IMPORTANT: We currently have a number of bugs related to image cropping and are actively trying to resolve them. In the meantime, we have disabled cropping. Apologies for any inconvenience. Stay informed: radiopaedia.org/chat

Nitrofurantoin-related organizing pneumonia

Case contributed by Ibrahim M. Jubarah
Diagnosis almost certain

Presentation

History of over a month of respiratory symptoms including cough and dyspnea, which was diagnosed as pneumonia, after a history of previous additional initial fever and urinary tract infection, and for which she was given antibacterial treatment including nitrofurantoin.

Patient Data

Age: 65 years
Gender: Female

The laboratory test results showed high white cell count (20,500/uL), slightly elevated serum creatinine, and markedly high (260mg/L) C-reactive protein levels.

Evidence of bilateral:

  • Bronchial wall thickening.
  • Scattered pulmonary centrilobular nodules, the largest one is in the right lower lobe measuring about 1 cm.
  • Subpleural minimal consolidative rim with slight adjacent outlining ground glass margin.
  • Interlobular, and some perilobular, septal thickening.

No honeycombing, bronchiectasis, or cavitary lesions.
No obvious or enhancing masses.

Minimal bilateral pleural effusion.
The heart size is enlarged.
Few prominent mediastinal lymph nodes, the largest is in the paratracheal group and is measuring about 1.6 x 1.5 cm.
Few subcentimeter in short axis right hilar and bilateral axillary lymph nodes.

Hyperenhancing hepatic tiny foci that is iso-attenuated on the non-shown portal phase.

Case Discussion

Differential diagnoses include early fibrotic changes (e.g., idiopathic or connective tissue disease- or drug-induced), metastasis, adenocarcinoma (formerly bronchoalveolar carcinoma), and others.

Lung biopsy was done with a histopathologic study revealed features that are consistent with cryptogenic organizing pneumonia (including an interstitial lung tissue with patchy areas of scattered fibroblastic plugs in air spaces "Masson bodies" and mild chronic surrounding inflammation) and small reactive intraparenchymal lymph nodes.

Some authors prefer to preserve the term "cryptogenic organizing pneumonia" for conditions with an unknown underlying cause, and call that with an identified cause "bronchiolitis obliterans organizing pneumonia" or "secondary organizing pneumonia". Nevertheless, it must be not confused with another separate entity called "obliterative bronchiolitis". 

So, along with the history of previous recent nitrofurantoin antibiotic treatment, and in the absence of definite evidence of other known etiology, it is appropriate to state this condition as nitrofurantoin-related organizing pneumonia.

Nitrofurantoin has multiple potential pathological implications types for the lungs (see: "nitrofurantoin-related lung changes" in the related articles section below).

The patient clinically started to improve with treatments including steroids. She was instructed not to use nitrofurantoin anymore in general. A follow-up high-resolution CT scan was advised.

Regarding the incidental tiny hepatic lesions, the differential diagnosis would include small hemangiomas among others. Follow-up would be recommended. 

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.