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Amiodarone induced lupus
  1. Department of Medicine, Hospital Central de Asturias (Universitary Centre), Oviedo, Spain

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Lupus related to amiodarone has not previously been described. We report on a patient who developed drug induced lupus (DIL) in association with amiodarone treatment. To our knowledge, this is the first report of amiodarone induced lupus (CD ROM: Medline, USA National Library: 1966–98).

A 71 year old white woman was admitted because of two weeks of pleuritic chest pain, dyspnea on exertion, and non-productive cough. She had malaise, intermittent fever, arthralgia, and weight loss for more than six months. There was no history of Raynaud’s phenomenon, oral ulcers or photosensitivity. She had a six year history of arterial hypertension and atrial fibrillation treated with amiloride, digital and amiodarone (200 mg two times daily) for the past two years.

Physical examination disclosed malar rash, an aortic systolic murmur (grade II/VI), and hypoventilation in both pulmonary bases. Laboratory studies showed an erythrocyte sedimentation rate of 90 mm 1st h. Peripheral blood examination revealed a mild normochromic and normocytic anaemia (10 g/dl), normal white blood cells count (4000/μl), with lymphopenia (20 per cent), and normal platelets count (180 000/μl). Coagulation tests were normal. All serum chemistries, including thyroid function tests, creatinine phosphokinase, immunoglobulins, complement levels, and urine analysis were within normal limits. Coombs’s tests were negative. Rheumatoid factor was 1:320. Circulating immune complexes (IgG-C1q) were positive. Antinuclear antibodies (ANAs) were positive at 1:640; anti-Ro, anti-La, anti-dsDNA, anti-Sm, anti-histone antibodies, antiphospholipid antibodies, cryoglobulins, C reactive protein, VDRL and Mantoux test were negative. Blood and urine cultures were negative. Electrocardiogram was within normal limits, and the two dimensional echocardiogram showed mild aortic stenosis. Chest radiography revealed bilateral pleural effusions, without fibrosis or cardiomegaly. Pleural fluid was exudative, with lymphocytic predominance, without cytological features for malignancy. Cultures of pleural fluid for bacteria, including for Mycobacterium tuberculosis, were negative. Bone scan with technetium-99m showed increase uptake in hands, elbows, and knees. The histopathological examination of biopsy specimens of the skin, including indirect immunofluorescence stain, muscle and temporal artery did not show abnormal features.

The amiodarone was stopped and the patient progressively improved. No corticosteroids were given. On the third week she developed a transient relapse, with fever, malaise and with evidence of unilateral pleural effusion. One year after no clinical, analytical or radiological findings were present, and three years later she still remained free of symptoms, and the ESR, complete blood count, and radiological data were normal. The titre of ANA decreased but remained weakly positive at 1:40.

It is estimated that 3–7% of all patients with systemic lupus erythematous (SLE) might have DIL.1 Clinical features of SLE and DIL are similar but there are certain distinguishing characteristics between them: the patients with DIL are usually older; the prevalence of men and women is similar; and the presenting symptoms are usually mild, with the patient usually complaining of malaise, fever and arthralgia, with or without arthritis, while skin, central nervous system or renal involvement is rare. Pleuropericardial disease is frequent and, as in classic SLE, anaemia and leucopenia may be present. Serum complement components are usually normal, ANAs are positive but anti-dsDNA and anti-Sm are negative, while anti-histones antibodies can be detected in most of patients.2

The pathogenic mechanisms proposed for DIL include: cross reactivity between drug and the nucleic acid; hapten complex formation between drug and nucleic acid, or structural damage to the chromosomal DNA; action of drug as an adjuvant or immunostimulant, which, in concert with appropriate immune response genes, triggers polyclonal B/T cell activation; and interference with the complement pathway.1

The incidence of side effects associated with amiodarone ranges from 40% to 93% and, in most of cases, these side effects are consequence of its potential to be directly toxic to several organ systems.3 ,4 However, there is also some evidence of immunologically mediated phenomena related to amiodarone. A positive skin and basophil degranulation tests with amiodarone, secretion of leucocyte inhibitory factor, positive lymphoblastic transformation and circulation of a specific antibody of the IgG class have been described.5 ,6 Moreover, several studies suggest that various biological and immunological markers of “systemic” disease activity are present in patients taking this drug. Circulating immune complexes, ANAs, and non-specific increase in ESR and white blood cell count, sometimes with eosinophilia, are common findings.7 ,8

Low ANA titre is not uncommon in an elderly patient. However, spontaneous SLE in elderly people is not usual and DIL must always be considered in the differential diagnosis. This case, presenting with malaise, fever, arthralgia, circulating immune complexes, and autoantibodies strongly suggests an immunological underlying condition. Moreover, this patient meets four SLE criteria: malar rash, serositis, haematological disorder (lymphopenia), and positive ANAs test. Imputability criteria of amiodarone induced lupus are present on a semiological basis with classic features of DIL and on a chronological basis with disappearance of most of the symptoms after amiodarone withdrawal. The relapse could be explained because of the long elimination half time of the drug9 and, in consequence, the immune response might progress despite discontinuation of the treatment.