[Case of minocycline-induced vasculitic neuropathy]

Nitrofurantoin and Minocycline-Associated Vasculitic Neuropathy: Case Reports and Literature Review

BACKGROUND

Vasculitic neuropathies usually present acutely to subacutely, with an asymmetric pattern, involving multiple peripheral nerve territories. Drug-induced vasculitis is an often overlooked etiology of vasculitic neuropathy.

METHODS

We present the first reported case of nitrofurantoin-associated and an illustrative case of minocycline-associated vasculitic neuropathy, with a review of the literature.

RESULTS

The first patient is a 60-year-old woman who developed axonal sensorimotor peripheral neuropathy after nitrofurantoin use, with a superficial radial nerve biopsy confirming vasculitis. The second patient is a 23-year-old woman, with a history of acne vulgaris treated with minocycline, who presented with a subacute right common peroneal mononeuropathy followed by a left deep peroneal mononeuropathy, with elevated antinuclear, perinuclear-antineutrophil cytoplasmic, and myleoperoxidase antibodies, and MPO titers, and a sural nerve biopsy showing large arteriole vasculitis. Finally, we provide a comprehensive review of previously published cases.

CONCLUSIONS

Medications should be considered as a trigger for medication-induced vasculitic neuropathy. Accurate diagnosis would ensure timely treatment.

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

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

Vasculitic neuropathy following exposure to minocycline

Objective:

To report 3 patients with minocycline-induced autoimmunity resulting in peripheral nerve vasculitis.

Methods:

We report 3 patients who, during minocycline treatment for acne vulgaris, developed subacute onset of pain and weakness caused by vasculitis in single and multiple mononeuropathy patterns.

Results:

Each patient underwent either a nerve or muscle biopsy that confirmed vasculitis. One patient additionally developed systemic symptoms (including fever, fatigue, and night sweats) and another had a posterior circulation stroke. Symptoms developed with either early or prolonged use of minocycline. Despite withdrawal of minocycline, patients needed long-term immunotherapy to gain neurologic improvement.

Conclusions:

Our findings suggest that the typical neuropathy associated with minocycline use is painful single or multiple mononeuropathy due to peripheral nerve vasculitis, which may also be accompanied by presumed CNS vasculitis (presenting as stroke).

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

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

Vasculitic neuropathy

Vasculitis is a primary phenomenon in autoimmune diseases such as polyarteritis nodosa, Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and essential mixed cryoglobulinemia. As a secondary feature vasculitis may complicate, for example, connective tissue diseases, infections, malignancies, and diabetes. Vasculitic neuropathy is a consequence of destruction of the vessel wall and occlusion of the vessel lumen of small epineurial arteries. Sometimes patients present with nonsystemic vasculitic neuropathy, i.e., vasculitis limited to peripheral nerves and muscles with no evidence of further systemic involvement. Treatment with corticosteroids, sometimes in combination with other immunosuppressants, is required to control the inflammatory process and prevent further ischemic nerve damage.

Minocycline-induced renal polyarteritis nodosa

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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