Unknown

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Unknown 126
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Case Presentation

• A 55 year old female with a history of HTN and
  chronic kidney disease, on HD presents to her
  primary care physician with fever, myalgias,
  rash, and joint pains for one week.

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• PMHx HTN, chronic kidney disease on
  hemodialysis
• Meds
• Hydralazine started 2 months prior
• Lisinopril started 5 years prior
• Metoprolol started 5 years prior
• Clonidine started 3 years prior
• Iron started 5 years prior

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• All NKDA
• Soc no smoking, ETOH, drugs
• Fam Hx non-contributory

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Physical Exam

• 135/85, 85, 16, 100 RA
• AO, NAD
• CV RRR, S1, S2, no m/r/g
• Pulm CTA B, no w/r/r
• Abd S/NT/ND
• Ext no edema

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Skin Exam
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Labs

• 138 112 12 14
• 85 8.2 232
• 4.1 24 .8 41
• ANA 1128
• Anti-ds-DNA negative
• C3, C4 wnl

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Question

• What would you expect to see on further serology?
• Anti SM ab
• Anti-histone antibodies
• ANA Speckled pattern
• C-ANCA
• Anti-PR3

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Answer
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Answer

• What would expect to see on serology?
• What would you expect to see on further serology?
• Anti SM ab
• Anti-histone antibodies
• ANA Speckled pattern
• C-ANCA
• Anti-PR3

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Drug Induced Lupus

• First reported in 1945 linked to sulfadiazine
• Estimated that 10 of cases with SLE may be
  drug-induced.
• Some medications can induce autoantibodies
  without clinical signs of autoantibody associated
  disease
• Can often resolve within days-months after
  withdrawal of offending medication

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Pathogenesis

• Unclear etiology but may develop more quickly
  with medications that are metabolized by
  acetylation, such as procainamide and hydralazine.

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Genetic Factors

• HLA alleles HLA-DR4
• Factors that affect drug metabolism

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Medications identified as definite causes of DILE

• Procainamide
• Hydralazine
• Minocycline
• Diltiazem
• Penicillamine
• Isoniazide
• Infliximab
• Etanercept
• Methyldopa
• Chlorpromazine

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Autoantibodies

• Antihistone antibodies present in gt95 of
  cases, particularly with the use of procainamide,
  hydralazine, chlorpromazine, and quinidine
• Anti-ds DNA usually absent in drug induced
  lupus due to procainamide, hydralazine, and
  isoniazid
• ANCA can be drug-induced and associated with a
  necrotizing vasculitis

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Hydralazine

• Possible risk factors
• Dose more than 200 mg/d
• Females
• Slow hepatic acetylation
• HLD-DR4 genotype.

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Features of spontaneous lupus vs. DILE
OBJECTIVE Diagnose drug-induced lupus and
anticipate laboratory findings.
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