Case report of a patient who survived after cardiac arrest and cardiogenic shock by anaphylactic reaction to gadolinium during magnetic resonance imaging

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Case

Report

Case

report

of

a

patient

who

survived

after

cardiac

arrest

and

cardiogenic

shock

by

anaphylactic

reaction

to

gadolinium

during

magnetic

resonance

imaging

Emanuela

Biagioni,

MD

a,∗

_,

_Irene

_Coloretti,

_MS

a

_,

_Fabrizio

_Disalvo,

_MS

a

_,

Alberto

Andreotti,

MD

a

_,

_Francesco

_Sani,

_MD

b

_,

_Pietro

_Torricelli

b

_,

_Roberta

_Gelmini

c

_,

Massimo

Girardis

a

a_Intensive_Care_Unit,_Modena_University_Hospital,_Largo_del_Pozzo₇₁₄₁₁₂₅_Modena,_Italy b_Radiology_Department,_Modena_University_Hospital,_Modena,_Italy

c_Surgical_Department,_Modena_University_Hospital,_Modena,_Italy

a r t i c l e

i n f o

Articlehistory: Received26August2019 Revised26November2019 Accepted11December2019 Keywords: Gadolinium Cardiogenicshock Anaphylaxis Anaphylacticshock MRI

Magneticresonanceimaging

a b s t r a c t

We report thecase of a youngadult whichsurvived to anaphylactic shockcaused by gadolinium-basedcontrastagent(GBCA)contrastagentinfusion.Thepatienthadno comor-biditiesandprevioushistoryofallergicreactionstocontrastagentsandunderwentelective magneticresonanceimaging(MRI)forparotidswelling.Sevenyearsbeforehereceived intra-venousGBCAadministrationduringanMRI,whichexactchemicalcompositionisunknown, withoutanyallergicreaction.AfterintravenousinjectionofGBCAforMRIthepatient devel-opedanaphylacticshock,causingrespiratoryfailure,cardiacarrest,andcardiogenicshock afterreturnofspontaneouscirculation.Becauseoftherarityofthedescribedevent,this reporthastheaimtoraiseawarenessinthehealthcarepersonnelofthepossibilityofthese life-threateningadversereactionsfromGBCAsalsoinapatientwithouthistoryofallergyto contrastagentsandsuggestapossibleclinicalmanagementofthesepatients.

Introduction

Gadolinium-based contrast agents (GBCAs) have been ap-proved forparenteral use since the late 80s and they are

DeclarationofConflictInterest:alltheAuthorsdiscloseanyfinancialandpersonalrelationshipswithotherpeopleororganizationsthat couldinappropriatelyinfluence(bias)thecontentsofthispaper.

Acknowledgment:Noprivateandpublicfundsusedforreportingthiscase.

∗_{Corresponding}_author.

E-mailaddress:emanuela.biagioni@gmail.com(E.Biagioni).

mostlyusedinmagneticresonanceimaging(MRI).Allergic re-actionsbyGBCAsarerarewithanestimatedrateofsevere anaphylaxisof1out of10,000patients.Duetotherarityof theseevents,theyarerarelytakenintoaccountwhenGBCAs areadministeredbyhealthcarestaff,leadingtothepossibility

https://doi.org/10.1016/j.radcr.2019.12.006

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ofadelaybothinthediagnosisandinthefirst-linetreatment provided.

Case

report

A 45-year-old Caucasian man without comorbidities and previoushistoryofallergicreactionstomedicationsor con-trastagents,underwentMRIforparotidswelling.Sevenyears before,thepatientunderwentMRIincludingGBCA adminis-trationforsuspectedparotidneoplasiawithout anyallergic reaction.Twominutesaftertheendoftheintravenous admin-istrationof0.2mL/kgofDotarem(activesubstance:gadoteric acid)withaninfusionrateof1.5mL/sec,followedby20mL ofcristalloids,thepatientshowedstingingcough,dyspnea, unleashednausea,and desaturation.TheMRIscannerwas locatedwithin the hospital, sothe hospital outreachteam foremergencieswaspromptlyalertedandarrivedintheMRI roomsafter2minutes:thepatientwasunconscious,apneic, incardiac arrest with asystole.Advanced life supportwas immediatelyprovidedincluding intravenousadministration ofadrenaline(1mgrepeatedeverysecondloopduring cardio-pulmonaryresuscitation (CPR),then 0.1 μg/kg/min in con-tinuousinfusion),massivefluidinfusion(around1.5Lin10 minutes),glucocorticoidsathighdosage(1gofhydrocortisone duringthearrest,followedby60mgevery6hoursinthenext 24hours),andendotrachealintubationdespitesevereglottic edema.Adefibrillationrhythmwasobtainedafter8minutes andastablepulseafter18minuteswithmultipleDCshocks and epinephrine continuous infusion. After intensive care unitadmission,westartedimmediatelywiththebrain protec-tionprotocolincludingdeepsedation,maintainingofmean arterialpressure>80mmHgbyepinephrineandscrupulous normothermiabyexternalcooling.In theinitial hours, pa-tientdevelopedtightbronchospasmandprogressivediffuse urticariathatweremanagedwithinhaledsalbutamol, gluco-corticoids,andH1antihistamines.Fourhoursafteradmission, thepersistenceoflowcardiacoutput(1.4L/min/m2_,_obtained withtranspulmonarythermodilutionmethod),global akine-sia,and ventricular left apoplexy byechocardiography,low progressionofRwavefromV1toV3andtheelevatedtroponin Ivalues,ledustoperformcoronaryangiographyforexcluding acoexistingcoronarydisease.Theangiographydidnotshow anydefectincoronaryperfusionand,inthefollowinghours, cardiacand respiratoryfailure progressivelyimproved with rapidweaning of epinephrine. At24 hours,the neurologic examinationduringtheinterruptionofsedationshowedno deficitswithGlasgowComaScale11/15(intubated)and,thus, the patient was rapidly extubated. He was discharged 24 hourslaterfromICUand,finally,athomewithoutanycardiac andneurologicaldysfunction4daysaftertheevent.

Discussion

In the last decades, magnetic resonance contrast media have been recognized to have an excellent safety profile

[1,2]. In fact, the rate of adverse reactions after injection

of MRI contrast media is low, ranging between 0.07% and 0.8%,withanincidenceofsevereanaphylactoidreactionsof around1outof10,000patients[1–9].Althoughcasesofsevere immediate hypersensitivity reactions with cardiovascular and respiratoryimpairment havebeenreported [10,11],the most common immediate hypersensitivity symptoms are mildpruritusandurticaria[5,9].Anarticlepublishedin2017 reportedthecaseofayounghealthyadultmandying after a severe immediate anaphylactic reaction to gadobutrol,a GBCA agent administered forelective MRI [12].Reasons of deathwere brainswelling and hypoxiaduetoa prolonged state of cardiac arrest. In this case is interesting that the patienthadundergonealsocontrast-enhancedCTpreviously withouttheoccurrenceofanyadverseeffects.

TheroleofimmunoglobulinE–mediatedreactionhasbeen advocatedinhypersensitivityreactions,withariskincreased upto8timesandmoresevereresponsesatthesecondGBCAs useinpatientswithhistoryofhypersensitivity[11,13].Skin testingwithdifferentGBCAsafterhypersensitivityreactions aresuggestedforidentifyingthebesttoleratedagent,butthe truemeaningofpositiveandnegativeresultsofthetestsare stillunclear[11].OurpatientreceivedGBCA7yearbefore,but hereferrednospecificreactionsatthattime.

Stress-related cardiomyopathy seems to play a pivotal roleinseveremyocardialdysfunctionoccurringduring ana-phylacticshock.Unfortunately,resuscitationmaneuversmay further potentiate cardiac dysfunction because of sympa-thetic nervous system upregulation and increaseof serum catecholamineconcentrations.Infact,severalstudiessuggest thatanexcessive β1-adrenergicstimulationbyepinephrine mayinduceleftventriculardysfunction.Thismayexplainthe profound and persistent myocardial dysfunction observed in our patient. Nevertheless, eco and electrocardiography findings combined to troponin values did not allow us to definitively ruleout acoronaryheartdisease and,thus,we decidedforangiography.Inanaphylaxis,systemic vasodilata-tion,reduced venousreturn, and volumelossby increased vascular permeability may lead to low cardiac output and hypotension,whichcaninducecoronaryhypo-perfusionand myocardialdamage,particularlyinpatientswithpreexisting coronarydisease[14,15].

Webelievethatisimportanttoreportthissevere anaphy-lacticreactionbyGBCAbecauseoftherarityofthedescribed events[16].Despiteoccasional,healthcarepersonneland pa-tientsshouldbeawareofthepossibilityoflife-threateningor fatalanaphylaxisfromGBCAsalsoinapatientwithouthistory ofallergytocontrastagents.Infact,inarecentlypublished ar-ticle,wassuggestedtomaintaintheintravenouscatheteras longasneededtobesurethepatientisnothavingany seri-ousadversereactions[17].Thereportprovidesalsouseful in-formationforthemanagementofpatientswithpersisting car-diogenicshockafteranaphylaxis,particularlyforthe interpre-tationofechocardiographyandelectrocardiographysignsand fortheroleandtimingofcoronaryangiographyinthissetting.

Supplementary

materials

Supplementary materialassociatedwiththis articlecanbe found,intheonlineversion,atdoi:10.1016/j.radcr.2019.12.006.

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