Abstract: SA-PO269
Methimazole-Induced Severe Anti-Neutrophil Cytoplasmic Antibody Associated Vasculitis with Rapidly Progressing Glomerulonephritis
Session Information
- Trainee Case Reports - VI
October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 1203 Glomerular Diseases: Clinical, Outcomes, and Trials
Authors
- Khan, Neelofar R., Zucker School of Medicine at Hofstra Northwell, GREAT NECK, New York, United States
- Wanchoo, Rimda, Zucker School of Medicine at Hofstra Northwell, GREAT NECK, New York, United States
- Bijol, Vanesa, Northwell Health Hofstra University, Lake Success, New York, United States
- Jhaveri, Kenar D., Northwell Health Sys, Great Neck, New York, United States
- Uppal, Nupur N., Hofstra Northwell School of Medicine, Great Neck, New York, United States
Introduction
Vasculitis associated with anti-neutrophil cytoplasmic antibodies (ANCA) is a rare complication of treatment with antithyroid medications. It has been mainly described in patients treated with Propylthiouracil(PTU), and rarely with use of Methimazole(MMI). While most reported cases of MMI induced ANCA associated vasculitis(AAV) were diagnosed on skin or lung pathology, we report a unique case of severe, systemic, kidney biopsy proven drug induced AAV with MMI.
Case Description
A 64-year-old Guyanese woman with primary hyperthyroidism presented with abdominal pain and diarrhea.On admission, herserum creatinine(Scr) was 2.8mg/dl( baseline 1.2mg/dl). She denied use of NSAIDs, PPIs or herbal medications however reported to have completed course of clarithromycin for a respiratory infection 2 weeks ago. Her only home medication at the time of presentation was methimazole. During the course of her hospitalization, she developed gross hematuria with worsening AKI. UA showed 173 RBCs, 13 WBCs and spot urine protein to creatinine ratio of 1.2. Serological work up was positive for Anti-Nuclear Antibody (ANA 1;640), p(perinuclar)-ANCA (1:320) and Myeloperoxidase antibody (MPO 109.4). C(cytoplasmic)-ANCA, proteinase 3(PR3) and double stranded DNA antibodies were negative.She was initiated on pulse dose corticosteroids and underwent kidney biopsy which showed 25 glomeruli, of which 2 were globally sclerosed, 4 had cellular crescents with all arteries revealing extensive necrosis and signs of small vessel vasculitis with minimal chronic changes and no tubular changes; Pathology findings were consistent with pauci immune vasculitis/ AAV, thought to be drug induced. Methimazole was held. Few days later, she developed hemoptysis and was initiated on plasmapheresis for concern of pulmonary alveolar hemorrhage. She eventually became oliguric requiring hemodialysis. Worsening of her vasculitis lead to her demise despite aggressive medical management.
Discussion
The reported incidence of MPO ANCA Vasculitis for PTU is 39.2 times higher compared to that with MMI. Although uncommon, MMI can lead to AAV. Nephrologists, rheumatologists and endocrinologists should all be aware of this rare, life threatening complication of MMI.