Hydralazine-Induced Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Asymptomatic and Renal-Restricted Presentation

Abstract

Patient: Female, 66-year-old Final Diagnosis: Hydralazine induced ANCA-associated vasculitis Symptoms: Asymptomatic Medication:— Clinical Procedure: — Specialty: Nephrology • Rheumatology Objective: Rare disease Background: Hydralazine, a potent vasodilator widely used to treat hypertension, has been implicated in an increasing number of cases of drug-induced autoimmune diseases in recent years. However, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis secondary to hydralazine use has rarely been described and most reported cases involved multi-organ-related vasculitis, including skin and lung-kidney manifestations. ANCA-associated vasculitis is an immune-inflammatory condition characterized by necrotizing vasculitis with few or no immune deposits, predominantly affecting small vessels. The fact that the vasculitis is associated with hydralazine use and improves with discontinuation of hydralazine supports the diagnosis of hydralazine-induced disease. The case we report is a hydralazine-induced, ANCA-associated, pauci-immune crescentic glomerulonephritis with a presentation limited to the kidneys. Case Report: A 66-year-old woman was admitted to the hospital for worsening renal function over a month with no symptoms. Serology work-up was significantly positive for antinuclear, perinuclear ANCA, anti-histone, anti-double-stranded DNA, anti-cardiolipin, and anti-myeloperoxidase antibodies. The patient ultimately underwent a kidney biopsy, which revealed pauci-immune crescentic glomerulonephritis. Her kidney function improved with cessation of hydralazine as well as therapy with pulse steroids. Conclusions: Hydralazine is commonly prescribed to treat hypertension. Healthcare providers should be aware of potentially severe hydralazine-induced ANCA-associated vasculitis, which can present with various clinical manifestations. Serologic studies have indicated that it has features that overlap with lupus. Biopsy is helpful for making a definitive diagnosis and developing individual treatment plans. Early diagnosis, cessation of the offending drug, and initiation of immunosuppressive therapy are key for favorable prognosis.

Anti-neutrophil Cytoplasmic Antibody-Associated Glomerulonephritis Secondary to Hydralazine: A Case Report

“…Other drug-induced causes of AAV include montelukast, minocycline, rituximab, tumor necrosis factor-ɑ inhibitors (etanercept, infliximab, adalimumab, golimumab), and anti-thyroid drugs (methimazole, propylthiouracil, carbimazole, and benzyl thiouracil). Risk factors for drug-induced renal injury include old age (>60 years), female gender, diabetes, heart failure, and pre-existing renal insufficiency [ 2 , 5 ].…”

“…Therefore, in the absence of other symptoms, positive AHA is not diagnostic of DIL [ 10 , 11 ]. Patients with HIG have severe progression compared to those with DIL because of vasculitis of vessels of kidneys, and therefore require aggressive immunosuppressant treatment [ 5 ].…”

“…There are reports of patients developing end-stage kidney disease requiring maintenance hemodialysis. In reported cases, renal outcomes for this disease have been variable, with one case study claiming full recovery in all patients and another reporting that one-third to half of the patients still needed long-term hemodialysis following immunosuppressive treatment [ 5 , 8 , 9 ].…”

Overlapping Syndromes: Drug-Induced Vasculitis From Hydralazine With Positive Antinuclear Antibodies

“…In the literature, only 4 studies have described kidney-limited presentation of hydralazine-induced ANCA-associated vasculitis. [3][4][5][6][7] We review this case to discuss and highlight the importance of a high degree of clinical acumen, and early diagnosis for better clinical outcomes.…”

A case report of hydralazine induced vasculitis with pulmonary-renal syndrome

“…Hydralazine induced vasculitis was rst described in the 1980s [2]. Since then, multiple case studies have reported this phenomenon [3][4][5]. The case studies have reported three frequent clinical manifestations: glomerulonephritis, cutaneous small vessel vasculitis and bilateral interstitial in ltrates.…”