1112 Chin Med J 2DD9 J 22r9)0 J J 2— 1114 C ase report P rop y lthiour acil induced anti--neutrop hil cy toplasm ic antib ody -· a SS0 Cl a te d v a sc u l i t i s w i t 1 1 Do n e m a r r o w Ol a sm a cy to si s a n cI g r an u l0cy t0p en ia ● J ' l●-● ●? - · ■ 1 A b dullah O zkok K eywords： propylthiouracil； anti— -neutrophil cytoplasmic antibody·-asso ciated vasculitis； pla smacytosis； g ranulocytopenia A ntithyroid thionamides that inhibit thyroid hormone synthesis by interfering w ith thy roid iodination of tVrosine residues in thyroglob uli n．T hese extensivelY used drug s a r e assoc iated w ith a vari ety of w ell— k n o w n sid e ef f ect s cytoplasmi c antibody (A N C A ) 一 positive gra n uloc y to peni a and ap lastic aty pic al h em atologic al f i ndingplasm acy t osis．related to the u se of m eth im az ole — — — —w as rep orted tw ice in E nglish literatu res． 1 ,z but bon e malTOW plasmacytosis with the use of propy lthiouracil (PTU ) has ha r dly been repor t ed so fa r ． H erein w e present a case of a p atien t w it h G rav es di sease in v estigated for plasm a cell diagno sed as 刖． in duced bon e m arro w plasm ac y tosis w it h gra n u locy to pen ia and A N C A — assoc iated v asc ulif i s． drugs are molecules known as ^peroxidase m ediated such as an ti— neu trophil vasculitis． a． R ec ently , ． ． ． ． — — b one a n em ian m arrow w h o dy sc rasia w as init i ally f inally but C A S E R E P o R T A 36一 yea r -o ld f emale patient with G rav es disease who h ad b een treated w ith P T U 150 mR daily f o r 3 y ea r s presented wit h hi gh feverpalpable， purpuri c lesions on her lower extrem i1)．Phy sical examination revealed marked exo pthalmus． grade 2 thyromegaly, oral aphthou s lesion s，tachyc ardia， b ilateral axillary ly m phadenopathies that m easured 2 cm in diameter, sp leno meg alY 3 c m Palp able und er th e c osta1 margin ．L aboratory resu lts were as f o llow s ：leuk ocy tes 1 850／ gl， neutrophils 57 0／ gl， hemoglob in platelets 259／ g1．E ry throcyte sedimentation rate (ESR 、 was 1 1 0 mm／ h and C — reactiv e protein (C R P1 25 mg／ L (normaJ range： 0- 81 ． Thyroid function test results included： thyrotropin (T SH) 0． 001 mU ／ L (nor m al range： 0-35_4． 94)。free t h yroxine (FT4) 24． 5 pmo1 ／ L (normal range：9． 10_ 1 8． 02)，triiodothyronine(nor m al range： 0． 58- 1． 59)． TSH receptor antibody was 16． 63 U ／ L (norma1 range：9— 14)．PTU was withdrawn becau se o f granulo cytop enia．A fter ces satio n of P T U ． 1euk ocy te and granu lo cy te c ounts gradually inc reased w itho ut a need f o r g ranuloc yte． c olony stimulating f ac tor admin istration ． (39。 C 1 a n d sy mmetr i ca1 ． ty (F igure 1 0． 4 g／ d l， (T 3)2． 6 ng／ ml M — spike of 0 ． 0 8 m g／ d 1 w as d etected．I mm unof i xation analy sis sh ow ed I gG kappa ty pe m o noc lo nality in plasm a bu t ur i n ary light chain c ould not be detec ted ．B one marrow b iopsy w as resu lted marrow with nu merous interstitially distrib uted plasma cell s (F igure 2) expressing predominantly kappa light chains． C omputed tomography (C T 1 of the chest showed bilateral multiple axillary ly mph nodes of 2 cm in di am eter a n d a m ediastin al ly m ph n ode of 1． 5 c m in di ameter in th e infrac arinal region ．A b dom inor m a1． A r n m— c ut b iopsy ly m p adenop athies rev ealed c om po sed m o stly of mon ocy toid B cells．In b one graph ies o f p elvis and c ranium．1 ytic 1esion was n ot d etected． as hy percellular bone n al C T w as t h e axillary ly m pho id f rom nor m al ly m p hoplasm ac y toid c ells and P unc h biopsy was taken f r om t h e lesion s on th e lower extrem ities and was resu lted as vascu litis con taining int r alumin al f i b rinoid thro mb oses，ext r av asatio n of red bloo d c ells．perivascular mononu clear inf l ammatory c ells a n d ra r e nuc lea r deb r i s ． A nti— nu clea r antibody fA N A a n d anti． ． D N A were negative but P ． ． A N C A w as p ositive and my eloperoxidase (MPO、 was detected as 24 R U， Inl fnorm al range： 0- 20) by E L IS A ． C omplement levels w ere nor m al (C 3 169 mg／ dl (normal range： 101- 186)； C 4 21． 8 mg／ dl(nor m al ra n ge： 1(； _4 7))．Alt h ough lupus anti． c oagulant w as negative and antic a r diolip in IgM and IgG w ere not signif i cantly increased f27． 2 M PL U／ ml (normal range： 0- 101 and 17． 1 G PLU／ ml (nor m al range：0L-l 1) respectively)， acetylsalicylic prescr i bed because of the thrombo ses ob served in skin biop sy．W ith t h e diagn osi s of P T U — indu ced．P ． A N C A ． asso ciated methylpredn isolone w it h a do se Of 20 mg per day w as started．A f t er t h e acute phase reactants ( C RP a n d E SR ) b ec am e n ormal a n d vasculitic le sion s impro ved ．steroid treatmen t w as tap ered w ithin 3 mont h s． acid intraluminal 100 mg／ d f i brinoid was v asculitis． T he p atient h ad a new on set of c ough ， h i gh reso lut i on C T o f the c hest w as perfo r m ed to detect a po ssible vascu litic p ulmonary disease an d n o p at h olo gical lesion cou ld be DOI： 10． 3760／ cma． j． issn． 0366— 6999． 2009． 09． 020 嚣 u o 90 2 12— 4l 42 2O n pe f i p h e r a bloo d s m e a r ， r。 u e a u f or ma ti。 n。 f re d blood c ells w as detec ted ． I n serum protein electrophoresis， “ u ． ． ． Em未 1 ： du1 lahozk0k@vaho0． com1
