Dyspnea is a common symptom and may be due to a multitude of conditions, including cardiopulmonary insufficiency, anemia, neuromuscular disorders, obesity, or deconditioning. It is not uncommon that more than one process contributes to shortness of breath. Here, we present a patient with a complaint of worsening shortness of breath who was found to have two very rare causes of dyspnea simultaneously. The symptoms resolved with treatment of pernicious anemia and myasthenia gravis (MG). The coexistence of pernicious anemia and MG is extremely rare, with only two other cases reported so far.
A 78-year-old man with newly diagnosed treatment-naïve chronic lymphocytic leukaemia (CLL) was referred to a pulmonary clinic for 1 month of dry cough and dyspnoea on exertion. Further workup with CT of the chest showed patchy ground-glass opacities predominantly on the right side. The patient was started on empiric antibiotic for presumed community-acquired pneumonia but did not have any improvement in his symptoms and eventually required supplemental oxygen. Bronchoscopy with bronchoalveolar lavage from the right middle lobe showed Pneumocystis jirovecii cysts on Grocott methenamine silver stains. The patient was HIV negative. He was placed on P. jirovecii pneumonia (PJP) treatment with clindamycin and primaquine due to history of significant allergy to sulfa drugs. The patient’s symptoms completely resolved after a 21-day course of treatment and no longer needed supplemental oxygen. This case highlights the importance of keeping PJP infection in differential diagnosis in both treated and untreated patients with CLL with dyspnoea and pulmonary infiltrates.
INTRODUCTION:Nitrofurantoin is a rare cause of interstitial lung disease, although it is a common culprit for medication induced lung disease. Nitrofurantoin pulmonary toxicity can present in many forms including acute to chronic interstitial pneumonia. This case highlights an insidious presentation of nitrofurantoin induced interstitial lung disease that showed resolution with the discontinuation of the medication.CASE PRESENTATION: 74 year old female presented to pulmonary clinic for evaluation for unresolved pulmonary infiltrates. She had complaints of 4 months of cough and progressive dyspnea on exertion. Prior to the consultation, she was treated by her primary care provider with 2 separate courses of antibiotics without any resolution of symptoms. The patient's only new medication was nitrofurantoin for recurrent urinary tract infections started 9 month prior. CT Imaging showed patchy areas of ground glass opacity predominately in the upper lobes in the central lung fields with bronchovascular distribution. The nitrofurantoin was discontinued. She underwent bronchoscopy with no endobronchial lesions and negative cultures. Bronchial alveolar lavage (BAL) cell counts were 6% neutrophils and 53% lymphocytes. The diagnosis of nitrofurantoin induced interstitial lung disease was made on the basis of the clinical impression and BAL cell counts. She was treated with a prednisone taper and supplemental oxygen due to the severity of her symptoms. Her repeat imaging demonstrated the resolution of the infiltrates.DISCUSSION: Nitrofurantoin has been prescribed for prophylaxis urinary tract infections in patients with predisposing factors. Nitrofurantoin is not a benign medication. It is a common medication to induce pulmonary toxicity, which can range from acute to chronic with a variety of radiologic patterns. The pulmonary toxicity ranges in severity but can be fatal; and thus patients on prophylactic nitrofurantoin should routinely be assessed for possible lung toxicity. CONCLUSIONS:Nitrofurantoin is a common medication to induce pulmonary toxicity, including reversible interstitial lung disease. Urinary tract prophylaxis with nitrofurantoin should be prescribed only when the benefits outweigh the risks. Patients on nitrofurantoin who develop respiratory symptoms should be assessed for possible lung toxicity.
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