When Chest Pain Reveals More: A Case of Hydrochlorothiazide-Induced Systemic Lupus Erythematosus

Abstract

Patient: Male, 57 Final Diagnosis: Drug induced lupus erythematosus Symptoms: Anemia • arthralgia • fever • weight loss Medication: Hydrochlorothiazide Clinical Procedure: — Specialty: Rheumatology Objective: Unusual clinical course Background: Drug induced lupus erythematosus is considered an autoimmune entity which is precipitated by medications. Hydrochlorothiazide has been recognized to cause subacute cutaneous lupus erythematosus, but very few cases of systemic drug induced lupus systemic erythematosus have been reported. Case Report: A 57-year-old Caucasian male with a past medical history of hypertension and hyperlipidemia presented with recurrent fevers, chest pain, and dyspnea. Initial evaluation revealed diffuse ST elevations, small pericardial effusion, anemia, and leukopenia. He was initially treated with nonsteroidal anti-inflammatory drugs and prednisone for pericarditis. Six months later, he reported fatigue, arthralgias, morning stiffness, weight loss, fevers, and night sweats. Laboratory tests revealed persistent anemia and leukopenia. Extensive workup, including bone marrow biopsy and infectious evaluations, was negative. Autoimmune workup, however, revealed positive antihistone and antichromatin antibodies despite negative antinuclear antibody. A diagnosis of drug induced lupus secondary to hydrochlorothiazide was made. The medication was stopped, and prednisone was initiated resulting in marked improvement in his symptoms and hematologic abnormalities. Conclusions: This report is one of the few known cases of systemic lupus erythematosus most likely induced by hydrochlorothiazide. Based on our finding, hydrochlorothiazide should be considered a possible offending agent when a patient presents with symptoms suspicious of drug induced lupus.

Differentiation of hydrochlorothiazide-induced dermatitis from stasis dermatitis

“…Hydrochlorothiazide has been associated with photosensitivity, extensive sunburn, eczematous and lichenoid eruptions, and drug-induced lupus among other skin conditions 2–5. Thiazide diuretics became available in the 1950s with several cases of photosensitivity reported immediately soon after.…”

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“…Equally not yet well understood is the mechanism by which hydrochlorothiazide interferes with the glucose homeostasis [12][13][14]. There is also a whole range of side effects, fortunately rarer, but described in the medical literature, ranging from the appearance of lupus [15], interstitial lung disease [16], even severe allergic states [17], pulmonary edema [18][19][20], all conditions linked to immunological changes induced by the molecule itself. The effect on the sense organs (hypoacusis) is more known and less rare (although investigated with low frequency, especially in the elderly subjects), with various reports from the organs of vigilance drug, for which there are well defined indications for the diagnosis of this adverse event (Austin Bradford-Hill criteria, Naranjo criteria), well applied in pharmacovigilance [21,22].…”