Immune complex-mediated vasculitis ...

Immune complex-mediated vasculitis is a well-recognized form of idiosyncratic physic reaction.[1] We report cutaneous vasculitis in association with therapy with rifampin (rifampicin). To our knowledge, this has not previously been documented. Rifampin is widely used, and of the like kind reactions are therefore important to note. (Chest 1989; 96:215-16)

Adverse forces of antituberculosis chemotherapy are well recognized. We describe a serious vasculitis which occurr with therapy with rifampin, as this does not appear to have been previously recorded.

Case Report

A 79-year-old retired printing works director was admitted to our unit, because of general debility and immobility. He described los of appetite and a chronic productive cough unless denied any hemoptysis. His alcohol consumption was 10 to 15 units (100-150 g) daily.

in succession examination the patient was emaciated, with no cutaneous lesions or lymphadenopathy. He had signs of right apical consolidation. Examination of the abdomen revealed polished hepatomegaly. The findings from examination of the nervous hypothesis were normal.

The chest x-ray film taken onward admission showed multiple rib fractures and a fracture of the right clavicle. The right upper lobe was consolidated with areas of cavitation. A direct smear of the sputum revealed numerous acid-fast and alcohol-fast bacilli. The hemoglobin of the same height was 13.1 g/dl, and the white vital current cell count was 5.9 x [10sup9]/L Plasma electrolyte evens and test of hepatic function were entirely normal.

Standard quadruple antituberculosis chemotherapy was begun with isoniazid (300 mg) ethambutol (800 mg) rifampin (600 mg) and pyrazinamide (15 g) all one time daily with pyridoxine. The patient was discharged seven days later. Unfortunately, he continued to drink heavily and, being unable to cope at hearthstone was readmitted four weeks later.

forward readmission, clinical signs and the chest x-ray film were unchanged. The deductions of tests of hepatic function were abnormal (alkaline phosphatase even of 141 IU/L, [gamma]-glutamyl transferase even of 177 IU/L, bilirubin even of 68 [mu]mol/L, and alanine aminotransferase horizontal of 58 IU/L). The hemoglobin flat white blood cell count, electrolyte of the same heights and creatinine level were all within normal limits.

The patient's therapy was changed to isoniazid and streptomycin (300 mg daily and 05 onward alternate days, respectively). Therapy with prednisolone was commenc (20 mg daily). There was resolution of the abnormalities of hepatic function. The ends of culture confirmed growth of Mycobacterium tuberculosis sensitive to all antibiotics prescribed.

After four weeks, therapy with rifampin with isoniazid was restarted, with streptomycin twice weekly. Reintroduction of rifampin was associated with the exhibition of rapidly progressive vasculitic lesions involving the patient's hands (Fig 1) Simultaneously, there was deterioration in his renal function (urea horizontal of 49.7 mmol/L, creatinine flat of 275 [mu]mol/L, potassium on a level of 5.7 mmol/L, and sodium on a level of 137 mmol/L. Testing of the patient's urine confirmed hematuria and proteinuria; he also had fecal invisible blood.

Levels of antinuclear factor, autoantibodies, rheumatoid factor, and fulness were all normal. Circulating immune complexe were demonstrated at 0272 units (normal, 006 units). The hemoglobin horizontal and platelet counts were normal.

Rifampin and isoniazid were withdrawn, and the patient was treated with prednisolone, ranitidine, and intravenous rehydration. Progressive improvement in his vasculitic lesions and renal function were noted (urea flat of 15.3 mmol/L and creatinine of the same height of 137 [mu]mol/L). flats of circulating immune complexes barbarous to normal. Isoniazid was reintroduced and streptomycin continued. The patient's roentgenographic appearances improved, and sputum remained negative for acid-fast and alcohol-fast bacilli; however, his clinical condition remained poor. Steroid dosage was gradually reduc The patient's condition continued to deteriorate, and he died three month after presentation.

Postmortem findings confirmed marked scarring in the right upper lobe. Histologic findings in the lung confirmed areas of necrosis with surrounding organization and endarteritis obliterans. The necrotic foci contained acid-fast and alcohol-fast bacilli. No gros abnormality of the glomeruli, tubule or renal interstitium was seen in the kidneys. No abnormality was establish in the cardiovascular, nervous, or gastrointestinal a whole s Features of healed vasculitic lesions were observ forward the patient's feet.

Discussion

There looks little doubt that this man's vasculitis related to rifampin therapy. He expanded deranged hepatic function while being treated with rifampin; hepatic function improved after withdrawal of rifampin and treatment with steroids. Reintroduction of rifampin was associated with a florid vasculitic reaction in association with raised on a levels of circulating immune complexes. Isoniazid therapy remained constant from beginning to end this period, and later reintroduction of isoniazid did not consequence in adverse effects.