Assistant Professor University of Kentucky, United States
Introduction: Drug-induced vasculitis (DIV) is a rare condition involving inflammation of small and medium blood vessels. Drugs of all categories are associated with DIV, but hydralazine is strongly linked to it. Typically, DIV is confined to the skin, but we present a case of hydralazine-associated DIV with unique manifestations of the rarer multisystem involvement.
Description: A 62-year-old male with history of hypertension on hydralazine, coronary artery disease, and aortic valve replacement presented with worsening bilateral lower extremity rash and edema. Six months prior, skin biopsy of the rash showed leukcytoclastic vasculitis. While awaiting rheumatology evaluation, he presented to the ED. On admission, he was on room air with blood pressure 97/66, prompting discontinuation of anti-hypertensive therapy. Labs showed normal white blood cell and platelet count, creatinine 1.91 mg/dL, and elevated C-reactive protein. Urinalysis showed hematuria and significant proteinuria. Chest x-ray showed mild bibasilar atelectasis. Skin and renal biopsies were obtained. On day 4, he developed an oxygen requirement of 2L/min, escalating to 12L/min within 24 hours. Chest X-ray and CT scan showed large, dense consolidations in the right upper and lower lobes and small consolidation in the left upper lobe. There was concern for acute infection, but labs showed elevated ANA, ANCA with a p-ANCA pattern, PR3, and anti-histone antibodies. He started on high-dose corticosteroids for likely pulmonary DIV, with oxygenation improving to room air the next morning. Biopsies showed thrombotic vasculopathy with vasculitis in the skin and C3 deposition in the mesangium with a cellular crescent in the kidney, confirming the diagnosis of DIV. He transitioned to azathioprine and steroid taper and discharged to a rehabilitation.
Discussion: Hydralazine-associated DIV occurs in 5-10% of patients, often limited to the skin with leukoclastic vasculitis on biopsy often seen as an early finding. Pulmonary and renal complications can develop rapidly, requiring prompt treatment to prevent death. Prior reports of DIV describe ground glass opacities on CT. Our case demonstrates that pulmonary DIV can present as dense consolidations, highlighting that pulmonary DIV must be considered beyond what is currently described in the literature.
