Kidney Week

Abstract: SA-PO0599

Successful Use of Ethacrynic Acid for Pulmonary Congestion in a Patient with Bullous Pemphigoid and Prior Stevens-Johnson/Toxic Epidermal Necrolysis (TEN) Reaction to Loop Diuretics

Session Information

• Fluid, Electrolyte, and Acid-Base Disorders: Case Reports - 2
  October 24, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Fluid, Electrolytes, and Acid-Base Disorders

• 1102 Fluid, Electrolyte, and Acid-Base Disorders: Clinical

Authors

• Bhatt, Parjanya K., Trinity Health Oakland Hospital, Pontiac, Michigan, United States

Parjanya K. Bhatt, MBBS

• Hirani, Chetna N., Trinity Health Oakland Hospital, Pontiac, Michigan, United States

Chetna N. Hirani, MD

• Vora, Tanisha, Trinity Health Oakland Hospital, Pontiac, Michigan, United States

Tanisha Vora, MD

• Shah, Rushi, Trinity Health Oakland Hospital, Pontiac, Michigan, United States

Rushi Shah, MD, MBBS

• Muneeb, Muhammad, Trinity Health Oakland Hospital, Pontiac, Michigan, United States

Muhammad Muneeb, MD, MBBS

• Hanna, James, Trinity Health Oakland Hospital, Pontiac, Michigan, United States

James Hanna, MD

Introduction

We present a case of acute hypoxic respiratory failure complicated by worsening bullous pemphigoid (BP), infection risk from high-dose immunosuppression, and a history of toxic epidermal necrolysis to loop diuretics.

Case Description

An 80-year-old male with chronic hypoxic respiratory failure on 4 L home oxygen, HF with improved EF (35% → 53%), atrial fibrillation, hypertension, anemia, benign prostatic hyperplasia, and bullous pemphigoid (BP) on mycophenolate and prednisone taper presented with worsening dyspnea. He had a recent hospitalization for BP flare and acute interstitial nephritis. On arrival, he was tachypneic and hypoxic, requiring escalation from home oxygen to BiPAP. Chest radiography showed new bilateral opacities. Empiric azithromycin, cefepime (later piperacillin-tazobactam), and vancomycin were initiated. IV methylprednisolone (16 mg BID) and topical corticosteroids were started for worsening BP lesions. His respiratory status was complicated by recurrent bloody airway secretions, altered mental status, and progressive pulmonary congestion. Hemoglobin dropped, requiring a blood transfusion. Worsening bilateral opacities prompted initiation of bumetanide; however, the patient had a documented history of TEN from furosemide and related sulfonamide loop diuretics. After pharmacy confirmation, ethacrynic acid 100 mg was administered with excellent urine output and marked improvement in pulmonary venous congestion. Immunosuppression was intensified with methylprednisolone 40 mg three times daily for 3 days.

Discussion

This case highlights the complexity of managing acute decompensated heart failure in the setting of significant dermatologic, renal, and infectious comorbidities. Ethacrynic acid remains a safe and effective diuretic option when sulfonamide loop diuretics are contraindicated due to severe hypersensitivity reactions such as TEN. Early recognition of diuretic limitations and timely initiation of ethacrynic acid were pivotal in improving respiratory status and avoiding further clinical deterioration.In patients with life-threatening sulfonamide allergies, ethacrynic acid serves as a valuable alternative for diuresis in acute decompensated heart failure. This case emphasizes the importance of individualized pharmacologic decision-making in complex, multi-system presentations.