AP-VAS 2012 case report: two patients with rheumatoid arthritis suspected of relapsed microscopic polyangiitis after initiation of dialysis

Abstract

We report two patients with rheumatoid arthritis (RA) who were suspected of microscopic polyangiitis during maintenance dialysis. Case 1 was a 52-yearold woman with RA diagnosed at the age of 38 years and treated successfully with gold compounds. At the age of 43 years, she presented with progressive renal dysfunction and abnormal urine sediments, and a renal biopsy revealed crescentic nephritis with advanced glomerular sclerosis. Myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) was not measured on that occasion. She reached end-stage renal failure within 4 months and started peritoneal dialysis. Eight years later, soon after she was switched to hemodialysis, she developed fever of unknown origin. MPO-ANCA was elevated to 37 EU, although there were no other signs or symptoms suggestive of vasculitis. After taking prednisolone orally (10 mg/day), her fever withdrew, and MPO-ANCA became undetectable. Case 2 was a 71-year-old woman with RA diagnosed at the age of 60 years and treated with gold compounds. She developed renal failure of unknown cause (no biopsy was performed), and started hemodialysis at the age of 69 years. One year later, she presented with fever and subsequently developed cough with hemoptysis. MPO-ANCA was elevated to 62 EU. Treatment with azathioprine 50 mg and prednisolone 35 mg daily brought remarkable clinical improvement, and MPO-ANCA became undetectable. These cases highlight the importance of measuring ANCA even in RA patients on dialysis who present with fever of unknown origin or with underlying kidney disease of uncertain etiology.

Anti-neutrophil cytoplasmic antibody associated vasculitis in patients with rheumatoid arthritis

“…In our center, as well as in the literature, AAV usually occurred after RA in patients with both RA and AAV [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]. This may partially be ascribed to the successful inhibition of RA occurrence by intense immunosuppression in the treatment of AAV.…”

“…RA is largely an inflammatory disease limited to joints, whereas AAV is a systemic autoimmune disease usually with multi-organ destructive processes and devastating outcomes. It has been reported that AAV can coexist with RA [3,[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]. This coexistence may not be entirely coincidental, as evidenced by facts such as ANCA positivity in 20% of RA patients [25], a positive association between ANCA titer and rapid joint destruction in early RA [26], the presence of myeloperoxidase-ANCA in synovial fluid of RA patients [27], and AAV sharing susceptibility loci with RA [28,29].…”

“…Patients with suspected drug-induced AAV were excluded. We pooled these cases with those from our center [3,[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]…”