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Auscultation revealed bilateral crackling sounds&#46; A chest X-ray showed a bilateral interstitial pattern and high resolution computerised tomography &#40;HRCT&#41; showed ground glass areas corresponding to acute&#47;sub acute interstitial pneumonia &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Blood tests highlighted GOT 360<span class="elsevierStyleHsp" style=""></span>U&#47;l&#44; GPT 432<span class="elsevierStyleHsp" style=""></span>U&#47;l and GGT 279<span class="elsevierStyleHsp" style=""></span>U&#47;l with normal abdominal ultrasound&#46; The hepatropos virus serology and autoimmune antibody study tested negative&#46; Autoimmunity studies detected ANCA&#43; 1&#47;640 perinuclear staining &#40;negative anti-myeloperoxidase and anti-proteinase 3&#41;&#46; Due to these findings toxicity by nitrofurantoin was suspected and the drug was withdrawn&#46; Treatment with prednisone was established&#44; with a good response at respiratory level&#44; a drop in hepatic enzymes and a complete resolution of arthralgias&#46; During follow-up&#44; the transaminase values remained normal&#44; respiratory symptoms disappeared and posterior lung imaging tests were normal&#46; The arthralgias abated and the ANCAs tested negative&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">There have been case reports of concomitant pulmonary and hepatic toxicity attributed to the use of nitrofurantoin&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Pulmonary toxicity and hepatic toxicity have 2 types of presentations&#58; acute and chronic&#46; Chronic pulmonary toxicity symptoms develop after several months of treatment&#46; The most common are dyspnoea&#44; irritative cough and fatigue&#46; Crackling sounds&#44; especially around the lung bases<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> are usually the result of auscultation&#46; All types of radiographic anomalies in most patients exist&#44; mostly in inferior and bilateral fields&#46; In the HRCT scan ground glass areas may be observed&#44; together with septal enlargement and traction bronquiectasias&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The acute form of hepatic toxicity generally presents after only a few weeks of treatment and is uncommon&#46; It is usually accompanied by fever and rash&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Normally withdrawing the medication resolves this&#44; although cases of fulminant hepatitis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> have been known to exist&#46; The more common chronic disorder may present months or years later&#46; Symptoms are usually fatigue&#44; muscle weakness and jaundice and an increase of transaminases in lab tests&#46; Autoimmunity markers are occasionally detected &#40;ANA&#43;&#44; anti-ML antibodies and elevated IgG&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Recovery after the removal of the drug is usually slow and hepatic damage may persist&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In the event of suspected diagnosis the temporary relationship between the onset of symptoms and exposure to the drug must be sought&#46; Treatment is based on withdrawal of nitrofurantoin&#46; Although glucocorticoids are usually combined with it&#44; it is believed that the symptoms may cease after discontinuation of the drug&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Prognosis is good if there is an early suspected diagnosis and exposure to the drug is limited&#46; A case of cutaneous vasculitis and positive anti-MPO renal ANCA associated with the use of nitrofurantoin<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> has been reported&#46; In our case the ANCAs tested positive although without vasculitis-associated specificity&#46; Given the patient&#39;s favourable evolution no hepatic or pulmonary biopsies were performed which could have highlighted vasculitis&#46; We did not find any cases of arthralgias with simultaneous pulmonary and hepatic involvement with positive ANCA related to the use of nitrofurantoin&#46; In this case the arthralgias were the predominant symptom and led to the detection of concomitant pulmonary and hepatic toxicity&#46; We therefore believe that the involvement of joints may suggest systemic toxicity and its early detection may improve prognosis&#46;</p></span>"
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Letter to the Editor
Migratory arthralgia as the initial sign of systemic toxicity associated with chronic nitrofurantoin treatment
Artralgias migratorias: manifestación inicial de toxicidad sistémica asociada al tratamiento crónico con nitrofurantoína
Karla Arévalo Rualesa,
Corresponding author
karlaarevalorualed@gmail.com

Corresponding author.
, José Ivorra Cortésa, José Román Ivorraa, Manuela Martinez Francésb
a Servicio de Reumatología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
b Servicio de Neumología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">High resolution computerized tomography&#46; Axial slice at lung base level&#46; Ground glass pattern is observed which corresponds to acute&#47;sub acute pneumonia&#46; There are no areas of fibrosis or any distortion of the lung architecture&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Nitrofurantoin is an antibiotic widely used in the treatment and prevention of urinary tract infections &#40;UTI&#41;&#46; The most common adverse effects are gastrointestinal but cases of pulmonary and hepatic<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> toxicity&#44; and even vasculitis<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> have been reported&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 63-year-old woman with a history of repetitive UTI&#44; with no other relevant medical history&#46; Prophylaxis with nitrofurantoin had been initiated a year prior to the presentation of symptoms&#46; She was referred to the rheumatology department for migratory asymmetrical arthralgias of 4-month onset&#46; During examination she referred to dyspnoea with moderate effort which had appeared after the arthralgias&#46; Auscultation revealed bilateral crackling sounds&#46; A chest X-ray showed a bilateral interstitial pattern and high resolution computerised tomography &#40;HRCT&#41; showed ground glass areas corresponding to acute&#47;sub acute interstitial pneumonia &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Blood tests highlighted GOT 360<span class="elsevierStyleHsp" style=""></span>U&#47;l&#44; GPT 432<span class="elsevierStyleHsp" style=""></span>U&#47;l and GGT 279<span class="elsevierStyleHsp" style=""></span>U&#47;l with normal abdominal ultrasound&#46; The hepatropos virus serology and autoimmune antibody study tested negative&#46; Autoimmunity studies detected ANCA&#43; 1&#47;640 perinuclear staining &#40;negative anti-myeloperoxidase and anti-proteinase 3&#41;&#46; Due to these findings toxicity by nitrofurantoin was suspected and the drug was withdrawn&#46; Treatment with prednisone was established&#44; with a good response at respiratory level&#44; a drop in hepatic enzymes and a complete resolution of arthralgias&#46; During follow-up&#44; the transaminase values remained normal&#44; respiratory symptoms disappeared and posterior lung imaging tests were normal&#46; The arthralgias abated and the ANCAs tested negative&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">There have been case reports of concomitant pulmonary and hepatic toxicity attributed to the use of nitrofurantoin&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Pulmonary toxicity and hepatic toxicity have 2 types of presentations&#58; acute and chronic&#46; Chronic pulmonary toxicity symptoms develop after several months of treatment&#46; The most common are dyspnoea&#44; irritative cough and fatigue&#46; Crackling sounds&#44; especially around the lung bases<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> are usually the result of auscultation&#46; All types of radiographic anomalies in most patients exist&#44; mostly in inferior and bilateral fields&#46; In the HRCT scan ground glass areas may be observed&#44; together with septal enlargement and traction bronquiectasias&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The acute form of hepatic toxicity generally presents after only a few weeks of treatment and is uncommon&#46; It is usually accompanied by fever and rash&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> Normally withdrawing the medication resolves this&#44; although cases of fulminant hepatitis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> have been known to exist&#46; The more common chronic disorder may present months or years later&#46; Symptoms are usually fatigue&#44; muscle weakness and jaundice and an increase of transaminases in lab tests&#46; Autoimmunity markers are occasionally detected &#40;ANA&#43;&#44; anti-ML antibodies and elevated IgG&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Recovery after the removal of the drug is usually slow and hepatic damage may persist&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In the event of suspected diagnosis the temporary relationship between the onset of symptoms and exposure to the drug must be sought&#46; Treatment is based on withdrawal of nitrofurantoin&#46; Although glucocorticoids are usually combined with it&#44; it is believed that the symptoms may cease after discontinuation of the drug&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Prognosis is good if there is an early suspected diagnosis and exposure to the drug is limited&#46; A case of cutaneous vasculitis and positive anti-MPO renal ANCA associated with the use of nitrofurantoin<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> has been reported&#46; In our case the ANCAs tested positive although without vasculitis-associated specificity&#46; Given the patient&#39;s favourable evolution no hepatic or pulmonary biopsies were performed which could have highlighted vasculitis&#46; We did not find any cases of arthralgias with simultaneous pulmonary and hepatic involvement with positive ANCA related to the use of nitrofurantoin&#46; In this case the arthralgias were the predominant symptom and led to the detection of concomitant pulmonary and hepatic toxicity&#46; We therefore believe that the involvement of joints may suggest systemic toxicity and its early detection may improve prognosis&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ar&#233;valo Ruales K&#44; Ivorra Cort&#233;s J&#44; Rom&#225;n Ivorra J&#44; Martinez Franc&#233;s M&#46; Artralgias migratorias&#58; manifestaci&#243;n inicial de toxicidad sist&#233;mica asociada al tratamiento cr&#243;nico con nitrofuranto&#237;na&#46; Reumatol Clin&#46; 2020&#59;16&#58;432&#8211;433&#46;</p>"
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Article information
ISSN: 21735743
Original language: English
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