GADOLINIUM-INDUCED ANAPHYLAXIS: NOT ALL CONTRAST AGENTS ARE CREATED EQUAL

Abstract

Introduction Hypersensitivity reactions to gadolinium-based contrast agents (GBCAs) are uncommon but anaphylaxis and fatalities have occurred. Case Description A 40-year-old woman with a past medical history of hypertension and chronic urticaria developed facial urticaria, flushing, angioedema, and presyncope within minutes of undergoing a gadobenate-based Magnetic Resonance Imaging (MRI) to detect breast cancer. The procedure was stopped, and her condition improved after treatment with IM dyphenhydramine. Tryptase was not obtained. Six-weeks later, undiluted skin prick tests (SPTs) and intradermal testing were performed using 1:1000, 1:100 and 1:10 dilution of the suspected and alternative GBCAs. SPT was positive to gadobenate and gadoterate meglumine (Figure 1), while the alternative GBCAs were negative (gadobutrol, gadodiamide, and gadoxetrate). Baseline tryptase was within normal limits (2.7; ref Discussion In patients with a history of gadolinium-induced anaphylaxis SPT may offer a viable option to select an alternative agent. There are few studies which investigate SPTs which can detect the presence of IgE thus predicting reactions to GBCAs. In our case, SPTs were utilized to avoid certain agents, while a subsequent graded dose challenge further helped identify gadobutrol as a safe agent. Hypersensitivity reactions to gadolinium-based contrast agents (GBCAs) are uncommon but anaphylaxis and fatalities have occurred. A 40-year-old woman with a past medical history of hypertension and chronic urticaria developed facial urticaria, flushing, angioedema, and presyncope within minutes of undergoing a gadobenate-based Magnetic Resonance Imaging (MRI) to detect breast cancer. The procedure was stopped, and her condition improved after treatment with IM dyphenhydramine. Tryptase was not obtained. Six-weeks later, undiluted skin prick tests (SPTs) and intradermal testing were performed using 1:1000, 1:100 and 1:10 dilution of the suspected and alternative GBCAs. SPT was positive to gadobenate and gadoterate meglumine (Figure 1), while the alternative GBCAs were negative (gadobutrol, gadodiamide, and gadoxetrate). Baseline tryptase was within normal limits (2.7; ref In patients with a history of gadolinium-induced anaphylaxis SPT may offer a viable option to select an alternative agent. There are few studies which investigate SPTs which can detect the presence of IgE thus predicting reactions to GBCAs. In our case, SPTs were utilized to avoid certain agents, while a subsequent graded dose challenge further helped identify gadobutrol as a safe agent.