Anti-thyroid drug and ANCA positive vasculitis

JCEM, vol84, No1, p13, 1999

ANCA

• Anti-neutrophil cytoplasmic antibody

Clinical manifestation

• 27 year-old female

• Thyroid goiter for 3 years.

• Follow up at OPD regularly.

• 91-8-12,

C.C.： Thyroid goiter, palpitation(120/min), hand tremor for several weeks.

PE： goiter, tachycardia, no exophthalmos

T3 T4 TSH AMA

87-9-13 8.8 0.18 neg

88-8-7 1.2 FT4： 1.1 neg

89-12-28 1.75 FT4： 1.2 0.166

90-3-5 0.206

91-7-24 0.84 FT4： 1.27 0.116

Thyroid function test

Thyroid sonogram

• 87-9-16: Multiple nodular goiter, bilateral , R/O autoimmune thyroiditis

• 88-8-5: Ditto• 89-7-11:in favor of MNG rather than

autoimmune thyroid disease.• 90-1-1:MNG• 90-12-27: atypical MNG• 91-7-23: more favor autoimmune thyroid

disease, D/D include MNG.

Diagnosis ?

Thyroid I-131 uptake and scan

1. Uptake at 24 hour is 45%

2. Thyroid scan: the gland is enlarged with even distribution of radioactivity

Impression: The scintigraphic findings are compatible with thyrotoxicosis.

• 91-8-12,

Inderal and Tapazol were prescribed.

Clinical manifestation

• 91-8-21, acute nuchalgia for 2 days with fever off and on.

• PE:

HA: negative, photophobia: negative

Neck : not rigid, no meningeal sign,

BT : 38.5 c, Multiple small petechiae over ??, • Dx: R/O dengue fever. • Admission

BUN/ Cr

Na/K GOT/GPT

91-8-22

4/0.7 138/ 3.7

26/21

WBC HG PLT ESR CRP

8/21 6500 12.4 152k 33

8/23 3600 11.8 131k

8/24 11.7

8/26 4700 12.3 186k

PT/APTT D-dimer

8/23 Normal 2x positive

ANA C3 C4 IgE

8/23 <1： 40 129 20

•Figure 3. Purpura on the Lower Leg of a Patient Found to Have Leukocytoclastic Angiitis in a Skin-Biopsy Specimen. There are also several darker areas of necrosis. (Photograph kindly provided by Robert A. Briggaman.)

•Persistent fever with chillness during hospital days

•Refer to NCKU on 91-8-26, W1

Figure 4. Leukocytoclastic Angiitis in a Skin-Biopsy Specimen from a Patient with Purpura. There is extensive karyorrhexis of the vascular and perivascular leukocytes (leukocytoclasia). (Hematoxylin and eosin, x500.)

ANCA positive vasculitides

• Wegener's granulomatosis (WG),

• Churg-Strauss syndrome (CSC)

• Microscopic polyangiitis, (MP)

• some drug-induced vasculitides.

ANCA

• pericytoplasmic (pANCA)

1. directed against a number of antigens

2. the most important -- myeloperoxidase (MPO-ANCA)

3. Most patients with CSS or MP are pANCA and MPO-ANCA positive

• cytoplasmic (cANCA)

1. strongly associated with for antiproteinase3 (PR3-ANCA)

2. 90% WG are PR3-ANCA and cANCA positive

3. cANCA is 80-97% specific for WG

• Drug-induced ANCA positive vasculitis

1. may be associated with pANCA, MPO-ANCA, cANCA or PR3-ANCA

Analysis of cases• There are 26 previously reported cases of ANCA p

ositive vasculitis in association with antithyroid drugs ( Table 1).

• Seventy-four percent were female. • Forty-eight percent were Japanese patients. • The average age of affected patients was 46.6 year

s (range 8 to 82 years of age). • PTU therapy was implicated in 88%. • Underlying disease

– 63%was not clear from the case report,– in all but one of the remainder was Graves'.

JCEM, 1999,

Organ involvement

• Renal involvement-- 66.7%, • arthralgia in 48%, • fever in 37%, • skin involvement in 29.6%, • respiratory tract involvement in 25.9%, • myalgia in 22.2%, • scleritis in 14.8% • other manifestations in 18.5%.

Renal biopsy

• 17 patients was done

1. Crescentic or necrotizing GN in 94.1%.

2. Mesangial proliferation in 11.8%.

• Immunofluorescence test—– pauci-immune – or non-specific in all biopsies.

Analysis of cases

• pANCA pattern--81.5%, • an undifferentiated positive ANCA was repo

rted in a further 14.8%.• cANCA was positive in 11.1% and was seen

in isolation in one patient. • MPO-ANCA was positive in 78.3% of cases • PR3-ANCA was positive in 72.7% of the 11

cases

Therapy

1. Cessation of the initiating drug.

2. Renal involvementa. steroids and /or

b. cyclophosphamide was given to 88.2% patients

3. Plasmapheresis-One patient

Result

1. Improvement in 85.2%.

2. In 7.4%, renal function declined

3. In 3.7%, no significant change

4. Death occurred in a patient in whom renal function was stable and was due to LVF and COAD.

Discussion

• Vasculitis is a rare complication during treatment of thyro toxicosis

• Positive ANCA in association with the vasculitis has been recently described

• Antithyroid drugs related ANCA vasculitis– more frequently in women, reflect female prepo

nderagce of thyrotoxicosis – In fact men be more common

ANCA associated vasculitis

• a variety of constitutional symptoms

1. fever,

2. myalgia,

3. arthralgia,

4. "flu-like" syndrome

ANCA associated vasculitis

• Vessels in skin, kidneys, respiratory tract, skeletal muscle, peripheral nerves and other areas may be involved.

ANCA associated vasculitis

• The commonest cutaneous lesion is leukocytoclastic vasculitis

1. preferentially affects the lower limbs

2. typically causes purpuric lesions.

3. Other cutaneous manifestations are protean.

ANCA associated vasculitis

• pathogenesis not clearly understood.

1. PTU accumulate in neutrophils

2. bind to myelo peroxidase,

3. changing its structure

4. autoantibody formation

Pathogenesis

• The pauci-immune or non-specific pattern of immunofluorescence in renal biopsies implies that drug-induced lupus erythematosis is unlikely to be the mechanism.

Drug-induced pANCA vasculitis

1. hydralazine,

2. sulpha salazine therapy (n=2)

3. minocycline (n=1) • Diagnosis requires a positive ANCA. • MPO-ANCA is the commonest pattern. • Biopsies from clinically involved area.• If renal involvement renal biopsy determini

ng appropriate therapy and long term prognosis.

Drug-induced pANCA vasculitis

• Diagnosis –

1. positive ANCA.

2. MPO-ANCA is the commonest pattern.

3. Biopsies from clinically involved area.

4. If renal involvement renal biopsy determining appropriate therapy and long term prognosis.

Drug-induced pANCA vasculitis

• Treatment – depends upon severity of the illness.

1. Fever, arthralgia, myalgia, malaise, "flu-like" syndrome and cutaneous vasculitis respond well to cessation of the drug.

Treatment

• Steroids and/or cyclophosphamide is warranted --If renal manifestation are severe, rapidly progressive, or biopsy shows, crescentic GN,.

• In most cases, renal function will improve, but creatinine clearance sometimes does not return to baseline

Drug-induced pANCA vasculitis

• Crescentic or necrotizing GN-- high risk for CRI• Pulmonary manifestations

– from minor nasal involvement to life-threatening pulmonary haemorrhage.

• If severe or life-threatening, – plasmapheresis should be considered, in addition to ster

oids and/or cyclophosphamide.

• Scleritis --either topical or systemic steroids.

Drug-induced pANCA vasculitis• Prognosis is good. • ANCA titers may fall with time, but remain

positive in many patients.• We found several ANCA positive patients tr

eated with either PTU or carbimazole without clinical manifestations of vasculitis (unpublished data).

Conclusion

• ANCA positivity may lead to – earlier consideration of definitive therapy.– Possibly long-term anti thyroid therapy should n

ot be given to patients with positive ANCA,– carbimazole should be better than PTU.