012; 8:476-83. [PMID: 22664738 DOI: 10.1038/nrneph.2012.108] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) refers to a group of potentially life-threatening autoimmune diseases. A recent development in this field is the recognition that certain drugs can induce AAV. Among these agents, the drug most often implicated in causing disease is the commonly used antithyroid agent propylthiouracil (PTU). This Review provides an update on PTU-induced AAV. Clinical characteristics of PTU-induced AAV are similar to that of primary AAV, but usually have a milder course and better prognosis, provided early cessation of the disease-causing drug. PTU-induced ANCAs usually react to several components of myeloid granules, which is helpful in differentiating PTU-induced AAV from primary AAV. Early cessation of PTU is crucial in the treatment of PTU-induced AAV. The duration of immunosuppressive therapy might be shorter than in primary AAV, depending on the severity of organ damage, and maintenance therapy is not always necessary.
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Affiliation(s)
- Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Xicheng District, Beijing 100034, China
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Lee JH, Kim MS, Lee JG, Kim DS, Yang HJ, Kang KW. A Case of Diffuse Alveolar Hemorrhage with Glomerulonephritis after Propylthiouracil Treatment. Tuberc Respir Dis (Seoul) 2012. [DOI: 10.4046/trd.2012.72.1.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ji Hyun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Min Su Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jae Gon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Dae Sik Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Hae Jin Yang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Kyung Woo Kang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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Lee JY, Chung JH, Lee YJ, Park SS, Kim SY, Koo HK, Lee JH, Lee CT, Yoon HI. Propylthiouracil-induced nonspecific interstitial pneumonia. Chest 2011; 139:687-690. [PMID: 21362656 DOI: 10.1378/chest.10-1558] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Propylthiouracil (PTU) is a drug used to treat hyperthyroidism. A number of adverse effects have been reported with this drug, including fever, agranulocytosis, skin rash, and vasculitis. PTU-induced interstitial pneumonia is rare--only three cases have been reported--and PTU-induced nonspecific interstitial pneumonia (NSIP) has not been reported. We report a patient who developed NSIP after taking PTU for 1 year. She developed dyspnea, cough, and mild fever lasting 1 month, and a chest CT scan showed multifocal patchy consolidation in both lungs. She underwent a surgical lung biopsy, and NSIP was confirmed pathologically. The symptoms and abnormalities seen in the chest radiograph improved after withdrawal of PTU. To our knowledge, this is the first documented case of pathologically proven PTU-induced NSIP.
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Affiliation(s)
- Ji Yeon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul
| | - Jin-Haeng Chung
- Department of Pathology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul
| | - Sung Soo Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul
| | - Seo Yun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul
| | - Hyeon-Kyoung Koo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul; Division of Pulmonary and Critical Care Medicine, the Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, the Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Ho Il Yoon
- Division of Pulmonary and Critical Care Medicine, the Department of Internal Medicine and Lung Institute, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.
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Yazisiz V, Ongüt G, Terzioğlu E, Karayalçin U. Clinical importance of antineutrophil cytoplasmic antibody positivity during propylthiouracil treatment. Int J Clin Pract 2010; 64:19-24. [PMID: 18284438 DOI: 10.1111/j.1742-1241.2007.01485.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Propylthiouracil (PTU) is the mainstay of antithyroid drug therapy. Previous studies reported antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis in patients treated for Graves' disease. ANCA has been associated with either PTU or to the disease itself. However, this issue has not been investigated in toxic multinodular goitre (TMNG). The aim of this study was to evaluate the frequency of ANCA positivity in both TMNG and Graves' disease patients treated with PTU, and to investigate the clinical importance of this issue. PATIENTS AND METHODS We studied the presence of ANCA in 46 patients treated with PTU (30 Graves' disease, 16 TMNG). Two years after the discontinuation of PTU, ANCA was re-evaluated in 29 patients (18 Graves' disease, 11 TMNG). RESULTS By indirect immunofluorescence, 19 of the 46 patients (41.3%) on PTU treatment were ANCA positive [13 of the 30 patients in Graves disease (43.3%), six of the 16 patients in TMNG (37.5%)]. There was no statistically significant difference between Graves' disease and TMNG patients for ANCA positivity (p = 0.362). ANCA positivity was not related to gender, thyroid autoantibodies, alanine aminotransferase, aspartate aminotransferase, neutrophil count and PTU dose. Two years after withdrawal of PTU treatment, 10.3% of patients continued to have positive ANCA (p < 0.0001). Signs and symptoms of vasculitis could not be detected in any of the ANCA-positive patients. CONCLUSION Our study suggests that PTU but not Graves' disease itself is the most important factor for ANCA development. The frequency of ANCA positivity is 41.3% in our country which was not different in Graves' disease and TMNG patients. The dose of PTU and ethnic factors are not associated with ANCA positivity. After cessation of PTU, vasculitis did not develop during the 2 years of follow-up despite positive ANCA.
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Affiliation(s)
- V Yazisiz
- Division of Rheumatology, Department of Medicine, Medical School, Akdeniz University, Antalya, Turkey
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15
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Hara A, Mukae H, Hara S, Amenomori M, Ishimoto H, Kakugawa T, Fujita H, Sakamoto N, Ishii H, Ishimatsu Y, Kohno S. Drug-induced eosinophilic pneumonia with pulmonary alveolar hemorrhage caused by benzbromarone. Intern Med 2010; 49:435-8. [PMID: 20190479 DOI: 10.2169/internalmedicine.49.2830] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 51-year-old man was admitted to our hospital with cough, hemosputum, dyspnea and chest pain. Chest high-resolution computed tomography (HRCT) revealed diffuse ground-glass opacities in both lungs with peripheral predominance. Bronchoalveolar lavage fluid was fresh-bloody and analysis indicated an increase in the eosinophil proportion. Benzbromarone-induced lymphocyte stimulation test was positive. Therefore, the patient was diagnosed as having drug-induced eosinophilic pneumonia with pulmonary alveolar hemorrhage caused by benzbromarone. After discontinuation of benzbromarone and administration of corticosteroids, chest HRCT images and respiratory manifestation improved. Here, we report this rare case of benzbromarone-induced eosinophilic pneumonia with pulmonary alveolar hemorrhage.
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Affiliation(s)
- Atsuko Hara
- Second Department of Internal Medicine, Nagasaki University School of Medicine
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16
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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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Benson A, Schwarz M. A 26-year-old woman with recurrent hemoptysis and a sleep disturbance. Chest 2009; 134:1325-1331. [PMID: 19059964 DOI: 10.1378/chest.08-1410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
| | - Marvin Schwarz
- University of Colorado Health Sciences Center, Denver, CO
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18
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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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Elshinawy AA, Khan S. PROPYLTHIOURACIL-INDUCED DIFFUSE ALVEOLAR HEMORRHAGE. Chest 2007. [DOI: 10.1378/chest.132.4_meetingabstracts.687a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
Until recently, the prognosis associated with many forms of systemic vasculitis was quite grim. Advances in this field have allowed us to begin to focus on issues related to quality of life such as fertility, conception, and pregnancy among women with vasculitis. Because the systemic vasculitides are rare diagnoses, many important questions remain unanswered. Overall, it seems that women who have inactive vasculitis may not be subject to unusual complications during pregnancy, but our understanding of the interaction between pregnancy and specific forms of vasculitis continues to evolve.
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Affiliation(s)
- Philip Seo
- The Johns Hopkins University, Division of Rheumatology, Baltimore, MD 21224, USA.
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Hadjiangelis NP, Harkin TJ. Propylthiouracil-related diffuse alveolar hemorrhage with negative serologies and without capillaritis. Respir Med 2007; 101:865-7. [PMID: 17296293 DOI: 10.1016/j.rmed.2006.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Accepted: 07/10/2006] [Indexed: 11/16/2022]
Abstract
Propylthiouracil (PTU) has been held responsible for diffuse alveolar hemorrhage (DAH) with positive antineutrophil cytoplasmic antibody (ANCA) and capillaritis. We describe a case of a 23-year-old pregnant female with Grave's disease treated with PTU who presented with flu-like symptoms and progressive dyspnea. Open lung biopsy showed DAH without evidence of capillaritis. All serologies were negative. Five days after PTU withdrawal and intravenous steroid therapy, the patient improved dramatically. She remained symptom free without relapse 9 months after the episode. To the best of our knowledge, this is the first reported case of PTU-related alveolar hemorrhage with negative serologic markers and without capillaritis.
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Affiliation(s)
- Nicos P Hadjiangelis
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, New York University School of Medicine, 462 First Avenue, NB 7N, New York, NY 10016, USA.
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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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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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Karincaoglu Y, Esrefoglu M, Aki T, Mizrak B. Propylthiouracil-induced vasculitic oral ulcers with anti-neutrophil cytoplasmic antibody. J Eur Acad Dermatol Venereol 2006; 20:120-2. [PMID: 16405633 DOI: 10.1111/j.1468-3083.2005.01351.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Mayaud C, Fartoukh M, Parrot A, Cadranel J, Milleron B, Akoun G. [Drug-associated interstitial lung disease: a diagnostic challenge]. REVUE DE PNEUMOLOGIE CLINIQUE 2005; 61:179-85. [PMID: 16142191 DOI: 10.1016/s0761-8417(05)84810-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Drugs are frequently incriminated as the cause of interstitial pneumonia. There are two major mechanisms of drug-associated interstitial lung disease: direct toxicity and immunoallergic reaction. When a drug is suspected, the difficulty lies in obtaining proof. The chronology of the disease and its manifestations together with earlier evidence reported in the literature can lead to a tentative diagnosis of drug-associated interstitial pneumonia. Proof is obtained through surveillance during the disease course. In nearly all patients, therapeutic decisions must be taken on the basis of suspected drug involvement.
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Affiliation(s)
- Charles Mayaud
- Service de Pneumologie, Hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris.
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Calañas-Continente A, Espinosa M, Manzano-García G, Santamaría R, Lopez-Rubio F, Aljama P. Necrotizing glomerulonephritis and pulmonary hemorrhage associated with carbimazole therapy. Thyroid 2005; 15:286-8. [PMID: 15785249 DOI: 10.1089/thy.2005.15.286] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Methimazole, carbimazole, and propylthiouracil (PTU) are the mainstays of antithyroid drug therapy. Adverse effects of these drugs have been documented in less than 15% of patients undergoing treatment for hyperthyroidism. Common problems include fever, skin rash, urticaria, arthralgias, and arthritis. Vasculitis associated with antineutrophil anticytoplasmic antibodies (ANCA) has been reported on several occasions following treatment with PTU. However, vasculitis rarely appears to be associated with carbimazole. We report the clinical history of a woman with a necrotizing glomerulonephritis and pulmonary hemorrhage associated with carbimazole therapy.
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Russo-Carbolante EMDS, Azzolini AECS, Polizello ACM, de Assis-Pandochi AI, Lucisano-Valim YM. Propylthiouracil and thiamazole do not alter in vitro neutrophil oxidative burst. Metabolism 2005; 54:300-5. [PMID: 15736106 DOI: 10.1016/j.metabol.2004.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Propylthiouracil and thiamazole are thionamides used in the treatment of hyperthyroidism. In addition to reducing thyroid hormone synthesis, these drugs have other activities that improve the hypermetabolic state of the patients as well as adverse and toxic effects. The capacity of these 2 drugs to interfere with the production of reactive oxygen species of human neutrophils exposed in vitro to these drugs was evaluated. The production of reactive oxygen species was assessed by chemiluminescence assays and the cells were stimulated with zymosan particles opsonized with a pool of normal human serum. No alteration was found in the chemiluminescence response of treated human neutrophils when compared to controls. The results show that these drugs, at the studied concentrations and with the experimental approach used, have no direct effect on the production of oxidative burst of neutrophils. We conclude that if these drugs have any action on the oxidative metabolism of neutrophils these might include some metabolization steps that do not take place in this in vitro model.
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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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30
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Braham A, Houman MH, Rais L, Ben Gborbel I, Lamloum M, Miled M. Vascularite à anticorps anticytoplasme de polynucléaires neutrophiles induite par le benzylthio-uracile. Presse Med 2004; 33:1331-3. [PMID: 15615240 DOI: 10.1016/s0755-4982(04)98919-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Several cases of vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA) have been reported in patients treated with synthetic anti-thyroid drugs but only 2 cases have incriminated benzylthiouracil. OBSERVATION A 36 year-old woman, 3 years after treatment with benzylthiouracil, rapidly developed progressive kidney failure, related to a pauci-immune extra-capillary glomerular nephropathy and necrotic vasculitis lesions. The search for p-ANCA was positive with anti-myeloperoxidase specificity. She was treated with corticosteroids and 6 monthly intravenous pulses of cyclophosphamide substituted by azathioprine. Renal failure and proteinuria significantly improved. However the high level of p-ANCA. CONCLUSION ANCA vascularities are a rare but serious complication of treatment with synthetic thiouracile-type anti-thyroid drugs. The ANCA must be measured when confronted with a systemic manifestation during treatment.
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Affiliation(s)
- Amel Braham
- Service de médecine interne, Hôpital La Rabta, Tunis, Tunisie
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Abstract
Diffuse alveolar hemorrhage represents a medical emergency, and clinicians must have an expedient approach to its identification. There are many causes of diffuse alveolar hemorrhage, including vasculitides, immunologic conditions such as Goodpasture's syndrome, collagen vascular disease, and idiopathic conditions. Careful attention to the medical history, physical examination, and targeted laboratory evaluation often suggests the underlying cause. Patients in whom the diagnosis of diffuse alveolar hemorrhage remains uncertain should undergo diagnostic bronchoscopy. In patients with evidence of diffuse alveolar hemorrhage and renal involvement, kidney biopsy should be considered to identify the underlying cause and help direct therapy.
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Affiliation(s)
- Harold R Collard
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Health Sciences Center, 4200 East 9th Avenue, C272, Denver, CO 80262, USA.
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Abstract
The most common causes of hyperthyroidism are Graves' disease, toxic nodular goiter, and iodine-induced hyperthyroidism. Hyperthyroidism can be treated medically with antithyroid drugs or radioactive iodine, or surgically. Multiple clinical factors must be weighed when choosing a treatment modality. All of the available forms of therapy have advantages and disadvantages, and treatment choices must be individualized.
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Affiliation(s)
- Elizabeth N Pearce
- Section of Endocrinology, Diabetes, and Nutrition, Boston Medical Center, Boston, MA02118, USA
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Affiliation(s)
- Marvin I Schwarz
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, Denver Health Medical Center, USA.
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34
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Abstract
Current and past drug intake is essential in the evaluation of a patient who has DAH. Simple treatments, such as reversal of a coagulation defect or withdrawal of the drug, can reverse a life-threatening situation. DAO may result in DAH, and depending on the severity of the drug withdrawl, will not be adequate and corticosteroid therapy is recommended.
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Affiliation(s)
- Marvin I Schwarz
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, C272, Denver, CO 80262, USA.
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35
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Yamauchi K, Sata M, Machiya JI, Osaka D, Wada T, Abe S, Otake K, Kubota I. Antineutrophil cytoplasmic antibody positive alveolar haemorrhage during propylthiouracil therapy for hyperthyroidism. Respirology 2003; 8:532-5. [PMID: 14708556 DOI: 10.1046/j.1440-1843.2003.00499.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: 11/20/2022]
Abstract
Recently, propylthiouracil (PTU) has been thought to be one of the possible causes of antineutrophil cytoplasmic antibody (ANCA)-associated small vessel vasculitis syndrome, resulting in glomerulonephritis and, infrequently, diffuse alveolar haemorrhage (DAH). The mechanism of ANCA-positive vasculitis during PTU therapy is still unknown. Herein, we describe the case of a 59-year-old woman who developed myeloperoxidase (MPO)- and proteinase 3 (PR3)-ANCA positive DAH, without any other organ system involvement, during PTU therapy. Diminution and discontinuation of PTU resulted in a positive response. To our knowledge, this is the first documentation of both MPO- and PR3-ANCA-positive DAH, without systemic manifestations, developing during PTU therapy.
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Affiliation(s)
- Keiko Yamauchi
- First Department of Internal Medicine, Yamagata University School of Medicine, Yamagata, Japan
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36
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Dinmezel S, Ogus C, Ozdemir T. Antineutrophil Cytoplasmic Antibody-Positive Vasculitis Associated with Propylthiouracil Therapy. Clin Drug Investig 2003; 23:817-21. [PMID: 17536895 DOI: 10.2165/00044011-200323120-00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- S Dinmezel
- Akdeniz Universitesi Tip Fakültesi Gögüs Hastaliklari Anabilim Dali 100, Antalya, Turkey
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37
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Yamashita Y, Yamane K, Fujikawa R, Okubo M, Kohno N. A successful pregnancy and delivery case of Graves' disease with myeloperoxidase antineutrophil cytoplasmic antibody induced by propylthiouracil. Endocr J 2002; 49:555-9. [PMID: 12507274 DOI: 10.1507/endocrj.49.555] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 30-year-old female patient, diagnosed as having Graves' disease in 1996, was treated with propylthiouracil (PTU) for 4 years. She developed a low-grade fever from December 1999. As myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) vasculitis is one of the adverse effects of PTU, we examined serum MPO-ANCA level and found it was positive, but cytoplasmic-ANCA (c-ANCA) was negative. There were no symptoms that indicated other diseases associated with MPO-ANCA. She was confirmed to be at 6 weeks gestation, and thyroid hormone levels were elevated at that time. We discontinued PTU and gave methyl-mercaptoimidazole (MMI), and the titer of MPO-ANCA fell along with fever. Therefore we estimated the case as probable MPO-ANCA positive vasculitis induced by PTU. MMI was also suspended because of the development of hepatic dysfunction. After thyroid function was normalized by administration of potassium iodide, she underwent subtotal thyroidectomy, and delivered a 2350 g infant at 38 weeks' gestation, which was less than the normal birth weight of 2400 g. MPO-ANCA is considered to be one reason of low birth weight infant including hyperthyroidism. It is necessary to consider the appearance of the possibility of MPO-ANCA positive vasculitis in patients who are treated with PTU.
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Affiliation(s)
- Yasuyo Yamashita
- Second Department of Internal Medicine, Hiroshima University School of Medicine, Hiroshima 734-8551, Japan
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38
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Sarui H, Sano A, Maruyama T, Nakashima K, Takeda N, Yasuda K. Severe graves ophthalmopathy accompanied by HTLV-1-associated uveitis (HAU) and anti-neutrophil cytoplasmic antibody-related vasculitis: a case report and a review of the literature of HAU with Graves disease. Am J Med Sci 2002; 324:109-14. [PMID: 12186105 DOI: 10.1097/00000441-200208000-00012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 50-year-old woman was admitted because of severe exophthalmos associated with Graves disease. She underwent methimazole (MMI) and methylprednisolone pulse therapy against exophthalmos. She noticed photophobia and blurred vision 3 weeks after the start of pulse therapy and she was diagnosed as having uveitis. Methylprednisolone pulse therapy was performed again for both exophthalmos and uveitis, followed by daily administration of 20 mg of prednisolone and instillation of betamethasone for 2 weeks and the uveitis was improved. Western blot analysis confirmed that human T lymphotropic virus type 1 (HTLV-1) antibody was present in her serum. Propylthiouracil was substituted for MMI and HTLV-1-associated uveitis (HAU) has not recurred. Six months after the beginning of administration of PTU, anti-neutrophil cytoplasmic antibody-related vasculitis developed in the patient. We review 43 cases of HAU with Graves disease, including the present case, in the literature. Only 2 of 27 cases (except unknown cases) (7.4%) had Graves ophthalmopathy. To the best of our knowledge, there has been no investigation of HAU and Graves ophthalmopathy.
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Affiliation(s)
- Hiroshi Sarui
- Third Department of Internal Medicine, Gifu University School of Medicine, Japan.
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Abstract
Diffuse alveolar hemorrhage (DAH) is a rare yet serious and frequently life-threatening complication of a variety of conditions. DAH may result from coagulation disorders, inhaled toxins, or infections. Most cases of DAH are caused by capillaritis associated with systemic autoimmune diseases such as antineutrophil cytoplasmic antibodies-associated vasculitis, anti-glomerular basement membrane disease, and systemic lupus erythematosus. Early recognition is crucial, because the prompt institution of supportive measures and immunosuppressive therapy is required for survival. Our understanding of DAH and its management is largely empiric and based on small case series and individual reports, many dating back more than one decade. To provide the practicing specialist with a rational diagnostic and management approach to the patient with DAH, this review summarizes the most recent publications and salient information derived from older publications.
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Affiliation(s)
- U Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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40
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Abstract
Vasculitis, inflammation, and necrosis of blood vessels can involve any size or type of vessel in the pulmonary vasculature, including the capillaries, so-called capillaritis. Although pulmonary capillaritis is a histopathologic diagnosis that is not pathognomonic of a specific disorder, it usually signals the presence of an underlying systemic vasculitis or collagen vascular disease. Patients with pulmonary capillaritis usually present with bilateral infiltrates on chest radiographs and can be acutely ill with diffuse alveolar hemorrhage that may be life threatening. Therapy depends on diagnosis of the underlying disease that gave rise to the capillaritis. Since many of the disorders leading to capillaritis are treated by immunosuppression with corticosteroids and cyclophosphamide or azathioprine, infection must be excluded early in the course of therapy.
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Affiliation(s)
- T J Franks
- Department of Pulmonary and Mediastinal Pathology, Armed Forces Institute of Pathology, Washington, DC 20306-6000, USA.
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