TO THE EDITOR: Pulmonary abnormalities, including diffuse infiltrates, eosinophilic alveolitis, and pneumonitis in patients taking nonsteroidal antiinflammatory drugs (NSAIDs), have been well documented.
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Respiratory complications of selective cyclooxygenase-2 (COX-2) inhibitors are not as well characterized. We report a case of pulmonary edema and possible pneumonitis in a patient taking celecoxib.
Case Report. A 60-year-old white woman with past history significant only for recurrent arthritis reported a sore throat and shoulder pain. Levofloxacin and celecoxib (doses unknown) were prescribed. Two days later, she developed exertional dyspnea. Several episodes of sudden diaphoresis without dizziness, chest pain, or palpitations occurred, which resolved quickly. Two weeks later, she presented with knee pain, was diagnosed with osteoarthritis, received a dose of celecoxib, and went home. One hour later, she became dyspneic. Upon paramedic arrival, she was diaphoretic and cyanotic, with blood pressure 230/80 mm Hg. After administration of intravenous furosemide, oxygen, and sublingual nitroglycerin, blood pressure was 130/90 mm Hg. She was afebrile; right-lung fine crackles, with clear left lung sounds, were heard.
Chest X-ray revealed diffuse right-sided infiltrates with a peripheral predominance without effusions. Doppler ultrasound and ventilation/perfusion scan were negative for deep-vein thrombosis and pulmonary embolism. An echocardiogram indicated an ejection fraction of 60%, with normal left-ventricular function and a slightly enlarged right ventricle. Laboratory data included an elevated white blood cell count of 25 × 103/mm3 and negative troponin and urinalysis. Empiric ceftriaxone and azithromycin were started. Urine, blood, and sputum cultures were negative. The chest X-ray cleared rapidly within 48 hours. Doppler echocardiogram revealed normal systolic function. The woman's right side was negative for infiltrates, with left lower lobe residual patchy infiltrates. On day 5, she was discharged.
Discussion. To our knowledge, as of April 23, 2004, only one other case has been published describing a patient developing pulmonary infiltrates after receiving celecoxib.
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A man who had taken celecoxib for 4 months together with sulfasalazine and hydroxychloroquine (each for 4 y) presented with dyspnea. Transbronchial biopsy results demonstrated acute eosinophilic pneumonia. Steroid treatment with discontinuation of celecoxib and sulfasalazine led to clinical improvement. The patient's presentation with fever, respiratory failure with no identifiable infection, and biopsy confirmation of eosinophilic infiltrates met proposed diagnostic criteria for eosinophilic pneumonia.
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Edema and hypertension have been reported adverse events with celecoxib; the package insert was amended to emphasize cautious use for patients at risk.
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Pneumonitis was described in association with sulindac, diclofenac, and naproxen.
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Our patient displayed signs and symptoms like those of the previously described patient, including diaphoresis, dyspnea, and interstitial shadows in both lungs through chest X-rays. Symptoms resolved without recurrence upon drug discontinuation.
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Diagnosis of drug-related lung toxicity includes absence of other etiologies, drug-intake temporal association, and lymphocytosis or eosinophilia with trans-bronchial biopsy and bronchoalveolar lavage.2,4 The patient rapidly improved with celecoxib discontinuation and supportive care, so pulmonary testing was not performed. According to the Naranjo probability scale, the association between celecoxib and our patient's symptoms is considered possible.
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Clinicians should be aware of potential pulmonary adverse events with celecoxib.
