Hydralazine-Induced Isolated Lupus Nephritis

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Figure 1.
Light microscopy shows diffuse proliferative glomerulonephritis (magnification ×40).
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Figure 2.
Electron microscopy shows immunologic damage to kidney with antibody deposits: thickened glomerular basement membrane; occasional subendothelial, rare subepithelial and scattered mesangial deposits; and rare reticular aggregates (magnification ×2800).
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Figure 3.
Demonstration of (A) immunoglobulin (Ig) G, (B) IgA, (C) complement component 1q (C1q), and (D) complement 3 component (C3) antibodies on immunofluorescence is consistent with the clinical picture of lupus nephritis. Images show codominant IgG and IgA (1-2+) diffuse segmental to global mesangial and capillary loop staining in a full house pattern and diffuse granular basement membrane staining for IgG, IgA, C1q, and C3.

Table 1.

Patient's Baseline Immunochemistry, 2010-2015

		Laboratory Test Date
Test	Reference Range	2/10/2010	9/27/2015	12/29/2015
Antinuclear antibody (ANA)	Negative <1:160	Negative
Antinuclear antibody human epithelial type 2 titer (ANA HEp-2)	Unknown		Positive 1:160
Anti-Sjögren syndrome related antigen A (anti-SSA), relative units	0.00-19.99		1.62
Anti-Sjögren syndrome related antigen B (anti-SSB), relative units	0.00-19.99		2.93
Double-stranded DNA antibody (dsDNA)	Negative 1:10		Negative 1:10	Negative 1:10
Anti-Smith antibody, relative units	0.00-19.99		1.09
Anti-Smith/ribonucleoprotein antibody, relative units	0.00-19.99		2.17
Smooth muscle antibody	Negative		Positive 1:40
Antimitochondrial antibody (indirect fluorescent antibody)	Negative	Negative	Negative 1:40
Cytoplasmic neutrophilic antibody	<1:20 titer			<1:20
Perinuclear antineutrophil cytoplasmic antibody (P-ANCA)	<1:20 titer			<1:20

Table 2.

Patient's Immunochemistry at Presentation and Posttreatment, 2016-2017

		Laboratory Test Date
Test	Reference Range	Presentation and Admission			Discharge	Posttreatment
		11/17/16	11/22/16	11/22/16	11/24/16	12/6/16	1/25/17	3/21/17
Double-stranded DNA antibody (dsDNA)	Negative 1:10	Positive 1:2560			Positive 1:2560		Positive 1:20	Negative 1:10
Anti-Smith antibody, relative units	0.00-19.99	5.04
Antihistone antibody, units	0.0-0.9			3.5
Cytoplasmic neutrophilic antibody	<1:20 titer		<1:20
Perinuclear antineutrophil cytoplasmic antibody (P-ANCA)	<1:20 titer		<1:20
Proteinase 3 antineutrophil cytoplasmic antibody (PR3-ANCA)	Negative <0.4		<0.2
Complement 3 (C3), mg/dL	50-180	71		65		53	120	144
Complement 4 (C4), mg/dL	11-44	13		13		11	34	40
Anti-glomerular basement membrane antibody, units	<1.0		<0.2			<0.2
Computed tomography urology		Negative

Table 3.

Prescribed Medications With Doses

Date	Medications
October 2016	Hydralazine 25 mg twice daily was initiated.
November 2016	Hydralazine stopped. Administered intravenous methylprednisolone (Solu-Medrol) 1,000 mg pulse dose daily for 3 days and then began prednisone 60 mg daily and mycophenolate mofetil 500 mg twice daily.
December 2016	Prednisone taper started. Initial prednisone dose was 60 mg daily for 1 week. Dose was decreased by 10 mg each subsequent week. Mycophenolate mofetil was increased to 1,000 mg twice daily.
January 2017	Prednisone tapered to 10 mg daily.
February 2017	Patient developed pneumonia and shingles. Mycophenolate mofetil therapy discontinued. Prednisone 10 mg daily dose continued.
May 2017	Prednisone tapered to discontinuation.