Propylthiouracil-induced anti-neutrophil cytoplasmic antibody-associated vasculitis

A 20-year-old woman was referred to Peking University First Hospital, Beijing, China, owing to massive pulmonary hemorrhage and gross hematuria. She had been well until 2 years before admission when she was diagnosed with Graves' disease and was treated with propylthiouracil (PTU) 300 mg/day first and then maintained with PTU 100 mg/day. Five months before admission, she complained of palpitations and was found to have an elevated serum T3 and T4 and decreased thyroid stimulating hormones. In response, the dose of PTU was changed to 300 mg/day by her local doctors. Shortly thereafter, she started to complain of arthralgia, myalgia, and skin rash. Three months before admission, she developed a cough, hemoptysis, and gross hematuria, and subsequently a gradual decline in her hearing, 'red eye', and weight loss. One week before admission, her PTU dose was further increased to 450 mg/day and then the patient became severely ill with massive pulmonary hemorrhage. At physical examination on admission, her paleness, exophthalmos, and goiter were revealed. The blood pressure was 120/80 mm Hg, the pulse 96 beats/min, the respiratory rate 24 breaths/min, and the temperature 37.2 degrees C. The body weight was 45 kg. Auscultation of the lungs revealed scattered expiratory wheezes and coarse bronchial breath sounds. A cardiac examination revealed tachycardia with normal heart sounds and no murmurs, rubs, or gallops. The abdomen was soft, nontender. There was no edema on lower extremities. Laboratory data are shown in Tables 1 and 2. Chest radiography indicated massive pulmonary hemorrhage ( Figure 1a). Her serum perinuclear cytoplasmic stained pattern on ethanol-fixed neutrophil was positive with specificity to myeloperoxidase, lactoferrin, and azurocidin. Anti-nuclear antibody and anti-glomerular basement membrane antibody were negative.Urology & NephrologySCI(E)PubMed21ARTICLE81477-14816