Page 29 - Delaware Medical Journal - March/April 2020

CASE REPORT
Focal segmental necrotizing and crescentic glomerulonephritis, pauci-immune type; diffuse, moderate interstitial inflammation; arterio- and arteriolosclerosis with hyalinosis.
Table 1: Medications associated with drug-induced vasculitis
Antibiotics
Cephotaxime, minocycline, methimazole, prophythiouracil
Anti-tumor necrosis factor- agents
Adalimumab, etanercept, infliximab
Psychoactive agents
Clozapine, thioridazine
Miscellaneous drugs
Allopurinol, D-Penicillamine, hydralazine, levamisole, phenytoin, sulfasalazine
INTRODUCTION
Hydralazine is associated with drug- induced lupus, with reported incidence ranging from 5-20%.1 This process is typically characterized by immune- complex deposition resulting in a wide variety of clinical manifestations, and associated with renal disease in 5% or less of cases.2 Here we report a lesser-known potential adverse effect of hydralazine,
an ANCA-associated pauci-immune vasculitis. The clinical presentation varies from arthralgias, myalgias, and rash to multi-organ involvement.3 When it presents with pulmonary and/or renal syndrome it can be fatal, so a high index of suspicion is imperative for early diagnosis and initiation of treatment to prevent progression of disease.4
CASE PRESENTATION
62-year-old male with chronic kidney disease stage,2 obstructive sleep apnea, hypertension, and heart failure with
reduced ejection fraction was referred to nephrology for uncontrolled hypertension. He was found to have a serum creatinine of 1.4 mmol/L and inactive urine sediment.
Antihypertensive therapy included hydrochlorothiazide, irbesartan, furosemide, spironolactone, labetalol, and hydralazine. Total exposure to hydralazine was approximately 20 months of 25-50
mg TID. Over the course of one year, the patient noticed steadily worsening fatigue, which he attributed to normal aging. He denied weight loss, fever, arthralgias, and rash or skin changes. He was eventually found to have markedly worsened renal function with a serum creatinine of
3.26 mmol/L. Urinalysis revealed >
300 mg/dl of protein and >100 rbc/hpf. Urine drug screen was unremarkable. Serologic studies revealed an elevated MPO antibody with titers greater than 8 units (normal < 0.4 units) in a P-ANCA pattern, a positive anti-histone antibody with titer of 5.7 units (normal <1 unit),
a negative DS-DNA antibody, normal complement with C’3 of 142 and C’4 of 42, a positive PR3 antibody with titer of 1.1 units (normal <0.4), and an equivocal antinuclear antibody (ANA) of 1:80.
Upon receipt of serology, the patient was directly admitted and received two doses of pulse intravenous methylprednisolone 1 gram per dose
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