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Yamaguchi Prefecture Central Hospital Hofu 747-8511, Japan
We read with interest the article by Cochran et al. [1] on the adverse effects of contrast media. Severe reaction of death occurred in two of 90,473 doses, both in the use of nonionic contrast media. We encountered a case of fatal cardiac arrest by infusion of a nonionic contrast medium in a patient with essential thrombocythemia.
A 47-year-old man with no notable history of illness developed chest pains and was admitted in September 2000. A complete blood count revealed RBC; 361 x 104/µL; hemoglobin, 7.6g/dL; hematocrit, 27.8%; platelet count, 267.8 x 104/µL; WBC, 39,900/µL. A bone marrow aspiration smear revealed hyper-cellular marrow with mature myeloid cells and megakaryocytes; cytogenetic analysis revealed del(3)(p13p21). Myeloproliferative disorder of essential thrombocythemia was diagnosed.
The patient had no history of allergy. A radiograph of the chest and
contrast-enhanced CT of the chest and abdomen showed no abnormalities. No
adverse reaction was observed at that time. His electrocardiogram showed no
abnormalities, and echocardiography showed normal performance. Pulmonary
perfusion scintigraphy revealed homogeneous distribution of radioactivity.
Administration of aspirin and interferon-
were started, and the
patient's condition was good for 2 weeks.
However, because dorsalgia developed and splenic infarction was suspected, contrast-enhanced CT of the abdomen was planned. During the infusion of 60mL of iohexol, 300mg I/mL, by an automatic pump with a scheduled 100-mL administration, the patient died of sudden onset cardiac arrest. Cardiac resuscitation was ineffective. In the autopsy, intramural, acute, and old organizing infarctions were observed in entire left ventricular wall.
The use of low-osmolar nonionic contrast media significantly reduced the frequency of life-threatening adverse reactions compared with high-osmolar ionic contrast media in a large scale comparative clinical study of 170,000 cases [2]. One death occurred in each group, but a causal relationship to contrast media could not be established. In the report by Cochran et al. [1], severe reactions were seen equally with ionic and nonionic contrast media. The reactions were allergic in the ionic contrast media but were predominantly attributable to cardiopulmonary decompensation in the nonionic contrast media group. However, the risk factors for severe reactions were not shown.
Essential thrombocythemia is a clonal myeloproliferative disorder characterized by a persistent increase in platelet count [3]. Arterial, including cerebral and cardiac, and deep vein thrombosis are observed as the thromboembolic complications. In our patient, it is clear that infusion of nonionic contrast media prompted cardiac arrest by the newly formed myocardial infarction. Careful monitoring of the patient during the infusion of contrast media is necessary in such a case with a markedly elevated platelet count.
References
UCLA School of Medicine Los Angeles, CA 90095-1721
We thank Shinohara et al. for their interest in our article [1] on adverse events after contrast media administration. They inquire about risk factors in the patients experiencing severe reactions in our series. The two deaths were described in detail in the original article. In the following paragraphs, we list the adverse events in the other 10 patients in our study who experienced severe reactions and provide short case summaries of each.
Bronchospasm. A 68-year-old woman presented for CT with the pancreas protocol for IV contrast medium administration at 3 mL/sec. She had undergone no previous contrast studies at our institution. She had a history of steroid-dependent asthma. She began to wheeze approximately 8 min after contrast medium administration and was treated with albuterol. She showed no improvement after two doses, and she was admitted to the emergency department and treated with albuterol and Solu-Cortef (hydrocortisone hemisuccinate sodium salt; Upjohn, Kalamazoo, MI). She was discharged from the emergency department 4 hr later.
Oral edema. A 43-year-old woman with chest pain presented for a chest CT angiogram with IV contrast medium administration at 3 mL/sec to evaluate for embolus. She had no previous contrast medium exposure. After a test injection of 20 mL of nonionic contrast material, the patient experienced nausea and vomiting. She experienced difficulty swallowing 10 min later, and her tongue became swollen. She was treated with diphenhydramine in the radiology department and was transferred to the emergency department, where she was treated with epinephrine, Solu-Medrol (methylprednisolone; Upjohn), and oxygen. She was returned to her hospital room after 2 hr.
Seizure. A 45-year-old woman presented for CT for hypertension. She had no previous studies at our facility. She experienced loss of consciousness without incontinence and three short episodes of tonic—clonic activity. She was transferred to the emergency department, where she had three more episodes of seizure activity. She was discharged 3 hr later.
Pulmonary edema. A 63-year-old woman presented for CT with the pancreas protocol for IV contrast medium administration at 3 mL/sec. She had previously undergone a CT study at another institution. The patient became acutely short of breath and began to wheeze 5-10 min after contrast medium administration. She was treated with 0.2 mg of epinephrine subcutaneously and Solu-Medrol. Her condition did not improve; her oxygen saturation level fell, and the patient began coughing up frothy sputum. She was transferred to the emergency department, where she went into respiratory arrest and was intubated. A radiograph of the chest showed pulmonary edema. She had experienced a previous episode of acute pulmonary edema associated with congestive heart failure, and she had underlying risk factors of insulin dependent diabetes mellitus and hypertension.
Acute shortness of breath. A 75-year-old woman presented for CT for renal cell cancer after three cycles of chemotherapy for lung metastases. She had previous contrast exposure with no reaction. The patient became acutely short of breath and experienced nausea and vomiting. She was treated for a presumed allergic reaction with diphenhydramine. Her oxygen saturation decreased. Ventilation was begun with a bag-valve-mask resuscitator. She was intubated and transferred to the emergency department. The patient was placed on a mechanical ventilator and admitted to the intensive care unit, where she was extubated 3 days after the episode. The patient was hospitalized for 8 days. She died of metastatic disease a year later.
Cardiac arrhythmia. A 31-year-old woman presented for CT for renal cell carcinoma. She had previously undergone interleukin-2 therapy for her renal cancer. The patient was premedicated with diphenhydramine and prednisone because of previous allergic reaction. She developed urticaria, pruritis, dyspnea, and skipping of heartbeats. She was transferred to the emergency department, where she was evaluated and sent home with prednisone and Benadryl (diphenhydramine hydrochloride; Parke-Davis, Morris Plains, NJ).
Chest pain. A 79-year-old man presented for CT with the pancreas protocol. He developed chest pressure radiating to the back. Paramedics determined that the patient's cardiac monitor showed first degree heart block. He was transferred to the emergency department, where an ECG showed a right bundle branch block. The patient was admitted to the hospital for evaluation for myocardial infarction. He was discharged the following day with a diagnosis of atypical chest pain and a negative workup for myocardial infarction. The patient had a history of myocardial infarction 39 years ago, but he had no history of angina. He had hypertension.
Chest pain. A 78-year-old woman with intracranial aneurysm presented for a CT angiogram with IV contrast medium administration at 3 mL/sec. She developed chest pain and was given nitroglycerine. She was transferred to the emergency department. A radiograph of the chest showed cardiomegaly but no pulmonary edema. She was admitted to the coronary care unit for evaluation for myocardial infarction. A stress ECG showed exercise-induced sinus tachycardia depression, ejection fraction of 55-60%, and ischemic changes induced by exercise. She was advised to undergo cardiac catheterization and angioplasty. She elected to leave the hospital.
Multiple reactions. A 51-year-old woman presented for CT after an orthotopic liver transplant. She had end-stage renal disease and was on dialysis. She had previous contrast studies without reaction. The patient complained of chest pain, shortness of breath with throat tightness, and dizziness 3 min after injection of contrast medium. She had a rash around her neck. The patient was treated with oxygen, diphenhydramine, and IV fluids, and she was transferred to the emergency department. In the emergency department, she underwent further treatment for allergic reaction and evaluation for myocardial infarction. A radiograph of the chest had negative findings, and her lungs were clear. Her ECG showed right ventricular hypertrophy. She was admitted for cardiac monitoring and was discharged the following day.
Chest pain. A 75-year-old woman presented for a CT angiogram of the neck to evaluate for carotid stenosis. She developed tightness in the chest and was given nitroglycerine. Her vital signs were stable. Paramedics were called because she had continued chest pain. She was transferred to the emergency department. A radiograph of the chest showed mild cardiomegaly. She was admitted to coronary care unit for evaluation for myocardial infarction. Her ECG showed left ventricular hypertrophy with no ischemia. A stress test showed anterior wall reversible defect. The cardiologist thought the chest pain was atypical and not likely due to reversible ischemia. The patient had a history of hypertension, claudication, and stroke, but she had no history of chest pain.
The faster injection rates associated with helical CT scanning may put certain populations of patients at risk for developing cardiopulmonary decompensation reactions like those seen in our study.
References
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