Recurrent Anaphylactic Shock To Radiocontrast Media

 K. Cayir, M.Bilici, S Basol Tekin

 Division of Medical Oncology, Department of Internal Medicine, Atatürk University, Faculty of Medicine, Erzurum, Turkey

 Corresponding Author: Kerim Cayir, Terminal Cad. Polat Sitesi C Blok Kat: 4 Erzurum - TURKEY

 E-mail : drkcayir@hotmail.com

SMJ 2006 51(4): 49

 

Summary

Radiocontrast media (RCM) is used commonly in clinical practice, and can be associated with significant adverse effects. Since non-ionic RCM’s have been introduced to radiological investigation, the incidence of adverse reactions has been significantly reduced in comparison to ionic compounds. However, acute anaphylactoid reactions with heterogeneous symptoms within minutes after intravenous administration of RCM are still a life-threatening risk of investigations with RCM. We report a patient who underwent two anaphylactic reactions  (acute and delayed) after intravenous administration of RCM.

Keywords: Radiocontrast media; acute anaphylactic reaction; delayed anaphylactic reaction

 

Introduction

Anaphylactic shock is an unexpected, sudden, and sometimes lethal event, usually induced by exposure to drugs, hymenopteria poisons, contrast media and nutrients. A recent literature review has suggested that anaphylaxis should be considered when one is faced with a history of exposure to an allergen within one hour of onset of one more of the following systemic signs: hypotension, upper or lower respiratory tract compromise and increased gastrointestinal tract motility. In 75 % of cases, there is no previous history of allergy.1

 

Over the past 75 years, radiocontrast agents have provided numerous diagnostic and therapeutic advances. The benefits of these agents must be weighed against the potential risk for each individual undergoing radiological test.2 Although the majority of the reactions of RCM are minor in nature, some are serious and can prove fatal. Mortality from RCM-induced reactions varies from 1in 14 000 to 1 in 117 000.3

 

Up to now, there has been only one case report related to recurrent anaphylactic shock to RCM in the literature.4 Therefore, we aimed to present such an interesting and rare recurrent anaphylactic reactions both acute and delayed to RCM.

 

Case Report

A 38-year old woman with a breast mass underwent a computed tomography at 11.15 a.m. During the procedure, she was given 100 ml of i.v iodixanol (low-osmolar, nonionic contrast media) (Visipaque 320, Opakim Medikal Products Group, İstanbul, Turkey). At 11.45 a.m, at the end of the procedure there was a sudden onset of glottal edema and bronchospasm. There was no history of allergy. I.V. 50 mg prednisolone, 100 mg ranitidine and 45 mg pheniramine i.v bolus was given. The patient became dyspnic with a rapidly ensued respiratory arrest. Mechanical ventilation was initiated. I.V. 1 mg adrenaline was given.  At that time, the patient developed severe arterial hypotension and not associated with ECG changes. 1000 ml of crystalloid solution was simultaneously administered. After 1 minute respiration returned. Although a crystalloid solution was administered, mean systemic arterial pressure could not be measured. Dopamine was initiated 10 mcg/kg/minute. Twenty minutes after dopamine was started, mean systemic arterial pressure rose to 75 mmHg. Two hours later, her blood pressure rose to 90 mmHg. The dopamine infusion was then discontinued. Vital signs and symptoms were stable. In the follow up period, 25 mg prednisolone and 45 mg pheniramine were given every 12 hours; and 100 mg ranitidine was given every 6 hours. In the 62nd hour of the follow up, glottal edema, bronchospasm, hypotension developed again. But there was no need for mechanical ventilation at this time. The patient was stabilised with the support of crystalloid solution, İV 50 mg prednisolone, 100 mg ranitidine and 45 mg pheniramine. She was discharged from hospital after 96 hours.

 

Discussion

The risk for adverse reactions to RCM is 4% to 12% with ionic contrast media and 1% to 3% with non-ionic materials. The risk for severe adverse reactions is 0.16% with ionic contrast media and 0.03% with nonionic materials. The death rate, one to three per 100.000 contrast administration, is similar for both ionic and nonionic agents. With the widespread use of nonionic contrast materials, adverse reactions are less frequently seen.5

 

Adverse reactions to RCM can be classified as anaphylactoid or chemetoxic.8 Anaphylactoid reactions occur unpredictably and independently of dose or the concentration of RCM and account for the majority of reactions. The exact cause remains unknown.  Chemetoxic reactions are result of specific physicochemical characteristics of RCM, such as their hyperosmolality and their potential for binding calcium ions and proteins. Chemetoxicity of RCM is also known to increase with a decrease in their hydrophilicity and increase in their lipophilicity, properties which depend on structural features including the presence of hydroxyl and carboxyl groups.3

 

Although pre-medication with corticosteroids, ranitidine and antihistaminic raise the threshold dose required to induce clinical anaphylaxis it does not raise sufficiently to allow safe administration of diagnostic quantities of RCM. On the other hand, it will diminish the incidence of reactions.6,7 It has been suggested that intradermal testing might predict tolerance of particular RCM agents; however, most authorities do not currently endorse this technique.7

 

As a result, it should be borne in mind that anaphylactic type reactions may also occur against non-ionic contrast media and such reaction may repeat at the late phase of administration. There is no reliable prophylaxis for these cases. Therefore, rapid recognition, diagnosis and management of such conditions can be life-saving.

  

References

  1. Antonio MON, Neison MD, Walter VAV, et al. Methylene blue: an effective treatment for contrast medium-induced anaphylaxis. Med Sci Monit 2003; 11: CS102-6.

  2. Hagan JB. Anaphylactoid and adverse reactions to radiocontrast agents. Immunol Allergy Clin North Am 2004; 3: 507-19.

  3. Thomas M, Peedicayil J, Koshi T, et al. Adverse reactions to radiocontrast media in an Indian population. Br J Radiol 1999; 859: 648-52.

  4. Kanny G, Maria Y, Mentre B, Moneret-Vautrin DA. Case report: recurrent anaphylactic shock to radiographic contrast media. Evidence supporting an exceptional IgE-mediated reaction. Allerg Immunol 1993; 10: 425-30.

  5. Cochran ST. Anaphylactoid reactions to radiocontrast media. Curr Allergy Asthma Rep 2005; 1: 28-31.

  6. Lasser EC. The radiocontrast molecule in anaphylaxis: a surprising antigen. Novartis Found Symp 2004; 257: 211-24; discussion 224-5, 276-85.

  7. Worthley D.L, Gillis D, Kette F, Smith W. Radiocontrast anaphylaxis with failure of premedication. Internal Medicine Journal 2005; 35: 58-60.

  8. Bush WH, Swanson DP. Acute reactions to intravascular contrast media: types, risk factors, recognition and specific treatment. AJR 1991; 157: 1153-61.

 

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