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nitrofurantoin is a broad - spectrum antibiotic used for the treatment of uncomplicated urinary tract infections and prophylaxis of chronic one .
although relatively rare , nitrofurantoin is one of the most common causes of drug - induced pulmonary disease .
nitrofurantoin induced pulmonary toxicity may manifest as acute or chronic interstitial pneumonia , pulmonary hemorrhage , bronchoconstriction , anaphylaxis , and pleural effusion .
knowledge of such adverse effects is essential for the early recognition and withdrawal of the drug .
, we describe the case summary of a 70-year - old man with nitrofurantoin induced interstitial lung disease and the spectrum of nitrofurantoin induced lung toxicity .
a 70-year - old man was admitted for the evaluation of dry cough and progressive shortness of breath of 8 weeks duration .
his past medical history was remarkable for diabetes mellitus , hypertension and benign hyperplasia of prostate ( bhp ) .
he had recurrent urinary tract infections and was on nitrofurantoin , 100 mg at night , for 6 months preceding the onset of symptoms .
there was no significant work place exposure , previous lung disease or significant smoking history .
physical examination revealed a respiratory rate of 20 breaths / min , blood pressure of 140/90 mmhg , pulse of 100/min and a saturation of 93% while room air .
arterial blood gas analysis while breathing room air showed a ph of 7.43 , pao2 of 64 mm hg , paco2 of 37 mm hg , and bicarbonate of 25 meq .
chest radiograph carried out revealed bilateral lower zone reticulo - nodular opacities [ figure 1a ] .
he was euthyroid and enzyme - linked immuno sorbent assay for human immunodeficiency virus was negative .
antinuclear antibody , antineutrophil cytoplasmic antibody and rheumatoid factor were normal . computed tomography of the chest demonstrated symmetric bilateral reticulation , architectural distortion , and honeycombing involving mainly the subpleural lung regions and lower lobes [ figure 1b ] .
pulmonary function tests showed moderate restrictive defect ( forced vital capacity was 58% predicted ) with severe reduction carbon monoxide diffusion capacity ( dlco 48% , diffusing capacity corrected for alveolar volume ( dlco / va ) , 49% predicted ) .
open lung biopsy was offered to the patient , but he did nt agree to it .
nitrofurantoin - induced lung disease was suspected and the drug was discontinued and prednisone 40 mg daily was initiated .
follow chest radiograph [ figure 2a ] and computed tomography [ figure 2b ] at 1 month showed significant improvement .
chest radiograph showing bilateral lower zone reticulonodular opacities high resolution computed tomography of chest showing symmetric bilateral reticulation , architectural distortion , and honeycombing involving subpleural lung regions of both the lower lobes chest radiograph carried out at 1 month interval shows clearing of the opacities high resolution computed tomography chest carried out at 1 month interval shows clearing of the reticulation and restoration of normal architecture
nitrofurantoin is used to treat uncomplicated acute urinary - tract infections and to prevent chronic ones in patients with predisposing factors .
the daily dosage of nitrofurantoin for adults is 5 - 7 mg / kg in four divided doses ( not to exceed 400 mg ) .
a single 50 - 100 mg dose at bedtime may be sufficient to prevent recurrences .
a course of therapy should not exceed 5 days and repeated courses should be separated by rest periods .
nitrofurantoin use to treat or prevent infections should be restricted to the bacterial isolates susceptible to it .
further , due to lack of broader tissue distribution of the drug , many patients who are treated with nitrofurantoin are predisposed to persistence or reappearance of bacteriuria .
urine specimens for culture and susceptibility testing should be obtained before and after completion of therapy . if persistence or reappearance of bacteriuria occurs after treatment with nitrofurantoin , other therapeutic agents with broader tissue distribution should be selected . in considering the use of nitrofurantoin
, lower eradication rates should be balanced against the increased potential for systemic toxicity and for the development of antimicrobial resistance . before advising continuous antibiotic prophylaxis for recurrent urinary tract infection ,
detailed urological evaluation to diagnose and detect structural abnormalities , urinalysis , and midstream urine culture and sensitivity should be undertaken .
the patients in whom continuous antibiotic prophylaxis with nitrofuraintoin is being considered for recurrent uti should be carefully screened for various adverse events and side - effects .
its most frequent side - effects are usually minor , ranging from nausea , flatulence , and headache .
various hypersensitivity reactions occur occasionally . these include chills , fever , leukopenia , granulocytopenia , hemolytic anemia associated with glucose-6-phosphate dehydrogenase deficiency , cholestatic jaundice .
uncommon but serious adverse events include aplastic anemia , polyneuritis , and liver and pulmonary toxicity .
the spectrum of nitrofurantoin induced pulmonary toxicity includes acute or chronic interstitial pneumonia , pulmonary hemorrhage , bronchoconstriction , anaphylaxis , and pleural effusion .
the incidence has been estimated to be anywhere from 1 in 550 to 1 in 5400 individuals .
toxicity can occur at relatively small doses , and does not appear to be dose - related .
acute pulmonary reaction generally present with fever , chills , cough , chest pain , dyspnea within days to weeks after the first dose of nitrofurantoin .
if unrecognized and the drug is continued , acute nitrofurantoin pulmonary toxicity has 10 - 15% mortality .
acute reactions are usually reversible with cessation of therapy and symptoms usually resolve within 72 h of discontinuing the drug . chronic pulmonary reaction to nitrofurantoin occurs far less common than acute pulmonary reactions and acute reactions do not predispose to a chronic one .
lung involvement is common in elderly women as long - term nitrofurantoin prophylaxis is used for recurrent urinary tract infections .
further , elderly population may have underlying cardiopulmonary disease and early recognition of its potential contribution to a patient 's respiratory decline is important .
it generally presents with insidious onset of dyspnea and cough usually , beginning 6 months to years after nitrofurantoin use .
high resolution computed tomography of chest may reveal ground - glass attenuation , honeycombing , inter- and intralobular septal thickening , traction bronchiectasis , and organizing pneumonia .
clinico - radiologically , this condition masquerades other forms of interstitial lung disease with the exception that there is history of nitrofurantoin use .
our patient presented with radiographic evidence of irreversible pulmonary fibrosis ( honeycombing pattern ) and the patient 's clinical symptoms and radiographic findings resolved rapidly within a month of stopping nitrofurantoin and use of prednisolone .
patients on long - term nitrofurantoin should be reviewed and monitored regularly , and the drug should be discontinued at the first sign of any abnormalities .
clinical improvement tends to be rapid following withdrawal of nitrofurantoin and initiation of corticosteroid treatment .
we describe the case summary of a 70-year - old man diagnosed with interstitial lung disease due to prolonged nitrofurantoin therapy . despite honeycombing confirmed by computed tomography of the thorax 
 , symptoms and radiographic findings disappeared within 1 month after withdrawal of nitrofurantoin . 
 the case highlights the fact that nitrofurantoin - induced lung disease may run a benign course and respond favorably despite radiographic evidence of established lung fibrosis ( honey combing ) .