Penicillamine and nephrotic syndrome

BACKGROUND: Penicillamine (PA) treatment may be associated with a wide spectrum of adverse effects. There are many case reports and small series of PA-induced nephrotic syndrome (NS). In addition to our patient, in this study, we review all the cases of NS due to PA treatment in the English literature. METHODS: A retrospective Medline search was done for the years 1963-2004 using the terms "penicillamine" and "proteinuria" or "penicillamine" and "nephrotic". Cases were also located through article references. Cases were included in our review only if they had enough clinical and laboratory data and if the NS was considered by the authors to be mainly or solely due to PA treatment. Diagnosis of the patient, dose and duration of PA treatment, maximal amount of proteinuria, kidney function, urine analysis, serological markers, clinical data, kidney biopsy results, treatment, and course of proteinuria were documented. RESULTS: Sixty-three patients met our criteria. The female/male ratio was 40:23. Seventy-five percent of the patients had rheumatoid arthritis (RA). Mean age at diagnosis of NS was 44 (+/-S.D. 14) years. Mean dose of PA at diagnosis was 1.09 (+/-S.D. 0.413) g. Mean duration of PA treatment prior to proteinuria was 7.6 (+/-S.D. 3.90) months and mean duration of PA treatment until diagnosis of NS was 11.9 (+/-S.D. 18.8) months. Peak level of proteinuria was 10.79 (+/-S.D. 9.436) g. Some 33% of the patients developed mild to moderate renal failure at the time of diagnosis of NS, and one patient developed acute renal failure. Fifty-five percent of the patients had membranous glomerulonephritis and 27% had minimal change disease. Twelve patients were treated with corticosteroids (CS) at a dose ranging from 40 to 90 mg/day. In the overwhelming majority of patients, the proteinuria decreased significantly or disappeared within 7 months after stopping PA treatment. Patients treated with CS had a faster response. Five patients died, two of them from the CS-treated group, due to sepsis. CONCLUSION: The mean duration of PA treatment prior to the development of NS is nearly 1 year (5 months after the development of proteinuria). The most common histopathological finding is membranous glomerulonephritis. Most patients will have a significant reduction in, or disappearance of, proteinuria within 7 months after stopping PA treatment. The decrease in proteinuria is faster with CS treatment.     

Penicillamine induced pemphigus

Three cases of penicillamine induced pemphigus are described and compared to 35 previously reported cases with typical direct immunofluorescence. The incidence in our clinic was 0.57%. The penicillamine dose ranged from 250 to 1500 mg/day and the mean duration of treatment was 11 months at the onset of pemphigus in the 38 cases. Morphology and immunopathology was indistinguishable from spontaneously occurring pemphigus. The majority of cases resolved within 4 months after stopping, penicillamine; however, 8 cases, including 2 in this report, have persistent pemphigus.     

Penicillamine in rheumatoid arthritis: adverse effects.

The use of penicillamine in rheumatoid arthritis (RA) is limited by the incidence of adverse effects, some of which are potentially hazardous. However, adverse effects are dose-related and the advantages and disadvantages of different fixed and flexible dose regimes are discussed. The incidence of adverse effects is significantly greater in patients previously treated with gold who developed toxicity to that drug--no such increase being found in gold treated patients whose only reason for stopping gold was ineffectiveness. Rashes which develop after several months of treatment are variants of pemphigus and their various presentations are described. Fatal reactions, fortunately rare, are predominantly associated with aplasia of the bone marrow. Monthly haematological checks coupled with meticulous charting of the results may reveal trends as well as numerical changes and serve as an early warning of marrow damage.     

Penicillamine induced polymyositis and dermatomyositis

Eight Australian cases of D-penicillamine induced polymyositis/dermatomyositis (PM/DM) are reported. In terms of clinical, pathological and electromyographic features, D-penicillamine PM/DM is similar to idiopathic PM/DM but is generally less severe. Recovery is usually rapid when D-penicillamine is withdrawn. Sera were available for study in 6 of the 8 reported cases. Two of the 6 had elevated titers of acetylcholine receptor autoantibodies. Neither of these patients had clinical signs of myasthenia gravis. In 3 of 6 patients typed for C2, no bands were detected suggesting homozygous C2 deficiency. D-penicillamine PM/DM is associated with HLA-B18, B35 and DR4 and is immunogenetically different from idiopathic PM/DM, rheumatoid arthritis and D-penicillamine myasthenia gravis.     

Abnormal collagen metabolism in cultured cells in osteogenesis imperfecta.

Cells obtained from normal human skin synthesize predominantly type I collogen in culture. Cells obtained from the skin of an infant with a severe form of osteogenesis imperfecta were found to synthesize as much type III as type I collagen. Decreased synthesis of type I collagen could explain the tissue fragility observed in this case.     

Effect of dietary avocado oils on hepatic collagen metabolism.

The effect of various avocado and soybean oils on collagen metabolism in the liver was studied in growing female rats for 8 weeks and in day-old chicks for 1 week. In comparison with rats fed either refined avocado oil, refined or unrefined soybean oils, rats fed unrefined avocado oil showed a significant decrease in total collagen solubility in the liver, while there were no changes in total collagen, protein and moisture content. Chicks fed unrefined avocado oil as compared to those fed refined avocado oil also showed a decrease in hepatic total soluble collagen while hepatic total collagen remained unaffected. Electron micrographs and light-microscope examinations of rats' liver revealed collagen accumulation in the periportal location. This is suggestive of the early stages of fibrosis.     

Influence of primary coronary intervention on myocardial collagen metabolism and left ventricle remodeling predicted by collagen metabolism markers

The aims of the present study were to analyze cardiac collagen metabolism changes in vivo during acute and nonacute phases of ST elevation myocardial infarction (STEMI) in patients who were treated with primary coronary intervention (PCI) only, and to determine the predictive significance of collagen I and III synthesis markers (PICP, PIIINP) as well as the collagen I degradation marker (ICTP) on left ventricular function and volume changes after STEMI. Serum levels of the carboxy-terminal propeptide of type I procollagen (PICP) and amino-terminal propeptide of type III procollagen (PIIINP) assessed on the 30th day and the carboxyterminal telopeptide located at the C end of collagen type I (ICTP) assessed on the 7th day after STEMI were significantly higher (P = 0.01, P = 0.019, P = 0.04, respectively) in the PCI unsuccessful group than in the PCI successful group. These findings support the theory that early and successful PCI not only limits the amount of muscle necrosis but also protects cardiac collagen from ischemia-related injury. PICP and PIIINP levels assessed on the fourth day after acute STEMI enables us to predict the development of left ventricular function (EF) and end-diastolic volume changes over the course of 6 months, irrespective of the initial EF or revascularization success.     

Age-related changes in lung collagen metabolism. A role for degradation in regulating lung collagen production

Lung collagen levels are determined by a balance between synthesis and degradation, processes known to have rapid rates in young animals. Here, we report age-related changes in lung collagen synthesis and degradation in rats at five ages from 1 month to 2 yr. Synthesis rates were determined after injection of [14C]proline with a flooding dose of unlabeled proline, and its appearance as hydroxy-[14C]proline in protein. To determine degradation of newly synthesized collagen, the appearance of hydroxy-[14C]proline, either free or in low-molecular-weight peptides, was compared with hydroxy-[14C]proline in protein. Fractional collagen synthesis rates decreased from 13.51 +/- 0.54%/day at 1 month to 0.97 +/- 0.14%/day at 2 yr of age (p less than 0.05). Total lung collagen production also fell, but only after 15 months, when it decreased from 2.01 +/- 0.16 mg/day at 15 months to 0.54 +/- 0.10 mg/day at 2 yr of age (p less than 0.05). Fractional rates of total collagen degradation, calculated from the difference between rates of synthesis and rates of collagen deposition, decreased 20-fold from 1 month to 2 yr of age. The proportion of newly synthesized collagen degraded increased from 27.6 +/- 3.2% at 1 month to a maximum of 82.3 +/- 1.1% at 15 months. These results suggest that lung collagen synthesis and degradation occur throughout life, and that degradative pathways may play important roles in regulating collagen production during growth and ageing.     

Penicillamine in eosinophilic granuloma

Eosinophilic granuloma may involve several organs or the lungs may by involved alone (Lewis 1964;Zinkham 1976). The prognosis of pulmonary involvement is unpredictable. Some patients appear to improve spontaneously but others develop pulmonary fibrosis and respiratory and cardiac failure leading to death. Corticosteroids, immunosuppressive drugs and Vinca alkaloids have not been effective in many progressive cases (Basset et al, 1978). We report recent experience in the treatment of eosinophilic granuloma of the lung with penicillamine in rapidly deteriorating patients who had failed to respond to corticosteroids and compare this to previous experience of the disease at this hospital.     

Penicillamine associated pulmonary hemorrhage

Penicillamine is the drug of choice in Wilson's disease and a therapeutic alternative in rheumatoid arthritis. Autoimmune complications associated with penicillamine include cases resembling systemic lupus erythematosus and Goodpasture's syndrome. We report a case of diffuse pulmonary hemorrhage associated with prolonged penicillamine use in a patient with Wilson's disease with evidence of circulating immune complexes and complement activation, but without serologic or morphologic evidence of systemic lupus erythematosus, Goodpasture's syndrome or renal disease.     

Penicillamine in rheumatoid arthritis: clinical pharmacology and biochemical properties.

The current status of the clinical pharmacology of penicillamine was reviewed. Its indications in the therapy of RA were defined, and current principles of dosage were presented. The autoimmune side effects were discussed in the light of their possible implication with regard to a locus of action of the drug on the immunological system. A comparison was presented of the biochemical properties of penicillamine and 5-thiopyridoxine, another mercaptan compound which appears to demonstrate a penicillamine-like action in patients with RA. It was found that 5-thiopyridoxine did not possess copper chelating properties, it failed to form a mixed disulfide with cystine, it did not induce dermolathyrism in the weanling rat, and it was not a vitamin B6 antagonist. If both of these compounds do work by a common mechanism in RA, then the aforementioned biochemical properties of penicillamine must be presumed to be not relevant to its fundamental action in this disease.     

Bleomycin-induced pulmonary fibrosis. Effects of steroid on lung collagen metabolism

Using bleomycin-induced pulmonary fibrosis as a model, we have set out to study collagen metabolism in the fibrotic process. As was previously shown, intratracheal administration of bleomycin in the rat caused increased deposition and net synthesis of collagen in the lung. This was accompanied by marked increases in the tissue-free proline pool size and less dramatic increases in the pool's radioactivity when lung mince was pulsed with radioactive proline to measure the net collagen synthesis. Using a technique based on the quantitation of the rate of release of hydroxyproline-containing peptides when lung homogenates were incubated in calcium-containing buffer, lung collagenolytic activity was markedly diminished as a result of bleomycin treatment. Concomitant treatment with the steroid methylprednisolone did not affect significantly this decrease in lung collagenolytic activity. Such steroid treatment, however, prevented the increase in bleomycin-induced lung collagen deposition and partially suppressed total lung collagen synthesis, without affecting the net rate of lung collagen synthesis expressed per mg of DNA. Steroid treatment also inhibited the marked increase in tissue-free proline pool size and radioactivity caused by bleomycin. The mechanism of amelioration of the fibrotic response by the steroid is discussed.