SHM Converge Scientific Abstract ePoster Gallery-A Fatal Case of Nitrofurantoin Induced Idiosyncratic Acute Liver Injury

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This case report describes a rare but potentially fatal episode of acute drug-induced liver injury (DILI) caused by nitrofurantoin. Nitrofurantoin is commonly used as a first-line treatment for uncomplicated cystitis and for prevention of recurrent urinary tract infections, but it can rarely cause severe hepatotoxicity.<br /><br />A 54-year-old woman with stage IV right renal cell carcinoma, status post right nephrectomy, and recurrent UTIs due to a left staghorn calculus was admitted with weakness, fatigue, nausea, vomiting, and altered mental status. She had been prescribed nitrofurantoin 100 mg twice daily for an E. coli UTI 10 days earlier. On examination, she had scleral jaundice and mild conjunctival pallor. Labs showed markedly elevated aminotransferases, bilirubin, and alkaline phosphatase in a mixed hepatocellular/cholestatic pattern, along with hyperammonemia, elevated creatinine and INR, hypoalbuminemia, and thrombocytopenia.<br /><br />An extensive evaluation for alternative causes was negative, including autoimmune studies, acute and chronic hepatitis testing, and salicylate and acetaminophen levels. Nitrofurantoin-induced DILI was suspected. The patient was treated for hepatic encephalopathy and hepatorenal syndrome, and prednisone 50 mg daily was started empirically for DILI. Despite stopping nitrofurantoin and receiving steroids, her condition worsened, with declining mental status requiring ICU transfer and intubation. Because of her underlying malignancy, she was not a candidate for liver transplantation, and the family ultimately chose comfort care with palliative extubation.<br /><br />The report emphasizes that acute nitrofurantoin hepatotoxicity is very uncommon but can present within 1–2 weeks of exposure and range from transaminitis to fulminant hepatic failure. The mechanism remains unclear, though oxidative injury from nitro-reductive metabolism is proposed. The case highlights the need for clinician awareness, early recognition, and further research into monitoring and treatment options.

Asset Subtitle

Syed R. Shah

Meta Tag

Author List Alisa Seng, Benton Huang, Maninderjit Singh, Sobia Syed, Syed R. Shah

Category Clinical Vignettes

Concept Nitrofurantoin

Concept Drug-Induced Liver Injury

Concept Acute Liver Injury

Concept Hepatotoxicity

Concept Drug Discontinuation

Distinguished Non-Finalist

Presenter Organization University of Washington

Presenting Author Syed R. Shah

Track Adult

Keywords

nitrofurantoin

drug-induced liver injury

acute hepatotoxicity

fulminant hepatic failure

mixed hepatocellular cholestatic pattern

hepatic encephalopathy

hyperammonemia

renal cell carcinoma

urinary tract infection

prednisone treatment

Nitrofurantoin

Drug-Induced Liver Injury

Acute Liver Injury

Hepatotoxicity

Drug Discontinuation