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Etiology and mechanisms of drug-induced lupus

Article  in  Current Opinion in Rheumatology · October 1999


DOI: 10.1097/00002281-199909000-00006 · Source: PubMed

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Toxicology 209 (2005) 135–147

Drug-induced lupus
Robert L. Rubin ∗
Department of Molecular Genetics and Microbiology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA

Abstract

Autoantibodies and, less commonly, systemic rheumatic symptoms are associated with treatment with numerous medications
and other types of ingested compounds. Distinct syndromes can be distinguished, based on clinical and laboratory features, as
well as exposure history. Drug-induced lupus has been reported as a side-effect of long-term therapy with over 40 medications. Its
clinical and laboratory features are similar to systemic lupus erythematosus, except that patients fully recover after the offending
medication is discontinued. This syndrome differs from typical drug hypersensitivity reactions in that drug-specific T-cells or
antibodies are not involved in induction of autoimmunity, it usually requires many months to years of drug exposure, is drug
dose-dependent and generally does not result in immune sensitization to the drug. Circumstantial evidence strongly suggests
that oxidative metabolites of the parent compound trigger autoimmunity. Several mechanisms for induction of autoimmunity
will be discussed, including bystander activation of autoreactive lymphocytes due to drug-specific immunity or to non-specific
activation of lymphocytes, direct cytotoxicity with release of autoantigens and disruption of central T-cell tolerance. The latter
hypothesis will be supported by a mouse model in which a reactive metabolite of procainamide introduced into the thymus results
in lupus-like autoantibody induction. These findings, as well as evidence for thymic function in drug-induced lupus patients,
support the concept that abnormalities during T-cell selection in the thymus initiate autoimmunity.
© 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Autoimmunity; Systemic lupus erythematosus; T cells; Thymus function; Oxidative drug metabolism

1. Overview munity. The vast majority of implicated agents are de-


liberately ingested medications, and these are associ-
Exposure to a wide variety of synthetic compounds ated most often with development of lupus-like signs
has been causally related to the appearance of autoim- and/or symptoms. However, it is useful to distinguish
bonafide drug-induced lupus from other categories of
Abbreviations: ANA, anti-nuclear antibody; GVHD, graft- xenobiotic-related autoimmune diseases based on the
versus-host disease; IL, interleukin; MHC, major histocompatibil- features of the syndromes and their natural history as
ity complex; MPO, myeloperoxidase; NSAID, non-steroidal anti- summarized in Table 1 because the underlying disease
inflammatory drugs; PAHA, procainamide-hydroxylamine; RBC, mechanisms are probably distinct.
red blood cells; SLE, systemic lupus erythematosus; TCR, T cell
receptor; TREC, T cell receptor excision circle
From a clinical perspective drug exposure that is
∗ Tel.: +1 505 272 4640; fax: +1 505 272 6029. temporally related to symptoms of systemic lupus ery-
E-mail address: rlrubin@salud.unm.edu. thematosus (SLE) encompasses both drug-induced lu-

0300-483X/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.tox.2004.12.025
136 R.L. Rubin / Toxicology 209 (2005) 135–147

Table 1
Autoimmune diseases due to ingested or injected xenobiotics
Syndrome Main features Causative agents Exposure duration
requirement
Drug-induced lupus Lupus-like (Table 3) Many medications (Table 2) Months to years
Drug-induced lupus SLE (Table 3) Numerous medications (see text) Hours to days
flares/exacerbation
Autoimmune Anemia and/or Penicillin, stibophen, quinidine Days to months
hemolytic anemia (positive Coombs) (␣-methyldopa and others)
Eosinophilia-myalgia Myalgia, etc. l-Tryptophan contaminants Months
Toxic oil syndrome Myalgia, pleuropulmonary Oleic acid esters of aniline Months
and/or phenylaminopropanol
Cytokine toxicity Musculoskeletal IL-1, IL-2, interferons, anti-TNF␣ Weeks

pus and drug-associated exacerbation of SLE or ini- man et al., 1989). The major target of mercury-induced
tiation of SLE flares. The latter group involves cases autoantibodies is the nucleolar protein fibrillarin, a spe-
of pre-existing SLE which remain or recur after with- cific serologic marker for a subset of patients with scle-
drawal of the implicated medication, while bonafide roderma (Hultman et al., 1989). While these animal
drug-induced lupus usually occurs in the setting of a models are of considerable mechanistic interest, these
previously normal immune system and disappears af- agents have not been definitely implicated in autoim-
ter discontinuation of the medication. Careful patient mune disease in humans.
history is required to distinguish these phenomena, but Various immune modulating agents appear to pro-
their mechanistic significance is probably profoundly duce autoimmune features in a minority of treated
different as discussed below. patients. Cyclosporine A has been reported to pre-
Drugs or environmental agents may also be asso- cipitate graft-versus-host disease (GVHD) after with-
ciated with other distinct autoimmune diseases such drawal from patients receiving autologous bone mar-
as hemolytic anemia induced by certain medications, row transplants (Dale et al., 1989; Jones et al., 1989).
eosinophilia-myalgia syndrome associated with l- Gold therapeutics have been implicated in immune-
tryptophan ingestion, toxic oil syndrome associated mediated disease (Romagnoli et al., 1992), but this is
with ingestion of aniline-adulterated cooking oil, sil- usually limited to skin reactions or buccal irritation
icosis associated with inhaled silica or asbestos dust (Lockie and Smith, 1985) and falls outside the usual
and autoimmunity associated with vinyl chloride expo- presenting symptoms and clinical progression of SLE
sure. These syndromes have unique features (reviewed (Wallace, 1993) or drug-induced lupus.
in Kaufman and Varga, 1999), and their mechanistic Therapeutic biologics such as interleukin (IL)-2,
bases should not be confused with that of drug-induced interferon-␣, -␤, and -␥, and tumor necrosis factor
lupus. (TNF)-␣ inhibitors have been occasionally associated
There are also some environmental agents suspected with a variety of musculoskeletal manifestations and
of causing lupus-like disease based largely on stud- serological features of lupus-like autoimmunity. Up
ies in experimental animals. A lupus-like syndrome to 14% of rheumatoid arthritis patients treated with
was induced in monkeys by alfalfa sprouts and l- anti-TNF␣ developed anti-DNA antibodies, although
canavanine (Malinow et al., 1982), and several case these were predominately of the IgM isotype; only one
reports of lupus-like disease associated with the inges- patient in this prospective study of 156 patients de-
tion of abnormally large amounts of alfalfa seeds or veloped lupus-like symptoms (Charles et al., 2000).
tablets (Malinow et al., 1981; Roberts and Hayashi, SLE is associated with dysregulation of cellular im-
1983) implicate l-canavanine as capable of inducing munity, and TNF␣ protects against lupus nephritis in
or exacerbating lupus if excessive quantities are in- a mouse model of SLE (Jacob et al., 1991). It is pos-
gested. The other principal example in this category is a sible that therapeutic manipulation of cytokine levels
scleroderma-like autoimmunity associated with heavy in individuals predisposed to autoimmunity may dis-
metals in rats and mice (Robinson et al., 1986; Hult- rupt cytokine-mediated immune homeostasis, leading
R.L. Rubin / Toxicology 209 (2005) 135–147 137

to autoantibody induction and disease. However, drug- Table 2


induced lupus related to small molecule pharmaceuti- Drugs currently in use that can induce lupus-like disease
cals occurs by de novo induction of autoimmunity in Agenta Riskb
the setting of a formerly normal immune system, and Anti-arrhythmics
appears to be related to disruption of the central im- Procainamide (Pronestyl) High
Quinidine (Quinaglute) Moderate
mune tolerance machinery as discussed below. Disopyramide (Norpace) Very low
Propafenone (Rythmol) Very low
Anti-hypertensives
2. Drug-induced lupus Hydralazine (Apresoline) High
Methyldopa (Aldomet) Low
Lupus-like symptoms of muscle and joint pain, fever Captopril (Capoten) Low
Acebutolol (Sectral) Low
and occasionally pleuritis and pericarditis occasionally Enalapril (Vasotec) Very low
develop as a side effect of long-term medication with Clonidine (Catapres) Very low
40 drugs currently in use (Rubin, 1999). Table 2 di- Atenolol (Tenormin) Very low
vides these drugs into therapeutic classes and indicates Labetalol (Normodyne, Trandate) Very low
Pindolol (Visken) Very low
their approximate risk levels based on the number of Minoxidil (Loniten) Very low
reports. In all cases drugs that induce lupus also in- Prazosin (Minipress) Very low
duce autoantibodies in a much higher frequency. By Anti-psychotics
far the highest risk drugs are procainamide and hy- Chlorpromazine (Thorazine) Low
dralazine, with approximately 20% incidence for pro- Phenelzine (Nardil) Very low
cainamide and 5–8% for hydralazine during 1 year of Chlorprothixene (Taractan) Very low
Lithium carbonate (Eskalith) Very low
therapy at currently used doses. The risk for develop-
ing lupus-like disease for the remainder of the drugs is Antibiotics
Isoniazid (INH) Low
much lower, considerably less than 1% of treated pa- Minocycline (Minocin) Low
tients. Quinidine can be considered moderate risk while Nitrofurantoin (Macrodantin) Very low
sulfasalazine, chlorpromazine, penicillamine, methyl- Anti-convulsants
dopa, carbamazepine, acebutalol, isoniazid, captopril, Carbamazepine (Tegretol) Low
propylthiouracil and minocycline are relatively low Phenytoin (Dilantin) Very Low
risk. The remaining 27 drugs should be considered very Trimethadione (Tridone) Very low
Primidone (Mysoline) Very low
low risk based on the paucity of case reports in the lit- Ethosuximide (Zarontin) Very low
erature. Some drugs of very low risk may be falsely
Anti-thyroidals
implicated or are currently of negligible risk because Propylthiouracil (propyl-thyracil) Low
customary treatment doses have been decreased, but
Anti-inflammatories
most reports on drug-induced lupus are convincing be- d-Penicillamine (Cuprimine) Low
cause cessation of therapy usually results in prompt Sulfasalazine (Azulfidine) Low
resolution of symptoms and eventually autoantibodies. Phenylbutazone (Butazolidin) Very low
It should be appreciated that criteria for reaching a di- Diuretics
agnosis of drug-induced lupus-like disease are not as Chlorthalidone (Hygroton) Very low
rigorous as those for diagnosis of SLE. While drug- Hydrochlorothiazide (Diuchlor H) Very low
induced lupus is not a major clinical problem because Miscellaneous
it can be fully cured by discontinuing use of the medi- Anti-tumor necrosis-␣ (Remicade) Very low
Lovastatin (Mevacor) and other statins Very low
cation, it is of mechanistic interest that a low molecular
Levodopa (Dopar) Very low
weight xenobiotic has capacity to initiate and sustain a Aminoglutethimide (Cytadren) Very low
well-defined systemic autoimmune disease. Interferon-␣ (Wellferon) and other cytokines Very low
The clinical and laboratory features of Timolol eye drops (Timoptic) Very low
procainamide- and hydralazine-induced lupus are aCommonly used brand names are enclosed in parentheses.
shown in Table 3 and compared with SLE. The bRisk refers to likelihood for lupus-like disease, not autoantibody
onset of symptoms can be slow or acute, although induction, which is usually much more common.
138 R.L. Rubin / Toxicology 209 (2005) 135–147

Table 3
Prevalence of clinical and laboratory abnormalities in drug-induced and idiopathic lupus
Feature Hydralazine-induced Procainamide-induced Systemic lupus
lupus (%) lupus (%) erythematosus (%)
Symptoms
Arthralgia/arthritis/myalgia 80 85 80
Pleuritis/pleural effusion <5 50 44
Fever/weight loss/fatigue 40–50 45 >80
Hepatosplenomegaly 15 25 5–10
Pericarditis <5 15 20
Rash 25 <5 71
Glomerulonephritis 5–10 <5 42
Neuropsychiatric <5 <5 32
Signs
Anti-nuclear antibodies >95 >95 >95
Lupus erythematosus cells >50 80 71
Anti-histone Abs >95 >95 54
Anti-[(H2A–H2B)–DNA] Ab 43 96 70
Anti-denatured DNA Ab 50–90 50 82
Anti-native DNA Ab <5 <5 28–67
Anti-cardiolipin Ab 5–15 5–20 35
Rheumatoid factor Ab 20 30 25–30
Anemia 35 20 65
Elevated erythrocyte sed. rate 60 60–80 >50
Leukopenia 5–25 15 50
Thrombocytopenia <5 <5 30–50
Elevated gammaglobulins 10–50 25 32
Hypocomplementemia <5 <5 51

For sources see Rubin (2002); Ab = antibody.

an interval of 1–2 months typically passes before the lupus usually resolve within days to weeks after
diagnosis is made. Approximately 50% of patients discontinuing the offending drug without introduction
have constitutional symptoms of fever, weight loss of anti-inflammatory medications; this observation
and fatigue. Musculoskeletal complaints are also provides a key (although retrospective) diagnostic tool.
commonly observed, with arthralgia heading the list The frequency of serologic abnormalities in lupus
for both drugs. Arthritis is a less common feature induced by procainamide and hydralazine are essen-
with lupus induced by procainamide (20%) than by tially identical (Table 3). As with idiopathic SLE the
hydralazine (50–100%), whereas serositis (pleuritis most commonly observed abnormality is the presence
and/or pericarditis) and/or myalgia are more common of anti-nuclear antibodies (ANA), and these autoanti-
presenting features of procainamide-induced lupus. bodies usually react with chromatin, the histone–DNA
By contrast, hydralazine-induced lupus is associated macromolecular complex in the cell nucleus. Within
with a higher frequency of skin rashes although these this structure the (H2A–H2B)–DNA subnucleosome
are not usually malar rashes typical of SLE. Lupus-like particle shows predominant antigenicity (Burlingame
disease associated with quinidine or minocycline is and Rubin, 1996). However, unlike in patients with
often atypical in that the former can manifest only as SLE, anti-chromatin antibodies rarely react with na-
polyarthalgias (Cohen et al., 1988) and the latter with tive (double-stranded) DNA. Other laboratory features
symmetrical polyarthritis and evidence of hepatitis noted in a minority of patients include a mild anemia,
and pneumonitis (Christodoulou et al., 1999). How- leukopenia, and hypergammaglobulinemia. Although
ever, the clinical features of an isolated, individual the reactivity of drug-induced antibodies is highly re-
case of drug-induced lupus is not characteristic of stricted, it is neither characteristic of nor dependent on
a particular drug. The symptoms of drug-induced the particular drug and is similar to the anti-chromatin
R.L. Rubin / Toxicology 209 (2005) 135–147 139

autoantibodies that arise spontaneously in the absence tients are of this category (Petri and Allbritton, 1992;
of any drugs (i.e. in SLE). This apparent paradox may Wang et al., 1993). Another, possibly related category
be resolved by the finding that a metabolite of a lupus- of patients is those with acute or subacute cutaneous lu-
inducing drug has capacity to non-specifically disrupt pus erythematosus related to photoactive medications;
central immune tolerance to chromatin (see below), these patients may have systemic disease and may even
possibly related to the origin of these autoantibodies fulfill criteria for a diagnosis of SLE (Sontheimer and
in SLE as well. Provost, 1997). Some of these drugs are also associ-
ated with typical drug-induced lupus and are included
in Table 2. Drug-induced aseptic meningitis in SLE
3. Drugs that may exacerbate SLE patients is occasionally associated with ibuprofen and
other NSAIDs (e.g., sulindac, tolmetin, diclofenac).
A report in 1945 is often cited as the first descrip- Unknown or suspected environmental chemicals such
tion of drug-induced lupus (Hoffman, 1945). In actual- as hair dyes and permanent wave preparations are also
ity this patient probably had a hypersensitivity-like re- occasionally implicated as aggravating agents in SLE
action to sulfadiazine associated with exacerbation of and related diseases.
preclinical SLE or with the onset SLE. This and sub- Whether or not an environmental or pharmaceutical
sequent, similar reports helped to entrench the view agent might aggravate or unmask incipient SLE should
that many cases of idiopathic SLE are “unmasked” be considered as a clinical problem distinct from drug-
during drug therapy in patients with a lupus diathesis induced lupus because, by definition, symptoms of the
(Alarcon-Segovia, 1967). This idea is difficult to dis- latter resolve after discontinuation of therapy, although
count or prove but now appears unlikely. Various drugs in severe cases full recovery may require up to 1 year.
have been noted to have a temporal relationship with If drugs or environmental agents are truly causative in
the exacerbation of SLE or with the onset of chronic initiating or aggravating SLE, the mechanistic basis is
SLE prior to diagnosis (Wallace and Dubois, 1987). In probably different from that of drug-induced lupus be-
these cases SLE remains after withdrawal of the im- cause the steady-state blood levels of lupus-inducing
plicated agent. In case-controlled studies of this phe- drugs must generally be sustained for many months to
nomenon 12% of SLE patients with drug allergies were years for development of drug-induced lupus. In con-
considered to display disease exacerbation, predomi- trast for most cases believed to be exacerbated SLE,
nately lupus rash (Petri and Allbritton, 1992; Wang et exposure is of very low level or infrequent when the
al., 1993). Since SLE patients are significantly more suspected agent is environmental or of relatively short
prone to develop drug allergies especially to antibi- duration when a drug is implicated. The association
otics such as sulfonamides, penicillin/cephalosporin between drugs and the onset of SLE resembles the lu-
and erythromycin (Petri and Allbritton, 1992), these pus flares following exposure to sunlight, exercise or
agents should be avoided in patients with SLE. pregnancy.
A wide variety of drugs have been thought to ex-
acerbate SLE including antibiotics, anti-convulsants,
hormones, non-steroidal anti-inflammatory drugs 4. Drug-induced immune hemolytic anemia
(NSAIDs), and dermatologic; particularly impli-
cated are hydralazine, sulfonamides, penicillin, para- Long-term therapy with some drugs is associated
aminosalacylic acid, hydrochlorothiazide, cimetidine, with development of hemolytic anemia due to anti-
phenylbutazone and mesantoin. Sulfonamides, tetracy- bodies bound to red blood cells (RBC) in vivo (direct
clines, griseofulvin, piroxicam, and benoxaprofen are Coombs test positivity). In the penicillin-type, antibody
reported to be photosensitizers of varying frequency; to the drug binds to RBC as a result of adsorption of
the rash or dermatitis related to these drugs typically the drug or its metabolite to the RBC membrane. In the
has a history of rapid onset and behaves as a drug methyldopa-type, the drug is not required for (and does
hypersensitivity-type reaction that may be triggered not affect) antibody binding, and anti-RBC antibodies
by exposure to ultraviolet light. The majority of ad- typically have specificity for rhesus locus or other in-
verse drug reactions in previously diagnosed SLE pa- trinsic RBC antigens. These antibodies rarely produce
140 R.L. Rubin / Toxicology 209 (2005) 135–147

frank hemolytic anemia, possibly because their isotype as drug-induced autoimmune hemolytic anemia. Be-
or low avidity does not support complement fixation. cause the clinical expression, time course and natural
Hemolytic anemia is commonly associated with the history of drugs that exacerbate SLE are so heteroge-
stibophen-type of drug-induced antibodies (as is quini- neous it is not readily possible to place them into either
dine and quinine) in which presumably immune com- of these categories, and their pathogenic mechanisms
plexes consisting of the drug or drug metabolite bind are probably varied as previously discussed. Also,
to RBC (see Aster R, in these proceedings). cytokine-active biologics that induce asymptomatic au-
The mechanism underlying the penicillin-type of toimmunity in patients with an autoimmune diathe-
anti-RBC response is frequently used as the basis for sis are not included because their underlying disease-
models for autoantibody elicitation in drug-induced lu- promoting mechanism is presumably a reflection of
pus. Interestingly, the autoantibodies associated with their known capacity to disrupt cytokine networks.
drug-induced lupus behave more like the methyldopa- Drug-induced lupus does not behave like a classi-
type of autoimmune response in that the likelihood cal drug hypersensitivity reaction in that it lacks drug-
for autoantibody appearance is dose-dependent (rather specific T cells or antibodies and the target autoanti-
than a hypersensitivity-type reaction to even low dose gens are not directly affected by the inducing drug.
drug exposure), but the drug is not required for anti- Also, the time course for development of drug-induced
body binding to its target antigen. In fact many of the lupus tends to be much slower than that of classical
drugs associated with Coombs positivity of this drug- drug allergies (Table 1), and reintroduction of a lupus-
independent type (methyldopa, l-dopa, mefanamic inducing drug is not associated with memory of prior
acid, procainamide, chlorpromazine and streptomycin) exposure if systemic autoimmunity had been allowed
are also known to cause drug-induced lupus (Table 2), to normalize. However, there are predisposing factors
although there is generally no correlation between pos- in drug-induced lupus including slow drug acetylator
itive Coombs test and other autoantibodies or symp- phenotype (Perry et al., 1970; Mongey et al., 1999),
toms. However, patients with methyldopa-induced HLA-DR4 (Batchelor et al., 1980) or -B47 (Gastineau
hemolytic anemia have been reported to have positive et al., 1985), complement protein C4 null allele (Speirs
lupus erythematosus cells and ANA. The mechanism et al., 1989), female gender (Totoritis et al., 1988) and
for induction of this type of anti-RBC autoantibody is Caucasian race (Mongey et al., 1999). Finally, while
unknown. However, despite the drug-independence of drug hypersensitivity can be triggered by relatively low
anti-RBC binding, a drug-altered RBC model is com- or transient doses of the inciting agent at least after sen-
monly (inappropriately) invoked, and this model is in- sitization, the probability of expressing drug-induced
correctly applied to the origin of autoantibodies asso- autoantibodies and symptomatic lupus increases as the
ciated with drug-induced lupus as well. dose and duration of exposure increases (Woosley et
al., 1978). This feature suggests a phenomenon that de-
pends on at least one event of low probability, so that
5. Summary of features of drug-induced lupus drug-induced lupus is more likely as time and dose in-
crease. Circumstantial evidence strongly suggests that
Table 4 compares the overall features of drug- this event is metabolic transformation of the drug to a
induced lupus with classical drug hypersensitivity such reactive product.

Table 4
Comparison between overall features of classical drug hypersensitivity and drug-induced lupus
Drug hypersensitivity reactions Drug-induced lupus
Drug-altered B or T cell epitope, MHC or TCR mediate disease Autoantibody binding unaffected by drug; drug-specific T
cells unrelated to autoimmunity
Rapid recurrence of symptoms upon challenge Once systemic autoimmunity has faded, drug reintroduction
restarts the induction period
Symptoms triggered by low or transient drug exposure Strong correlation between development of autoimmunity
and accumulative dose
R.L. Rubin / Toxicology 209 (2005) 135–147 141

6. Oxidative drug metabolism event could account for the long lag time for autoim-
munity to unfold.
The following features of drug-induced autoimmu- Phagocytic leukocytes including neutrophils, mono-
nity are difficult to explain by a direct action of the cytes, macrophages and skin Langerhans cells have
ingested, parent compound on some component of the drug metabolizing capacity due to the presence within
immune system: these cells of various enzymes with promiscuous sub-
strate properties such as myeloperoxidase (MPO),
1. Lupus-inducing drugs are highly diverse in chemi-
prostaglandin H synthase or, less commonly, the cy-
cal structure and pharmacological action (Table 2),
tochrome P450s. Neutrophils are clearly the greatest
yet the laboratory and clinical features of lupus in-
drug-metabolizing engine outside the liver because of
duced by all the drugs are essentially the same.
their preponderance in the circulation, apparently un-
2. Except for their pharmacological action, lupus-
limited hematopoietic regenerative capacity, ability to
inducing drugs are largely inert at normal doses.
freely circulate and populate essentially any organ or
Drug-induced lupus is an idiosyncratic drug reac-
tissue including lymphoid tissue where autoimmunity
tion not predicted by any known property of the
presumably develops and capacity to generate in re-
implicated drugs.
sponse to stimulants a robust extracellular oxidizing
3. Drugs reach a steady-state concentration within a
machinery. It is this latter feature that is particularly
few hours, but drug-induced autoimmunity and lu-
important because generation of reactive drug metabo-
pus require many months or years of continuous
lites outside a cell sets up a condition for delivering
treatment for manifestation.
these agents some distance from their immediate site
The requirement for metabolic transformation of the of formation.
ingested drug to a reactive compound would account Essentially all pharmacological classes of lupus-
for many of the features of drug-induced lupus. In vivo inducing drugs (Table 2) but not their non-lupus-
metabolism of dissimilar drugs to a product with a com- inducing analogues have been demonstrated to un-
mon, reactive property could explain how compounds dergo oxidative metabolism by activated neutrophils
with widely different pharmacological and chemical including procainamide, hydralazine, phenytoin, quini-
characteristics could produce the same adverse reac- dine, dapsone, propylthiouracil, penicillamine, chlor-
tion. The low probability for a productive metabolic promazine, isoniazid and carbamazepine. The gen-

Fig. 1. Extracellular transformation of procainamide to procainamide-hydroxylamine by neutrophils. Activation of neutrophils by opsonized


particles or certain soluble factors triggers the ectoenzyme NADPH oxidase to produce superoxide anion (O2 − ) in the extracellular environment.
O2 − spontaneously dismutates to hydrogen peroxide (H2 O2 ). Degranulation often follows, releasing myeloperoxidase. If a drug with an
appropriate functional group is present, it will participate in electron transfer with the H2 O2 –MPO intermediate. Consequently, the functional
group accepts an oxygen atom from H2 O2 , resulting in a new compound.
142 R.L. Rubin / Toxicology 209 (2005) 135–147

eral mechanism responsible for drug transformation is as immune presentation of the conjugate to initiate an
shown in Fig. 1 using the metabolism of procainamide immune response (Griem et al., 1998). Autoreactive B
to procainamide-hydroxylamine (PAHA) as the proto- cells within the microenvironment of a drug-specific
type (Rubin and Curnutte, 1989). Neutrophil-mediated T cell response might become activated by cytokine-
drug metabolism by this mechanism requires the en- mediated bystander mechanisms. However, mice that
zymatic action of MPO, as evidenced by the compet- developed enlarged lymph nodes in response to lupus-
itive inhibition of MPO activity by all lupus-inducing inducing drugs or their oxidative metabolites failed to
drugs tested and the correlation of this property with develop autoreactive T cells or autoantibodies, indicat-
neutrophil-dependent drug cytotoxicity (Jiang et al., ing that drug-specific T cells do not typically lead to
1994). N-acetylation of hydralazine and procainamide autoimmunity. In addition the autoantibodies that arise
competes with N-oxidation of these drugs, accounting in people with drug-induced lupus or drug-induced cy-
for the lower probability for development of autoimmu- topenias are limited in specificity, a feature not consis-
nity in people with the rapid acetylation phenotype. Re- tent with a bystander activation scenario. However, it
active intermediates of lupus-inducing drugs are strong is possible that drug-specific T cells could accelerate
candidates for triggering autoimmunity (Rubin, 1994). development of autoimmunity if an incipient autoim-
mune response were independently underway.

7. Mechanisms 7.2. Cytotoxic drug metabolites cause pathology

7.1. Drugs act as haptens or agonists for Cytopenias associated with certain drugs may
drug-specific T cells be related to the capacity of various reactive drug
metabolites to directly cause cell death in a non-
This concept as well as much of the older litera- immune-mediated process. Demonstration that oxida-
ture on drug-induced lupus is based on the presumed tive metabolites of many lupus-inducing drugs can kill
capacity of lupus-inducing drugs or their metabolites under certain in vitro conditions at pharmacologically
to form stable complexes with self-macromolecules relevant concentrations (Rubin et al., 1987; Wheeler et
or to directly stimulate lymphocytes. Autoantibodies al., 1988; Adams et al., 1989; Jiang et al., 1994) or en-
might develop if an immune response to the drug hance reactive oxygen species generation by murine
in the form of a hapten or to a self-antigen altered macrophage (Adams et al., 1990) and human neu-
by the drug induces antibodies that cross-react with trophils (Adams et al., 1989) is consistent with this
or cause spreading of the immune response to na- view. Reports implicate apoptosis rather than necrotic
tive self-macromolecules. A number of lupus-inducing cell death in cytotoxicity mediated by sulfamethoxa-
drugs (hydralazine, chlorpromazine, carbamazepine, zole hydroxylamine (Hess et al., 1999) or by the nitre-
phenylbutazone, and nitrofurantion) or of their oxida- nium ion of clozapine (Williams et al., 2000). Extra-
tive metabolites (procainamide, isoniazid and propy- cellular cytotoxic drug metabolites generated by neu-
lthiouracil) have capacity to cause significant enlarge- trophils in vitro (see Fig. 1) have been demonstrated for
ment of the draining popliteal lymph node when in- amodiaquine, carbamazapine, chlorpromazine, cloza-
jected subcutaneously into the hind foot pad of mice pine, hydralazine, isoniazid, procainamide, propylth-
(Kammüller et al., 1989; Kubicka-Muranyi et al., 1993; iouracil, quinidine and sulfonamides at therapeutically
Goebel et al., 1999). In this popliteal lymph node as- feasible concentrations. In addition to direct toxicity,
say (PLNA) T cells apparently respond to drug-altered cells sensitized by drug binding to the cell surface
self proteins although it is possible that a direct, non- at sub-toxic concentrations could be destroyed by an
covalent binding of the drug to the T cell receptor immune-mediated mechanism. Lymphocytes from pa-
(TCR) (Engler et al., 2004) underlies responses in some tients with a history of agranulocytosis secondary to
cases. Since monocytes, macrophages and Langerhans clozapine therapy were more sensitive to the cytotoxic
cells can present antigens to T cells, they have received effects of oxidative metabolites of clozapine than nor-
special attention as a potential source of both—drug mals or patients who did not develop agranulocytosis
biotransformation producing drug conjugates as well (Gardner et al., 1998; Tschen et al., 1999), suggest-
R.L. Rubin / Toxicology 209 (2005) 135–147 143

ing killing was mediated by drug-specific antibody or affinity self-antigens. While the immunopathological
cytotoxic T cells. features of this mouse model resemble the more global
Cytotoxicity of drug metabolites could be an in- autoimmune characteristics of a GVHD (Gleichmann
dependent pathogenic mechanism especially in cer- et al., 1984) or of idiopathic SLE (Table 3) rather than
tain susceptible populations, but such a process can- drug-induced lupus, it is possible that autoreactive T
not explain the autoimmune abnormalities in drug- cells developing through an independent mechanism
induced lupus. It is formally possible that drug toxi- become more aggressive due to such a drug-induced
city alters degradation, clearance or processing of self- LFA-1 over-expression process.
materials by antigen presenting cells, producing ab-
normal macromolecular forms or unusual peptides. 7.4. Drug metabolites disrupt central immune
These “cryptic” T cell autoepitopes may induce classi- tolerance
cal adaptive immune responses because immune tol-
erance to such unusual forms of self-materials was Because no autoimmune or even hyperimmune ef-
never established. Autoreactive B cells pre-existing fect had been elicited by treatment of any component of
in the immune repertoire could present such cryp- the peripheral immune system with drug metabolites,
tic epitopes to T cells, resulting in B cell activa- we injected PAHA into the thymus of young adult mice
tion and autoantibody secretion. Alternatively, repet- to tested whether disruption of central T cell tolerance
itive macromolecular structures released from dying by a lupus-inducing drug could result in autoimmunity.
cells could theoretically elicit T-independent autoim- Two intrathymic injections with PAHA resulted in a de-
mune responses. This type of scenario has been pro- layed but sustained production of IgG anti-chromatin
posed to account for autoantibodies associated with di- antibodies (Kretz-Rommel et al., 1997). The autoan-
verse medications, environmental agents and viruses, tibodies in PAHA-treated mice had a specificity re-
but there remains little in the way of experimental markably similar to that of patients with procainamide-
support. induced lupus in reacting with the (H2A–H2B)–DNA
complex (Table 3), suggesting that the immune system
7.3. Drugs non-specifically activate lymphocytes had undergone similar perturbations in both species. In
the peripheral immune organs of PAHA-treated mice,
Mouse splenocytes exposed to procainamide or hy- chromatin-reactive T cells were detected at a time-point
dralazine while activated in vitro displayed an in- when anti-chromatin antibodies started to rise, suggest-
creased proliferative response to autologous antigen ing that PAHA action in the thymus resulted in the ex-
presenting cells without the need for cognate antigen, port of autoreactive T cells to the periphery where they
killed autologous macrophage and promoted B cell dif- provided T-helper cell function to B cells with poten-
ferentiation into antibody-secreting cells (Cornacchia tial to produce autoantibodies. Transfer into naı̈ve mice
et al., 1988). Autoantibodies and glomerulonephritis of autoreactive peripheral T cells derived from PAHA-
were produced after adoptive transfer of such drug- injected animals elicited a similar autoantibody profile,
treated cells into mice (Yung et al., 1995). The au- indicating that autoreactive T cells that emigrated from
toreactive nature of drug-treated cells was due to the the thymus to the periphery accounted for autoantibody
inhibition by procainamide or hydralazine of DNA production in this system (Kretz-Rommel and Rubin,
methyltransferase in CD4+ T cells (Yung et al., 1995). 1999) by acting on constitutive B cells with capacity to
Hypomethylation of promoter sequences is associated secrete anti-chromatin antibodies (Kretz-Rommel and
with enhanced gene transcription, and drug-treated Rubin, 2001).
T cells showed increased expression of lymphocyte PAHA did not reverse self-tolerance of the mature
function antigen-1 (LFA-1), an important adhesion thymocyte and did not prevent deletion of high affin-
molecule that helps stabilize the interaction between ity autoreactive T cells in the thymus. Instead, PAHA
T cells and antigen presenting cells. Longer contact apparently interfered with the establishment of toler-
between the TCR on T cells and the major histocom- ance to endogenous self-antigens that are normally pre-
patibility complex (MHC) on antigen presenting cells sented by the MHC on thymic epithelial cells during
may promote T cell activation upon contact with low the positive selection of thymocytes (Kretz-Rommel
144 R.L. Rubin / Toxicology 209 (2005) 135–147

Fig. 2. Proposed mechanism for PAHA-induced autoimmunity. At the top are depicted three possible developmental fates of CD4+ CD8+
(double positive, immature) T cells in the thymic cortex bearing TCRs differing in affinity for self-antigens. T cells with negligible affinity for
self-peptides + the MHC die by neglect. Engagement of the TCR by self-antigens presented on thymic epithelial cells (TEC) activates signal
transduction pathways, initiating a program of cellular differentiation that includes enhanced expression of the TCR and CD69. Normally,
selected thymocytes acquire non-responsiveness (anergy) to the selecting self-antigens. The presence of a xenobiotic such as PAHA appears to
act at this stage, preventing establishment of anergy. Because some of these cells have low affinity TCRs, they are ignored by the negative selection
machinery that causes the active deletion in the thymic medulla of thymocytes with high affinity for self-antigens. After differentiating into
CD4+ mature T cells and emigrating to the periphery, these non-self-tolerant T cells will encounter chromatin-derived peptides on professional
antigen presenting cells (APC), similar to those that were involved in their positive selection. Because they have a reduce activation threshold
as a consequence of exposure to PAHA during their development, they can respond, resulting in IL-2 production and clonal expansion. Upon
encountering chromatin-specific B cells which concentrate the T cell antigen on their MHC, a T–B immune unit is created, initiating systemic
autoimmunity.

and Rubin, 2000). As a result mature T cells are pro- 8. Thymus function in drug-induced lupus
duced that are capable of undergoing spontaneous acti-
vation when they encounter similar self-antigens in the It is widely assumed that the thymus is non-
periphery. The implication of this scenario is that the re- functional in the adult, raising doubts about the rel-
stricted autoantibody production associated with drug- evance of the mouse model of drug-altered central T
induced lupus reflects the putative predominance of cell tolerance. Semi-quantitative measurement of thy-
pre-T cells undergoing positive selection on chromatin- mus function can be made by determining the content
derived antigens and that the subsequent establish- of TCR rearrangement excision circles (TRECs) in pe-
ment of tolerance to these self-antigens is compro- ripheral blood lymphocytes. TRECs are by-products
mised by non-specific toxicity of the lupus-inducing of the DNA rearrangement process accompanying
drug (Fig. 2). nascent T cell production in the thymus and can be
R.L. Rubin / Toxicology 209 (2005) 135–147 145

readily detected in recent thymic emigrants (Douek et Burlingame, R.W., Rubin, R.L., 1996. Autoantibody to the nucleo-
al., 1998). Eventually the TRECs disappear from pe- some subunit (H2A–H2B)–DNA is an early and ubiquitous fea-
ripheral T cells due to cell division or death, so TREC ture of lupus-like conditions. Mol. Biol. Rep. 23, 159–166.
Charles, P.J., Smeenk, R.J., De Jong, J., Feldmann, M., Maini, R.N.,
levels in the periphery correlate with relatively recent 2000. Assessment of antibodies to double-stranded DNA induced
T cell production in the thymus. Studies with normal in rheumatoid arthritis patients following treatment with inflix-
donors demonstrated TRECs in patients in their seventh imab, a monoclonal antibody to tumor necrosis factor alpha:
decade (Jamieson et al., 1999) and along with other findings in open-label and randomized placebo-controlled trials.
evidence supports the notion that the thymus remains Arthritis Rheum. 43, 2383–2390.
Christodoulou, C.S., Emmanuel, P., Ray, R.A., Good, R.A., Schnapf,
functional throughout life. B.M., Cawkwell, G.D., 1999. Respiratory distress due to
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cainamide had in their circulating lymphocyte pool tinct quinidine induced rheumatic syndromes. Ann. Intern. Med.
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Cornacchia, E., Golbus, J., Maybaum, J., Strahler, J., Hanash, S.,
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