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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Contents</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44;</span></p><p class="elsevierStylePara">Drug-induced lupus is a syndrome that shares clinical and analytical characteristics with idiopathic systemic lupus erythematosus and which appears after exposure to certain drugs that induce autoantibody formation&#46;</p><p class="elsevierStylePara">In 1945&#44; Hoffman described the first case of drug-induced lupus&#44; which involved the antibiotic sulfadiazine as the agent responsible for the condition&#46; Eight years later&#44; in 1953&#44; Morrow et al&#46; published a new case relating to the use of hydralazine<span class="elsevierStyleSup">1</span>&#46; Since then&#44; the list of associated drugs has continued to increase and in recent years&#44; biological therapies&#44; such as tumour necrosis factors &#40;TNF&#41; and interferons &#40;IFN&#41;&#44; have joined with classic agents&#44; such as procainamide&#44; the aforementioned hydralazine&#44; isoniazid or minocylcine<span class="elsevierStyleSup">2&#44;3&#44;4</span>&#46;</p><p class="elsevierStylePara">The mechanism causing this condition has not been fully defined&#59; immunogenetic &#40;certain HLA alleles&#41; and pharmacogenetic &#40;slow acetylator phenotype&#41; factors appear to play an important role in its aethiopathogeny<span class="elsevierStyleSup">1&#44;5</span>&#46;</p><p class="elsevierStylePara">In terms of clinical presentation&#44; the most common symptoms are fever&#44; general malaise&#44; muscle pain&#44; joints pain&#44; arthritis&#44; rash and serositis&#46; Unlike idiopathic lupus&#44; kidney&#44; haematologic and nervous system disorders are uncommon<span class="elsevierStyleSup">6</span>&#46; Antihistone antibodies are typical laboratory findings&#46; Hypocomplementaemia and anti-double-stranded DNA&#44; characteristics of idiopathic lupus&#44; tend to be absent&#44; although the latter can test positive in cases of anti-TNF- or IFN-induced lupus &#40;Table 2&#41;&#46;</p><p class="elsevierStylePara">The interval of time between starting the drug and the condition appearing is highly variable&#44; being between 2 weeks and 7 years in the case of IFN-&#945;&#59; a case developing two months after the drug&#8217;s suspension has been described<span class="elsevierStyleSup">7</span>&#46;</p><p class="elsevierStylePara">This condition&#8217;s prognosis is favourable&#44; such that discontinuation of the responsible drug is followed by recovery in the majority of cases&#44; in a time frame that can stretch from weeks to months&#46; Until then&#44; non-steroidal anti-inflammatory drugs &#40;NSAID&#41;&#44; hydroxychloroquine and low-dose systemic corticosteroids can be used temporarily to control symptoms&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE</span></p><p class="elsevierStylePara">We present a 51-year-old male&#44; with chronic kidney failure secondary to IgA glomerulonephritis&#44; on a periodic haemodialysis programme&#44; hypertensive&#44; an ex-user of cocaine by inhalation and with chronic hepatitis C virus &#40;HCV&#41; disease&#44; for which reason he was treated with ribavirin and pegylated IFN-&#945; &#40;180&#956;g per week&#41; for 49 weeks&#44; obtaining a sustained viral response&#46; Two weeks after finishing this treatment&#44; he sought consultation due to asthenia and generalised joint pain of 10-15 days evolution&#44; also experiencing in the last 48 hours 38&#160;&#186;C fever and increased right hip pain&#46; In the physical examination he presented pain on moving the aforementioned joint&#44; with neither functional weakness nor inflammatory signs at this level nor in other joints&#46; The increase of acute-phase reactants &#40;C reactive protein was 9&#44; ESR 120 and neutrophilia&#41; stood out in the laboratory analysis&#46; Blood cultures were taken &#40;which were sterile&#41; and&#44; in order to rule out septic arthritis&#44; an ultrasound of the joint was requested&#44; which did not show signs of arthritis nor joint fluid on being drained and analysed&#46; An echocardiogram ruled out endocarditis&#46; In the study undertaken to rule out tumours&#47;inflammation &#40;bone scan&#44; body gallium scan and chest&#47;abdominal&#47;pelvic CT scan&#41;&#44; degenerative changes were only observed in the scapulohumeral&#44; glenohumeral and coxofemoral joints&#44; with no other significant findings&#46; The autoimmunity test was positive for ANA &#40;IIF&#41; at titres of 1&#58;80 and anti-chromatin &#40;antihistone&#41;&#44; with negative anti-dsDNA and normal complement levels&#46; Other findings were rheumatoid factor 29 and positive cryoglobulins &#40;but with only 0&#46;33&#37; cryocrit&#41;&#46; It must be mentioned that one year before&#44; prior to starting treatment with pegylated IFN&#44; autoimmunity was negative and by contrast&#44; cryoglobulins were positive with 4&#46;4&#37; cryocrit&#46; Given these results suggesting drug-induced lupus &#40;related to the pegylated IFN-&#945; that the patient had been receiving until two weeks before due to his HCV&#41;&#44; treatment with NSAID&#44; low dose corticosteroids and hydroxychloroquine was started&#44; with significant improvement of symptoms&#46;</p><p class="elsevierStylePara">Lymphocyte populations were also counted before and during IFN-&#945; therapy&#44; showing significant lymphopenia&#44; with a decrease of both T cells &#40;CD4&#43; and CD8&#43;&#41; and B cells during treatment &#40;Figure 1&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Drug-induced lupus is a condition without established diagnostic criteria&#46; It should be considered in those patients who have received one of the implied drugs for longer than one month and who have compatible symptoms and autoimmunity test&#46; The growing appearance of new pharmacological therapies&#44; as well as the important pharmacosurveillance of their adverse effects&#44; make the list of agents associated with this condition increasingly comprehensive&#46; For this reason&#44; high clinical suspicion is key&#44; and therefore timing is of great importance&#46;</p><p class="elsevierStylePara">For our patient&#44; significant lymphocyte depletion induced by IFN-&#945; should also be noted&#46; Although T cell lymphopenia is an effect already described with the use of IFN-&#945; due to thymus&#8217; function alteration&#44; this situation&#44; together with the patient&#8217;s significant B lymphopenia&#44; would mean a dysregulation of the immune response which could be involved in autoimmunity&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12349&#95;16025&#95;60187&#95;en&#95;t112349&#46;jpg" class="elsevierStyleCrossRefs"><img src="12349_16025_60187_en_t112349.jpg" alt="Medicines associated with drug-induced lupus &#40;4&#41;"></img></a></p><p class="elsevierStylePara">Table 1&#46; Medicines associated with drug-induced lupus &#40;4&#41;</p><p class="elsevierStylePara"><a href="grande&#47;12349&#95;16025&#95;60188&#95;en&#95;t212349&#46;jpg" class="elsevierStyleCrossRefs"><img src="12349_16025_60188_en_t212349.jpg" alt="Characteristics of spontaneous and drug-induced lupus &#40;6&#41;"></img></a></p><p class="elsevierStylePara">Table 2&#46; Characteristics of spontaneous and drug-induced lupus &#40;6&#41;</p><p class="elsevierStylePara"><a href="grande&#47;12349&#95;16025&#95;60192&#95;en&#95;f112349&#46;jpg" class="elsevierStyleCrossRefs"><img src="12349_16025_60192_en_f112349.jpg" alt="Evolution of lymphocyte populations following treatment with interferon alpha"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Evolution of lymphocyte populations following treatment with interferon alpha</p>"
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