Aplastic anemia is characterized by bone marrow failure and pancytopenia. It could be due to autoimmune disorders, radiation, drugs, or chemicals. Drugs that mostly cause aplastic anemia include chloramphenicol, non-steroidal anti-inflammatory drugs, antiepileptic drugs, gold salts, and antithyroid drugs. Clinical sign and symptoms often result from pancytopenia that includes signs of anemia and bleeding. In some patients, fever and sepsis are seen that are due to neutropenia. AZATHIOPRINE is a purine antimetabolite, an immunosuppressive drug that causes myelosuppression and pancytopenia, especially in patients who have some degrees of TPMT (Thiopurine Methyltransferase) activity. We present a patient who admitted to our hospital with fever and pancytopenia and a history of recent AZATHIOPRINE treatment. Because of delay in the recovery of pancytopenia, she was suspected of aplastic anemia, and bone marrow aspiration and biopsy were done for her.

AZATHIOPRINE (AZA) is a purine antimetabolite. It is a prodrug of 6-mercaptopurine (6-MP); both are  widely used drugs for IBD. Sustained leukopenia (that may cause malignancy), acute pancreatitis, and allergy are the most common complications. 6-MP and AZA can take up to 3 months or longer. Leukopenic patients were more likely to respond, more likely to have their dose of steroids reduced, and more likely to be adequately treated for complications of IBD. By using newer technologies, clinicians can determine the safe / therapeutic dose of these agents. The clinical usage of AZA and 6- MP include: inflammatory bowel disease, refractory sprue, autoimmune hepatitis, primary sclerosing cholangitis, minimal change nephrotic syndrome, IgA nephropathy, Myesthina gravis, Henoch- Schonlein purpura, rheumatoid arthritis, sarcoidosis, acute lymphoblastic leukemia, refractory anemia with excess of blasts, liver, lung, renal,and pancreas transplantation, and some dermatologic disorders (e.g., eczema, pemphigus,etc.).

Introduction: Achievements in short-term graft survival since the introduction of cyclosporine has not been matched by improvement in long-term graft function, and chronic allograft nephropathy remains the second commonest cause of graft attrition over time. We aimed to evaluate the long-term results of conventional immunosuppression by steroid and AZATHIOPRINE in comparison with cyclosporine-based triple therapy in living donor kidney transplants. Materials and Methods: We evaluated the long-term follow-up data of 369 living related kidney transplant recipients that were on prednisolone-AZATHIOPRINE immunosuppressive therapy (group 1) or triple therapy by prednisolone, cyclosporine, and AZATHIOPRINE (group 2). All recipients were followed-up for more than 10 years (mean, 240±12 months). Comparative analyses included patient and graft survival rates, condition at last follow-up, graft rejection, and graft function. Results: There were 130 patients in group 1 and 239 in group 2. The overall frequency of acute rejection episodes was not significantly different between the two groups. However, the proportion of patients with chronic allograft nephropathy was significantly higher in group 2 (21% versus 35%, P=.001). Graft survival rates were 85.3% versus 92.4% at 1 year, 69.9% versus 71.9% at 5 years, and 52.5% versus 50.8% at 10 years in groups 1 and 2, respectively (P=.03). The two groups were comparable regarding posttransplant malignancies, diabetes mellitus, serious bacterial infections, and hepatic diseases. However, hypertensive patients were significantly more frequent in group 2. Conclusions: Chronic allograft nephropathy was significantly higher in patients receiving cyclosporine, possibly due to the risk of drug-induced nephrotoxicity, glomerular disease recurrence, and hypertension. Nowadays, it is possible to achieve excellent calcineurin inhibitors-free regimen using newer maintenance immunosuppressive agents.

Dear Editor, AZATHIOPRINE, a steroid sparing immunosuppressant, is used in organ transplantation and various immunological diseases like pemphigus vulgaris, pemphigus foliaceous, vitiligo, lichen planus, and alopecia areata. Anagen effluvium (AE) is the abrupt loss of hairs in their growing phase most commonly due to chemotherapy and radiation 1. AZATHIOPRINE can cause AE in association with myelosuppression 2. A 20 year old married female presented to our department with extensive cutaneous and oral lesions and was diagnosed as pemphigus vulgaris based on clinical examination (Figure 1A) and histopathology.

Background and Objective: Therapeutic effects of methotrexate (MTX) and AZATHIOPRINE (AZA) in rheumatoid arthritis (RA) patients have been compared in a few double blind studies and there is only one in study Iran which showed different results. We conducted a double - blind, clinical trial.Materials and Methods: From jun 2003 to jul 2004, 76 patient with active RA were entered into a 24-week, prospective, double - blind, clinical trial and were randomly assigned to two treatment groups (41 in MTX and 35 in AZA). In the course of study patients received MTX 7.5 mg weekly or AZA 100 mg daily. All patients were evaluated for clinical (tender and swollen joint counts, Ritchie arthicular index, duration of morning stiffness, pain score (VAS), grip test and bboratory variables (Hemoglobin, platelet, WBC, ESR, CRP, RF) at the beginning of study and every 8 weeks thereafter.Results: sixty nine Patients completed the trial. There were no statistically significant differences among the treatment groups in the time of onset of response, clinical improvement, overall physician assessment and laboratory variables at 8th and 24th weeks except higher decrease in RF titer in MTX group.Adverse drug reactions were slightly more common in AZA group and withdrawals because of side effects was 2 in AZA because of neutropenia and 1 in MTX because of elevation of SGPT.Conclusion: No significant difference in the therapeutic results of AZA and MTX on RA patients was noted. but adverse events were higher in AZA group.

Background: Therapeutic effects of AZATHIOPRINE (AZA) and Doxycycline (DOX) on arthritis Rheumatoid (RA) patients have been recognized. However, there is not much information available about the difference of their effects in the treatment of RA. Methods and Materials: Seventy-one patients finished 16 weeks of the study. (32 patient in AZA and 39patients in DOX group). All patients received less than 10 mg/day prednisolone. Group 1 and 2 received 50 mg AZA and 100mg DOX twice in day respectively. We evaluated clinical (tender & swollen joint counts, Ritchi articular index, morning stiffness, pain score (VAS), gripe strength) and laboratory measurements (hemoglobin, platelets counts, WBC, ESR, CRP, RF) and physician overall assessment. Results: At entry, demographic, clinical and laboratory measurements were similar in both groups. At 16th week both groups showed statistically significant improvement in clinical and laboratory measurements. There were no statistically significant differences between the treatment groups in clinical and laboratory variables (P<0.05) except for ESR and CRP that were better improvement in AZA group (P<0/001,P<0/01respectively). Minor adverse effects (Gastrointestinal, skin) were more frequent in DOX group, but withdrawals because of sever adverse effects were similar in both groups. Conclusions: Therapeutic effects of DOX and AZA on arthritis Rheumatoid patients were alike and there was not significant difference in clinical and laboratory variable of illness recovery as well as overall evaluation of the two drugs, but side effects of DOX were more than those of AZA.

Background: Granulomatosis with polyangiitis (GPA) is a rare disease affecting medium-small vessels, causing granuloma formation and inflammation. This study aimed to assess the efficacy and safety of RTX versus AZATHIOPRINE (AZA) for maintenance treatment in GPA patients. Methods: This retrospective cohort study involved a review of medical records of recently diagnosed GPA patients undergoing maintenance treatment with RTX or AZA. The main variable was the frequency of relapses within an 18-month follow-up period. Additionally, the study compared changes in BVAS. WG score (The Birmingham Vasculitis Activity Score-Wegner specific) and Damage (vasculitis damage index (VDI)), mortality, and treatment complications between the two groups. Results: Among the 43 patients receiving RTX maintenance treatment, 8 (18. 6%) experienced relapses during 24 months follow-up, while 14 (66. 6%) out of the 21 patients receiving AZA relapsed (Hazard Ratio = 6. 9 and 95% confidence interval = 1. 95-19. 3, p <001). Notably, the increase in the BVAS-WG score was significantly lower in the RTX group compared to the AZA group (p <001). The cumulative steroid dose was 143±21 mg in the RTX group and 125±25 mg in the AZA group (P = 0. 1). Treatment side effects were similar in both groups (p >0. 05). Conclusion: Maintenance treatment with RTX is associated with better treatment response and lower relapse rate compared to AZA. There was no difference in treatment complications between AZA or RTX in maintenance treatment.

Background and Purpose: Rhinocerebral mucormycosis is a rare fatal fungal infection which is on a growing trend, particularly among immunocompromised patients. Immunosuppressive drugs, including corticosteroids and antimetabolites, increase the risk of this infection. Herein, we reported the case of fulminant rhinocerebral mucormycosis in a patient with ulcerative colitis receiving AZATHIOPRINE and corticosteroid. Case report: A 58-year-old woman was admitted to the hospital in a state of coma with an extensive necrosis in her nose. She was afflicted with intestinal bleeding after 1 month of fasting and was treated with AZATHIOPRINE and a high dose of prednisolone for ulcerative colitis 2 months prior to hospital admission. The direct microscopic examination of the necrotic tissues of the paranasal sinuses showed several non-septate hyphae consistent with Mucorales. Culture media yielded Rhizopus species, which was identified as Rhizopus oryzae by internal transcribed spacer polymerase chain reaction sequencing. Despite the implementation of surgical and pharmaceutical (liposomal amphotericin B) treatments, the patient expired after 2 weeks of admission. Conclusion: The gastroenterologists should be aware of the adverse effect of immunosuppressive drugs they prescribe for the treatment of inflammatory bowel disease.