propylthiouracil and Respiratory-Insufficiency

The side effects of propylthiouracil, including cytopenia and vasculitis, are well established.  We present an interesting case in which cytopenia and cutaneous vasculopathy occurred concomitantly in a critically ill patient.  The patient was initially treated for suspected infection until dermatologic and rheumatologic workup revealed ANCA-positivity and vasculopathy on histopathology, most consistent with an atypical presentation of ANCA-positive vasculitis.  Upon initiation of immunosuppressive therapy, the patient's condition rapidly improved emphasizing the importance of early recognition of this condition.

Topics: Adult; Anorexia; Anti-Inflammatory Agents; Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis; Antithyroid Agents; Blister; Eyelid Diseases; Fatigue; Female; Graves Disease; Hemorrhage; Humans; Immunosuppressive Agents; Methylprednisolone; Pancytopenia; Pharyngitis; Prednisone; Propylthiouracil; Respiratory Insufficiency

Pulmonary manifestations of hyperthyroidism not only include pulmonary hypertension and hydrostatic pulmonary oedema, but also treatment/drug-associated pulmonary diseases have to be considered as an exclusion diagnosis. A 27-year-old woman with hypoxaemic respiratory failure under an arterial-venous extra-corporeal membrane oxygenator (AV-ECMO) was admitted to the intensive care unit (ICU). The patient had progressive dyspnoea with haemoptysis, palpitations and failure to thrive. The patient had Graves' disease treated previously with propylthiouracil (PTU). Diffuse alveolar haemorrhage is a non-specific syndrome characterised by evidence of diffuse alveolar damage, exclusion of infectious aetiology and progressively bloodier bronchoalveolar lavage (and/or 20% hemosiderin laden macrophages on cytological examination). PTU associated perinuclear antineutrophil cytoplasmic antibodies (p-ANCA) vasculitis appears to be more common in younger female patients presenting with leukocytoclastic vasculitis, myalgias and arthralgias. The latter compared to non-drug associated ANCA vasculitis which are more common in older males with visceral involvement. PTU-induced ANCA vasculitis prognosis appears to be better compared to primary ANCA syndromes.

Topics: Antibodies, Antineutrophil Cytoplasmic; Antithyroid Agents; Diagnosis, Differential; Enzyme-Linked Immunosorbent Assay; Female; Follow-Up Studies; Graves Disease; Hemoptysis; Humans; Hypoxia; Peroxidase; Propylthiouracil; Respiratory Insufficiency; Thyrotoxicosis

We reported the case of pulmonary alveolar hemorrhage caused by propylthiouracil (PTU) with severe respiratory failure and anemia, who improved with PTU discontinuance and steroid therapy. A 35-year-old woman presented with pyrexia, shortness of breath, and arthralgia. Her chest radiograph and CT showed diffuse ground-glass opacities, and her arterial blood gas analysis revealed severe respiratory failure. Laboratory results included a hemoglobin level of 5.2 g/dl, and a myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) level of 203 EU (normal range <9.0 EU). As bronchoalveolar lavage (BAL) fluid showed fresh blood-like fluid containing hemosiderin-laden macrophages, pulmonary alveolar hemorrhage was diagnosed. Since she had been taking PTU for 4 years, PTU was immediately discontinued. Steroid pulse therapy was performed, followed by oral prednisolone 30 mg per day, and her symptoms and chest radiograph findings rapidly improved. Based on the time-course changes, MPO-ANCA may have been involved in the development of pulmonary alveolar hemorrhage.

Topics: Adult; Antibodies, Antineutrophil Cytoplasmic; Antithyroid Agents; Female; Hemorrhage; Humans; Hyperthyroidism; Lung Diseases; Methylprednisolone; Peroxidase; Prednisolone; Propylthiouracil; Pulmonary Alveoli; Pulse Therapy, Drug; Respiratory Insufficiency; Treatment Outcome

Hypersensitivity vasculitis associated with propylthiouracil therapy is a well-documented clinical entity. Although any organ system may be involved, it is most unusual for pulmonary manifestations to be the cardinal presenting features. We report a 72-year-old woman presenting with respiratory failure and hemoptysis following initiation of propylthiouracil therapy for Graves' disease. She had cutaneous stigmata of hypersensitivity vasculitis and diffuse pulmonary infiltrates. The infiltrates improved dramatically after discontinuation of the propylthiouracil therapy and initiation of intravenous corticosteroid therapy.

Topics: Aged; Female; Humans; Lung; Propylthiouracil; Radiography; Respiratory Insufficiency; Skin; Vasculitis, Leukocytoclastic, Cutaneous

Topics: Child, Preschool; Dantrolene; Drug Therapy, Combination; Female; Fever; Humans; Propranolol; Propylthiouracil; Respiratory Insufficiency; Thyroid Crisis