Gadolinium-induced acute respiratory distress syndrome: A rare clinical entity

Lalit Gupta; Prathap T H

doi:10.4103/mamcjms.mamcjms_6_23

CASE REPORT

Year : 2023 | Volume : 9 | Issue : 1 | Page : 61-63

Gadolinium-induced acute respiratory distress syndrome: A rare clinical entity

Lalit Gupta, Prathap T H
Department of Anaesthesiology and Critical Care, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India

Date of Submission	11-Jan-2023
Date of Acceptance	28-Mar-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Prathap T H
Department of Anaesthesiology and Critical Care, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi-110002
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/mamcjms.mamcjms_6_23

Abstract

Gadolinium-based magnetic resonance imaging (MRI) contrast is considered stable and safe compared to iodine-based contrast agents; however, unseen and unexpected complications may occur at any time. We present the case of a 45-year-old patient who was posted for MRI contrast of the abdomen. After a few minutes of contrast injection, the patient was found having shortness of breath, chest pain with nausea, and vomiting. Pulmonary auscultation revealed bilateral fine crepitations, but he did not develop rash or angioedema and was immediately managed with steroids and with supplemental oxygen support. However, he started desaturating and shifted to the nearby emergency department where high-resolution computed tomography (HRCT) was done and showed ground-glass opacities. Coronavirus disease (COVID) swab test was negative and the patient was shifted to intensive care unit (ICU) with the provisional diagnosis of developing acute respiratory distress syndrome (ARDS). He was managed conservatively on bilevel positive airway pressure (BiPAP) and discharged after 10 days with full recovery. There is no specific biomarker for ARDS triggered by MRI contrast, and the clinical presentation is indistinguishable from other causes. Gadolinium contrast-induced ARDS is a rare but potentially life-threatening complication that should be considered in the differential diagnosis of respiratory failure following an MRI contrast injection. It is critical to be aware of this potential complication in order to provide the best outcome for the patient’s management.

Keywords: Gadolinium, Magnetic resonance imaging, Corticosteroids, Acute respiratory distress syndrome

How to cite this article:
Gupta L, T H P. Gadolinium-induced acute respiratory distress syndrome: A rare clinical entity. MAMC J Med Sci 2023;9:61-3

How to cite this URL:
Gupta L, T H P. Gadolinium-induced acute respiratory distress syndrome: A rare clinical entity. MAMC J Med Sci [serial online] 2023 [cited 2023 Jun 6];9:61-3. Available from: https://www.mamcjms.in/text.asp?2023/9/1/61/375336

Introduction

For radiological contrast imaging, newer contrast agents that are gadolinium based are frequently used as they are comparatively safer. The paramagnetic compounds that makeup gadolinium have a large magnetic component and are best stable when they have an unpaired electron, making it a relatively safer alternative to widely used iodine-based contrasts, with a comparatively low frequency of serious adverse events such as dyspnea and hypotension.^[1] The potentially fatal illness known as acute respiratory distress syndrome (ARDS) is characterized by noncompliant lungs and insufficient oxygenation. Gadolinium-induced ARDS has rarely been documented in the past, and the exact mechanism of onset is still unclear.

We present a case that developed ARDS without anaphylactic symptoms after the use of contrast agent and had a successful treatment with steroids and oxygen therapy.

Case Report

A 45-year-old male patient underwent magnetic resonance imaging (MRI) of the lower abdomen with gadolinium contrast medium for persistent lower abdominal pain for 3 months. He had no significant medical history apart from his current illness and was not on any medications.

Shortly after giving MRI contrast, he pressed the emergency alarm bell of MRI machine for difficulty in breathing with chest discomfort and nauseating feeling. The anesthetist available there immediately gave him inj. hydrocortisone 200 mg and further MRI was stopped, and he was put on an oxygen mask with 6 L/min of oxygen. His symptoms did not improve and saturation was fluctuating around 92 to 95% on oxygen. So, he was rushed to a nearby hospital casualty.

Upon admission, his vitals were measured as temperature 36.9°C; blood pressure (BP) of 92/48 mmHg; heart rate (HR) 116/min; labored respiration with the rate of 24 to 26/min; and pulse oximeter showing saturation of around 88 to 90%. On auscultation of the chest, there were bilateral fine crepts. Rest of the physical examination did not reveal any significant findings such as body rashes or apparent angioedema. He was shifted to a nonrebreathing mask (NRBM) at the rate of 10 L/min as his oxygen saturation was not improving. He immediately received 8 mg of dexamethasone and an intravenous (IV) fluid bolus as 1 L of ringer lactate. The treating physician also started with IV ceftriaxone and levofloxacin.

His laboratory reports demonstrated a hemoglobin level of 12.6 g/dL with a slightly raised total leukocyte count (12.1 × 109/L). His C-reactive protein (CRP) was raised (15.6 mg/L, normal: <3 mg/L), and a D-dimer was 1.3 mg/L (normal: <0.5 mg/L). Trop-T was negative, and the echocardiogram was unremarkable with left ventricular ejection fraction (LVEF) of 55%.

High-resolution computed tomography (HRCT) chest performed in hospital casualty showed bilateral multiple confluent fluffy opacities more in the posterior and lateral aspects. There were also some regions of ground-glass opacities in the middle and posterior lobes. His corona virus disease 2019 (COVID-19) test came negative [Figure 1].

Figure 1 High-resolution computed tomography of chest image showing multiple confluent opacities in the posterior and lateral aspects.

Click here to view

After HRCT chest with stable vital signs (BP 129/74 mmHg, HR 102/min, and SpO₂ 92–94% on NRBM), he was shifted to the intensive care unit (ICU) for further workup and management. He was placed on noninvasive bilevel positive airway pressure (BiPAP) ventilation using a facemask in the ICU and started on methylprednisolone 1 mg/kg. The patient significantly improved during the next 24 hours, and NRBM was once more administered in place of BiPAP. The next day, he was shifted from ICU to ward on oxygen through a nasal cannula at a rate of 2 L/min throughout his hospital stay, he stayed afebrile. On day 4, he was sent home with an SpO₂ of 97% on room air. Antibiotics were stopped since the patient recovered quickly from supportive care and there was no clinical sign of infection. Over the course of 10 days following discharge, the corticosteroid dosage was gradually reduced.

Discussion

Contrast usage for diagnostic purposes has significantly increased because of significant advancements in imaging technology. Although, gadolinium-based contrast agents (GBCAs) have lower rates of allergic reactions than the older iodine-based contrast agents,^[2] the danger of renal toxicity has been the major focus of guidelines for their judicious use. Recent researches have strongly suggested that gadolinium can accumulate in tissue even in people with healthy kidneys.^[3],[4] The contrast medium based on GBCAs has been associated with some unfavorable consequences, such as allergic and nonallergic reactions, but they are rarely documented.

There are two types of MRI contrast-related adverse events: nonallergic side effects (headache, nausea, dizziness, vomiting, pain on injection site) and infrequent allergy-like side effects.^[5] Allergic reactions are thought to be equal to or less than those seen with iodinated contrast, with reported rates ranging from 0.004 to 0.7%.^[6] Rarely, severe responses or anaphylaxis-like reactions that could be fatal have been documented to occur between 0.1 and 0.001% of the time.^[7]

Drug-induced acute lung injury might be difficult to diagnose in clinical practice without any temporal association. Due to the lack of a distinguishing biomarker, the clinical picture of ARDS developed in response to MRI contrast cannot be easily recognized. The timing between the administration of the contrast and the beginning of symptoms is the only temporal association regarding the etiology in the absence of any other risk factors. In the literature, there is not much information about ARDS linked to the use of gadolinium contrast media. A clinical picture similar to our case was reported only in a small number of cases where symptoms appeared immediately after contrast administration.^[8],[9] The variable time interval of 10 minutes to 3 hours between the injection of MRI contrast and the onset of symptoms has also been reported in some published data.^[10],[11]

Measurement of tryptase levels, which correlates with severity,^[12] may have helped in the differential diagnosis, but we could not do this in our patient. Our patient, like other such clinical cases, had only supportive treatment in accordance with the clinical condition and quickly recovered clinically, without requiring either invasive respiratory support techniques or vasopressor drugs. Initially considering sepsis as the main cause of ARDS, antibiotics were started as per the recommendations of the Sepsis Bundle, but blood cultures were unfortunately not taken. In our patient, there was a slight increase in CRP and white cell counts in the absence of fever suggesting that there was no pre-existing blood-borne infection leading to current illness. In addition, the lack of an obvious indicator of the sepsis or respiratory failure before contrast administration and the time to onset of symptoms after contrast administration strongly suggest that no pre-existing disease triggered the ARDS-like clinical picture.

Conclusion

Gadolinium contrast-induced ARDS, a rare but potentially life-threatening condition, should be considered as a possible diagnosis of respiratory failure occurring shortly after MRI contrast injection. Supportive care appears to be the cornerstone of these conditions, although no definitive treatment suggestions have been made.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Kodzwa R. Updates to the ACR manual on contrast media. Radiol Technol 2017;89:186–9.
2.	Herborn CU, Honold E, Wolf M et al. Clinical safety and diagnostic value of the gadolinium chelate gadoterate meglumine (Gd-DOTA). Invest Radiol 2007;42:58–62.
3.	Rogosnitzky M, Branch S. Gadolinium-based contrast agent toxicity: a review of known and proposed mechanisms. Biometals 2016;29:365–76.
4.	Blomqvist L, Nordberg GF, Nurchi VM, Aaseth JO. Gadolinium in medical imaging-usefulness, toxic reactions and possible countermeasures-a review. Biomolecules 2022;12:742.
5.	Andreucci M, Solomon R, Tasanarong A. Side effects of radiographic contrast media: pathogenesis, risk factors, and prevention. Biomed Res Int 2014;2014:741018.
6.	Granata V, Cascella M, Fusco R et al. Immediate adverse reactions to gadolinium-based MR contrast media: a retrospective analysis on 10,608 examinations. Biomed Res Int 2016;2016:3918292.
7.	Forsting M, Palkowitsch P. Prevalence of acute adverse reactions to gadobutrol—a highly concentrated macrocyclic gadolinium chelate: review of 14,299 patients from observational trials. Eur J Radiol 2010;74:e186–92.
8.	Gupta N, Davidson J, Li A. Acute respiratory distress syndrome due to gadolinium administration. J Intensive Care Soc 2013;14:159–62.
9.	Demirhan A, Yasar Tekelioglu U, Akkaya A et al. Magnetic resonance imaging contrast agent related pulmonary edema: a case report. Eur Rev Med Pharmacol Sci 2012;16(Suppl 4):110–2.
10.	Nguyen C, Pham T. Non-cardiogenic pulmonary oedema following the use of gadolinium-based contrast medium: a case report. J Crit Care Med (Targu Mures) 2020;6:181–5.
11.	Lucas A, Mohan G, Winkler A, Gardner K, Whalen M. Acute lung injury following gadolinium contrast: a case report. J Emerg Crit Care Med 2021;5:1–6.
12.	Sala-Cunill A, Cardona V, Labrador-Horrillo M et al. Usefulness and limitations of sequential serum tryptase for the diagnosis of anaphylaxis in 102 patients. Int Arch Allergy Immunol 2013;160:192–9.