Methimazole-induced antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis and lupus-like syndrome with a cutaneous feature of vesiculo-bullous systemic lupus erythematosus [1]
Journal
Acta Dermato-Venereologica
Journal Volume
82
Journal Issue
3
Pages
206-208
Date Issued
2002
Author(s)
Abstract
Sir, It has been reported that lupus erythematosus (LE)-like adverse reaction is induced by various drugs, e.g. procainamide, hydralazine, isoniazid and diphenylhydantoin (1, 2). Antithyroid agents can also induce this syndrome. Propylthiouraci l has been reported to induce perinuclear antineutrophil cytoplasmic antibody (MPO-ANCA)positive vasculitis (3, 4). Methimazole and carbimazole, two other antithyroid drugs classi ed with propylthiouracil as thionamides, can also cause ANCA-positive vasculitis, but much less frequently than propylthiouracil (4, 5). Other adverse eVects related to methimazole include fever, rash, arthralgia, hepatitis, agranulocytosis and lupus-like syndrome (4, 6). However, only a few reports have described the skin symptoms and the Fig. 1. Vesicles (arrows) and crusts are present on the lower leg. histological ndings in detail in antithyroid agentinduced lupus-like syndrome. We report on a patient 62% segmental neutrophils and 1% eosinophils, a platelet with Graves’ disease who, after being treated with count of 470 null 109/l, a hemoglobin level of 6mg/dl, a reticulocyte count of 4.4%, a mean corpuscular volume of 87.6 , methimazole for one week, developed a blistering erupprothrombin time 9 s (control 10 s) and activated partial tion on the hands and legs. To our knowledge, this is thromboplastin time 25 s (control 30 sec). Urinalysis was the rst report describing methimazole-induced lupusunremarkable. A chest X-ray lm showed a bilateral, groundlike syndrome and ANCA-positive vasculitis with a glass appearance. Treatment with blood components and cutaneous feature of vesiculo-bullous systemic lupus methylprednisolone was given. Owing to persistent respiratory insuYciency, the patient was intubated. A skin biopsy specimen erythematosus (SLE). from the lower leg revealed a neutrophilic in ltrate with nuclear dusts in the dermal papillae and tips of rete ridges, and vacuolar degeneration at the basement membrane zone CASE REPORT with subepidermal blister formation (Fig. 2). Direct immunoAn 18-year-old female with a 2-year history of hyperthyroid uorescence study showed linear deposition of IgG and IgA ism, which was treated with a 6-month course of propylthiouraat the basement membrane zone (Fig. 3). The indirect cil and propranolol, had discontinued the medications for one immuno uorescence study was negative. An open lung biopsy year until the recurrence of hyperthyroidism presented as specimen revealed an intra-alveolar hemorrhage and capillartremor, palpitation and heat intolerance. The patient did not itis, as suggested by focally expanded and disrupted alveolar have a history of systemic rheumatic disease or any previous septa replaced by a neutophilic in ltrate. Further investigation complaint of photosensitivity and Raynaud phenomenon. The revealed PR3-ANCA (enzyme immunoassay, Pharmacia laboratory studies revealed the anti-thyroglobulin antibody Diagnostics GmbH & C. KG, Freiburg, Germany) 4 EU/ml (particle agglutination method, Fujirebio Co., Japan) level (normal <7),MPO-ANCA (enzyme immunoassay, Pharmacia 1:25,600 (normal <1:80), anti-microsomal antibody (particle Diagnostics) 62 EU/ml (normal < 7), C3 35.7mg/dl (normal agglutination method) 1:10,240 (normal <1:80), free T4 81.61–118.41 ) and C4 6.5mg/dl (normal 27.45 ± 10.72). 0.53 ng/dl (normal 0.6–1.6), and TSH 0.27 mU/ml (normal Antinuclear antibody of speckled type was found at a serum <6.5). She was then treated with methimazole 15mg and dilution of 1:80 by means of indirect immuno uorescence propranolol 40mg daily. A week later, hemoptysis, cough, microscopy, using HEP-2 cells (Medical & Biological dyspnea and an itchy skin rash were noted. The skin lesions Laboratories Co., Japan (MBL)). Anti-ds DNA (enzyme consisted predominantly of vesicles 1–3mm in size and crusted immunoassay, MBL) 24.3 IU/ml (normal <12) was also erosions on the legs and dorsa of the hands and feet (Fig. 1). noted. The anti-phospholipid antibody (enzyme immunoassay, The patient was admitted to our hospital where laboratory Diagnostica Stago, France) level was 33.95 IU/ml (normal investigation showed a leukocyte count of 10.1 null 109/l with <5), but anti-cardiolipin antibody (enzyme immunoassay, Shield Diagnostics Ltd., UK) was negative. The anti-SS-A *Author for correspondence. antibody (double radial immunodiVusion, MBL) was positive,
SDGs
Other Subjects
antithyroid agent; carbimazole; hydralazine; isoniazid; methylprednisolone; neutrophil cytoplasmic antibody; phenytoin; procainamide; propranolol; propylthiouracil; thiamazole; thyrotropin; antithyroid agent; neutrophil cytoplasmic antibody; thiamazole; adult; antibody detection; bullous skin disease; case report; clinical medicine; disease course; female; histopathology; human; human tissue; hyperthyroidism; immunofluorescence; letter; lung biopsy; plasmapheresis; priority journal; skin biopsy; steroid therapy; systemic lupus erythematosus; thyroid function; vasculitis; adolescent; blood; bullous skin disease; chemically induced disorder; fluorescent antibody technique; Graves disease; pathology; skin lupus erythematosus; treatment outcome; vasculitis; Adolescent; Antibodies, Antineutrophil Cytoplasmic; Antithyroid Agents; Case Report; Female; Fluorescent Antibody Technique, Indirect; Graves' Disease; Human; Lupus Erythematosus, Cutaneous; Methimazole; Skin Diseases, Vesiculobullous; Treatment Outcome; Vasculitis; Adolescent; Female; Fluorescent Antibody Technique, Indirect; Graves Disease; Humans; Treatment Outcome
Type
letter