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Drug-induced haemolysis: another reason to be cautious with nitrofurantoin
  1. Chaitanya Bhatt1,
  2. Zainab Doleeb1,
  3. Priya Bapat1,
  4. Christian Pagnoux2
  1. 1 Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
  2. 2 Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Christian Pagnoux; Christian.pagnoux{at}

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In conjunction with BMJ Case Reports, DTB will feature occasional drug-related cases that are likely to be of interest to readers. These will include cases that involve recently marketed drugs for which there is limited knowledge of adverse effects and cases that highlight unusual reactions to drugs that have been marketed for several years.


We report the case of a previously healthy woman in her 60s who presented to the emergency department with acute confusion, vomiting and fever. She was recently diagnosed with a urinary tract infection as an outpatient and had completed the fifth day of a 7-day course of treatment with nitrofurantoin. We maintained a wide differential diagnosis including infectious, metabolic, autoimmune and medication-related causes. She developed an acute normocytic anaemia in hospital with a haemoglobin drop from 121 g/L to 89 g/L. Further investigation revealed evidence of haemolysis with an elevated bilirubin, lactate dehydrogenase, reticulocyte count and decreased haptoglobin. She was worked up for both inherited and acquired causes of haemolysis and found to have glucose-6-phosphate dehydrogenase deficiency. Her presentation was thought to be secondary to nitrofurantoin-induced haemolysis and she recovered completely with conservative management through intravenous fluids and discontinuation of nitrofurantoin.


Nitrofurantoin is recommended by both the Canadian and American Urological Association as a first-line antibiotic for uncomplicated urinary tract infections (UTIs),1 even though it only exerts bactericidal effects in the urine when reacting with susceptible bacteria at therapeutic doses.2 As a commonly prescribed antibiotic, clinicians should be aware of its broad side effect profile. Nitrofurantoin is frequently associated with nausea, vomiting, diarrhoea and loss of appetite.2 It has also been associated with severe adverse events such as pulmonary toxicity, hepatotoxicity and peripheral neuropathy. Haemolytic anaemia in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency is another possible side effect, which may be easily overlooked, …

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  • Contributors All authors (CB, ZD, PB and CP) made substantial contributions to the conception of this case report, including the acquisition, analysis, and interpretation of data. CB and ZD were also involved in the patient consent process. All authors were involved in drafting the work, revising it critically, and approved of the final version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests The authors of this article have no conflicts of interest to disclose.

  • Provenance and peer review Not commissioned; externally peer reviewed.