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Acute pulmonary function decline and radiographic abnormalities: chronic cause?

Kathleen M. Capaccione, Clement V. Tran, Jay S. Leb, Mary M. Salvatore, Belinda D'souza
Breathe 2021 17: 200286; DOI: 10.1183/20734735.0286-2020
Kathleen M. Capaccione
Dept of Radiology, Columbia University Irving Medical Center, New York, NY, USA
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  • ORCID record for Kathleen M. Capaccione
  • For correspondence: kmc9020@nyp.org
Clement V. Tran
Dept of Radiology, Columbia University Irving Medical Center, New York, NY, USA
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Jay S. Leb
Dept of Radiology, Columbia University Irving Medical Center, New York, NY, USA
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Mary M. Salvatore
Dept of Radiology, Columbia University Irving Medical Center, New York, NY, USA
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Belinda D'souza
Dept of Radiology, Columbia University Irving Medical Center, New York, NY, USA
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    Figure 1

    a, b) Non-contrast chest CT 8 months prior to presentation, when the patient was mildly symptomatic, in the coronal and axial planes, respectively. These show mild basilar-predominant peripheral reticulations (dashed white arrows) and minimal GGOs (solid white arrows). c, d) Representative coronal and axial images during acute exacerbation, the solid white arrows indicate GGOs. e, f) Representative coronal and axial images after discontinuation of nitrofurantoin and initiation of steroid therapy, with near-complete resolution of GGOs and peripheral reticulations.

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    Figure 2

    Representative a) coronal and b) axial images from a non-contrast chest CT of the abdomen and pelvis of this 64-year-old female obtained to evaluate for renal calculus. An obstructive calculus is seen in the distal right ureter (solid white arrow) with proximal hydroureteronephrosis (dotted white arrow).

Tables

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  • Table 1

    Pulmonary function tests before and after discontinuation of nitrofurantoin

    FVCFEV1DLCO mL·min−1·mmHg−1Tiffeneau Index
    Initial encounter1.78 L (56%)1.83 L (62%)10.14 (49%)87%
    6-week follow-up2.25 L (71%)1.7 L (69%)13.4 (65%)76%
  • Table 2

    Drug-induced pneumonitis clinical and radiographic features

    AetiologyMany drugs, most commonly chemotherapy agents (bleomycin, busulfan, cyclophosphamide, methotrexate, thalidomide), immunosuppressive agents (sirolimus), amiodarone, antibiotics (nitrofurantoin, amphotericin B), pembrolizumab
    IncidenceOverall incidence unknown (varies depending on agent)
    Sex ratioUnknown
    Age predilectionVaries depending on agent (e.g. bleomycin-induced lung injury risk is increased in the elderly)
    Median age for acute and chronic nitrofurantoin-induced pulmonary reactions was 59 and 68 years, respectively
    Risk factorsVaries depending on agent (e.g. marked increased risk of bleomycin lung injury if cumulative dose exceeds 450 units)
    TreatmentCessation of offending agent
    Corticosteroid therapy is often used, although evidence is lacking
    PrognosisVaries widely, from complete clinical recovery and resolution of imaging findings to respiratory failure and death
    Findings on imagingCT findings vary among different aetiologies, includes multifocal GGOs with intralobular interstitial thickening, patchy GGO, centrilobular nodules
  • Table 3

    Differential diagnosis for presenting symptoms of this patient

    Differential diagnosisRadiographic findingsCT findings
    Hypersensitivity pneumonitisLow sensitivity, with many patients having normal radiographs
    Findings may include: nodular opacities, GGOs or consolidation, fine reticulation, eventual fibrosis with honeycombing
    Mid and upper lobe predominance, centrilobular nodules, bilateral and symmetric airspace opacities (ground glass or consolidation), air trapping with mosaic pattern, head cheese sign, fibrosis with honeycombing
    Pulmonary interstitial oedemaPeribronchial cuffing, septal (Kerley B) lines, interlobular fissure thickeningGGOs, interlobular septal thickening, bronchovascular bundle thickening
    SarcoidosisMid and upper lobe predominant opacities, lymphadenopathy, calcified lymph nodesMid and upper lobe predominant reticulation, honeycombing, traction bronchiectasis, lymphadenopathy, calcified lymph nodes
    Coronavirus disease 2019 (COVID-19)Bilateral lower lobe predominant airspace opacitiesBilateral lower lobe predominant ground glass and consolidative opacities
    Mycoplasma pneumoniaeUnilateral or bilateral patchy consolidation, nodular or reticular opacitiesPatchy or ground-glass opacities, centrilobular nodules, tree-in-bud, bronchial wall thickening
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Acute pulmonary function decline and radiographic abnormalities: chronic cause?
Kathleen M. Capaccione, Clement V. Tran, Jay S. Leb, Mary M. Salvatore, Belinda D'souza
Breathe Mar 2021, 17 (1) 200286; DOI: 10.1183/20734735.0286-2020

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Acute pulmonary function decline and radiographic abnormalities: chronic cause?
Kathleen M. Capaccione, Clement V. Tran, Jay S. Leb, Mary M. Salvatore, Belinda D'souza
Breathe Mar 2021, 17 (1) 200286; DOI: 10.1183/20734735.0286-2020
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