AN UNEXPECTED CULPRIT OF SHORTNESS OF BREATH

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Nitrofurantoin is one of the recommended first-line agents for the treatment of uncomplicated urinary tract infections. Nitrofurantoin-induced pulmonary toxicity is a documented rare, though potentially fatal adverse reaction. CASE PRESENTATION: A 35-year-old woman presented with complaints of worsening shortness of breath, fevers and abdominal discomfort. She had had an uncomplicated pregnancy and uncomplicated vaginal delivery 11 weeks prior to presentation. Two weeks prior she had been diagnosed with an uncomplicated urinary tract infection at a routine postpartum follow-up visit and prescribed Nitrofurantoin. Six days into treatment she developed subjective fevers and a generalized lace-like rash; both resolved spontaneously. Three days after the rash she started experiencing progressively worsening shortness of breath and recurrent subjective fevers which prompted her presentation to the Emergency Department. On presentation, she was febrile, tachycardic and tachypneic. The only notable physical exam finding was crackles at bilateral lung bases prompting concern for pulmonary edema due to peripartum cardiomyopathy. CBC, CMP, BNP, and UA were within normal limits and an echocardiogram revealed elevated right ventricular systolic (35-40mmHg) and a dilated inferior vena cava suggestive of increased right atrial pressure. This prompted a CT-Chest with contrast which showed increased interlobular septi and prominent of peribronchial interstitial structures, particularly in the right lower lobe and mediastinum. A careful reexamination of her history of presenting illness lead to a clinical diagnosis of acute Nitrofurantoin-induced pulmonary toxicity. This diagnosis was made on the basis of her unremarkable past medical history, previously uncomplicated peripartum clinical course, prior normal chest imaging and the temporal relationship between the initiation of Nitrofurantoin and the onset of her symptoms. She was managed supportively. She did not receive glucocorticoids and had already completed her course of Nitrofurantoin at the time of diagnosis. DISCUSSION: Nitrofurantoin-induced pulmonary toxicity has an incidence of less than 1%. Diagnosis can be made based on characteristic symptoms and temporal relation to drug exposure. Symptoms typically include fever, dyspnea, cough and/or rash. Crepitant crackles at the lung bases are heard in most patients and the most common laboratory findings are eosinophilia, leukocytosis, and elevated ESR. The majority of patients have parenchymal changes on imaging. Treatment is the cessation of Nitrofurantoin, however, it may take weeks to months for complete symptom resolution. The benefit of glucocorticoids has not been clearly demonstrated and typically are only employed in patients with significant respiratory compromise. CONCLUSIONS: This case illustrates the importance of knowing the possible adverse reactions to commonly prescribed medications. Reference #1: Camus P, Fanton A, Bonniaud P, et al. Interstitial lung disease induced by drugs and radiation. Respiration 2004; 71:301. Reference #2: Holmberg L, Boman G. Pulmonary reactions to nitrofurantoin. 447 cases reported to the Swedish Adverse Drug Reaction Committee 1966-1976. Eur J Respir Dis 1981; 62:180. Reference #3: Bhullar S, Lele SM, Kraman S. Severe nitrofurantoin lung disease resolving without the use of steroids. J Postgrad Med 2007; 53:111. DISCLOSURES: No relevant relationships by Oshioke Esivue, source=Web Response No relevant relationships by Diana Rodriguez, source=Web Response