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Anaphylactoid reaction after retrograde pyelography despite preoperative steroid preparation
CASE REPORT
ANAPHYLACTOID REACTION AFTER RETROGRADE PYELOGRAPHY DESPITE PREOPERATIVE STEROID PREPARATION PATRICK A. ARMSTRONG, JOSEPH F. PAZONA, and ANTHONY J. SCHAEFFER
ABSTRACT A 19-year-old woman with a known allergy to iodinated contrast presented with intermittent, gross hematuria of 2 years’ duration. The patient was scheduled to undergo cystoscopy with bilateral retrograde pyelography, because this is considered a safe alternative to intravenous pyelography or computed tomography. Because of her contrast allergy, the patient completed a 13-hour steroid preparation before the procedure. However, within minutes of extubation, she developed an anaphylactoid reaction and, despite appropriate management, required reintubation and subsequent transfer to the intensive care unit. The patient was subsequently extubated 8 hours later and recovered completely. UROLOGY 66: 880.e1–880.e2, 2005. © 2005 Elsevier Inc.
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he incidence of anaphylactoid reactions after the administration of iodinated contrast for retrograde pyelography (RPG) and cystography is not well known. In the hope of preventing an anaphylactoid reaction in patients with a known iodinated contrast allergy, some clinicians administer a preoperative steroid preparation before RPG, despite an unknown efficacy. We report a patient who developed an anaphylactoid reaction requiring reintubation after RPG despite use of a preoperative steroid preparation. CASE REPORT A 19-year-old woman with a known allergy to iodinated contrast presented with intermittent, gross hematuria of 2 years’ duration. During a prior intravenous urogram at an outside institution, she had become dyspneic and developed a urticarial rash; however, she improved with medical management and did not require intubation. The patient was scheduled to undergo cystoscopy with bilateral RPG. Because of her contrast allergy, she completed a steroid preparation consisting of 50
From the Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Address for correspondence: Anthony J. Schaeffer, M.D., Department of Urology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Tarry 16-703, Chicago, IL 60611-3008. E-mail: [email protected] Submitted: August 23, 2004, accepted (with revisions): March 22, 2005 © 2005 ELSEVIER INC. ALL RIGHTS RESERVED
mg prednisone at 13, 7, and 1 hour before surgery and 50 mg of Benadryl 1 hour before surgery. Immediately before the procedure, she received antimicrobial prophylaxis with vancomycin and gentamicin and was induced for intubation with midazolam, fentanyl, propofol, and succinylcholine. Cystoscopy revealed hypervascular areas of the posterior bladder wall that were subsequently biopsied and fulgurated. Adequate hemostasis was attained. Before the bladder biopsies, bilateral RPGs were performed using 2.5 mL of a 50% iohexol/50% normal saline solution injected, under low pressure, into each ureter. Fluoroscopic imaging revealed normal anatomy with prompt drainage of contrast on delayed images. No evidence of pyelosinus or pyelolymphatic backflow was found. The patient was stable throughout the procedure, but after extubation, a urticarial rash developed on her chest and face. Within 5 minutes, she became dyspneic and on chest auscultation had wheezing and decreased aeration bilaterally. The patient was treated with diphenhydramine, methylprednisolone, intravenous epinephrine, racemic epinephrine nebulizers, and an albuterol metered dose inhaler; however, she remained dyspneic. She eventually required reintubation for impending respiratory failure. During this time, her blood pressure was stable, and she did not become hypotensive. After observation in the intensive care unit for 8 hours, she was successfully extubated and subsequently did well. 0090-4295/05/$30.00 doi:10.1016/j.urology.2005.03.047 880.e1
COMMENT Anaphylactoid reactions to intravenous contrast are relatively common, causing many clinicians to consider retrograde pyelography as a safe alternative to intravenous urography or computed tomography for visualizing the collecting system. Only 6 case reports have documented anaphylactoid reactions during RPG, and 2 of these cases were reported as part of a retrospective review of 783 voiding cystourethrograms and RPGs, for an estimated incidence of 0.26%.1,2 Although the results of this retrospective review by Weese et al. have indicated that reactions to RPG are certainly more common than the few case reports would suggest, the true incidence is likely lower than 0.26%. This is because the aforementioned review used high-osmolar contrast, which, at least during intravenous use, has been associated with a fourfold increased risk of reactions.3 The etiology of these reactions has not yet been elucidated, but could be attributed to systemic absorption through the urothelium, primarily in the renal pelvis.4 On the basis of this theory of systemic absorption, patients with a history of adverse reactions to contrast are often given steroid and diphenhydramine premedication before RPG. This practice has been studied for reactions to intravenous contrast and has been shown to reduce, but not eliminate, the risk of an anaphylactoid reaction. Approximately 10% of the patients still had an adverse reaction even after the steroid preparation, considered a “breakthrough reaction.”5 This case represents the first reported anaphylactoid reaction during RPG for which the patient had been given steroid premedication. Given the
880.e2
knowledge that anaphylactoid reactions could occur in up to 1 in 400 RPGs and that steroid premedication is not universally protective, it is likely that such reactions are more prevalent than our single case report would indicate. Exactly how prevalent is difficult to determine, because one could argue that breakthrough reactions would be less common for RPG than the 10% reported in patients receiving intravenous contrast,5 because the intravenous concentration achieved during RPG is only a fraction of that achieved with direct intravenous or intraarterial injection. On the basis of the body of published data that exists, it is clear that anaphylactoid reactions to RPGs are likely more prevalent than is commonly thought. It is, therefore, prudent to provide premedication to patients with a history of, or who are at risk of, adverse reactions to contrast. Finally, as this case and the available reports clearly demonstrate, adverse reactions can still occur, despite premedication, and it is important for all clinicians to be vigilant and react appropriately when they do. REFERENCES 1. Johenning PW: Reactions to contrast material during retrograde pyelography. Urology 16: 442– 444, 1980. 2. Weese DL, Greenberg HM, and Zimmern PE: Contrast media reactions during voiding cystourethrography or retrograde pyelography. Urology 41: 81– 84, 1993. 3. Lieberman P: Anaphylactoid reactions to radiocontrast material. Ann Allergy 67: 91–100, 1991. 4. Castellino RA, and Marshall MH: The urinary mucosal barrier in retrograde pyelography: experimental findings and clinical implications. Radiology 95: 403– 409, 1970. 5. Freed KS, Leder RA, Alexander C, et al: Breakthrough adverse reactions to low-osmolar contrast media after steroid premedication. AJR Am J Roentgenol 176: 1389 –1392, 2001.
UROLOGY 66 (4), 2005
ANAPHYLACTOID REACTION AFTER RETROGRADE PYELOGRAPHY DESPITE PREOPERATIVE STEROID PREPARATION PATRICK A. ARMSTRONG, JOSEPH F. PAZONA, and ANTHONY J. SCHAEFFER
ABSTRACT A 19-year-old woman with a known allergy to iodinated contrast presented with intermittent, gross hematuria of 2 years’ duration. The patient was scheduled to undergo cystoscopy with bilateral retrograde pyelography, because this is considered a safe alternative to intravenous pyelography or computed tomography. Because of her contrast allergy, the patient completed a 13-hour steroid preparation before the procedure. However, within minutes of extubation, she developed an anaphylactoid reaction and, despite appropriate management, required reintubation and subsequent transfer to the intensive care unit. The patient was subsequently extubated 8 hours later and recovered completely. UROLOGY 66: 880.e1–880.e2, 2005. © 2005 Elsevier Inc.
T
he incidence of anaphylactoid reactions after the administration of iodinated contrast for retrograde pyelography (RPG) and cystography is not well known. In the hope of preventing an anaphylactoid reaction in patients with a known iodinated contrast allergy, some clinicians administer a preoperative steroid preparation before RPG, despite an unknown efficacy. We report a patient who developed an anaphylactoid reaction requiring reintubation after RPG despite use of a preoperative steroid preparation. CASE REPORT A 19-year-old woman with a known allergy to iodinated contrast presented with intermittent, gross hematuria of 2 years’ duration. During a prior intravenous urogram at an outside institution, she had become dyspneic and developed a urticarial rash; however, she improved with medical management and did not require intubation. The patient was scheduled to undergo cystoscopy with bilateral RPG. Because of her contrast allergy, she completed a steroid preparation consisting of 50
From the Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Address for correspondence: Anthony J. Schaeffer, M.D., Department of Urology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Tarry 16-703, Chicago, IL 60611-3008. E-mail: [email protected] Submitted: August 23, 2004, accepted (with revisions): March 22, 2005 © 2005 ELSEVIER INC. ALL RIGHTS RESERVED
mg prednisone at 13, 7, and 1 hour before surgery and 50 mg of Benadryl 1 hour before surgery. Immediately before the procedure, she received antimicrobial prophylaxis with vancomycin and gentamicin and was induced for intubation with midazolam, fentanyl, propofol, and succinylcholine. Cystoscopy revealed hypervascular areas of the posterior bladder wall that were subsequently biopsied and fulgurated. Adequate hemostasis was attained. Before the bladder biopsies, bilateral RPGs were performed using 2.5 mL of a 50% iohexol/50% normal saline solution injected, under low pressure, into each ureter. Fluoroscopic imaging revealed normal anatomy with prompt drainage of contrast on delayed images. No evidence of pyelosinus or pyelolymphatic backflow was found. The patient was stable throughout the procedure, but after extubation, a urticarial rash developed on her chest and face. Within 5 minutes, she became dyspneic and on chest auscultation had wheezing and decreased aeration bilaterally. The patient was treated with diphenhydramine, methylprednisolone, intravenous epinephrine, racemic epinephrine nebulizers, and an albuterol metered dose inhaler; however, she remained dyspneic. She eventually required reintubation for impending respiratory failure. During this time, her blood pressure was stable, and she did not become hypotensive. After observation in the intensive care unit for 8 hours, she was successfully extubated and subsequently did well. 0090-4295/05/$30.00 doi:10.1016/j.urology.2005.03.047 880.e1
COMMENT Anaphylactoid reactions to intravenous contrast are relatively common, causing many clinicians to consider retrograde pyelography as a safe alternative to intravenous urography or computed tomography for visualizing the collecting system. Only 6 case reports have documented anaphylactoid reactions during RPG, and 2 of these cases were reported as part of a retrospective review of 783 voiding cystourethrograms and RPGs, for an estimated incidence of 0.26%.1,2 Although the results of this retrospective review by Weese et al. have indicated that reactions to RPG are certainly more common than the few case reports would suggest, the true incidence is likely lower than 0.26%. This is because the aforementioned review used high-osmolar contrast, which, at least during intravenous use, has been associated with a fourfold increased risk of reactions.3 The etiology of these reactions has not yet been elucidated, but could be attributed to systemic absorption through the urothelium, primarily in the renal pelvis.4 On the basis of this theory of systemic absorption, patients with a history of adverse reactions to contrast are often given steroid and diphenhydramine premedication before RPG. This practice has been studied for reactions to intravenous contrast and has been shown to reduce, but not eliminate, the risk of an anaphylactoid reaction. Approximately 10% of the patients still had an adverse reaction even after the steroid preparation, considered a “breakthrough reaction.”5 This case represents the first reported anaphylactoid reaction during RPG for which the patient had been given steroid premedication. Given the
880.e2
knowledge that anaphylactoid reactions could occur in up to 1 in 400 RPGs and that steroid premedication is not universally protective, it is likely that such reactions are more prevalent than our single case report would indicate. Exactly how prevalent is difficult to determine, because one could argue that breakthrough reactions would be less common for RPG than the 10% reported in patients receiving intravenous contrast,5 because the intravenous concentration achieved during RPG is only a fraction of that achieved with direct intravenous or intraarterial injection. On the basis of the body of published data that exists, it is clear that anaphylactoid reactions to RPGs are likely more prevalent than is commonly thought. It is, therefore, prudent to provide premedication to patients with a history of, or who are at risk of, adverse reactions to contrast. Finally, as this case and the available reports clearly demonstrate, adverse reactions can still occur, despite premedication, and it is important for all clinicians to be vigilant and react appropriately when they do. REFERENCES 1. Johenning PW: Reactions to contrast material during retrograde pyelography. Urology 16: 442– 444, 1980. 2. Weese DL, Greenberg HM, and Zimmern PE: Contrast media reactions during voiding cystourethrography or retrograde pyelography. Urology 41: 81– 84, 1993. 3. Lieberman P: Anaphylactoid reactions to radiocontrast material. Ann Allergy 67: 91–100, 1991. 4. Castellino RA, and Marshall MH: The urinary mucosal barrier in retrograde pyelography: experimental findings and clinical implications. Radiology 95: 403– 409, 1970. 5. Freed KS, Leder RA, Alexander C, et al: Breakthrough adverse reactions to low-osmolar contrast media after steroid premedication. AJR Am J Roentgenol 176: 1389 –1392, 2001.
UROLOGY 66 (4), 2005