Propylthiouracil-Induced Antineutrophil Cytoplasmic Antibody-Associated Vasculitis with Overlap IgA Nephropathy: A...

The anti-thyroid medication propylthiouracil (PTU) is a recognised cause of drug-induced antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Pauci-immune crescentic glomerulonephritis is the characteristic feature of this condition on renal biopsy. We present a case of PTU-induced AAV with the unusual histological finding of overlap IgA nephropathy (IgAN) in a young female with treatment-resistant Graves' disease.

A 26-year-old female presented with an acute kidney injury, macroscopic haematuria, and proteinuria 14 months after starting PTU for Graves' disease. She had a history of established thyroid eye disease and a previous severe adverse reaction to carbimazole. Her autoantibodies were strongly positive for myeloperoxidase-ANCA (199 U/mL). Renal biopsy demonstrated both necrotising crescentic glomerulonephritis and prominent (3+) mesangial deposition of IgA. She was treated with glucocorticoids and rituximab with sustained improvement in her renal function but persisting mild proteinuria and microscopic haematuria. PTU was ceased following a dose of radioactive iodine (RAI). Twelve months post-RAI, her Graves' orbitopathy remained stable, and her thyroid function was gradually normalising.

This was a case of drug-induced AAV with histological features of overlap IgAN. We suggest that this patient had pre-existing subclinical IgAN and then developed AAV secondary to PTU. The management of her thyroid disease was complex given the PTU-induced vasculitis, previous reaction to carbimazole, the risks of a thyroidectomy on immunosuppression, and the possible worsening of her eye disease with RAI. The glucocorticoids and Rituximab prescribed for vasculitis may have prevented the progression of her Graves' orbitopathy after RAI.