Nitrofurantoin-associated lung and liver toxicity leading to liver transplantation in a middle-aged patient.

Nitrofurantoin is indicated for the treatment or prophylaxis of uncomplicated urinary tract infections. Currently, it is considered as second-line treatment for this type of infection because of emerging bacterial resistance. Nitrofurantoin is bioactivated to various reactive intermediates that interfere with bacterial ribosomal proteins and inhibit the synthesis of critical cellular macromolecules (e.g., DNA). Nitrofurantoin is extensively absorbed by the gastrointestinal tract, is rapidly eliminated (with a half-life of about 0.3–1 h) by the kidneys, and is concentrated in the urine. Typical dosages in adults with normal renal function (creatinine clearance > 60 mL/min) are 50–100 mg PO qid for 1 week (for treatment) or 50–100 mg PO at bedtime (for prophylaxis). The clearance of nitrofurantoin depends on glomerular function, so its concentration in the urine, and hence its bactericidal effects, is reduced in patients with compromised creatinine clearance. Various adverse effects are associated with nitrofurantoin. Gastrointestinal complaints are common. Very rarely, neurological, hematological, pulmonary, and hepatic reactions may occur. Peripheral neuropathy of the sensorimotor type is a common neurological complaint. Acute hemolytic anemia, typically associated with deficiency of glucose-6-phosphate dehydrogenase, is the predominant hematological adverse effect. Most nitrofurantoin-induced pulmonary toxicity is acute and immunologic in nature, but cases of chronic pulmonary fibrosis have also been reported. Likewise, hepatotoxicity caused by nitrofurantoin is generally of acute onset, but patients may also present with chronic, active hepatitis. Nitrofurantoin-associated pulmonary or hepatic toxicity is rare. Even rarer are patients who present with concurrent pulmonary and hepatic complications. We present a case of nitrofurantoin-associated lung and liver toxicity in a 57-yearold woman who required liver transplantation. We also provide an up-to-date summary of previously published cases. CASE REPORT