Hydralazine-induced autoimmune conditions may include drug-induced lupus, vasculitis
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Key takeaways:
- Early recognition of conditions such as drug-induced lupus overlapping with vasculitis is crucial.
- Part of treatment may include discontinuing a drug causing the syndrome.
LONG BEACH, Calif. — Hydralazine-induced autoimmune conditions may have a varied presentation, including drug-induced lupus or vasculitis, according to a speaker, here.
Patients with nephritic syndrome and multiorgan involvement should learn to identify overlap syndromes, Renuka Tolani, DO, of the Houston Methodist Hospital, and colleagues wrote in a poster presented at the National Kidney Foundation Spring Clinical Meetings.
“The point of the study was basically to keep in mind the importance of drug-induced vasculitis, its overlap with lupus syndrome and how a patient presenting with pulmonary renal findings, as well as hematological findings, can have a drug-induced vasculitis overlapping with lupus,” Tolani told Healio. “And it's important to be able to recognize this, since part of the treatment is discontinuing that drug that [is] causing the syndrome.”
An 82-year-old woman with a history of chronic kidney disease stage G4, hypertension, heart failure, stroke and anemia was hospitalized with generalized fatigue, abdominal pain and dyspnea. She had renal, pulmonary and hematological involvement.
Medical history included recent admissions for suspected pneumonia and transfusion-dependent anemia. The patient was also hospitalized at an outside facility recently for hypoxic respiratory failure and hemoptysis and was treated for pulmonary edema.
On current presentation, labs showed a hemoglobin level of 5.6 g/dL and AKI with a creatinine level of 2.98 mg/dL. Urinalysis was +1 protein and 116 red blood cells per high-power field, while the patient’s urine microalbumin-creatinine ratio was 400 mg/g and urine sediment showed several dysmorphic red blood cells and granular casts.
Further workup revealed positive serologies for antinuclear antibodies, anti-histone antibodies and perinuclear anti-neutrophil cytoplasmic antibodies (P-ANCA).
A renal biopsy confirmed diffuse mesangial and segmental endocapillary immune complex glomerulonephritis, without crescents or fibrinoid necrosis. Immunofluorescence showed positive results for immunoglobulin G, immunoglobulin M, C3, C1q, kappa and lambda. Results were negative for immunoglobulin A.
Electron microscopy showed mesangial expansion with subendothelial and mesangial immune-complex deposits, as well as immune complex-mediated glomerulonephritis.
The patient became acutely hypoxic and hypotensive and required intubation, dialysis and pressor support. Chest imaging and bronchoscopy confirmed alveolar hemorrhage.
Researchers also found evidence of ANCA vasculitis, but the biopsy showed an immune complex mediated process with no evidence of pauci-immune glomerulonephritis. Tolani and colleagues made a diagnosis of an overlap autoimmune syndrome due to hydralazine.
The patient was treated with pulse dose steroids and plasma exchange but deteriorated in condition before the family decided to transition the patient to comfort care.
Early recognition of conditions such as drug-induced lupus overlapping with vasculitis is crucial to prevent further organ damage, the researchers found.
“The key findings of this [are] that hydralazine can cause a pauci-immune glomerulonephritis and that can have manifestations that are systemic, such as pulmonary-renal syndrome,” Tolani said. “More research is needed to be done on finding what prognosis patients can have based on the biopsy findings and more research into when these drugs should be discontinued and [the] patient prognosis.”
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Tolani R, et al. Poster 405. Presented at: NKF Spring Clinical Meetings; May 14-18, 2024; Long Beach, Calif.
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