Montelukast
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First report on diffuse alveolar haemorrhage: case report A 76-year-old man developed diffuse alveolar haemorrhage during treatment with montelukast for recurrent bronchospasm episodes. The man presented with the deteriorated dyspnoea, cough with hyaline expectoration and malleolar oedema for 1 week. His medical history included chronic obstructive pulmonary disease (COPD), for which, he was receiving oxygen and treatment with formoterol, budesonide, and tiotropium-bromide [Tiotropium]. He was admitted. At the time, his vital signs were within normal limits but with decreased haematocrit. No changes in the mucosae, skin, joints, abdomen or central nervous system were noted on physical examination. After that, an ECG showed no abnormalities in sinus rhythm, and B-type natriuretic peptide was normal. A transthoracic echocardiogram revealed preserved ejection fraction without structural or functional alterations and normal myocardial damage markers. Hence, an ischaemic substrate was ruled out. He underwent a high-resolution chest tomography (HRCT), which showed impaired transparency of the bilateral pulmonary parenchyma compared to the HRCT performed 3 weeks ago. The viral panel was negative for acute phase reactants, and other paraclinical findings were within normal ranges, including the autoimmunity profile. Therefore, a bronchoscopy plus bronchoalveolar lavage were performed in the anterior segment of the right upper lobe. However, no evidence of macroscopic alterations of the tracheobronchial tree was noted. Thereafter, a microscopic examination revealed negative Bk, negative KOH, haemosiderophages >28%, slight neutrophilia, and negative cultures. These findings were consistent with diffuse alveolar haemorrhage. Thereafter, he was interviewed again, and he revealed that 2 weeks before his presentation, he had been initiated on montelukast [dosage and route not stated] for recurrent episodes of bronchospasm, considering a possible asthma-COPD overlap. The man’s treatment with montelukast was discontinued. He received unspecified glucocorticoid pulses for 3 days following which he showed a remarkable improvement in symptomatology. As per the clinical presentation, autoimmune and infectious aetiologies were ruled out. Considering the recent initiation of the montelukast, with acute changes in the chest tomography compared to the previous study and findings of diffuse alveolar haemorrhage, it was considered highly likely to have been an adverse reaction to montelukast. Martinez Montalvo CM, et al. Montelukast-induced alveolar hemorrhage: Report of a case. Acta Medica Peruana 37: 198-203, No. 2, Apr-Jun 2020. Available from: URL: 803514892 http://doi.org/10.35663/amp.2020.372.919 [Spanish; summarised from a translation]
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Editorial comment: A search of AdisBase, Medline and Embase did not reveal any previous case reports of diffuse alveolar haemorrhage associated with montelukast. The WHO ADR database contained 2 reports of alveolar haemorrhage associated associated with montelukast.
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