Nitrofurantoin
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Acute lung injury: case report A 79-year-old woman developed acute lung injury during treatment with nitrofurantoin for urinary tract infection (UTI). The woman, whose medical history was notable for hypertension, coronary artery disease, stent implantation, type 2 diabetes mellitus and hyperlipidemia, presented with mid-sternal non-radiating chest pain. The chest pain started 6 hours prior to this presentation. Initially, she went to the urgent care, where aspirin was initiated. However, her pain did not improve with aspirin. She also reported nausea with chest pain. Her home medications included atorvastatin, metformin, amlodipine, metoprolol and losartan/hydrochlorothiazide. Two days prior to this presentation, she started receiving nitrofurantoin twice daily [dose and route not stated] for UTI. However, nitrofurantoin was discontinued at the time of admission. At the presentation, her laboratory examinations were noted to be normal. However, the oxygen saturation level was found to be 89% on room air, but it improved to 94% with 2 litres of oxygen support. At the same time, she was found to have mild leukocytosis with elevated eosinophils and transaminitis. Subsequent chest x-ray revealed bibasilar infiltrates with small left-sided effusion. A chest computer tomography (CT) showed 8.2mm pleural nodule in right lung base, a 5.4×5.6 mm left upper lobe nodule and left lower lobe pleural effusion, that all together suggested a possible neoplasm. Thereafter, she developed acute respiratory failure with hypoxia, and was thus admitted to hospital. A follow-up chest, abdomen and pelvis CT-scan revealed multiple enlarged mediastinal lymph nodes without any evidence of a hilar or lung parenchymal mass. Subsequent echocardiogram and endobronchial ultrasound (EBUS) guided biopsy also showed a normal result. Neoplasm was thus ruled out. During the hospital stay, her pre-existing UTI was treated with ceftriaxone. After 3 days of hospitalisation, she developed fever and new-onset atrial fibrillation. The woman’s atrial fibrillation was treated with rivaroxaban and metoprolol, and she was empirically treated with doxycycline for the respiratory symptoms. Subsequently, she developed a maculopapular rash on abdomen and back, along with hypoxia requiring 6 litres of oxygen. Subsequent CT angiogram showed bilateral pleural effusions. Therefore, antibiotics were broadened to vancomycin and piperacillin/tazobactam and she was admitted to the intensive care unit (ICU). She received furosemide and supplemental oxygen support during ICU admission. Due to negative blood cultures, the absence of clinical or radiological evidence of pneumonia or a cardiac cause of fluid overload, a nitrofurantoin-induced lung injury was suspected. Hence, the antibiotics treatments with ceftriaxone, piperacillin/tazobactam, vancomycin and doxycycline were discontinued. Eventually, her symptoms improved. Her oxygen support gradually decreased. Despite the improvement, she required 2 litres of oxygen with persistent eosinophilia. Hence, she started rece
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