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Sullivan CM, Paul NS, Rieder MJ. Bridging the gap between bench and clinic: the importance of understanding the mechanism of iodinated contrast media hypersensitivity. Br J Radiol 2023; 96:20220494. [PMID: 36395475 PMCID: PMC10997019 DOI: 10.1259/bjr.20220494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/28/2022] [Accepted: 11/09/2022] [Indexed: 11/18/2022] Open
Abstract
Since the advent of CT, iodinated contract media (ICM) has become one of the most regularly administered intravenous medications in clinical settings. Although considered generally safe, ICM is one of the most common causes of adverse drug reactions in clinical practice, accounting for more than 2 million adverse reactions worldwide. Currently, there are few useful tools to diagnose patient hypersensitivity, with the major limitation being the lack of consensus regarding the mechanisms of hypersensitivity to ICM. While there is an overwhelming abundance of literature pertaining to clinical features including incidence, symptomatology, and risk, few studies have further investigated the underlying mechanisms behind their clinical observations. Of the available literature discussing pathophysiology, most primary studies were completed over 20 years ago, since which the molecular characteristics of ICM have changed. Furthermore, many reviews mentioning pathophysiology fail to adequately emphasize the clinical importance of understanding the molecular pathways involved in hypersensitivity. In this review, we aim to emphasize the clinical relevance of pathophysiology as it relates to the prediction and diagnosis of hypersensitivity reactions to ICM. To this end, we will first briefly characterize hypersensitivity reactions to ICM with respect to epidemiology and clinical presentation. We will then present the existing evidence supporting various proposed mechanisms of hypersensitivity, highlighting the gaps that remain in the mechanistic delineation of both immediate and delayed reactions. Finally, we discuss the possibility of in vitro testing as a way to predict and diagnose hypersensitivity reactions, pending a more complete elucidation of mechanisms.
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Affiliation(s)
- Caitlin M Sullivan
- Undergraduate Medicine, Schulich School of Medicine and
Dentistry, University of Western Ontario, London, ON,
Canada
| | - Narinder S Paul
- Undergraduate Medicine, Schulich School of Medicine and
Dentistry, University of Western Ontario, London, ON,
Canada
| | - Michael J Rieder
- Undergraduate Medicine, Schulich School of Medicine and
Dentistry, University of Western Ontario, London, ON,
Canada
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Torres MJ, Trautmann A, Böhm I, Scherer K, Barbaud A, Bavbek S, Bonadonna P, Cernadas JR, Chiriac AM, Gaeta F, Gimenez‐Arnau AM, Kang H, Moreno E, Brockow K. Practice parameters for diagnosing and managing iodinated contrast media hypersensitivity. Allergy 2021; 76:1325-1339. [PMID: 33170954 DOI: 10.1111/all.14656] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/30/2020] [Accepted: 10/14/2020] [Indexed: 12/17/2022]
Abstract
Immediate and nonimmediate hypersensitivity reactions to iodinated contrast media (ICM) have been reported to occur in a frequency of about 0.5%-3% of patients receiving nonionic ICM. The diagnosis and management of these patients vary among guidelines published by various national and international scientific societies, with recommendations ranging from avoidance or premedication to drug provocation test. This position paper aims to give recommendations for the management of patients with ICM hypersensitivity reactions and analyze controversies in this area. Skin tests are recommended as the initial step for diagnosing patients with immediate and nonimmediate hypersensitivity reactions; besides, they may also help guide on tolerability of alternatives. Re-exposition or drug provocation test should only be done with skin test-negative ICMs. The decision for performing either re-exposition or drug provocation test needs to be taken based on a risk-benefit analysis. The role of in vitro tests for diagnosis and pretreatment for preventing reactions remains controversial.
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Affiliation(s)
- María José Torres
- Allergy Unit Regional University Hospital of Malaga‐IBIMA‐UMA‐ARADyAL Malaga Spain
| | - Axel Trautmann
- Department of Dermatology and Allergy University Hospital Würzburg Würzburg Germany
| | - Ingrid Böhm
- Department of Diagnostic, Interventional, and Pediatric Radiology Inselspital University of Bern Bern Switzerland
| | | | - Annick Barbaud
- Service de Dermatologie et Allergologie Sorbonne Université INSERM Institut Pierre Louis d’Epidemiologie et de Sante Publique AP‐HP Sorbonne Universite, Hopital Tenon Paris France
| | - Sevim Bavbek
- Department of Chest Disease Division of Immunology and Allergy School of Medicine Ankara University Ankara Turkey
| | | | | | - Anca Mirela Chiriac
- Department of Pulmonology Division of Allergy Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
| | - Francesco Gaeta
- Allergy Unit Columbus Hospital Agostino Gemelli IRCCS University Hospital Rome Italy
| | - Ana M. Gimenez‐Arnau
- Department of Dermatology Hospital del Mar IMIM Universitat Autònoma Barcelona Barcelona Spain
| | - Hye‐Ryun Kang
- Department of Internal Medicine Division of Allergy and Clinical Immunology Seoul National University College of Medicine Seoul Korea
| | - Esther Moreno
- Allergy Unit University Hospital of Salamanca‐IBSAL‐UMA‐ARADyAL Salamanca Spain
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein School of Medicine Technical University of Munich Munich Germany
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Abstract
Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose The current evidence regarding iodine-containing compounds and iodine allergy cross-reactivity is reviewed. Summary Iodine is an essential human nutrient found in the thyroid gland. It is used in the synthesis of the thyroid hormones thyroxine and triiodothyroxine. Patients who report having adverse reactions to iodine-containing substances are often labelled as having an “iodine allergy,” which can result in delays in care or patients being denied essential ICM or other iodine-containing drugs. A literature review was conducted to evaluate the evidence regarding iodine allergy and iodine-containing drugs. Of 435 articles considered potentially appropriate for full review (plus 12 additional articles included on the basis of references from the eligible articles), 113 could not be obtained. After exclusion of 353 articles that did not meet all inclusion criteria, the remaining 81 articles were included in the review. The results of the literature review indicated that iodine has not been shown to be the allergen responsible for allergic reactions to iodinated contrast media, amiodarone, povidone-iodine, and other iodine-containing compounds. Conclusion There is a lack of evidence to support cross-reactivity between iodine-containing compounds in so called iodine-allergic individuals.
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Affiliation(s)
| | - John Schmitz
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Amy Choi
- Stanson Health, Charlotte, NC, USA
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Kim MH, Lee SY, Lee SE, Kim MY, Jo EJ, Park CM, Lee W, Cho SH, Kang HR. Clinical features of delayed contrast media hypersensitivity. ALLERGY ASTHMA & RESPIRATORY DISEASE 2014. [DOI: 10.4168/aard.2014.2.5.352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Min-Hye Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Suh-Young Lee
- Department of Internal Medicine, Institute of Allergy and Clinical Immunology, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Eun Lee
- Department of Internal Medicine, Institute of Allergy and Clinical Immunology, Seoul National University College of Medicine, Seoul, Korea
| | - Mi-Yeong Kim
- Department of Internal Medicine, Institute of Allergy and Clinical Immunology, Seoul National University College of Medicine, Seoul, Korea
| | - Eun-Jung Jo
- Department of Internal Medicine, Institute of Allergy and Clinical Immunology, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Min Park
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Whal Lee
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Heon Cho
- Department of Internal Medicine, Institute of Allergy and Clinical Immunology, Seoul National University College of Medicine, Seoul, Korea
| | - Hye-Ryun Kang
- Department of Internal Medicine, Institute of Allergy and Clinical Immunology, Seoul National University College of Medicine, Seoul, Korea
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Bircher AJ, Brockow K, Grosber M, Hofmeier KS. Late elicitation of maculopapular exanthemas to iodinated contrast media after first exposure. Ann Allergy Asthma Immunol 2013; 111:576-7. [PMID: 24267376 DOI: 10.1016/j.anai.2013.09.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Revised: 09/13/2013] [Accepted: 09/28/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Andreas J Bircher
- Allergy Unit, Dermatology Clinic, University Hospital Basel, Basel, Switzerland.
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Nonimmediate hypersensitivity reactions to iodinated contrast media. Curr Opin Allergy Clin Immunol 2013; 13:345-53. [DOI: 10.1097/aci.0b013e328362b926] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Scherer K, Brockow K, Aberer W, Gooi JHC, Demoly P, Romano A, Schnyder B, Whitaker P, Cernadas JSR, Bircher AJ. Desensitization in delayed drug hypersensitivity reactions -- an EAACI position paper of the Drug Allergy Interest Group. Allergy 2013; 68:844-52. [PMID: 23745779 DOI: 10.1111/all.12161] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2013] [Indexed: 01/15/2023]
Abstract
Drug hypersensitivity may deprive patients of drug therapy, and occasionally no effective alternative treatment is available. Successful desensitization has been well documented in delayed drug hypersensitivity reactions. In certain situations, such as sulfonamide hypersensitivity in HIV-positive patients or hypersensitivity to antibiotics in patients with cystic fibrosis, published success rates reach 80%, and this procedure appears helpful for the patient management. A state of clinical tolerance may be achieved by the administration of increasing doses of the previously offending drug. However, in most cases, a pre-existent sensitization has not been proven by positive skin tests. Successful re-administration may have occurred in nonsensitized patients. A better understanding of the underlying mechanisms of desensitization is needed. Currently, desensitization in delayed hypersensitivity reactions is restricted to mild, uncomplicated exanthems and fixed drug eruptions. The published success rates vary depending on clinical manifestations, drugs, and applied protocols. Slower protocols tend to be more effective than rush protocols; however, underreporting of unsuccessful procedures is very probable. The decision to desensitize a patient must always be made on an individual basis, balancing risks and benefits. This paper reviews the literature and presents the expert experience of the Drug Hypersensitivity Interest Group of the European Academy of Allergy and Clinical Immunology.
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Affiliation(s)
- K. Scherer
- Allergy Unit; Department of Dermatology; University Hospital Basel; Basel; Switzerland
| | - K. Brockow
- Division Environmental Dermatology and Allergology Helmholtz Zentrum Munich/TUM; Department of Dermatology and Allergology Biederstein; Technical University Munich; Munich; Germany
| | - W. Aberer
- Department of Dermatology; University of Graz; Graz; Austria
| | - J. H. C. Gooi
- Regional Adult Cystic Fibrosis Unit; St James's Hospital; Leeds; UK
| | - P. Demoly
- Allergy Department; INSERM U657; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier Cedex 5; France
| | | | - B. Schnyder
- Division of Allergology; Inselspital; University of Bern; Bern; Switzerland
| | - P. Whitaker
- Regional Adult Cystic Fibrosis Unit; St James's Hospital; Leeds; UK
| | - J. S. R. Cernadas
- Department of Allergy and Clinical Immunology; H. S. João; Medical University; Porto; Portugal
| | - A. J. Bircher
- Allergy Unit; Department of Dermatology; University Hospital Basel; Basel; Switzerland
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Moneret-Vautrin DA, Codreanu F, Drouet M, Plaud B, Karila C, Valfrey J, Debaene B, Malinovsky JM, Mertes JM. [Allergologic screening and management of patients with previous self-reported hypersensitivity reactions. Société française d'anesthésie et réanimation. Société française d'allergologie]. ACTA ACUST UNITED AC 2011; 30:246-63. [PMID: 21397445 DOI: 10.1016/j.annfar.2011.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- D-A Moneret-Vautrin
- Service de médecine interne, immunologie clinique et allergologie, hôpital central, avenue du Maréchal de-Lattre-de-Tassigny, Nancy cedex, France.
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Late adverse reactions to intravascular iodine based contrast media: an update. Eur Radiol 2011; 21:2305-10. [DOI: 10.1007/s00330-011-2200-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 05/18/2011] [Accepted: 05/27/2011] [Indexed: 12/11/2022]
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Scherer K, Harr T, Bach S, Bircher AJ. The role of iodine in hypersensitivity reactions to radio contrast media. Clin Exp Allergy 2010; 40:468-75. [PMID: 20210815 DOI: 10.1111/j.1365-2222.2009.03361.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Hypersensitivity reactions to iodinated radio contrast media (RCM) are either immediate-type (IT) or delayed reactions (DT). In IT, the pathomechanism is unclear. In DT, delayed positive patch (PT) and intradermal tests (IDT) and RCM-specific T cells suggest a T cell-mediated mechanism. In both, the role of iodine has not been clarified; however, patients are often labelled as 'iodine allergic'. Occasionally, positive skin tests to iodine-containing drugs are observed. OBJECTIVE We investigated the presence of hypersensitivity to iodine in patients with a history of hypersensitivity reactions to RCM. METHODS Nineteen patients with a history of IT (n=9) or DT (n=10) to RCM were investigated. Skin prick tests, IDT and PT with several RCM and iodine formulations were carried out. All underwent oral provocation with Lugol's solution (LS). Two patients each with iodine mumps, contact dermatitis to iodized antiseptics and chronic idiopathic urticaria served as control or proof of concept. RESULTS In the IT group, skin tests were positive in three out of nine patients to one RCM. One patient with negative skin tests reacted twice to oral iodine with urticaria. In the DT group, sensitization to one or several RCM was identified in 10 out of 10 patients. In seven out of 10 patients, additional sensitizations to the iodine formulations were found. Two patients developed a mild exanthema after oral provocation with LS. CONCLUSION We have previously demonstrated in patients with iodine mumps that an oral challenge with LS is a valid means to elicit hypersensitivity reactions to iodine. In 19 patients, we showed that iodine is rarely the eliciting agent in hypersensitivity reactions to RCM. Only one patient with a late urticaria to an RCM with a late urticaria to LS and two patients with DT and broad sensitization to all RCM tested reacted to LS with an exanthema. In most cases, more likely the RCM molecules and not iodine are the eliciting compounds.
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Affiliation(s)
- K Scherer
- Allergy Unit, Department of Dermatology, University Hospital Basel, Basel, Switzerland
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12
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Keller M, Lerch M, Britschgi M, Tâche V, Gerber BO, Lüthi M, Lochmatter P, Kanny G, Bircher AJ, Christiansen C, Pichler WJ. Processing-dependent and -independent pathways for recognition of iodinated contrast media by specific human T cells. Clin Exp Allergy 2009; 40:257-68. [PMID: 20030663 DOI: 10.1111/j.1365-2222.2009.03425.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND One to three percent of patients exposed to intravenously injected iodinated contrast media (CM) develop delayed hypersensitivity reactions. Positive patch test reactions, immunohistological findings, and CM-specific proliferation of T cells in vitro suggest a pathogenetic role for T cells. We have previously demonstrated that CM-specific T cell clones (TCCs) show a broad range of cross-reactivity to different CM. However, the mechanism of specific CM recognition by T cell receptors (TCRs) has not been analysed so far. OBJECTIVE To determine how T cells specifically recognize CM. METHODS CM-specific TCCs were generated from human blood of three CM-allergic patients and a specific TCR was transfected into a mouse T cell hybridoma. Functional analysis such as proliferation assays, IL-2 secretion assays, and calcium influx experiments were performed using irradiated, glutaraldehyde-fixed, CM-pre-incubated, human leucocyte antigen (HLA)-DR-matched or -mismatched antigen-presenting cells (APCs), and HLA-blocking antibodies. RESULTS We identified two mechanisms of T cell stimulation: some TCCs and the transfectant reacted to CM independent of uptake by APCs because proliferation/IL-2 secretion occurred in the presence of glutaraldehyde-fixed APCs, and intracellular calcium increased within seconds after drug addition. Other TCCs required functional APCs, compatible with uptake and presentation of CM on MHC-class II molecules, as implied by three findings: (1) glutaraldehyde fixation of APCs abrogated presentation; (2) CM could not be washed away from CM-pre-incubated APCs; and (3) the optimal pulsing time was 10-20 h. Because allogeneic, MHC-matched, CM-pulsed APCs could induce proliferative responses as well, the ability of CM uptake and presentation is not unique to APCs from patients with CM-induced delayed hypersensitivity. CONCLUSION Our data suggest that CM may be stimulatory for T cells either by direct binding to the MHC-TCR complex or by binding after uptake and processing by APCs. This questions the assumed inert nature of CM.
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Affiliation(s)
- M Keller
- Adverse Drug Reactions - Analysis and Consulting (ADR-AC) GmbH, Bern, Switzerland
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Khachman D, Gandia P, Sallerin F, Mailly N. [Immediate and delayed hypersensitivity reactions to iodinated radiographic contrast agents: an update]. Therapie 2009; 64:331-9. [PMID: 19863909 DOI: 10.2515/therapie/2009040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Diagnostic and interventional radiology of patients is nowadays crucial with increasing requirement for iodinated contrast agents infusion. Besides adverse reactions after administration of the iodinated contrast agents due to their toxicity, immediate hypersensitivity reactions and reactions resembling delayed hypersensitivity appearing from 1 hour to several days later, have been reported. Patients at high risk to develop such adverse events have to be detected on the basis of their risk factors in order to prevent or limit serious outcomes. Previous reactions to contrast media, asthma, atopy and cardiovascular disorders are risk factors for anaphylactic or anaphylactoid reactions. Female gender, age and beta-blockers increase the severity. This article aims to summarize the risk of allergic reactions related to the use of iodinated contrast agents and to suggest a way for diagnosis, treatment and prevention according to each clinical situation.
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Affiliation(s)
- Dalia Khachman
- Laboratoire de Pharmacocinétique et Toxicologie Clinique, Hôpital Purpan, Institut Fédératif de Biologie, Toulouse, France
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Seitz CS, Pfeuffer P, Raith P, Bröcker EB, Trautmann A. Radiocontrast media-associated exanthema: Identification of cross-reactivity and tolerability by allergologic testing. Eur J Radiol 2009; 72:167-71. [DOI: 10.1016/j.ejrad.2008.06.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Accepted: 06/04/2008] [Indexed: 12/11/2022]
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Brockow K. Immediate and Delayed Reactions to Radiocontrast Media: Is There an Allergic Mechanism? Immunol Allergy Clin North Am 2009; 29:453-68. [DOI: 10.1016/j.iac.2009.04.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Ilan Gottlieb
- Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287, USA
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Torres MJ, Mayorga C, Cornejo-Garcia JA, Lopez S, Chaves P, Rondon C, Fernandez T, Blanca M. Monitoring non-immediate allergic reactions to iodine contrast media. Clin Exp Immunol 2008; 152:233-8. [PMID: 18341616 DOI: 10.1111/j.1365-2249.2008.03627.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Non-immediate reactions to iodine contrast media (ICM) affect 2-5% of patients receiving these agents. We studied the immunological mechanisms involved in patients with a confirmed non-immediate reaction, maculopapular exanthema, after administration of ICM. The diagnosis was carried out by skin testing or drug provocation test. The immunological study was performed in sequential peripheral blood mononuclear cells taken from the onset of the reaction by flow cytometry and in skin biopsy by immunohistochemistry, with specific recognition by the lymphocyte transformation test (LTT) with different ICM. Flow cytometry showed an increase in the different activation markers [CD69, CD25 and human leucocyte antigen D-related (HLA-DR)] and the skin homing receptor [cutaneous lymphocyte-associated antigen (CLA)] in CD4 lymphocytes, whereas perforin was higher in the CD8 lymphocytes. The skin biopsy showed a perivascular mononuclear infiltrate composed of CD4 lymphocytes, expressing CD25, HLA-DR and CLA, with eosinophils. Intradermal skin tests and the LTT were positive to several ICM, including the culprit agent in four and three patients, respectively, with negative results in all 10 tolerant controls. We showed that a specific immunological mechanism was implicated in patients with non-immediate reactions to ICM. Moreover, the positive results in skin tests and lymphocyte proliferation tests indicated that an important cross-reactivity exists.
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Affiliation(s)
- M J Torres
- Allergy Service, Carlos Haya Hospital, Malaga, Spain
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19
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Gilgen-Anner Y, Heim M, Ledermann HP, Bircher AJ. Iodide mumps after contrast media imaging: a rare adverse effect to iodine. Ann Allergy Asthma Immunol 2007; 99:93-8. [PMID: 17650837 DOI: 10.1016/s1081-1206(10)60628-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Exposure to iodinated contrast media may elicit a variety of adverse reactions. Anaphylactoid and delayed cell-mediated unwanted effects are common; rare adverse reactions include iodine-related sialadenopathy, iododerma, and acneiform eruptions. OBJECTIVES To describe the occurrence of iodide mumps in a patient examined using contrast-enhanced computed tomography and to outline differential diagnoses. METHODS A detailed diagnostic approach, including histologic analysis, skin tests, controlled reexposure, efficacy of premedication, and imaging studies, is presented. The findings unique to this reaction and differential diagnoses are highlighted. RESULTS While undergoing repeated contrast-enhanced computed tomography a patient developed recurrent swellings of the sublingual glands, identified as iodide mumps. These swellings resolved within a few days. Imaging studies and histologic analysis showed distinct patterns without inflammation. The important role of iodine in this adverse reaction is demonstrated. CONCLUSIONS Iodine from iodinated contrast media may rarely elicit noninflammatory edema of the salivary glands. The reaction should be differentiated from other swellings in the head and neck area.
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Lerch M, Keller M, Britschgi M, Kanny G, Tache V, Schmid DA, Beeler A, Gerber BO, Luethi M, Bircher AJ, Christiansen C, Pichler WJ. Cross-reactivity patterns of T cells specific for iodinated contrast media. J Allergy Clin Immunol 2007; 119:1529-36. [PMID: 17412404 DOI: 10.1016/j.jaci.2007.02.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2006] [Revised: 02/09/2007] [Accepted: 02/09/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Approximately 3% of patients exposed to iodinated contrast media develop delayed hypersensitivity reactions. OBJECTIVE We wanted to better understand the molecular basis of contrast media cross-reactivity. METHODS Cross-reactivity was assessed by skin testing and measurement of T-cell activation (CD69 upregulation) and proliferation ((3)H-thymidine uptake, 5,6-carboxyfluorescein diacetate succinimidyl ester staining) of PBMCs, T-cell lines, and T-cell clones of 2 patients with delayed hypersensitivity reactions to iohexol and iomeprol, respectively. Thirteen different contrast media and potassium iodide were compared. RESULTS Skin testing and analyses of PBMCs, T-cell lines, and clones showed broad cross-reactivity in both patients. Broad as well as more restricted cross-reactivity patterns were found in iohexol-specific and iomeprol-specific CD4(+) T-cell clones, whereas 1 iomeprol-specific CD8(+) T-cell clone showed no cross-reactivity at all. The reactivity to equimolar concentrations of iohexol and its dimer iodixanol was very similar, suggesting that the dimer was not more stimulatory than its monomer. Consistently low reactivity to iobitridol was found in both patients, but never to iodide. A frequency analysis of contrast medium-specific peripheral T cells gave values between 0.6 % (iomeprol) and 0.05 % (iobitridol). CONCLUSION Clinically observed cross-reactivity between different contrast media is a result of the presence of contrast media-specific T cells, some of which show a broad cross-reactivity pattern. Iodide ions, known to be present at low concentration in contrast media solutions, do not seem to be the causative moiety. CLINICAL IMPLICATIONS Detailed in vitro analysis might help identify noncross-reactive contrast media.
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Affiliation(s)
- Marianne Lerch
- Clinic for Rheumatology and Clinical Immunology/Allergology, Inselspital, University of Bern, Bern, Switzerland
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Immediate and non-immediate reaction after non-ionic X-ray contrast medium injection: Case report and review of the literature. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.ejrex.2006.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Arnold AW, Hausermann P, Bach S, Bircher AJ. Recurrent Flexural Exanthema (SDRIFE or Baboon Syndrome) after Administration of Two Different Iodinated Radio Contrast Media. Dermatology 2006; 214:89-93. [PMID: 17191055 DOI: 10.1159/000096920] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 03/27/2006] [Indexed: 12/31/2022] Open
Abstract
In 1984, the baboon syndrome was described as a particular form of systemic contact dermatitis that occurred after the administration of a contact allergen in individuals previously sensitized by topical exposure to the same allergen. Its clinical picture presents as an erythema of the buttocks and upper inner thighs resembling the red bottom of baboons. This specific reaction was originally observed with mercury, nickel and ampicillin. Since then over 100 cases have been described, most of them without known prior sensitization to the causative agent. In 2004, our group proposed the acronym SDRIFE specifically for cases associated with systemic drugs; it stands for symmetrical drug-related intertriginous and flexural exanthema, as a distinct reaction pattern related to systemic drugs. Here we describe a case of SDRIFE after administration of the iodinated radio contrast medium (RCM) iomeprol (Iomeron), accidentally reproduced by the RCM iopromide (Ultravist). Positive delayed skin tests with both drugs were observed indicating that the pathomechanism of SDRIFE is likely a cell-mediated type IV allergy. Oral potassium iodide and a skin-test-negative RCM were administered and both tolerated, indicating that the antigen is related to the molecules and not to iodine itself. Therefore, in our case skin tests had a good positive and negative predictive value.
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Affiliation(s)
- A W Arnold
- Allergy Unit, Department of Dermatology, University Hospital Basel, Basel, Switzerland
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23
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Böhm I, Schild HH. A practical guide to diagnose lesser-known immediate and delayed contrast media-induced adverse cutaneous reactions. Eur Radiol 2006; 16:1570-9. [PMID: 16770655 DOI: 10.1007/s00330-006-0202-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2005] [Revised: 01/11/2006] [Accepted: 02/07/2006] [Indexed: 10/24/2022]
Abstract
The terms "immediate" and "delayed" adverse reactions induced by contrast media (CM) refer to the reactions' onset but do not provide substantial information concerning the clinical manifestation, the potential risk factors, the treatment modalities, or prevention. Because a variety of different reactions caused by different pathophysiological mechanisms may arise immediately or be delayed after CM injection, and because these need different management, the aim of the present paper is to present the clinical features and to exactly characterize lesser-known cutaneous reactions. A thorough knowledge of the clinical features, their adequate treatment, and, possibly, the subsequent diagnostic procedure for preventing recurrence after reexposure to CM would improve patient management.
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Affiliation(s)
- Ingrid Böhm
- Department of Radiology, University of Bonn, Sigmund-Freud Strasse 25, 53105, Bonn, Germany.
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24
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Garza A, Waldman AJ, Mamel J. A case of toxic epidermal necrolysis with involvement of the GI tract after systemic contrast agent application at cardiac catheterization. Gastrointest Endosc 2005; 62:638-42. [PMID: 16185990 DOI: 10.1016/j.gie.2005.06.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Accepted: 06/29/2005] [Indexed: 02/08/2023]
Affiliation(s)
- Austin Garza
- Department of Digestive Diseases and Nutrition, Department of Cardiology, University of South Florida, Tampa, Florida 33612, USA
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25
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Idée JM, Pinès E, Prigent P, Corot C. Allergy-like reactions to iodinated contrast agents. A critical analysis. Fundam Clin Pharmacol 2005; 19:263-81. [PMID: 15910651 DOI: 10.1111/j.1472-8206.2005.00326.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Allergy-like reactions may occur following administration of iodinated contrast media (CM), mostly in at-risk patients (patients with history of previous reaction, history of allergy, co-treated with interleukin-2 or beta-blockers, etc.) but remain generally unpredictable. Severe and fatal reactions are very rare events. All categories of CM may induce such reactions, although first generation (high osmolar CM) have been found to induce a higher rate of adverse events than low osmolar CM. However, no differences were found between the two categories of CM with respect to mortality. Delayed reactions can also occur. There are no differences between the various categories of CM except for non-ionic dimers, which are more likely to induce such effect. Numerous clinical studies have evaluated the prophylactic value of drugs (mostly antihistamines and corticosteroids). Results are unclear and highly variable. Any prevention depends upon the mechanism involved. However, the mechanism of CM-induced allergy-like reaction remains disputed. Relatively recent data revived the hypothesis of a type-I hypersensitivity mechanism. Positive skin tests to CM have been reported. However, the affinity of IgE towards CM has been found to be very low in the only study which actually evaluated it. Other pathophysiological mechanisms (involving direct secretory effects on mast cells or basophils, or activation of the complement system associated or not with the plasma contact system) are also much debated. Anaphylaxis and anaphylactoid reactions are, in the end, clinically undistinguishable.
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Affiliation(s)
- Jean-Marc Idée
- Guerbet, Research Division BP57400 Roissy-Charles de Gaulle Cedex, France.
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26
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Romano A, Guéant-Rodriguez RM, Viola M, Gaeta F, Caruso C, Guéant JL. Cross-reactivity among drugs: clinical problems. Toxicology 2005; 209:169-79. [PMID: 15767031 DOI: 10.1016/j.tox.2004.12.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cross-reactivity among drugs is either mediated by immunologic mechanisms or not. The former kind is usually explained by the presence of common antigenic determinants in the cross-reacting drugs. In the case of compounds provoking non-allergic hypersensitivity reactions, cross-reactivity is explained by a common pharmacological characteristic, such as the inhibitory effect of non-steroidal anti-inflammatory drugs on cyclooxygenase-1 and the capability of muscle relaxants or contrast media to release histamine through a non-immunologic mechanism. The main clinical problem deriving from cross-reactivity among drugs is the compelling need to choose a potentially cross-reactive compound and, therefore, to assess cross-reactivity by diagnostic tests. In choosing alternative compounds, skin testing has been used in evaluating IgE-mediated cross-reactivity between penicillins and cephalosporins, as well as among muscle relaxants. In assessing T cell-mediated cross-reactivity among contrast media, corticosteroids, anticonvulsants and heparins, delayed-reading intradermal tests and patch tests, together with lymphocyte transformation tests, can be performed. Because of the limited sensitivity of in vivo and in vitro testing, the most prudent way of establishing the tolerability of a compound of the same group in patients who especially require one is a graded challenge when other allergologic tests are negative.
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Affiliation(s)
- Antonino Romano
- Department of Internal Medicine and Geriatrics, UCSC-Allergy Unit, Unità di Allergologia, Complesso Integrato Columbus, Via G. Moscati 31, 00168 Rome, Italy.
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27
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Brockow K, Christiansen C, Kanny G, Clément O, Barbaud A, Bircher A, Dewachter P, Guéant JL, Rodriguez Guéant RM, Mouton-Faivre C, Ring J, Romano A, Sainte-Laudy J, Demoly P, Pichler WJ. Management of hypersensitivity reactions to iodinated contrast media. Allergy 2005; 60:150-8. [PMID: 15647034 DOI: 10.1111/j.1398-9995.2005.00745.x] [Citation(s) in RCA: 205] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
There has been a remarkable progress in our understanding of the pathophysiology of hypersensitivity to contrast media (CM). Immediate reactions develop within one hour after application of CM under the clinical picture of anaphylaxis. Pruritic exanthems appearing several days afterwards account for the majority of non-immediate reactions. Current evidence indicates an allergic basis of severe immediate as well as of non-immediate reactions involving CM-reactive IgE-antibodies and T-lymphocytes, respectively. Skin tests are helpful to establish the diagnosis of these reactions. The use of skin tests to predict tolerability of CM in patients with previous hypersensitivity reaction to CM is controversial. The value of cellular in-vitro tests is unknown. In patients with previous hypersensitivity to CM, premedication with antihistamins and/or corticosteroids is recommended, but current premedication protocols do not suppress all repeat reactions. European multicenter studies addressing sensitivity, specificity and predictive value of test procedures as well as prophylaxis and risk factors of CM hypersensitivity are currently ongoing.
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Affiliation(s)
- K Brockow
- Klinik und Poliklinik für Dermatologie und Allergologie Biederstein und Zentrum für Allergie und Umwelt GSF/TUM, Technische Universität München.
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Vernassiere C, Trechot P, Commun N, Schmutz JL, Barbaud A. Low negative predictive value of skin tests in investigating delayed reactions to radio-contrast media. Contact Dermatitis 2004; 50:359-66. [PMID: 15274727 DOI: 10.1111/j.0105-1873.2004.00367.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Delayed reactions to radio-contrast media (RCM) with positive skin tests are rare. We report the study of a series of 15 patients who presented delayed reactions to RCM, with an analysis of the clinical features and the results of standardized drug skin tests. Patch tests were performed with RCM and iodized antiseptics (IAs). If negative, prick tests were performed, followed by intradermal tests (IDTs), then intravenous administration under hospital surveillance. The main clinical features were maculopapular rashes or a macular rubella-like rashes. Patch tests were positive with RCM in 2 of 15 cases and with IAs in 4 of 15 cases. All the prick tests were negative. IDTs were positive at 24 h in 8 of 15 cases. 5 of 12 patients had a non-severe relapse of the rash upon receiving an RCM despite clearly negative skin tests with the readministered RCM. Visipaque cross-reacted with Iopamiron, Iomeron, Telebrix, Omnipaque, Xenetix and Hexabrix. Omnipaque cross-reacted with Hexabrix and Iopamiron. IDTs with delayed readings are of better value than patch tests in such patients. The readministration of RCM with negative IDTs must be performed with progressive amounts under hospital surveillance. Cross-reactions between various classes of RCM are frequent. The responsible epitopes are unknown. Iodine itself could be involved.
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Affiliation(s)
- C Vernassiere
- Department of Dermatology, Fournier Hospital, Nancy, France
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Szebeni J. Hypersensitivity reactions to radiocontrast media: the role of complement activation. Curr Allergy Asthma Rep 2004; 4:25-30. [PMID: 14680617 DOI: 10.1007/s11882-004-0038-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although intravenous use of radiocontrast media (RCM) for a variety of radiographic procedures is generally safe, clinically significant acute hypersensitivity reactions still occur in a significant percentage of patients. The mechanism of these anaphylactoid, or "pseudoallergic," reactions is complex, involving complement activation, direct degranulation of mast cells and basophils, and modulation of enzymes and proteolytic cascades in plasma. In this review, basic information on different RCMs and their reactogenicity is summarized and updated, and the prevalence, pathomechanism, prediction, prevention, treatment, and economic impact of hypersensitivity reactions are discussed. Particular attention is paid to the in vitro and in vivo evidence supporting complement activation as an underlying cause of RCM reactions.
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Affiliation(s)
- Janos Szebeni
- Department of Membrane Biochemistry, Walter Reed Army Institute of Research, 501 Robert Grant Avenue, Silver Spring, MD 20910, USA.
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Laffitte E, Nenadov Beck M, Hofer M, Hohl D, Panizzon RG. Severe Stevens-Johnson syndrome induced by contrast medium iopentol (ImagopaqueR). Br J Dermatol 2004; 150:376-8. [PMID: 14996121 DOI: 10.1111/j.1365-2133.2003.05763.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Romano A, Artesani MC, Andriolo M, Viola M, Pettinato R, Vecchioli-Scaldazza A. Effective prophylactic protocol in delayed hypersensitivity to contrast media: report of a case involving lymphocyte transformation studies with different compounds. Radiology 2002; 225:466-70. [PMID: 12409581 DOI: 10.1148/radiol.2251011654] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A patient with maculopapular reactions to iopamidol needed to undergo angiography for a cerebral arteriovenous malformation. In vivo and in vitro tests were performed with ionic and nonionic contrast media, including iopamidol and iobitridol. All results were positive, demonstrating delayed hypersensitivity. The patient received 6-alpha-methylprednisolone and cyclosporine 1 week before and 2 weeks after four angiograms were obtained with the use of iobitridol, which was well tolerated.
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Affiliation(s)
- Antonino Romano
- Department of Internal Medicine and Geriatrics, Universita' Cattolica del Sacro Cuore, Allergy Unit, Complesso Integrato Columbus, Via G. Moscati 31, 00168 Rome, Italy.
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Abstract
PURPOSE OF REVIEW The purpose of the present review is to describe recent insight into the pathomechanism of the late-onset allergy-like reactions which affect 2-3% of contrast medium-exposed patients, and to give advice regarding prophylactic measures to avoid recurrence of such reactions. RECENT FINDINGS It is well recognized that the majority of contrast media-induced late-onset reactions are cutaneous reactions of the maculopapular, urticarial and angioedema types, with occasional occurrence of more serious, bullous eruptions. Recent findings strongly indicate that these reactions are T cell-mediated. The current evidences for this concept are the described clinical symptoms; the high incidence of reactions in interleukin-2-treated patients; the positive results from skin, provocation and lymphocyte transformation testing of affected patients; and the histopathology of skin eruptions and positive skin test sites. SUMMARY On the basis of this new knowledge, several prophylactic measures are proposed to avoid repeat reactions in patients with previous late-onset contrast medium reactions. All persons receiving contrast media should be informed that transient skin reactions may develop up to 7 days after contrast medium exposure. Those who experience such reactions should be advised to see an allergist for diagnosis of the reaction. Skin testing with a panel of different contrast media appears to be useful for confirming the presence of an allergic reaction and for identifying alternative contrast media that can be safely used. For undiagnosed persons, a contrast medium that is structurally different from the product that precipitated the reaction should be chosen if re-exposure to contrast media is required. Pretreatment with corticosteroids may also be tried, although its protective effect has not been systematically studied.
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Affiliation(s)
- Cath Christiansen
- Research and Development, Amersham Health, PO Box 4220, Nydalen, 0401 Oslo, Norway.
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Affiliation(s)
- Sachiko T Cochran
- Department of Radiological Sciences, UCLA School of Medicine, Los Angeles, CA 90095-1721, USA
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Sedano E, Vega JM, Rebollo S, Callejo A, Asensio T, Almendros R. Delayed exanthema to nonionic contrast medium. Allergy 2001; 56:1015-6. [PMID: 11576087 DOI: 10.1034/j.1398-9995.2001.00250.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- E Sedano
- C/ Cervantes 22, 8th D, 47005 Valladolid, Spain
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Moneret-Vautrin DA, Kanny G, Morisset M, Beaudouin E, Renaudin JM. [Anaphylactoid reactions and late skin reactions to iodinated contrast media: present state of the question--idea development]. Rev Med Interne 2001; 22:969-77. [PMID: 11695320 DOI: 10.1016/s0248-8663(01)00455-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE Adverse reactions to iodinated contrast media (ICM) share various mechanisms. Anaphylactoid reactions are among the most serious reactions when they are characterized by the elevation of seric tryptase. Pretreatment with corticosteroids and anti-H1 or the use of non-ionic contrast media do not prevent anaphylaxis. Late skin reactions could be mostly related to delayed hypersensitivity. Previous reactions to contrast media, cardiovascular disorders, beta-blockers, asthma, and atopy are risk factors. Female gender and age increase the severity. CURRENT KNOWLEDGE AND KEY POINTS Anaphylaxis can be demonstrated by intradermal tests and the identification of specific IgEs. Delayed hypersensitivity is shown by the results of epicutaneous tests and the immunohistology of the skin. FUTURE PROSPECTS AND PROJECTS Allergologic tests are advised in the case of previous reactions. In case of emergency, gadopentetate dimeglumine can be alternatively used. The other risk factors lead to the combination of pretreatment and use of non-ionic monomeric contrast media. Immediate hypersensitivity to iodinated media might increase in the near future with the use of divalent molecules.
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Affiliation(s)
- D A Moneret-Vautrin
- Service de médecine interne, immunologie clinique et allergologie, hôpital Central, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France.
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38
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Stellato C, Adkinson NF. Pathophysiology of contrast media anaphylactoid reactions: new perspectives on an old problem. Allergy 1998; 53:1111-3. [PMID: 9930585 DOI: 10.1111/j.1398-9995.1998.tb03829.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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