Allergic-like Reactions Research Articles

Contrast media controversies in 2015: imaging patients with renal impairment or risk of contrast reaction.

The incidence and significance of complications related to intravascular contrast material administration have become increasingly controversial. This review will highlight current thinking regarding the imaging of patients with renal impairment and those at risk for an allergiclike contrast reaction. The risk of contrast-induced acute kidney injury remains uncertain for patients with an estimated glomerular filtration rate (GFR) less than 45 mL/min/1.73 m(2), but if there is a risk, it is greatest in those with estimated GFR less than 30 mL/min/1.73 m(2). In this population, low-risk gadolinium-based contrast agents appear to have a large safety margin. Corticosteroid prophylaxis remains the standard of care in the United States for patients identified to be at high risk of a contrast reaction, but it has an incomplete mitigating effect on contrast reaction rates and the number needed to treat is large.

Contrast Is the New Penicillin, and Possibly Worse

Surprising to many clinicians, less than 20% of purported penicillin allergies are validated in those undergoing skin testing [1]. Reporting a false penicillin allergy is not benign. Patients are deprived of a class of drugs that are effective, available, and potentially lifesaving. In addition, they open themselves to complications from alternative antibiotics that are potentially less effective, have more side effects, and are more expensive. Unnecessary use of newer-generation antibiotics hastens the inevitable emergence of antibiotic-resistant pathogens, with potentially grave long-term public health consequences. Fortunately, in less than 30 minutes, patients with suspected penicillin allergies may undergo skin testing to confirm or disprove an immunoglobulin-E (IgE)emediated allergy with a high level of confidence [2]. As with penicillin, allergic or allergiclike reactions to iodinated intravascular contrast media are well documented and can range from minor cutaneous eruptions to fatal anaphylaxis. The mechanism of reaction remains controversial, with some reactions demonstrating an IgE or T-cell dependence and others not [3]. A gradual adoption of nonionic contrast material has taken place, owing to market forces, patent expiration, and most importantly, an improved safety profile. Use of nonionic iodinated contrast (either low-osmolar or isoosmolar) is the current standard of care [4,5]. Still, among identified culprit drugs, contrast remains second to only antibiotics as a cause of medicationinduced fatal anaphylaxis in the United States [6]. Interestingly, despite the perceived safety of gadolinium-based

Elevated total serum IgE in nonatopic patients with aspirin-exacerbated respiratory disease.

Aspirin-exacerbated respiratory disease (AERD), also known as Samter's triad, is characterized by asthma, recurrent nasal polyps, and by allergic-like reactions to aspirin and other nonsteroidal anti-inflammatory drugs, although it is not a true immunoglobulin E (IgE)-mediated allergy. Atopy, although common in patients with AERD, is not a characteristic of the disease. Recently, we have observed a subgroup of patients with AERD who have no history of atopy but have abnormally elevated total serum IgE, a phenomenon that has been observed in patients with asthma but has not been further explored. We sought to explore this phenomenon of elevated total serum IgE in the absence of atopy in a subset of patients with AERD. Patients were diagnosed with AERD with an oral aspirin challenge at the Brigham and Women's Hospital Allergy and Clinics. Atopy was defined as a positive test result to at least one of the common aeroallergens. Elevated total serum IgE was defined as IgE of >100 IU/mL. We present six patients with AERD and elevated total serum IgE in the absence of any clear atopy. Total serum IgE in these patients ranged from 110 to 1760 IU/mL. Mean blood eosinophil levels for these patients were not significantly different from those of the entire cohort of patients with AERD included in the study. In a subset of patients with AERD, we observed elevated total serum IgE even when atopy was not present. To better understand the disease, the cause and clinical relevance of this phenomenon deserves further exploration.

Errors of epinephrine administration during severe allergic-like contrast reactions: lessons learned from a bi-institutional study using high-fidelity simulation testing

To determine the most common errors of epinephrine administration during severe allergic-like contrast reaction management using high-fidelity simulation surrogates. IRB approval and informed consent were obtained for this HIPAA-compliant bi-institutional prospective study of 40 radiology residents, fellows, and faculty who were asked to manage a structured high-fidelity severe allergic-like contrast reaction scenario (i.e., mild hives progressing to mild bronchospasm, then bronchospasm unresponsive to bronchodilators, and finally anaphylactic shock) on an interactive manikin. Intravenous (IV) and intramuscular epinephrine ampules were available to all participants, and the manikin had a functioning intravenous catheter for all scenarios. Video recordings of their performance were reviewed by experts in contrast reaction management, and errors in epinephrine administration were recorded and characterized. No participant (0/40) failed to give indicated epinephrine, but more than half (58% [23/40]) committed an error while doing so. The most common mistake was to administer epinephrine as the first-line treatment for mild bronchospasm (33% [13/40]). Other common errors were to administer IV epinephrine without a subsequent IV saline flush or concomitant IV fluids (25% [10/40]), administer an overdose of epinephrine (8% [3/40]), and administer epinephrine 1:1000 intravenously (8% [3/40]). Epinephrine administration errors are common. Many radiologists fail to administer albuterol as the first-line treatment for mild bronchospasm and fail to flush the IV catheter when administering IV epinephrine. High-fidelity contrast reaction scenarios can be used to identify areas for training improvement.

L’imagerie médicale diagnostique est-elle iatrogène ?

Imaging is an indispensable element of modern medicine but is not without risk. Low-dose irradiation due to spinal, abdominal, pelvic or cardiac radiography, and the increasing use of CT carries an additional, albeit moderate risk of cancer. Iodinated and gadolinium-containing contrast media, besides their direct toxicity, can trigger hypersensitivity and allergic-like reactions. Spinal and articular diagnostic injections can also lead to complications. This article reviews the direct iatrogenicity of diagnostic imaging and current efforts to limit it through the use of new radiological systems, lower-dose CT non ionic contrast media, and alternative imaging techniques. The authors also examine the less known but more frequent problem of indirect iatrogenesis, which is highly dependent on the quality of the imaging personnel and technique. Finally, we propose some legislative solutions to this problem.

Clinically useful dilution factors for iodine and gadolinium contrast material: an animal model of pediatric digital subtraction angiography using state-of-the-art flat-panel detectors

Iodinated and gadolinium contrast agents pose some risk for certain pediatric patients, including allergic-like reactions, contrast-induced nephropathy (CIN) and nephrogenic systemic fibrosis (NSF). Digital flat-panel detectors enhance image quality during angiography and might allow use of more dilute contrast material to decrease risk of complications that might be dose-dependent, such as CIN and NSF. To assess the maximum dilution factors for iodine- and gadolinium-based contrast agents suitable for vascular imaging with fluoroscopy and digital subtraction angiography (DSA) on digital flat-panel detectors in an animal model. We performed selective catheterization of the abdominal aorta, renal artery and common carotid artery on a rabbit. In each vessel we performed fluoroscopy and DSA during contrast material injection using iodinated and gadolinium contrast material at 100%, 80%, 50%, 33% and 20% dilutions. An image quality score (0 to 3) was assigned by each of eight evaluators. Intracorrelation coefficient, paired t-test, one-way repeated analysis of variance, Spearman correlation and receiver operating characteristic curve analysis were applied to the data. Overall the image quality scores correlated linearly with dilution levels. For iodinated contrast material, the optimum cut-off level for DSA when a score of at least 2 is acceptable is above 33%; it is above 50% when a score of 3 is necessary. For gadolinium contrast material, the optimum cut-off for DSA images is above 50% when a score of at least 2 is acceptable and above 80% when a score of 3 is necessary. Knowledge of the relationship between image quality and contrast material dilution might allow a decrease in overall contrast load while maintaining appropriate image quality when using digital flat-panel detectors.

Effect of Abrupt Substitution of Gadobenate Dimeglumine for Gadopentetate Dimeglumine on Rate of Allergic-like Reactions

To evaluate the effect of abruptly substituting gadobenate dimeglumine for gadopentetate dimeglumine on allergic-like reactions. The institutional review board approved and waived patient consent for this HIPAA-compliant retrospective study. Allergic-like reactions related to gadolinium-based contrast media were assessed 2 years before and 3.5 years after gadobenate dimeglumine was substituted for gadopentetate dimeglumine. Reaction rates and severity were compared by using χ(2) tests, Fisher exact tests, odds ratios (ORs), and confidence intervals (CIs). Allergic-like reactions (137 mild, 19 moderate, and six severe) occurred in 162 (0.15%) of 105 607 injections of gadolinium-based contrast media (gadopentetate dimeglumine, 31 540; gadobenate dimeglumine, 66 152; other, 7915). Gadobenate dimeglumine was associated with significantly more overall (0.19% [123 of 66 152] vs 0.08% [24 of 31 540]; OR, 2.4; 95% CI: 1.6, 3.8; P < .0001) and mild (0.16% [107 of 66 152] vs 0.06% [18 of 31 540]; OR, 2.8; 95% CI: 1.7, 4.7; P < .0001) allergic-like reactions than was gadopentetate dimeglumine. The reaction rate for gadobenate dimeglumine peaked (maximum per quarter, 0.38% [16 of 4262]; minimum per quarter, 0.07% [three of 4237]) in the 2nd year after it replaced gadopentetate dimeglumine (maximum per quarter, 0.10% [four of 4122]; minimum per quarter, 0.05% [two of 4222]) and then declined in the 3rd year. The final gadobenate dimeglumine reaction rate (last 3 quarters, 0.12% [17 of 14 387]) did not significantly differ from the original baseline reaction rate with gadopentetate dimeglumine. After gadobenate dimeglumine was substituted for gadopentetate dimeglumine, a significant transient increase occurred in the frequency of reported allergic-like reactions that demonstrated a temporal pattern suggestive of the Weber effect (a transient increase in adverse event reporting that tends to peak in the 2nd year after a new agent or indication is introduced). © RSNA, 2012.

A Phase 2, randomized, partially blinded, active-controlled study assessing the efficacy and safety of variable anticoagulation reversal using the REG1 system in patients with acute coronary syndromes: results of the RADAR trial

We sought to determine the degree of anticoagulation reversal required to mitigate bleeding, and assess the feasibility of using pegnivacogin to prevent ischaemic events in acute coronary syndrome (ACS) patients managed with an early invasive approach. REG1 consists of pegnivacogin, an RNA aptamer selective factor IXa inhibitor, and its complementary controlling agent, anivamersen. REG1 has not been studied in invasively managed patients with ACS nor has an optimal level of reversal allowing safe sheath removal been defined. Non-ST-elevation ACS patients (n = 640) with planned early cardiac catheterization via femoral access were randomized 2:1:1:2:2 to pegnivacogin with 25, 50, 75, or 100% anivamersen reversal or heparin. The primary endpoint was total ACUITY bleeding through 30 days. Secondary endpoints included major bleeding and the composite of death, myocardial infarction, urgent target vessel revascularization, or recurrent ischaemia. Enrolment in the 25% reversal arm was suspended after 41 patients. Enrolment was stopped after three patients experienced allergic-like reactions. Bleeding occurred in 65, 34, 35, 30, and 31% of REG1 patients with 25, 50, 75, and 100% reversal and heparin. Major bleeding occurred in 20, 11, 8, 7, and 10% of patients. Ischaemic events occurred in 3.0 and 5.7% of REG1 and heparin patients, respectively. At least 50% reversal is required to allow safe sheath removal after cardiac catheterization. REG1 appears a safe strategy to anticoagulate ACS patients managed invasively and warrants further investigation in adequately powered clinical trials of patients who require short-term high-intensity anticoagulation.

Les réactions d’hypersensibilité allergique et non allergique aux antalgiques non opiacés, antipyrétiques et anti-inflammatoires non stéroïdiens chez l’enfant : épidémiologie, aspects cliniques, physiopathologie, diagnostic et prévention

Non-opioid analgesics, antipyretics and nonsteroidal anti-inflammatory drugs are widely used, but suspected allergic reactions to these drugs are rare, especially in children. Most frequent reactions are cutaneous (urticaria, angioedema) and respiratory (rhinitis, asthma). Other reactions (anaphylaxis, potentially harmful toxidermias) are rare. In a few patients, reactions may result from a specific (allergic) hypersensitivity, with positive responses in prick and intradermal tests (anaphylaxis, immediate urticaria and/or angioedema) and in intradermal and patch tests (non-immediate reactions). However, most reactions result from a non-specific (non-allergic) hypersensitivity (intolerance), with a frequent cross-reactivity between the various families of analgesics, antipyretics and nonsteroidal anti-inflammatory drugs, including paracetamol. Based on a convincing clinical history and/or positive responses in challenge tests, intolerance to non-opioid analgesics, antipyretics and nonsteroidal anti-inflammatory drugs has been diagnosed in 13 to 50% of the patients with allergic-like reactions to these drugs. Risk factors are a personal atopy and age. Prevention is based on administration of other (families of) analgesics, antipyretics and nonsteroidal anti-inflammatory drugs in patients with allergic hypersensitivity to these drugs. In patients with non-allergic hypersensitivity, prevention is based on administration of drugs with a low cyclo-oxygenase-1 inhibitory activity (if tolerated). Desensitization is efficient in patients with respiratory reactions, but does not work in patients with mucocutaneous reactions and anaphylaxis.

Current Status of Residency Training of Allergic-like Adverse Events to Contrast Media

Acute allergic-like adverse reactions to contrast media are rare but life-threatening events. Residents may complete training without ever managing such an event. Surveys have shown practicing radiologists to incorrectly dose and administer medications for treatment. Thus, contrast education may be deficient or inconsistent. The purpose of this study was to assess the current status of contrast reaction education in US radiology residency programs and the methods used to test residents' knowledge. A 10-question anonymous survey on residency education methods and testing pertaining to allergic-like adverse events to contrast media was distributed through the Association of Program Directors in Radiology to program directors of US diagnostic radiology residency programs. The past 4 years of the American College of Radiology in-service examination were reviewed to assess the number of contrast reaction questions. Fifty-one programs responded to the Association of Program Directors in Radiology survey. Forty-nine percent of programs train with one lecture per year, 29.4% train with two lectures, and 16% train with three or more lectures. Only 44% include role-playing training during the lectures. Eighteen percent of programs are incorporating simulation training. Fewer than 50% of programs formally test residents' knowledge, and there were no questions on the 2007 to 2010 American College of Radiology in-service examinations. Resident education for contrast reaction management is primarily performed with annual lectures. Only 18% of programs are using simulation training, and <50% are testing residents' knowledge or skills. These findings suggest that education may need revision to incorporate simulation or other means of psychomotor learning.

Rate of Contrast Material Extravasations and Allergic-like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37°C

To retrospectively determine whether extrinsic warming of the low-osmolality contrast material iopamidol to 37°C prior to intravenous administration at computed tomography (CT) affects extravasation and allergic-like reaction rates. The need to obtain informed patient consent was waived for this HIPAA-compliant and institutional review board-approved analysis. All adverse events related to the intravenous administration of iopamidol during CT examinations occurring 200 days before (period 1) and 200 days after (period 2) the cessation of extrinsic contrast material warming (37°C) for intravenous injections of less than 6 mL/sec at Duke University Medical Center (Durham, NC) were retrospectively reviewed. Adverse event rates were compared by using χ2 statistics. There were 12,682 injections during period 1 (10,831 injections of iopamidol 300 and 1851 injections of iopamidol 370) and 12,138 injections (10, 064 injections of iopamidol 300 and 2074 injections of iopamidol 370) during period 2. Adverse event rates for iopamidol 300 were not affected by extrinsic warming (extravasation rates: 0.30% [32 of 10,831] in period 1 vs 0.23% [23 of 10,064] in period 2, P=.64; allergic-like reaction rates: 0.39% [42 of 10,831] in period 1 vs 0.46% [46 of 10,064] in period 2, P=.74; overall adverse events: 0.68% [74 of 10,831] in period 1 vs 0.69% [69 of 10,064] in period 2, P=.99). Discontinuation of extrinsic warming was associated with significantly increased extravasation and overall adverse event rates for iopamidol 370 (extravasation rates: 0.27% [five of 1851] vs 0.87% [18 of 2074], P=.05; allergic-like reaction rates: 0.16% [three of 1851] vs 0.39% [eight of 2074], P=.42; overall adverse events: 0.43% [eight of 1851] vs 1.25% [26 of 2074], P=.02). Extrinsic warming (to 37°C) does not appear to affect adverse event rates for intravenous injections of iopamidol 300 of less than 6 mL/sec but is associated with a significant reduction in extravasation and overall adverse event rates for the more viscous iopamidol 370.

Patterns of intravenous contrast material use and corticosteroid premedication in children—a survey of Society of Chairs of Radiology in Children’s Hospitals (SCORCH) member institutions

There are few data available concerning the use of intravenous contrast materials in children. To assess patterns of intravenous iodinated/gadolinium-based contrast material (ICM/GBCM) use in children. Society of Chairs of Radiology in Children's Hospitals (SCORCH) members were invited to complete a Web-based survey regarding intravenous contrast material use at their institutions. Sixty-six percent (42/64) of SCORCH member institutions responded, 76% of which are academic hospitals. Ioversol and gadopentetate dimeglumine are the most commonly used ICMs and GBCMs (52% and 81%, respectively). Premedication policies to mitigate risk of allergic-like contrast reactions are more common for ICMs than GBCMs (71% vs. 32%). For both ICMs and GBCMs, most institutions premedicate or avoid contrast material in the setting of a prior allergic-like contrast reaction of any severity. Policies regarding ICM and GBCM use in children with renal insufficiency are in place at 74% and 88% of institutions, respectively, but are variable. Policies concerning premedication for prevention of allergic-like contrast agent reactions and administration of contrast materials in children with renal insufficiency are variable and not consistently present at all pediatric institutions. This highlights the need for standardization of practice patterns and pediatric-specific research on these topics.

Repeat Contrast Medium Reactions in Premedicated Patients: Frequency and Severity

To determine the frequency, type, and severity of breakthrough and repeat breakthrough reactions to iodinated low-osmolality contrast medium (LOCM) in patients who were premedicated with corticosteroids and antihistamines. Institutional review board approval was obtained, and informed consent was waived for this retrospective HIPAA-compliant analysis. One hundred ninety breakthrough allergic-like reactions to intravenous LOCM in 175 patients with a history of contrast medium reactions were reviewed. The repeat breakthrough reactions that resulted from 197 additional LOCM-enhanced examinations performed in 58 patients after the initial breakthrough reaction were also reviewed. The Fisher exact test was used to determine if certain risk factors were associated with an increased risk of a moderate or severe breakthrough reaction. Subgroup analysis was performed to determine if the contrast medium type, contrast medium volume, and/or time between the initial (index) and breakthrough reactions affected the breakthrough reaction severity. Of 128 breakthrough reactions in which the index reaction severity was known, 103 (81%) were of a severity similar to that of the index reaction, 15 (12%) were less severe, and 10 (8%) were more severe. The severity of the breakthrough reactions in the patients with a mild index reaction was usually (in 94 [91%] of 103 reactions) mild. When the index reaction was severe, the breakthrough reaction was usually moderate or severe (in eight [42%] of 19 cases and four [67%] of six cases, respectively). The majority (174 [88%] of 197) of LOCM injections after the initial breakthrough reaction did not result in a repeat breakthrough reaction. Breakthrough reactions were significantly more likely to be moderate or severe in patients with a history of chronic oral corticosteroid use (P = .01), drug (P = .04) or severe (P < .001) allergies, or allergies to four or more allergens (P = .01). Breakthrough reactions are usually similar in severity to the index reaction, and subsequent contrast medium injections usually do not induce repeat breakthrough reactions. Breakthrough reactions are more likely to be moderate or severe in patients with certain risk factors.

Quoi de neuf en allergologie pédiatrique en 2007–2008 ? Partie 3 : allergies cutanées, alimentaires et médicamenteuses (une revue de la littérature internationale d’octobre 2007 à septembre–octobre 2008)

Severity of atopic dermatitis appears to be related to the extend of Th1 immune deficiency, leading to surinfection by Staphylococcus aureus and increased numbers of sensitizations to aeroallergens and foods. Diagnostic decision points for serum specific IgE levels with good positive and negative predictive values in children with food allergy are difficult to determine. Remission of allergy to common foods occurs more frequently in children with a low level of sensitization ( prick-tests and/or specific IgE) at the time of diagnosis and in children exhibiting a rapid decline in sensitization. Regular administration of heat-denaturated foods (milk, egg) may help the acquisition of tolerance to foods, and interesting results have been reported in children with persistent food allergy “hyposensitized” with foods administered by the oral and sublingual routes. Only a few children with suspected drug allergy are really allergic to commonly used drugs and biological substances. Most children with negative responses in skin and challenge tests with betalactams do not develop sensitizations and allergy to betalactams administered during challenge tests and subsequent treatments with betalactams. Although cross-reactivity between penicillins and imipenem is frequent, most children with immediate-type allergy to penicillins have negative responses in skin and challenge tests with meropenem. Finally, more than 40% of the children with allergic-like reactions to non opioid analgesics, antipyretics and nonsteroidal anti-inflammatory drugs are really allergic or intolerant to these drugs, especially when the reactions are severe, immediate and accelerated, and relapse with the same and/or other drugs.

Combined pegylated liposomal doxorubicin and carboplatin in the treatment of recurrent epithelial ovarian cancer

To evaluate the efficacy and toxicity of combined pegylated liposomal doxorubicin (PLD) and carboplatin in the treatment of patients with recurrent epithelial ovarian cancer. We retrospectively reviewed 67 patients with recurrent epithelial ovarian cancer or primary peritoneal adenocarcinoma (8 cases) who were treated with combined PLD and carboplatin. The response rate, survival and toxicity were evaluated. The mean age for 67 patients was 52.1 (39 - 76) years. All of them received cytoreductive surgery followed by platinum-based chemotherapy either with paclitaxel or cyclophosphamide and doxorubicin after diagnosis. Combined PLD and carboplatin was used as first or second-line treatment or even after multiple lines of treatment after disease recurred. Patients were treated with PLD at 35 - 40 mg/m(2) combined with carboplatin at an area under curve (AUC) of 5 once every 4 weeks. Forty-nine patients were evaluable for response. Twenty-three (47%) patients had a complete response, 13 (27%) had a partial response, 3 (6%) had stable disease and 10 (20%) had progressive disease. The estimated median progression-free survival (PFS) was 8 months. The 1-year and 2-year survival rates were 73% and 55%, respectively. All of the 67 patients were evaluated for toxicity. The treatment was terminated in 2 patients due to allergic-like infusion reaction. Four patients who had acute infusion reaction with shortness of breath and tightness of chest did not terminate the treatment because no such reaction occurred when restarted the infusion. There were 2 patients with G(2) and 3 patients with G(3) hand-foot syndrome, 2 patients had G(4) stomatitis, and 8 patients had G(3) leukopenia. No G(4) leukopenia or cardiotoxicity occurred. The combination of PLD and carboplatin is an active and well-tolerated regimen in the treatment of patients with recurrent epithelial ovarian cancer.

Contrast-media-induced hypersensitivity or allergic/allergic-like reactions? Suggestion for a more appropriate use of the nomenclature

With great interest we read the paper by Lapi et al. [1]. This article focuses on safety aspects of iodinated contrast media (CM) related to their physicochemical properties in an excellently presented form. Therefore, we congratulate the authors for their work. In addition, we have some remarks on the nomenclature concerning the mentioned adverse CM-related reactions. As with many other researchers, including ourselves [2], Lapi et al. [1] uses “allergy-like” established terms. On the other hand, there are now some papers available that designate such reactions as hypersensitivity [3]. Therefore, when reading different papers on CM-induced adverse drug reactions (ADRs), it becomes apparent how inconsistently physicians and scientists use the terms for its designation: allergy-like reaction, allergic-like reaction, nonallergic reaction, pseudoallergic reaction, or anaphylactoid reaction are currently in use [1–5]. This was also clearly pointed out by Lapi et al. [1] that currently there is a “...quite rich terminology used to classify CM-related ADRs.” Most terms used were created more than 40 years ago. Moreover, the confusion is further enhanced by terms that solely describe the time of onset of the adverse reaction, such late CM-related reaction, but also cover allergic and nonallergic manifestations of hypersensitivity reactions. The intention of these descriptions is to refer to the nonallergic nature of CM-related adverse events that have clinical features of allergic ones and/or its onset. As in rare cases true allergic reactions to contrast material may occur [3, 6], the use of terms such as allergic-like anticipate the nonallergic nature (in most instances when such terms occur, the allergic nature of the reaction has not been excluded), and could possibly inhibit scientific progress. Therefore, it may be meaningful to replace such terms by hypersensitivity reaction, which has been suggested by the European Academy of Allergology and Clinical Immunology (EAACI) nomenclature task force for drug-, venom-, and food-induced reactions [7], for example, and it seems reasonable to apply it for pertinent CM-induced reactions as well [3]. This term should be used as an “umbrella” to cover the whole spectrum of possible adverse events, including anaphylaxis with its manifestations (urticaria, angioedema, rhinitis, conjunctivitis, asthma, blood pressure drop, cardiac arrest), eczema/dermatitis, and fixed or exanthematous drug eruptions [7].

Frequency, Outcome, and Appropriateness of Treatment of Nonionic Iodinated Contrast Media Reactions

The objective of our study was to evaluate the frequency, outcome, and appropriateness of treatment of adults with acute allergiclike reactions related to IV-administered nonionic iodinated contrast media. For IV injections of nonionic iodinated contrast media between January 1, 1999, and December 31, 2005, contrast reaction reports and medical records of patients in whom contrast reactions occurred were reviewed. Data collected included patient sex and age, symptoms, reaction manifestations, treatment, and long-term sequelae. The appropriateness and efficacy of patient management were assessed. Allergic-type reactions occurred in 545 (0.6%) of patients injected with nonionic iodinated contrast media: 418 (77%) reactions were mild, 116 (21%) were moderate, and 11 (2%) were severe. Two hundred twenty-one patients (41%) received treatment. The most commonly administered medication was diphenhydramine (145 patients or 27%). Corticosteroids were administered to 17 patients, nebulized albuterol to 16, and epinephrine to 15. Although 99% of the treatments did not result in any complication, three patients may have had short-term sequelae as a result of receiving a nonrecommended treatment. Patients usually do well after developing acute allergiclike reactions to nonionic iodinated contrast media. Fortunately, in our series, this was true even in the rare cases in which the instituted treatment was considered to be inappropriate. Reacting patients rarely develop serious long-term sequelae.

Allergic-like reactions are possible with gadolinium-containing contrast agents despite premedication

Allergic-like reactions are possible with gadolinium-containing contrast agents despite premedication

Allergic-Like Breakthrough Reactions to Gadolinium Contrast Agents After Corticosteroid and Antihistamine Premedication

The objective of our study was to determine the number and severity of allergic-like breakthrough reactions to i.v. gadolinium-containing contrast agents in children and adults after premedication with corticosteroids and antihistamines. Contrast material reaction forms from the department of radiology for pediatric (under 19 years old) and adult patients were reviewed for the time period from January 1, 2001, through December 31, 2006. All documented allergic-like reactions to i.v. gadolinium-containing contrast media after premedication with corticosteroids and antihistamines were identified. Forms were evaluated for reaction manifestations, management, and patient outcome. Our institutional electronic medical record system was accessed for each individual patient to identify pertinent medical history, including demographic information, history of allergic-like reaction to contrast media (gadolinium- or iodine-containing), and additional factors that led to prophylactic premedication. Eight patients experienced nine allergic-like reactions after the i.v. administration of gadolinium-containing contrast media despite premedication. A single patient had two breakthrough reactions. Six breakthrough reactions were mild, and three were moderate. No severe or fatal breakthrough reaction occurred. Eight of nine breakthrough reactions occurred in adults. All patients who experienced breakthrough reactions had a history of allergic-like reaction to either gadolinium- or iodine-containing contrast media. Allergic-like reactions to gadolinium-containing contrast media can occur despite premedication with corticosteroids and antihistamines.

Incidence and Severity of Acute Allergic-Like Reactions to IV Nonionic Iodinated Contrast Material in Children

Incidence and Severity of Acute Allergic-Like Reactions to IV Nonionic Iodinated Contrast Material in Children