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most severe pulmonary manifestation of DIAV; it may initially manifest as only a cough and slight dyspnea. Patients with DIAV may also complain of chest pain, reflecting pericarditis. Neurologi- cally, patients may experience nonspecific cognitive symptoms and sensorineural hearing loss. Finally, while uncommon, hypocomplementemia predicts a worse prognosis with more severe organ damage. 10 When either DIL or DIAV are suspected, the di- agnostic testing should include an ANA titer, antihis- tone antibody, C3, C4 for DIL, and an ANCA for DIAV. Furthermore, to assess the extent of the disorder, the practitioner should order a CBC with differential, CMP, and urinalysis with microscopy, with additional tests based on those initial test results. However, because these laboratory tests are not diagnostic for DIL or DIAV, an extensive differential diagnosis list should include infections, malignancies, endo- crinopathies, and other autoimmune conditions. The most important therapy/intervention in the management of DIL or DIAV is discontinuing the offending drug. Depending on the severity of the disease manifestations, nonsteroidal anti-inflam- matory drugs can be used for arthralgias. Patients with serositis or other significant organ involvement may require systemic steroids or immunosuppres- sive agents after a tissue diagnosis. In our patient, despite discontinuing the hy- dralazine and treatment with methylprednisolone- 1 gram intravenous/day x 3 days followed by oral pred- nisone-60 mg/day and rituximab-375 mg/m 2 /week x 4 weeks, she remained dialysis dependent. CONCLUSION We conclude that it is important to recognize the autoimmune adverse effects of hydralazine, es- pecially in the setting of its increased clinical use. When patients that have autoimmune disease as a complication develop new, unexplained symptoms after starting medications, prompt investigation is necessary to prevent irreversible end organ damage. REFERENCES 1. Morrow JD, Schroeder HA, Perry HM Jr. Studies on the control of hypertension by hyphex. II. Toxic reactions and side effects. Circulation. 1953 Dec;8(6):829-839. 2. Reinhardt DJ, Waldron JM. Lupus erythema- tosus-like syndrome complicating hydralazine (apresoline) therapy J Am Med Assoc. 1954 Aug 21;155(17):1491-1492. 3. Mongey AB, Hess EV. Drug insight: autoimmune effects of medications: what’s new?  Nat Clin Pract Rheumatol. 2008 Mar;4(3):136-144. 4. P J Sheldon and W R Williams. Procainamide- induced systemic lupus erythematosus. Ann Rheum Dis. 1970 May:29(3): 236-243. 5. Elkayam O, Yaron M, Caspi D. Minocycline- induced autoimmune syndromes: an overview. Semin Arthritis Rheum. 1999 Jun:28(6):392- 397. 6. Crownson AN, Magro CM. Diltiazem and sub- acute cutaneous lupus erythematosus-like le- sions. N Engl J Med. 1995 Nov 23;333(21):1429. 7. Debandt M, Vittecoq O, Deschamps V, et al. Anti-TNF-α-induced systemic lupus syndrome. Clin Rheumatol (2003) 22: 56-61. 8. Chang C, Gershwin ME. Drug-induced lupus er- ythematosus: incidence, management and pre- vention. Drug Saf. 2011 May 1;34(5):357-74. 9. Gao, Y. and Zhao, MH. Review article: Drug- induced anti-neutrophil cytoplasmic antibody associated vasculitis. 2009 Nephrology, 14 (1): 33–41. 10. Molad Y, Tovar A, Ofer-Shiber S. Association of low serum complement C3 with reduced pa- tient and renal survival in antimyeloperoxidase- associated small-vessel vasculitis. Nephron Clin Pract 2014; 126:67–74. IT’S TIME TO FIGHT BACK Collectively, we can all work together to help combat the opioid epidemic that is destroying families and communities across the nation. We are excited to introduce our new educational training portal for medical professionals like you. These online professional education courses are available at no cost to you 24/7 so you can access them on your schedule. There are three ways to learn: visit prescribereducation.artakeback.org watch a weekly interactive video conference at arimpact.uams.edu learn on-demand with our new UAMS CME/CE portal at learnondemand.org. NUMBER 11 MAY 2019 • 251