Carbimazole-induced lupus

Abstract

SUMMARYWe describe the case of a 50-year-old lady admitted with a 3-week history of dyspnoea and left-sided pleuritic pain associated with pleural effusion. This common clinical picture nevertheless gave rise to a significant diagnostic challenge. The medical history included a diagnosis of thyrotoxicosis made 6 months previously that was being treated with carbimazole by her general practitioner. Key-investigation results were as follows: (1) pleural fluid was sterile and exudative, with no malignant cells, (2) erythrocyte sedimentation rate, C reactive protein and D-dimer were raised, (3) antinuclear antibody, anti-dsDNA and antihistone antibodies were newly positive, (4) imaging revealed a large left ventricular mass consistent with thrombus in the absence of evidence of a myocardial infarction. Based on the above investigations we hypothesised that carbimazole had induced systemic lupus erythematosus, manifesting as serositis resulting in an exudative pleural effusion and a proinflammatory/prothrombotic state. Carbimazole was stopped. The patient's pleural effusion completely resolved and she remains asymptomatic. BACKGROUND

Methimazole associated eosinophilic pleural effusion: a case report

“…There are only nine reported cases of carbimazole-induced vasculitis and seven cases of vasculitis associated to methimazole [ 2 – 9 , 13 , 14 , 17 , 25 – 29 ]. In addition, a lupus-like syndrome can be induced by any of the thionamides [ 8 , 13 , 14 , 21 , 30 ]. Clinical manifestations are similar to systemic lupus erythematosus (SLE) and usually patients have positive anti-nuclear, anti-dsDNA and anti-histone antibodies [ 21 ].…”

Carbimazole-induced exudative pleural effusions

“…As for the timing of such adverse events, carbimazole induced a pleural effusion after 6 months of high dose treatment (40 mg daily) in one case5 and after 3 months of treatment at a lower dose (20 mg daily) in another patient 6. Our patient presented with bilateral pleural effusions 27 months into his carbimazole therapy.…”

“…Pulmonary capillaritis with associated intra-alveolar haemorrhage has also been reported with methimazole 4. However, to our knowledge, carbimazole-induced pleural effusions have been reported in only two patients 5 6. We report a case of carbimazole-induced exudative bilateral pleural effusions in a middle-aged Caucasian man.…”

“…One such case involved an elderly woman with a unilateral exudative pleural effusion, whose vasculitic screen was negative 6. Additionally, a 50-year-old woman has been reported to develop carbimazole-induced lupus complicated by bilateral exudative pleural effusions 5. Carbimazole has also been associated with leucocytoclastic vasculitis, interstitial nephritis9 and gastric oesinophilic granulomatous vasculitis 10.…”

Non-Anti-Neutrophil Anti-Cytoplasmic Antibodies Associated Methimazole-Induced Nephritis: Case and Review of Literature

“…In addition, our patient's pericardial effusion may also be secondary to drug-induced vasculitis. There have been five cases of pleural effusion induced by anti-thyroid drugs, two with PTU [17,18] and three with carbimazole [19][20][21], that have been reported in the literature. It is unknown whether there were eosinophils in his pleural effusions, which if present, would be more evidence for a potential drug cause.…”