title: Trojan horses: drug culprits associated with antineutrophil cytoplasmic autoantibody (ANCA) vasculitis.
abstract: OBJECTIVE
  Antineutrophil cytoplasmic autoantibody (ANCA) vasculitis is a systemic autoimmune disease resulting in small-vessel inflammation caused by pathogenic autoantibodies directed against proteinase 3 or myeloperoxidase. Legal drug culprits have been implicated as causative agents in secondary forms of disease, and a recent burst of reports also implicate levamisole-adulterated cocaine as a culprit.
  
  
  RESULTS
  Here, we briefly discuss all drug culprits associated with ANCA vasculitis and then focus on clinical, serologic, therapeutic and mechanistic aspects of four main drug culprits receiving attention of late, namely hydralazine, minocycline, propylthiouracil (PTU) and levamisole-adulterated cocaine.
  
  
  CONCLUSIONS
  Hydralazine, minocycline, propylthiouracil and levamisole-adulterated cocaine use should be closely considered in any patient where ANCA vasculitis is entertained given the wide use of these drugs in the community. Furthermore, medical practitioners should test urine for the presence of cocaine in any patient with presumed ANCA vasculitis, and if positive, then urine should also be tested for levamisole. Clinical features can be severe requiring not only drug cessation and supportive care, but also immunosuppression, plasma exchange in severe cases and dialysis as needed. Clinical trial investigators should strongly consider excluding patients with drug-induced forms of disease and mechanistic inroads are greatly needed in these secondary forms of disease to help elucidate the underlying cause and pathogenesis of ANCA vasculitis.
authors.affiliation: aJoint Nephrology Fellowship Program, Brigham and Women's Hospital and Massachusetts General Hospital (MGH) bDivision of Nephrology, Department of Medicine cVasculitis and Glomerulonephritis Clinic, Division of Nephrology, MGH, Boston, Massachusetts, USA.
authors.forename: William F
authors.initials: WF
authors.lastname: Pendergraft
authors.forename: John L
authors.initials: JL
authors.lastname: Niles
mesh_terms: D056648:Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis / Q000139:chemically induced*; D003042:Cocaine; D019970:Cocaine-Related Disorders / Q000150:complications; D004340:Drug Contamination; D006801:Humans; D006830:Hydralazine / Q000009:adverse effects; D007978:Levamisole / Q000009:adverse effects; D008911:Minocycline / Q000009:adverse effects; D011441:Propylthiouracil / Q000009:adverse effects
chemical_list: D006830:Hydralazine; D007978:Levamisole; D011441:Propylthiouracil; D008911:Minocycline; D003042:Cocaine