Recurrent nitrofurantoin-induced giant cell interstitial pneumonia: Case report and literature review

Acute pulmonary function decline and radiographic abnormalities: chronic cause?

A 64-year-old female nonsmoker with a history of hypertension, obesity, type II diabetes, and recurrent urinary tract infections secondary to chronic kidney stones presented to an outpatient pulmonology clinic with new onset shortness of breath and cough. Her pulmonary history was unremarkable, with no history of asthma, tuberculous, emphysema or pulmonary fibrosis. She denied any farm or factory exposure and reported no exposure to other potential respiratory irritants such as bird or mould; she had no pets. Her home was a townhouse with a forced hot air system and she had worked in an office for the length of her career. Her family history was similarly noncontributory; her parents had passed away from nonrespiratory causes. She was one of 11 children, none of which had a history of asthma, COPD, pulmonary fibrosis, or tuberculous. Her two grown children also had no history of pulmonary disease.

Nitrofurantoin is a cause of drug-induced pneumonitis and can result in clinically significant respiratory symptoms manifesting as interstitial lung disease on chest CT, even if the patient has been taking the drug chronically without side-effectshttps://bit.ly/3v2m29h

Hard metal lung disease: a case series

Objective:

To describe diagnostic and treatment aspects of hard metal lung disease (HMLD) and to review the current literature on the topic.

Methods:

This was a retrospective study based on the medical records of patients treated at the Occupational Respiratory Diseases Clinic of the Instituto do Coração, in the city of São Paulo, Brazil, between 2010 and 2013.

Results:

Of 320 patients treated during the study period, 5 (1.56%) were diagnosed with HMLD. All of those 5 patients were male (mean age, 42.0 ± 13.6 years; mean duration of exposure to hard metals, 11.4 ± 8.0 years). Occupational histories were taken, after which the patients underwent clinical evaluation, chest HRCT, pulmonary function tests, bronchoscopy, BAL, and lung biopsy. Restrictive lung disease was found in all subjects. The most common chest HRCT finding was ground glass opacities (in 80%). In 4 patients, BALF revealed multinucleated giant cells. In 3 patients, lung biopsy revealed giant cell interstitial pneumonia. One patient was diagnosed with desquamative interstitial pneumonia associated with cellular bronchiolitis, and another was diagnosed with a hypersensitivity pneumonitis pattern. All patients were withdrawn from exposure and treated with corticosteroid. Clinical improvement occurred in 2 patients, whereas the disease progressed in 3.

Conclusions:

Although HMLD is a rare entity, it should always be included in the differential diagnosis of respiratory dysfunction in workers with a high occupational risk of exposure to hard metal particles. A relevant history (clinical and occupational) accompanied by chest HRCT and BAL findings suggestive of the disease might be sufficient for the diagnosis.

Objetivo:

Descrever aspectos relacionados ao diagnóstico e tratamento de pacientes com doença pulmonar por metal duro (DPMD) e realizar uma revisão da literatura.

Métodos:

Estudo retrospectivo dos prontuários médicos de pacientes atendidos no Serviço de Doenças Respiratórias Ocupacionais do Instituto do Coração, localizado na cidade de São Paulo, entre 2010 e 2013.

Resultados:

Entre 320 pacientes atendidos no período do estudo, 5 (1,56%) foram diagnosticados com DPMD. Todos os pacientes eram do sexo masculino, com média de idade de 42,0 ± 13,6 anos e média de tempo de exposição a metal duro de 11,4 ± 8,0 anos. Os pacientes foram submetidos a avaliação clinica, história ocupacional, TCAR de tórax, prova de função pulmonar, broncoscopia com LBA e biópsia pulmonar. Todos apresentaram distúrbio ventilatório restritivo. O achado de imagem à TCAR de tórax mais frequente foi de opacidades em vidro fosco (em 80%). Em 4 pacientes, o LBA revelou presença de células gigantes multinucleadas. Em 3, foi diagnosticada pneumonia intersticial por células gigantes na biópsia pulmonar. Houve o diagnóstico de pneumonia intersticial descamativa associada à bronquiolite celular em 1 paciente e de pneumonite de hipersensibilidade em 1. Todos foram afastados da exposição e tratados com corticoide. Houve melhora em 2 pacientes e progressão da doença em 3.

Conclusões:

Apesar de ser uma entidade rara, a DPMD deve ser sempre considerada em trabalhadores com risco ocupacional elevado de exposição a metais duros. A história clínica e ocupacional associada a achados em TCAR de tórax e LBA sugestivos da doença podem ser suficientes para o diagnóstico.

Unrecognized Interstitial Lung Disease as a Result of Chronic Nitrofurantoin Use

Drug-induced interstitial lung disease is a rare condition attributed to several medications, including antimicrobial agents such as amphotericin B, anti-inflammatory agents such as methotrexate, biologic agents such as bevacizumab, and cardiovascular agents and chemotherapeutic agents. We describe the case of a 73-year-old female who developed interstitial lung disease following chronic use of nitrofurantoin for a urinary tract infection (UTI). The patient was taking nitrofurantoin 100 mg capsules twice daily for approximately 3 years. She presented to the hospital with complaints of a persistent dry cough that started 2 years previously. Her chest radiograph revealed bilateral reticular opacities and some atelectasis. Computed tomography of the chest demonstrated development of subpleural reticular opacities with minimal honeycombing. The patient had a severe restrictive defect on her pulmonary function tests, with a significant reduction in her carbon monoxide diffusion capacity. Multiple infectious disease and autoimmune tests were negative. Utilizing the algorithm of Naranjo (score of 9), it was determined that chronic use of nitrofurantoin was the definite cause of the patient’s interstitial lung disease. Nitrofurantoin was discontinued and she was treated with oxygen and started on an oral steroid, both of which were continued permanently once discharged. Upon discharge, the patient was maintained on 5 L of oxygen at rest and 10 L of oxygen when ambulating. Unfortunately, her lung disease ultimately resulted in her demise several months after her diagnosis. This case report illustrates the importance of rapid recognition of drug-induced lung injuries and discontinuation of the offending agent.