Systemic Inflammatory Response Syndrome due to Nitrofurantoin Use

Abstract

Laboratory values. Cefepime, fourth-generation cephalosporin, is used for gram-negative and pseudomonal infections. It is drug of choice for febrile neutropenia. Since its approval in 1996, it has stayed on top for almost every sever gram-negative and pseudomonal infection in intensive care unit and cancer chemotherapy settings. 2 Cefepime being renally metabolized can precipitate overdose toxicity if dose is not modified in patients with endstage renal disease. Cefepime can cross blood-brain barrier. Neurotoxicity is mainly secondary to inhibitory effects of GABA-A receptors (gamma amino butyric acid-A). 3 GABA receptors are inhibitory, limiting excitation which can lead to seizures. Our patient was admitted with chest discomfort and bacterial pneumonia with right-sided pleural effusion leading to hypoxic respiratory failure. He received 2 g of leading cefepime followed by 1 g daily for 2 days before he started with altered mental status with myoclonic seizures. His mentation improved after hemodialysis.In 1996, at the time of approval of cefepime, neurotoxicity was reported as seizures in 3 patients. 4 Neurotoxicity has direct relation to plasma cefepime levels with higher levels leading to neurotoxicity. 5 Cefepime crosses bloodbrain barriers. Most common neurotoxic presentation is altered level of consciousness, delirium, and myoclonus (80%, 47%, and 40%, respectively) as per a care review published. 1 Neurotoxicity has been reported in 15% of intensive care unit as per Payne et al. 6 Our patient had an episode of myoclonic seizure which was documented by electrocardiogram and was in altered mental status. Convulsive or nonconvulsive status epilepticus can also be another presentation. 1 Electrocardiogram can be helpful in diagnosing. The Naranjo score was 11 for this patient. 7 Treatment is stopping the antibiotic. Antiepileptic medication such as levetiracetam, valproic acid, and benzodiazepines can be used. Our patient was started on levetiracetam. He had no further episodes of seizures after hemodialysis and after cefepime was stopped. Patient was given couple secession of hemodialysis which improved his mentation.

Nitofurantoin Induced Dress—Rarely Seen and MIMICKS HfPEF

“…Myocarditis and respiratory failure are other main causes of death [28]. There have been isolated case reports describing systemic inflammatory response syndrome (SIRS) after nitrofurantoin administration with associated abrupt onset of fever, malaise, leucocytosis, and occasionally pleuritis [30][31][32][33]. Back and colleagues also discussed a similar clinical syndrome like in our patient.…”

Systemic Inflammatory Response Syndrome from Nitrofurantoin: A Case Report

“…The patient was found to meet SIRS criteria, with a new left bundle branch block (LBBB), thrombocytopenia, and elevated transaminases, which resolved with cessation of the nitrofurantoin. Gohar and colleagues [ 6 , 7 ] reported a case of SIRS due to nitrofurantoin use in an 83-year-old woman with a history of recurrent UTIs. She developed fevers, chills, and lethargy and was treated for presumed sepsis from a UTI.…”

Systemic Inflammatory Response Syndrome Secondary to Nitrofurantoin

“…The patient was re-dosed with nitrofurantoin 2 different times during the same week and experienced SIRS each time, with resolution of symptoms after discontinuation of nitrofurantoin. 5 Gohar and colleagues 6 reported a case of SIRS due to nitrofurantoin use in an 83-year-old female with a history of recurrent UTIs. Within a few hours of receiving nitrofurantoin, the patient developed lethargy, chills, and fever and was treated with presumed sepsis secondary to UTI.…”

“…With no evidence of infection and return of hemodynamic stability after discontinuation of nitrofurantoin, the patient was discharged home and advised against the use of future use of nitrofurantoin. 6 In one final case reported by Hospital Medicine , a 79-year-old woman with a history of recurrent UTIs presented with a 1-week history of fever, chills, nausea, vomiting, and abdominal discomfort after treatment with nitrofurantoin for a UTI. With negative cultures, no signs of infection, and symptomatic improvement after nitrofurantoin discontinuation, it was determined that nitrofurantoin was the likely cause of symptoms.…”

“…2 , 3 There have been isolated case reports describing systemic inflammatory response syndrome (SIRS) after nitrofurantoin administration with associated abrupt onset of fever, malaise, leukocytosis, and occasionally pleuritis. 4 - 7 This often leads to a diagnostic challenge to determine if SIRS is due to transition to a more complicated UTI, such as acute pyelonephritis, or to a drug-associated adverse event.…”