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Article Excerpt
We describe a case of sulfasalazine-induced pneumonitis in a complex medical patient. This case illustrates the potential for drug-induced pulmonary disease and the vigilance needed in evaluating patients with subacute respiratory decompensation. Proper recognition and treatment most likely prevented the progression of acute respiratory failure and, possibly, irreversible lung injury or death.
THE CASE
A 44-year-old man with severe rheumatoid arthritis (RA) and hepatitis C was admitted to the medical ICU with methicillin-sensitive Staphylococcus aureus septic arthritis of the right knee requiring surgical debridement. He had a history of methicillin-resistant S aureus skin infections and a remote history of polysubstance abuse, including injection drug use.
Sepsis developed, and the patient had acute respiratory failure requiring mechanical ventilation. Ventilator-associated pneumonia ensued, and the patient was treated with intravenous cefepime and vancomycin. He also received nafcillin for septic arthritis and warfarin for deep venous thrombosis of the right lower extremity.
[FIGURE 1 OMITTED]
A chest radiograph showed a resolving retrocardiac opacity with low lung volumes and small bilateral pleural effusions, but otherwise clear lung parenchyma. The patient's clinical recovery paralleled the radiographic improvement, and he was weaned from mechanical ventilation and transferred to the hospital ward.
The patient's RA had been treated with adalimumab without known complications, but this therapy was discontinued for insurance-related reasons approximately 1 month before hospitalization. While hospitalized, he was treated with oral prednisone (20 mg daily) and sulfasalazine (1 g twice daily). He continued to receive vancomycin, cefepime, and nafcillin. His other medications included esomeprazole, tamsulosin, oral morphine, potassium chloride, and metoclopramide.
Five days after the initiation of sulfasalazine therapy, he had a low-grade fever, subacute breathlessness, and mild hypoxemia without cough or hemoptysis. A chest radiograph taken 11 days after sulfasalazine treatment was started demonstrated bilateral infiltrates with right lung perihilar consolidation, early left mid-lung zone infiltrate, and bilateral perihilar interstitial prominence (Figure 1). Pulmonary consultation was requested.
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Chest CT scanning revealed patchy ground-glass opacities bilaterally, but greater on the right than on the left; evidence of early consolidation in the right lower lung; mediastinal lymphadenopathy with bilateral hilar fullness; and bilateral small pleural effusions (Figure 2).
On examination, the patient was febrile (temperature, 39.8[degrees]C [103.6[degrees]F]); tachycardic (130 beats per minute); tachypneic (33 breaths per minute); and hypoxemic on room air, with an oxygen saturation of 99% on 10 L per minute of oxygen by non-rebreather mask. His blood pressure was 130/80 mm Hg. He was visibly uncomfortable, spoke in incomplete sentences, and had a ruddy facial complexion. No cervical lymphadenopathy or jugular venous distention was found.
Mid-lung zone crackles were louder on the right than on the left, but there was no wheezing or egophony. No heart murmurs, rubs, or gallops were heard, and the cardiac point of maximal impulse was nondisplaced. The patient's abdomen was soft, non-tender, and nondistended with active bowel sounds. There was no clubbing, cyanosis, or edema of the extremities. However, both hands had characteristic deformities of RA. No rash, petechiae, bruising, or hyperpigmentation was found. There were no focal neurological deficits.
Laboratory results included a peripheral blood leukocyte count of 12,800/[micro]L, with 76% neutrophils, 12% lymphocytes, and 12% monocytes without peripheral eosinophilia; eosinophilia; hematocrit level of 21%; and platelet count of 491,000/[micro]L. The patient had chronic anemia without any clinical evidence of bleeding. Liver function test results were normal except for a mildly elevated total bilirubin level (1.8 mg/dL) and a low albumin level (1.9 g/dL).
His...
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