Hydralazine-associated adverse events: a report of two cases of hydralazine-induced ANCA vasculitis

Rituximab as possible therapy in TNF inhibitor-induced IgA vasculitis with severe renal involvement

BACKGROUND

We observe the increasing use of tumor necrosis factor (TNF) inhibitors in patients affected by chronic inflammatory diseases. These drugs provide good control of symptoms, contributing to significant improvement in the quality of life in individuals with high disease burden. On the other hand, along with their wider use and longer follow-up periods the number of reports regarding their adverse effects is also increasing. The reported complications include drug-induced vasculitis with possible kidney involvement. In the literature we can distinguish more frequently described ANCA-associated vasculitis and more rarely occurring immunoglobulin A vasculitis. Although uncommon, such complications may present with potentially life-threatening vital organ dysfunction; therefore, adequate monitoring and effective therapy are necessary.

CASE PRESENTATION

We report two cases of TNF inhibitor-induced vasculitis with severe acute worsening of renal function and significant proteinuria. The first patient was receiving golimumab therapy for ankylosing spondylitis and the second patient was treated with adalimumab for psoriasis and psoriatic arthritis. In the second case dialysis treatment was necessary and the patient presented recurrence of vasculitis after rechallenge with adalimumab. Both patients underwent renal biopsy which showed findings compatible with drug-induced IgA vasculitis and both were treated successfully with corticosteroids and rituximab.

CONCLUSIONS

To the best of our knowledge this is the first report of rituximab use in drug-induced IgA vasculitis with renal involvement. Combination of corticosteroids and rituximab can be an effective therapy in case of vasculitis with kidney failure and a preferable option for selected patients with drug-induced IgA vasculitis compared to cyclophosphamide. More studies are necessary to establish suitable short- and long-term treatment. Given the rarity of this disorder, case reports and case series can provide practical guidance until additional studies become available.

Overlapping drug-induced vasculitis, ANCA-associated vasculitis, and lupus nephritis caused by low-dose hydralazine

INTRODUCTION

We present a case of drug-induced vasculitis secondary to low-dose hydralazine with overlapping features of antineutrophil cytoplasmic antibody-associated vasculitis and drug-induced lupus nephritis.

CASE PRESENTATION

A 52-year-old Hispanic woman with a medical history of resistant hypertension treated with hydralazine 10 mg twice daily for 1 year presented with generalized weakness, dizziness, nausea, vomiting, and gross hematuria. There was fever, tachycardia, leukocytosis, lactic acidosis, hyperkalemia, renal failure, and anemia. Chest computed tomography and bronchoscopy revealed a left lower lobe infiltrate and diffuse alveolar hemorrhage. Serologic testing was positive for anti-double-stranded DNA, anti-Smith, lupus anticoagulant, anti-histone, anti-cardiolipin IgM antibodies, and antineutrophil cytoplasmic antibodies (myeloperoxidase and proteinase 3). A kidney biopsy revealed crescentic glomerulonephritis with an overlapping finding of membranous nephropathy. Broad-spectrum antibiotics, immunosuppressants, corticosteroids, and plasmapheresis were initiated. The patient survived but required continuous hemodialysis.

CONCLUSIONS

Although a few cases of simultaneous antibody-associated vasculitis and drug-induced lupus nephritis secondary to hydralazine use have been reported, this case is singular. Similar findings were previously reported with doses of 50-100 mg two to three times daily over 1-5 years. In our patient, a dose of only 10 mg twice daily for a year caused a severe disease presentation. This brings to light the combination of different vasculitides that can coexist and the potentially life-threatening adverse effects of low-dose hydralazine that should be kept in mind.

Detoxification of the Lipid Peroxidation Aldehyde, 4-Hydroxynonenal, by Apple Phloretin In Vitro and in Mice

4-Hydroxy-2-nonenal (4-HNE) is a secondary cytotoxic product generated from lipid peroxidation of polyunsaturated fatty acids (PUFAs). The accumulation of 4-HNE can covalently modify biomolecules, such as DNA and proteins, leading to various pathological conditions. Apple phloretin has been shown to be able to trap 4-HNE in vitro, but the trapping mechanisms of 4-HNE by phloretin are not fully understood. Moreover, whether the in vitro trapping efficacy of phloretin toward 4-HNE could be transferred into in vivo environments has never been investigated. In the present study, we observed the formation of 4-HNE conjugates of phloretin increased as phloretin decreased during the in vitro incubation. We then purified and characterized three mono-4-HNE-conjugates of phloretin using NMR and LC-MS/MS techniques. We thereafter demonstrated that apple phloretin could scavenge in vivo 4-HNE via the formation of at least three mono-4-HNE-conjugates of phloretin in a dose-dependent manner in mice after oral administration of three doses of phloretin (25, 100, and 400 mg/kg). The findings from this study pave the way to understanding how dihydrochalcones could act as effective scavengers of 4-HNE by working as sacrificial nucleophiles in vivo, thereby preventing or reducing the risk of 4-HNE-associated chronic diseases.

Overlapping Syndromes: Drug-Induced Vasculitis From Hydralazine With Positive Antinuclear Antibodies

Hydralazine is an antihypertensive medication that has been associated with drug-associated autoimmune syndromes like interstitial lung disease, pauci-immune glomerulonephritis, and hypocomplementemia. Hydralazine-induced ANCA-associated vasculitis and hydralazine induced positive antinuclear antibodies are rare. Clinical manifestations range from arthralgia, petechiae, or rash to multiorgan involvement. When presented as pulmonary-renal syndrome, it can be rapidly progressive and fatal. Here, we describe a case of hydralazine-associated vasculitis with rapidly progressive glomerulonephritis and highlight the importance of early diagnosis and prompt treatment.

Anti-neutrophil Cytoplasmic Antibody-Associated Glomerulonephritis Secondary to Hydralazine: A Case Report

Hydralazine is a vasodilator used in the treatment of resistant hypertension. It is a safe and widely used antihypertensive medicine. Its common adverse effects include headache, rebound tachycardia, fluid retention, and angina. It is a rare cause of anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) with pulmonary and renal involvement. We report a case of a 74-year-old woman, with over eight years of use of hydralazine, who presented to the hospital with shortness of breath and cough. Blood work revealed deranged renal function with high creatinine levels. Serology workup was positive for anti-histone antibodies (AHA), anti-nuclear antibodies (ANA), myeloperoxidase (MPO) ANCA and proteinase-3 (PR-3) ANCA. Renal biopsy showed diffusely flattened tubular epithelium, focal micro vesicular degeneration, and focal loss of the brush border of the proximal tubular epithelium. Hydralazine was stopped and the patient was treated with corticosteroids, resulting in the resolution of her kidney injury.

Hydralazine-Induced Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis: A Case Report and Literature Review

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a disease that typically presents with multiorgan involvement. It can be idiopathic and at times drug-induced. Drugs that have been reported to cause AAV include propylthiouracil, minocycline, allopurinol, hydralazine, as in our case here, and many others. Other than stopping the offending agent, guidelines regarding treating drug-induced vasculitis (DIV) remain unclear. We present to you a case of hydralazine-induced vasculitis causing severe respiratory failure due to pulmonary hemorrhage, purpuric rash, and possible renal disease although not confirmed by biopsy. Our patient was successfully treated with rituximab and plasma exchange. This disease can be life-threatening, and aggressive treatment may be warranted at times.

Rare complication of a commonly used antihypertensive agent: A case of hydralazine-induced ANCA-associated vasculitis presenting as rapidly progressive glomerulonephritis

Hydralazine-induced ANCA-associated vasculitis is a rare clinical entity, with complications including rapidly progressive glomerulonephritis, pulmonary hemorrhage, and pulmonary-renal syndrome. We present this case to highlight the clinical features that support this challenging diagnosis and to emphasize the importance of prompt recognition and aggressive intervention given its significant morbidity and mortality.

Not Lupus Nephritis but a Rare Case of Drug-Induced Pauci-Immune Glomerulonephritis

Hydralazine-induced pauci-immune glomerulonephritis is a rare cause of glomerulonephritis. It is an anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis that can be rapidly progressive and potentially life-threatening. However, most cases are found to be asymptomatic, and patients often present with acute renal failure and painless hematuria. It has been confused with lupus nephritis but treatment differs, thus, necessitating the need for differentiation.

A case report of an 80-year-old African American woman with a history of hypertension, diabetes mellitus type 2, and hypothyroidism, who presented with generalized weakness and weight loss of 30-40 lbs. The patient had been treated with hydralazine for months for hypertension. She presented to the hospital with acute renal failure that worsened over the course of several months eventually requiring hemodialysis.

The patient was found to have drug-induced ANCA vasculitis from hydralazine. This etiology was confirmed with pauci-immune glomerulonephritis seen on renal biopsy. This presentation has the potential of being confused with lupus nephritis. Despite the initial serology being suggestive of lupus, this type of nephritis does not have positive immunofluorescence.

The treatment of nephritis in this patient was generally supportive. However, it was important to identify the underlying cause of renal failure. Equally important to initiating immunosuppressive therapy, it was imperative to discontinue the offending drug in a timely manner to prevent rapid organ failure. The causative agent, hydralazine, may have otherwise gone unnoticed without a thorough investigation into other causes of renal failure. Thus, it is important to consider this as a diagnosis with a patient who presents with rapidly progressive renal failure on hydralazine and may mimic lupus nephritis.

Hydralazine-Induced Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Asymptomatic and Renal-Restricted Presentation

Patient: Female, 66-year-old

Final Diagnosis: Hydralazine induced ANCA-associated vasculitis

Symptoms: Asymptomatic

Medication:—

Clinical Procedure: —

Specialty: Nephrology • Rheumatology

Hydralazine-Induced ANCA Associated Vasculitis (AAV) Presenting with Pulmonary-Renal Syndrome (PRS): A Case Report with Literature Review

Hydralazine, an arterial vasodilator, is a widely used medication for the management of hypertension and heart failure, especially for patients who cannot tolerate the use of ACEIs or ARBs. It is generally well-tolerated and has a safe profile in pregnancy. However, hydralazine can induce immune-mediated side effects, such as hydralazine-induced lupus and less commonly hydralazine- induced ANCA vasculitis. The latter most commonly affects the kidneys with or without other organ involvement. There are several cases reported in the literature of hydralazine-induced ANCA associated vasculitis (AAV) that have pulmonary manifestations, also known as hydralazine- induced pulmonary-renal syndrome (PRS), a condition with a high risk of mortality. We are reporting a case of Hydralazine-induced ANCA associated glomerulonephritis with severe diffuse alveolar hemorrhage (DAH). In addition, we will review the current literature and discuss the importance of prompt diagnosis and early management to decrease mortality and morbidity associated with this serious condition.

Hydralazine-Induced Dual Antineutrophil Cytoplasmic Antibody Positive Vasculitis and Nephritis

Drug-induced autoimmunity occurs when exposure to a causative agent leads to serologic or clinical autoimmune responses. Syndromes that may be associated with drug-induced autoimmunity include antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) and drug-induced lupus (DIL). When drug-induced autoimmunity involves the kidney, histological patterns of injury include pauci-immune glomerulonephritis (GN), which occurs with AAV, and immune complex-mediated GN, which is associated with DIL. We present a case of hydralazine-induced dual ANCA-positive vasculitis and nephritis.

Drug-induced cutaneous vasculitis and anticoagulant-related cutaneous adverse reactions: insights in pathogenesis, clinical presentation, and treatment

Drug-induced vasculitis and anticoagulant-related skin reactions are commonly encountered in the inpatient and outpatient settings. The spectrum of clinical presentation is broad and ranges from focal, skin-limited disease, to more extensive cutaneous and soft tissue necrosis, to potentially fatal systemic involvement. The prompt recognition of these adverse events can have a significant impact on patient morbidity and mortality. We highlight the key features of the clinical presentation with an emphasis on primary lesion morphology, distribution, and epidemiology of purpuric drug reactions. The proposed pathophysiology, histologic findings, and therapeutic interventions of these potentially life-threatening diseases are discussed.