A Case of ANCA-positive Crescentic Glomerulonephritis after Propylthiouracil Treatment in Graves' Disease / 대한신장학회잡지

ABSTRACT

Propylthiouracil (PTU) therapy is commonly used in the treatment of Graves' disease, but often accompanies several side effects, including a mild increase in liver enzymes, leukopenia, skin rash, and arthralgia. ANCA-positive vasculitis and crescentic glomerulonephritis have been rarely reported in patients suffering from (with) Graves' disease and treated with PTU. We experienced a rare case of ANCA-positive crescentic glomerulonephritis presenting rapid progressive renal failure in a 30-year-old woman, suffering from Graves' disease and treated with PTU for 6 years. She was admitted with dyspnea for 1 day and fever, gross hematuria, arthralgia and sore throat for several days. Her chest X-ray revealed moderate cardiomegaly, bilateral pulmonary edema, and bilateral pleural effusion. She had a palpable, firm, diffuse goiter. Anti-myeloperoxidase (anti-MPO) antibody and anti-protease 3 (anti-PR3) antibody were both positive by ELISA. A percutaneous renal biopsy showed crescentic golmerulonephritis showing active cellular crescent formation with some inflammatory cell infiltration and mesangial cell proliferation. Cellular crescents were present in 2 of 3 glomeruli. Immunofluorescence stain showed weak granular deposits of IgG, IgM and C3 in the mesangium and capillary wall. ANCA-positive crescentic glomerulonephritis associated with PTU was diagnosed. The patient was started on intravenous methylprednisolone 250 mg 2 times daily, and then oral prednisolone 100 mg every other day and PTU was discontinued. Her renal function was recovered gradually and anti-MPO antibody and anti-PR3 antibody subsequently fell. Second biopsy, 7 months after first biopsy, showed focal global glomerulosclerosis. 16 months after first biopsy. she had stable renal function with mild renal insufficiency and euthyroid state.