Desquamative interstitial pneumonia following long-term nitrofurantoin therapy

Nitrofurantoin-Induced Lung Injury: A Reminder of an Overlooked Threat

Nitrofurantoin is a commonly prescribed antibiotic for urinary tract infection (UTI) treatment and prophylaxis. Although relatively rare, nitrofurantoin can cause a spectrum of lung injuries, from acute hypersensitivity reactions that might be fatal to chronic reactions involving fibrosis. Therefore, treating physicians' awareness and regular monitoring is essential for early recognition, drug withdrawal, avoiding unnecessary treatment, and preventing irreversible fibrosis. Here, we report the case of a 77-year-old woman who had been hospitalized with interstitial lung disease due to chronic nitrofurantoin therapy. Despite the severity of symptoms and the extent of radiological lung involvement, she returned to her clinical and radiological baseline shortly following the drug cessation.

Cystic Interstitial Lung Diseases: A Pictorial Review and a Practical Guide for the Radiologist

A cyst is a round circumscribed area of low attenuation, surrounded by epithelial or fibrous wall. Cysts can frequently occur on chest computed tomography (CT) and high-resolution computed tomography (HRCT); multiple parenchymal cysts of the lungs are the most typical feature of cystic lung interstitial diseases, characterizing a wide spectrum of diseases—ranging from isolated lung disorders up to diffuse pulmonary diseases. The aim of this review is to analyze scientific literature about cystic lung interstitial diseases and to provide a practical guide for radiologists, focusing on the main morphological features of pulmonary cysts: size, shape, borders, wall, location, and distribution. These features are shown on free-hand drawings and related to HRCT images, in order to help radiologists pursue the correct differential diagnosis between similar conditions.

Desquamative interstitial pneumonia: Risk factors, laboratory and bronchoalveolar lavage findings, radiological and histopathological examination, clinical features, treatment and prognosis

Desquamative interstitial pneumonia is a type of smoking-associated major idiopathic interstitial pneumonia, which is characterized by accumulation of alveolar macrophages in alveolar lumens and septa and develops secondary to mainly active or passive exposure to cigarette smoke. Desquamative interstitial pneumonia mostly occurs in male smokers in association with non-specific symptoms responsive to steroid therapy and has a better prognosis than usual interstitial pneumonia. To date, no large-scale clinical studies have been performed on desquamative interstitial pneumonia patients. Factors responsible for the scarcity of data on the clinical course of this condition include the retrospective nature of the available information as well as its rare occurrence. Despite this, a general consensus exists as to the nature of its symptoms, association with smoking, age and gender distribution, findings of respiratory function tests, steroid responsivity and mortality. The objective of the present review article was to report on desquamative interstitial pneumonia and to describe its etiology, risk factors and clinical features, as well as the laboratory, bronchoalveolar lavage, radiological and histopathological findings, and the treatment and prognosis of affected patients.

Smoking-related idiopathic interstitial pneumonia: A review

For many years, cigarette smoking has been considered as the leading cause of chronic obstructive pulmonary disease and lung cancer. Recently, however, it has also been associated with the development of diffuse interstitial lung diseases. In the latest classification of the major idiopathic interstitial pneumonias (IIP), the term smoking-related IIP has been introduced, including two entities, namely desquamative interstitial pneumonia (DIP) and respiratory bronchiolitis-interstitial lung disease (RB-ILD). Other entities in which smoking has a definite or suggested role include pulmonary Langerhan's cell histiocytosis, smoking-related interstitial fibrosis, combined pulmonary fibrosis and emphysema syndrome and idiopathic pulmonary fibrosis. In this review, we will focus on the mechanisms of smoking-related lung damage and on the clinical aspects of these disorders with the exception of idiopathic pulmonary fibrosis, which will be reviewed elsewhere in this review series.

Pneumonia eosinofílica crônica secundária ao uso prolongado de nitrofurantoína: achados da tomografia computadorizada de alta resolução do tórax

Os autores relatam o caso de uma paciente com estenose de uretra que desenvolveu pneumonia eosinofílica crônica secundária ao uso prolongado de nitrofurantoína como profilaxia para infecção urinária de repetição. A paciente havia sido submetida a uma biópsia pulmonar a céu aberto. É dada ênfase aos achados da tomografia computadorizada de alta resolução do tórax, já que, embora as alterações pulmonares associadas à toxicidade da nitrofurantoína geralmente sejam basais e bilaterais, no caso aqui descrito, as lesões de natureza interstício-alveolares situaram-se nas regiões subpleurais dos lobos superiores. Esses achados, por si só, são muito sugestivos de pneumonia eosinofílica crônica. O diagnóstico foi confirmado por meio da revisão da biópsia.

Challenges in pulmonary fibrosis . 4: smoking-induced diffuse interstitial lung diseases

Smoking-induced diffuse interstitial lung processes include respiratory bronchiolitis, respiratory bronchiolitis-associated interstitial lung disease (RBILD), desquamative interstitial pneumonia (DIP) and Langerhans' cell histiocytosis. The histological, radiological and clinical features of respiratory bronchiolitis, RBILD and DIP are reviewed, with particular reference to management issues; Langerhans' cell histiocytosis is covered elsewhere in this series of articles. Possible relationships between smoking and other diffuse lung diseases are explored briefly.

Smoking-related interstitial lung diseases: radiologic-pathologic correlation

Smoking-related interstitial lung diseases (SRILD) are a heterogeneous group of entities of unknown cause. These diseases include desquamative interstitial pneumonia (DIP), respiratory-bronchiolitis-related interstitial lung disease (RB-ILD), pulmonary Langerhans' cell histiocytosis (LCH) and idiopathic pulmonary fibrosis (IPF). High-resolution CT is highly sensitive in the detection of abnormalities in the lung parenchyma and airways. Ground-glass attenuation can occur in DIP and RB-ILD. Whereas DIP is histologically characterized by intra-alveolar pigmented macrophages, RB-ILD shows alveolar macrophages in a patchy peribronchiolar distribution. LCH shows nodular infiltrates on histopathological examination containing varying amounts of characteristic Langerhans' histiocytes. The HRCT findings are characteristically bilateral, symmetrical and diffuse, involving the upper lobe zones with sparing of the costophrenic angles. The most prominent CT features are nodules (sometimes cavitary) measuring 1 to 10 mm in diameter, cysts and areas of ground-glass attenuation. Pathologically, IPF is characterized by its heterogeneity with areas of normal lung, alveolitis and end-stage fibrosis shown in the same biopsy specimen. High-resolution CT findings consist of honeycombing, traction bronchiectasis and intralobular interstitial thickening with subpleural and lower lung predominance. Since coexisting lesions in the same cases have been observed, a better understanding of the different smoking-related interstitial lung diseases (SRILD) allows a more confident and specific diagnosis.

Chronic nitrofurantoin-induced lung disease

OBJECTIVE

To reassess the clinical and radiological features of chronic nitrofurantoin-induced lung disease and eventual clinical outcome.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 18 patients with chronic nitrofurantoin-induced lung disease who were seen at the Mayo Clinic in Rochester, Minn, from January 1, 1997, to December 31, 2002.

RESULTS

The median age of the 18 patients was 72 years (range, 47-90 years) at the time of diagnosis; 17 (94%) were women. Onset of symptoms occurred after a median interval of 23 months (range, 10-144 months) following the initiation of nitrofurantoin therapy for the prevention of recurrent urinary tract infections. All patients presented with persistent dyspnea and cough associated with lung infiltrates detected on chest radiography. Ten computed tomograms were available for review and revealed bilateral areas of ground-glass opacities in all cases and showed subpleural Irregular linear opacities and patchy consolidation in some cases. Nitrofurantoin therapy was discontinued in all patients, and most improved subsequently; 9 patients received corticosteroid therapy.

CONCLUSIONS

Chronic nitrofurantoin-induced lung disease is seen predominantly in older women who present with respiratory symptoms after a year or more of nitrofurantoin therapy. Associated radiological features are relatively nonspecific but usually include bilateral areas of ground-glass opacities on computed tomography of the chest. Cessation of nitrofurantoin therapy leads to improvement and suffices in the management of some patients, although corticosteroid therapy may be helpful in those more severely affected.

[DIP (desquamative interstitial pneumonia): as a tobacco-associated disease -- case report]

DIP (desquamative interstitial pneumonia) is an interstitial lung disease with diffuse and uniform accumulation of alveolar macrophages. There is a strong association with tobacco since 90% of the patients are smokers. The interstitial lung diseases related to tobacco are diverse and include tumours, emphysema, chronic bronchitis, RBILD (Respiratory Bronchilites associated Interstitial Lung Disease), DIP and Langerhans Cell Histiocitosis. The authors present a case of DIP. A brief theorycal revision and discussion of a case is made facing the association with tobacco.

Respiratory bronchiolitis associated with interstitial lung disease and desquamative interstitial pneumonia

This article explores issues of the diagnosis and management of respiratory bronchiolitis, respiratory bronchiolitis-associated interstitial lung disease, and desquamative interstitial pneumonia. These three diseases have common and overlapping features and sometimes are viewed as a continuum of smoking-induced disease, rather than as distinct and separate entities.

Drug-induced and iatrogenic infiltrative lung disease

At present more than 350 drugs are known to cause injury of the lung parenchyma,upper and lower airways, pulmonary circulation, pleura, mediastinum, lymph nodes,and neuromuscular system. Infiltrative lung disease (ILD) is the most common pattern of drug-induced injury. This article, which is clinically oriented rather than drug oriented, reviews the patterns of ILD produced by therapeutic drugs and radiation therapy.

Interstitial Lung Disease Induced by Drugs and Radiation

An ever-increasing number of drugs can reproduce variegated patterns of naturally occurring interstitial lung disease (ILD), including most forms of interstitial pneumonias, alveolar involvement and, rarely, vasculitis. Drugs in one therapeutic class may collectively produce the same pattern of involvement. A few drugs can produce more than one pattern of ILD. The diagnosis of drug-induced ILD (DI-ILD) essentially rests on the temporal association between exposure to the drug and the development of pulmonary infiltrates. The histopathological features of DI-ILD are generally consistent, rather than suggestive or specific to the drug etiology. Thus, the diagnosis of DI-ILD is mainly made by the meticulous exclusion of all other possible causes. Drug dechallenge produces measurable improvement in symptoms and imaging in the majority of patients, whereas corticosteroid therapy is indicated if symptoms are present or drug dechallenge is without an effect. Rechallenge is justified in a minority of patients, and is discouraged for diagnostic purposes only. Pneumotox (www.pneumotox.com) provides updated information on drug-induced respiratory disease.

Nitrofurantoin-induced pulmonary toxicity during pregnancy: a report of a case and review of the literature

Acute pulmonary reactions to nitrofurantoin are an uncommon side effect of therapy and can cause minor or life-threatening pulmonary dysfunction. Symptoms include fever, chills, cough, pleuritic chest pain, dyspnea. Rarely, pleural effusion and/or pulmonary hemorrhage may occur. Diagnosis is made by clinical suspicion and exclusion of other causes of respiratory compromise. Bronchoalveolar lavage (BAL) may be used to rule out infectious etiologies, and an increase in BAL fluid eosinophils is suggestive of drug-induced toxicity. The acute reaction to nitrofurantoin is believed to be mediated by an immune mechanism. Treatment is mainly discontinuation of the drug, however, corticosteroid therapy is recommended for severe reactions. A chronic reaction associated with long-term treatment with nitrofurantoin has also been reported and causes irreversible pulmonary fibrosis. Nitrofurantoin is commonly used to treat urinary tract infections during pregnancy. Despite the known pulmonary side effects of nitrofurantoin, there is no report of this toxicity occurring in pregnant patients. We present a case of respiratory failure occurring in a woman at 16 weeks' gestation who was being treated with nitrofurantoin for a urinary tract infection.

Desquamative interstitial pneumonitis. Characterization of free intraalveolar cells

There is some disagreement concerning the nature of the free intraalveolar cells in desquamative interstitial pneumonitis, although the greatest weight of evidence suggests them to be alveolar macrophages. We have obtained these cells by bronchoalveolar lavage from two patients with desquamative interstitial pneumonitis and studied their in vitro antibacterial activity and their ultrastructural morphology. Our results indicate that the free intraalveolar cells in these two patients were alveolar macrophages with normal antibacterial function.

Pulmonary reactions to drugs

Reactions to drugs may take many forms, most commonly skin and gastrointestinal reactions. Often forgotten are the pulmonary toxic effects, which can be devastating. Unfortunately, treatment of many of these iatrogenically produced diseases is unsatisfactory. Supportive pulmonary care and corticosteroids, in some cases, are the major modalities of therapy. The physician must be aware of the serious pulmonary consequences of many commonly used agents. Judicious use of these drugs coupled with careful pulmonary monitoring will prevent serious toxicity.

Desquamative interstitial pneumonia-like reaction accompanying pulmonary lesions

Six patients with specific pulmonary diseases had pulmonary tissue surgically resected for diagnostic purposes. All six cases were characterized by space-occupying lesions surrounded by a peculiar reaction of the pulmonary parenchyma indistinguishable from desquamative interstitial pneumonia. If small biopsies from these areas had been taken, a diagnosis of desquamative interstitial pneumonia would have been made, and the underlying process would have gone undetected. These cases corroborate even further the concept that desquamative interstitial pneumonia is a pattern of pulmonary reaction, rather than a well-defined disease entity. Furthermore, it seems advisable to make the dianosis of desquamative interstitial pneumonia only when other conditions have been carefully ruled out by thorough clinical and pathologic investigations.