A 24-h urinary fractionated metanephrines, catecholamines and 5-hydroxyindoleacetic acid were normal. of the TCS 401 minocycline-induced renal PAN. Background Minocycline is usually a semi-synthetic derivative of tetracycline. It has bacteriostatic effect by inhibiting bacterial protein synthesis. It is long-acting and the most lipid-soluble of the tetracycline-class antibiotics. It is widely considered the most effective tetracycline derivative for the treatment of acne.1 Minocycline is generally well tolerated; however, in 2009 2009 the FDA added minocycline to its Adverse Event Reporting System, citing a potential link between the use of minocycline products and Drug Reaction with Eosinophilia and Systemic Symptoms syndrome.2 Polyarteritis nodosa (PAN), a necrotising vasculitis of medium-sized arteries, has been also linked to the use of minocycline; except for our report, this has been in relation to cutaneous lesions and vasculitic neuropathy. The following is usually a case of minocycline-induced PAN with renal and mesenteric artery involvement. To the authors best knowledge, this is the first case statement of minocycline-induced PAN documenting visceral involvement. Case presentation An athletic 21-year-old woman offered to her main care physician with several months of worsening fatigue and myalgias that were now interfering with her college coursework. She experienced developed salt-craving, polyuria, easy bruising, dyspnoea on exertion, a 10 pound excess weight loss and pharyngitis. She experienced intermittent, severe bitemporal headaches without vision changes. Her medications were minocycline for acne and Ortho-Tri-Cyclen Lo. She did not use tobacco, alcohol, diet supplements or recreational drugs. She was referred to the emergency room and hospitalised. On ER presentation, her BP was 177/121?mm?Hg and HR was 111 beats/min, with no orthostatic changes. Cardiac, lung, abdominal and neurological exams were all normal. Extremity exam was without rash or skin lesions. Investigations Laboratory evaluation revealed serum sodium of 129?mmol/l, potassium 3.0?mmol/l, chloride 85?mmol/l, bicarbonate 32?mmol/l, creatinine of 0.9?mg/dl, and, urine protein/creatinine ratio of 3500?mg/g. Urine microscopic evaluation did not show any reddish or white blood cells or casts. ECG was normal except for sinus tachycardia. Studies to evaluate the hypertension and electrolyte abnormalities showed TCS 401 a plasma renin activity of 110?ng/ml/h, aldosterone 89?ng/ml, TCS 401 with an aldosterone: renin ratio of 0.6. A 24-h urinary fractionated metanephrines, catecholamines and 5-hydroxyindoleacetic acid were normal. A two-dimensional echocardiogram revealed a diminished ejection portion of 40% without ventricular hypertrophy. Urine electrolytes showed sodium 37?mmol/l, potassium 25.2?mmol/l, chloride 20?mmol/l, osmolality 300?mosm/kg with a serum osmolality of 280?mosm/kg with normal urine toxicology and diuretic screens. Proteinuria experienced improved to 1680?mg/24?h with improved BP control. Imaging, including renal ultrasound with Doppler, computerised axial tomography with contrast of chest, stomach and pelvis and positron emission tomography were normal excluding renal artery stenosis and a renin-secreting tumour. Immunological studies showed an erythrocyte sedimentation rate of TCS 401 TCS 401 85?mm/h and C-reactive protein of 4.3?mg/dl. Antinuclear antibody titer was 1?:?160 but double-stranded DNA antibody, extractable nuclear antigen antibodies and ribonucleoprotein antibody were negative. Perinuclear anti-neutrophil cytoplasmic antibodies (pANCA), specifically antimyeloperoxidase at 1.7 were present, and antiproteinase-3 was absent. In the setting of minocycline use, this picture along with the symptoms and hypertension suggested drug-induced PAN. An arteriogram was performed that revealed numerous subcentimeter microaneurysms in both kidneys (physique 1) and the superior mesenteric arterial vasculature, highly suggestive of PAN. Open in a separate window Physique 1 Renal arteriogram demonstrating many round subcentimeter microaneurysms. Differential diagnosis These radiological findings along with myalgia, diastolic hypertension and excess weight loss fulfilled 4 of the 10 criteria of the American College of Rheumatology for diagnosis of Rabbit polyclonal to RAB9A PAN (table 1). Table 1 American College of Rheumatology.