title: A fatal case of propylthiouracil-induced ANCA-associated vasculitis resulting in rapidly progressive glomerulonephritis, acute hepatic failure, and cerebral angiitis.
abstract: BACKGROUND
  Propylthiouracil (PTU)-induced antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis presenting with renal failure, acute hepatic failure, and cerebral angiitis is a rare yet fatal disease. Early diagnosis and management may help in reducing mortality and morbidity. Plasmapheresis and induction with either cyclophosphamide or rituximab is indicated. Understanding the pathophysiology and complex management of this disease poses challenges to clinicians.
  
  
  METHODS
  A 42-year-old woman presented with acute renal and hepatic failure. She had been on PTU for 11 months for Graves' disease. Initial urine microscopy showed red blood cell casts. Anti PR-3 antibodies were positive. Kidney biopsy revealed pauci-immune glomerulonephritis with crescent formation. Renal and hepatic failures were attributed to PTU-induced c-ANCA production as other serological workup was negative. Pulse steroids and plasmapheresis were initiated. Later she developed pneumonia. She was also given rituximab. After the first dose of rituximab, plasmapheresis was held for 3 days. The second dose of rituximab was given in 5 days owing to removal by plasmapheresis. She got 8 sessions of plasmapheresis. She also developed seizures and MRA of her head revealed cerebral infarct, with findings suggestive of cerebral angiitis. She did not recover and expired 20 days after presentation.
  
  
  CONCLUSIONS
  PTU can cause ANCAassociated vasculitis resulting in multiorgan failure. Plasmapheresis should be held for 3 days after rituximab infusion in order to allow maximum exposure. The second dose of rituximab may be given before the recommended 7-day interval in cases in which plasmapheresis is being performed to maximize therapeutic benefit.
authors.forename: Talal Ali
authors.initials: TA
authors.lastname: Khan
authors.forename: Francis Cheuk
authors.initials: FC
authors.lastname: Yin Luk
authors.forename: Hakim Taalib
authors.initials: HT
authors.lastname: Uqdah
authors.forename: Azka
authors.initials: A
authors.lastname: Arif
authors.forename: Humira
authors.initials: H
authors.lastname: Hussain
authors.forename: Arundathi
authors.initials: A
authors.lastname: Jayatilleke
authors.forename: Sandeep
authors.initials: S
authors.lastname: Aggarwal
mesh_terms: D000328:Adult; D056648:Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis / Q000139:chemically induced* / Q000175:diagnosis; D019268:Antibodies, Antineutrophil Cytoplasmic / Q000097:blood; D058846:Antibodies, Monoclonal, Murine-Derived / Q000008:administration & dosage; D013956:Antithyroid Agents / Q000009:adverse effects*; D001706:Biopsy; D003131:Combined Modality Therapy; D018450:Disease Progression; D017809:Fatal Outcome; D005260:Female; D005921:Glomerulonephritis / Q000175:diagnosis / Q000209:etiology*; D006111:Graves Disease / Q000188:drug therapy*; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D017114:Liver Failure, Acute / Q000175:diagnosis / Q000209:etiology*; D018810:Magnetic Resonance Angiography; D008854:Microscopy, Electron; D009102:Multiple Organ Failure / Q000209:etiology; D010956:Plasmapheresis; D011441:Propylthiouracil / Q000009:adverse effects*; D020551:Pulse Therapy, Drug; D000069283:Rituximab; D013256:Steroids / Q000008:administration & dosage; D013997:Time Factors; D017211:Treatment Failure; D020293:Vasculitis, Central Nervous System / Q000175:diagnosis / Q000209:etiology*
chemical_list: D019268:Antibodies, Antineutrophil Cytoplasmic; D058846:Antibodies, Monoclonal, Murine-Derived; D013956:Antithyroid Agents; D007166:Immunosuppressive Agents; D013256:Steroids; D000069283:Rituximab; D011441:Propylthiouracil