Dear Editor, Propylthiouracil (PTU) is a thiouracil-derived drug used to treat hyperthyroidism. A number of adverse effects have been reported in association with this drug, including fever, agranulocytosis, skin rash, and vasculitis. Increasing evidence has recently suggested that PTU can induce autoimmune syndromes with the production of antinuclear antibodies or antineutrophil cytoplasmic autoantibody (ANCA) in patients with Graves’ disease. We herein report a patient who developed lupus nephritis with positive myeloperoxidase (MPO)/proteinase 3 (PR3)-ANCA after taking PTU for 17 years. A 51-year-old man with a history of Graves’ disease, treated with PTU at 50 mg/day for approximately 17 years, presented to another institution with persistent high fever, polyarthralgia, and foot edema and was subsequently referred to our hospital. Upon presentation, he had thrombocytopenia (platelet count, PLT: 3.8 9 10/lL), leukocytopenia (WBC: 2.9 9 10/lL with 47 % neutrophils), microhematuria ([100 red blood cells per highpower field), proteinuria (1.01 g/day, peak value 4.26 g/ day), and an elevated serum creatinine level (1.42 mg/dL, peak value 5.66 mg/dL; Fig. 1). Thyroid function tests were within the normal range. Serological examinations showed a high titer of antinuclear antibodies (1:320, speckled pattern), positive MPO-ANCA (140.0 U/mL), positive PR3-ANCA (19.5 U/mL), positive double-stranded DNA antibody (Ds-DNA IgG Ab: 19.1 IU/mL), positive single-stranded DNA antibody (Ss-DNA IgG Ab: 140.0 IU/mL), and hypocomplementemia (C3: 41.7 mg/dL, C4: 7.1 mg/dL, and CH50: 13.9 U/mL). Renal biopsy showed mesangial proliferative glomerulonephritis, and immunofluorescence revealed positive staining for IgG, IgM, C3, and C1q. The pathological finding of a crescentic lesion indicating ANCA-associated renal vasculitis was not seen. Based on these findings, ANCA-positive lupus nephritis (WHO class II) was diagnosed. PTU treatment was discontinued, and he was effectively treated with plasmapheresis and hemodialysis combined with two pulses of cyclophosphamide and three pulses of methylprednisolone, prednisolone, and intravenous immunoglobulin therapy. After 3 months, his thrombocytopenia, proteinuria, and MPO/PR3-ANCA titer were significantly improved (Fig. 1). Potassium iodide and radioiodine therapy was administered to treat Graves’ disease. At the current time point of 2-years follow-up with low-dose prednisolone, his serum creatinine level is 1.28 mg/dL with no proteinuria and microhematuria. MPO-ANCA is 12.5 IU/mL (normal range is \3.5 IU/ml) without any remarkable findings of vasculitis, and Ds-DNA/Ss-DNA IgG Ab and complement titers are within the normal range. While the renal biopsy showed lupus nephritis, this patient had overlapping clinical and laboratory findings of lupus and vasculitis. In a previous study, ANCA was detected in 37.3 % of patients with idiopathic systemic lupus erythematosus, and patients with this condition are almost always positive for MPO-ANCA [1]. In addition, MPO-ANCA is found in a similar proportion of patients with PTU-induced lupus and patients with vasculitis; however, PR3-ANCA is detected only in patients with PTU-induced vasculitis [2]. In the present case, the regular long-term use of PTU and overlapping clinical findings of lupus and vasculitis with positive PR3-ANCA highly indicated that this patient developed an autoimmune T. Taguchi (&) S. Nakayama S. Fujimoto Y. Terada Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku 783-8505, Japan e-mail: ttagu27k@axel.ocn.ne.jp