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Weekly Chest CasesArchive of Old Cases

Case No : 648 Date 2010-03-28

  • Courtesy of Jimi, Huh, Sung Shine Shim, Yookyung Kim / Mokdong Hospital, Ewha Womans University, Seoul, Korea
  • Age/Sex 28 / F
  • Chief ComplaintCough, palpitation for 1day
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Diffuse Pulmonary Hemorrhage associated with PTU-Induced ANCA-Positive Vasculitis
Radiologic Findings
She was diagnosed with hyperthyroidism at age 24 years and had been taking propylthiouracil (PTU) for 4 years irregularly. On simple roentgenography, bilateral diffuse ground glass opacities are noted in both lungs with symmetrical indentation of trachea in lower neck and thoracic inlet area suggesting possibility of enlarged thyroid gland. On chest CT scan, diffuse ground glass opacities with ill defined centrilobular nodules are observed in both lungs. These radiologic finding and laboratory finding including CBC suggested diffuse pulmonary hemorrhage. The serum study for antineutrophil cytoplasmic antibody (ANCA) was positive and the patient had no other possible cause f pulmonary hemorrhage. PTU therapy was discontinued and steroid therapy started. Follow up chest radiography after 4 days showed nearly complete improvement of diffuse GGO and follow up CBC with clinical symptom were also improved.
Brief Review
Propylthiouracil (PTU) is an antithyroid drug widely used for the treatment of hyperthyroidism. Adverse reactions of PTU had been reported about 1% of the patient receiving the drug. Propylthiouracil (PTU) related ANCA associated vasculitis syndrome has been thought to be one of the possible causes of vasculitis such as, glomerulonephritis and diffuse alveolar hemorrhage. The mechanisms involved in ANCA-positive vasculitis induced by PTU treatment were still unknown. PTU induced vasculitis often occurs within weeks of treatment, but may develop after months or even years.
DAH due to an ANCA-positive vasculitis associated with PTU is uncommon but important syndrome to recognize, since the early identification of the inciting agent is essential for recovery or prevention of recurrence.
References
1. Ohtsuka M, Yamashita Y, Doi M, Hasegawa S. Propylthiouracil-induced alveolar haemorrhage associated with antineutrophil cytoplasmic antibody. Eur Respir J 1997;10:1405-1407
2. Hadjiangelis NP, Harkin TJ. Propylthiouracil-related diffuse alveolar hemorrhage with negative serologies and without capillaritis. Respir Med 2007;101:865-867
3. Dhillon SS, Singh D, Doe N, Qadri AM, Ricciardi S, Schwarz MI. Diffuse alveolar hemorrhage and pulmonary capillaritis due to propylthiouracil. Chest 1999;116:1485-1488
4. Nakamori Y, Tominaga T, Inoue Y, Shinohara K. Propylthiouracil (ptu)-induced vasculitis associated with antineutrophil antibody against myeloperoxidase (mpo-anca). Intern Med 2003;42:529-533
Keywords
Lung, Vascular, Vasculitis, ANCA associated vasculitis, Drug related,

No. of Applicants : 99

▶ Correct Answer : 11/99,  11.1%
  • - University of British Columbia , Canada Amr Ajlan
  • - Goa Medical College , India Paresh Desai
  • - EWHA WOMANS MOKDONG UNIVERSITY HOSPITAL , Korea (South) Sang Min Lee
  • - HOSPITAL SOTIRIA , Greece AIKATERINI DELAVERI
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - Gangnam Severance Hospital , Korea (South) Min Jeong Kim
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - Chonnam university hospital , Korea (South) Minyoung Jung
  • - Chonnam national university hospital , Korea (South) Jang-hyeon Song
▶ Correct Answer as Differential Diagnosis : 22/99,  22.2%
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - McGill University , Canada Ben Smith
  • - radiologist, aditya imaging centre , India vivek patel
  • - MGM Saglik Hiz A.S , Turkey Murat Ulusoy
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - CHUM , Canada Laurent Letourneau-G.
  • - Osaka University , Japan Hiromitsu Sumikawa
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - All India Institute of Medical Sciences , India Ashish Gupta
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - CHRU Lille , France guillaume lefebvre
  • - SoonChunHyang univ. hospital , Korea (South) Kim Jae Hyun
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - JIPMER , India vijay murugesan
  • - Univ. of Miami/Jackson Memorial , United States mantosh rattan
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Vitalife Clinics , Pune , India. , India Rahul Deshmukh
  • - Hotel-Dieu Montreal , Canada nicolas gautier
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - UZ GASTHUISBERG , Belgium Johan COOLEN
  • - Chungnam national university hospital , Korea (South) Jeoung Eun Lee
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