Case no. 1
A 51-year-old woman with no genetic history tested positive for H. pylori during a physical examination on February 10, 2022. Chest computed tomography (CT) revealed slightly increased bilateral lung markings, clear structures of both pulmonary hili, and normal density. From February 16, 2022, oral administration of rabeprazole sodium enteric-coated capsule + colloidal bismuth pectin capsules + amoxicillin capsules + furazolidone tablets (100mg,twice daily) for the treatment of H. pylori infection was initiated. On February 25, 2022, the patient developed a fever, with the highest body temperature reaching 38.9℃, cough, and expectoration accompanied by chest tightness and shortness of breath; consequently, the quadruple anti-H. pylori treatment was discontinued. A routine blood examination at a local hospital showed a white blood cell (WBC: 3.5–9.5 ×109/L) count of 8.7×109/L, neutrophil percentage (N%: 40–75%) of 89.9%, C-reactive protein (CRP: 0.0–10.0 mg/L) level of 9.1 mg/L, and eosinophil (EO: 0.02–0.52×109/L) count of 0.05×109/L. After treatment with a cold medicine, the details of which are unknown, the patient’s fever symptoms slightly improved. On February 26, 2022, the patient redeveloped a fever and visited a local clinic for treatment with anti-inflammatory drugs, the details of which are unknown, and experienced temporary relief. However, on March 2, 2022, because of fever, cough, sputum, chest tightness, shortness of breath, and other nighttime symptoms, she visited our hospital for treatment. Chest CT examination showed a few inflammatory and fibrous foci in both lungs and pulmonary interstitial inflammatory changes with thickening of the interlobular septa (Fig. 1). Routine blood examination showed an increase in WBC count at 17.98×109/L, N% at 88.6%, CRP level at 87.8 mg/L, and EO count at 0.61×109/L. Auscultation of the bilateral lung sounds was harsh, although no rales were heard. On March 3, 2022, the patient was admitted to the Department of Respiratory Medicine and administered the following treatment regimen: intravenous 2 g cefoperazone sodium sulbactam sodium injection every 8 h for antibiotic activity; atomization inhalation of a suspension of 5 mg terbutaline, 2 mg budesonide, and 0.3 g acetylcysteine inhalation solution twice daily for antispasmodic, anti-inflammatory, and expectorant activity; and 30 mg ambroxol hydrochloride injection via a micropump twice daily to resolve phlegm. The patient experienced relief after this treatment. On March 4, 2022, a routine blood examination showed the following: WBC count 6.01×109/L, N% 45.7%, CRP level 56.4 mg/L, and EO count 0.63×109/L. Improved laboratory test results accompanied by lung imaging led to the exclusion of bacteria, viruses, fungi, Pneumocystis carinii pneumonia, connective tissue diseases, and other possibilities, and adverse pulmonary reactions caused by furazolidone were considered. On March 7, 2022, blood routine examination showed a WBC count of 5.77×109/L, N% 55.6%, CRP level 6.0 mg/L, and EO count 0.33×109/L. On March 7, 2022, the patient was discharged after her symptoms improved.
Case no.2
A 48-year-old man with a 15-year history of diabetes mellitus was under regular hypoglycemic therapy. On March 28, 2022, the patient underwent gastroscopy, and the pathological results showed H. pylori positivity. From April 6, 2022, rabeprazole sodium enteric-coated capsules + bismuth potassium citrate capsules + amoxicillin capsules + furazolidone tablets (100mg,twice daily)were administered orally to treat H. pylori infection. On April 17, 2022, the patient developed symptoms of headache, general muscle ache, fatigue, chills, and a body temperature of 38°C, for which he visited our hospital. A routine blood examination showed an increased WBC count of 13.16×109/L, N% of 83.2%, CRP level of 70.2 mg/L,EO were normal, with a count of 0.13×109/L. Amoxicillin and furazolidone tablets were discontinued based on clinical advice and a daily 100 mL intravenous levofloxacin injection via drip was initiated for anti-infection treatment. On April 18, 2022, the patient’s body temperature returned to normal. He revisited the emergency department of our hospital to continue the intravenous infusion of levofloxacin. While amoxicillin was still discontinued in accordance with medical advice, he resumed taking furazolidone, after which he developed a fever again, with a high temperature of 39.2℃. The patient visited our hospital again on April 19 and was prescribed a one-time 1 g intravenous ertapenem injection via drip for anti-infection treatment. Additionally, chest CT showed a small amount of inflammation, some fibrous foci in both lungs, and interstitial changes in both lungs with interlobular septal thickening (Fig. 2). Prior to this, the patient's most recent chest CT scan was on August 13, 2018, which revealed scattered chronic inflammatory lesions (mainly fibrous lesions) in the right lung.After consulting a clinical pharmacist, the doctor considered the possibility of adverse pulmonary reactions caused by furazolidone and instructed the patient to discontinue furazolidone tablets. On April 20, 2022, the patient's body temperature was 37.4℃. The breath sounds were thick upon auscultation of both lungs, with no wet or dry rales or wheezing. A routine blood examination showed an increased WBC count of 9.86×109/L, N% of 76.8%, CRP level of 223.7 mg/L,EO were still normal, with a count of 0.35×109/L; hence, he was admitted to the Department of Respiratory Medicine and his temperature was measured at 36.8℃. After admission, an intravenous infusion of 0.5 g meropenem was administered every 6 h, starting at approximately 21:00 h. Improved laboratory test results accompanied by lung imaging led to the exclusion of bacteria, pulmonary viruses, tuberculosis, and fungi.
On April 21, 2022, procalcitonin level increased to 0.67 ng/mL. Considering the patient’s history of diabetes mellitus, the possibility of infection in other parts of the body could not be ruled out. Moreover, given that the patient’s symptoms, such as fever and other signs of discomfort, were relieved after discontinuing furazolidone administration, the patient continued to receive only anti-infection treatment. The WBC count, CRP level, and N% decreased continuously during hospitalization.. On April 25, 2022, the blood results were as follows: WBC count: 6.28×109/L, N%: 50.3%, CRP level: 13.5 mg/L, EO count: 0.44×109/L, and procalcitonin: 0.11 ng/mL. The patient was discharged after his symptoms improved.