Levamisole Induced Pauci Immune Focal Necrotizing and Crescentic Glomerulonephritis

Abstract

To the Editor: Levamisole has been used successfully in the management of nephrotic syndrome (NS) in childhood [1]. Due to its ability to act as a hapten, levamisole may cause increased formation of antibodies to various antigens [2].Our patient, a 10-y-old girl with frequently relapsing steroid sensitive NS presented with purpuric rash and nodules over lower and upper limbs. She has been on levamisole (2.5 mg/kg) alternate days for two and half years. The serum creatinine 3 mo before was 56 μmol/l. She was pale but there was no organomegaly. She had elevated blood pressure of 134/72 mmHg.Her urine albumin/creatinine ratio was 156 mmol/mg. Full blood count (FBC) showed pancytopenia and serum creatinine was 98 μmol/l. Anti-neutrophil cytoplasmic antibodies (ANCA) were positive with high titres. Antinuclear antibodies (ANA) and anti-double stranded DNA antibodies (DsDNA) were negative. The complement C3 and C4 were normal. The bone marrow biopsy was normal. The renal biopsy showed pauci immune focal necrotizing and crescentic glomerulonephritis.The levamisole was stopped immediately. The patient received methyl prednisolone 600 mg/m 2 and was followed up by intravenous cyclophosphamide; then started on daily dose of oral prednisolone 60 mg/m 2 for 4 wk. All three cell lines showed improvement after two weeks of stopping levamisole.At the three months follow-up, urine albumin/creatinine ratio was normal, renal functions revealed serum creatinine of 62 μmol/L and serum ANCA was negative.

A Brief Overview of the management of Steroid-Sensitive Nephrotic Syndrome in Children

“…Safety data is not available for it to be used daily or for it to be continued for more than two years. Clinically important side effects of levamisole include neutropaenia and disseminated vasculitis [17].…”