BRIEF CLINICAL trent with the acauired immunadeficiencv svndrome. Arch Intern Med’1988; 148: 1608-10. ~ ’ 7. Bailey RO, Turok DI, Jaufmann BP, Singh JK. Myositis and acquired immunadeficiency syndrome. Hum Pathol 1987: 18: 749-51. 6. Derkash RS. Makley JT. Isolated tuberculosisof the triceps muscle. J Bone Joint Surg [Am] 1979; 61: 948. Submitted
February
15, 1990, and accepted March 21. 1990
ANAPHYLACTIC REACTION TO BARIUM ENEMA Although barium sulfate used in gastrointestinal radiography is considered to be an inert material, allergic reactions including anaphylaxis have previously been reported [l-7]. We report a case of anaphylaxis during barium-enema radiography of the colon, and discuss the possible predisposing factors for this uncommon and potentially lethal reaction [6]. A 51-year-old woman complained of lower abdominal pain and intermittent hematochezia for 3 weeks. Her past history included allergic rhinitis and prior allergic reaction to sulfa antibiotics. She had undergone upper-gastrointestinal barium radiography 18 years previously for evaluation of dyspepsia, with no adverse reaction. The patient’s family history included eight close relatives with cancer, five of whom had gastrointestinal malignancies. None of her family members were known to have had any reaction to barium contrast radiography. A barium enema was performed. The ingredients in this barium mixture include barium sulfate, sodium benzoate, potassium sorbate, citric acid, sodium saccharin, ethyl maltol, vegetable gum, sorbitol, simethicone, and natural and artificial flavors. No other medications were given. After 5 to 10 minutes, the patient developed nausea, shortness of breath, diaphoresis, and then shock. She was resuscitated with epinephrine injection and intravenous fluids, corticosteroids,
dopamine, and diphenhydramine. After resuscitation, physical examination showed lethargy, moderate respiratory distress, periorbital facial edema, and urticarial rash and wheezing. The barium enema showed a carcinoma of the sigmoid colon. One week later the patient underwent left hemicolectomy for an ulcerating adenocarcinoma of the colon with local lymph node involvement. Her postoperative course was uneventful. Subsequently, after giving informed consent, the patient underwent skin-prick testing with sodium benzoate, potassium sorbate, and diluted liquid barium suspension. No cutaneous hypersensitivity was detected. The patient declined to have further provocation testing. Allergic reactions, including anaphylaxis, to barium radiography have been previously reported [l71 and are estimated to occur in one patient per 750,000 examinations [2]. These reactions have been attributed to additives in the barium sulfate suspension [l-3] or to other medications such as glucagon, anticholinergic agents, or rectal lubricants given at the time of the procedure [4,5,8]. Our patient’s severe anaphylactic reaction about 5 to 10 minutes after the start of the barium enema could have been an IgE-mediated hypersensitivity reaction to one of the barium sulfate suspension constituents. The presence of an ulcerated carcinoma in the sigmoid-descending-colon area with recent bleeding may have permitted increased absorption of the contrast material into the circulation. Our patient also had a history of allergic rhinitis and medication allergy and a history of prior sensitizing exposure to barium radiographic contrast material. Authors of other reports of severe allergic reactions including anaphylaxis with barium enema have noted this history in their patients [1,4,6,8]. Our patient probably has a family cancer syndrome, and several other family members have had barium-enema
August
1990
The American
OBSERVATIONS
radiography of the gastrointestinal tract without known allergic reaction, suggesting that inherited predisposition may not be a factor in this type of reaction. No skin test reaction was detected with diluted sodium benzoate, potassium sorbate, and whole liquid barium sulfate suspension. Although we are unable to specifically incriminate any one of the agents used in this preparation, we suspect that benzoate, saccharin, or the vegetable gum is the most likely cause because allergic reactions to these agents have previously been reported. This patient’s severe reaction to barium may have been partly attributable to three factors: first, her history of atopy and prior medication allergy; second, a prior sensitizing exposure to barium sulfate suspension; and third, possible increased absorption of allergens into the bloodstream through the recently bleeding ulcerated carcinoma in her sigmoid colon. RIAD AL-MUDALLAL, M.D. HARVEY ROSENBAUM, M.D. HOWARD J. SCHWARTZ, M.D. JAMES M. BOYLE, M.D. Saint Luke’s Hospit;, Case Western
Reserve University School of Medicine Cleveland, Ohio
1. Schwartz EE. Glick SN. Fog@ MB, et a/. Hypersensitivity reaction after barium enema examination. Am J Roentgen01 1984: 143: 10334. 2. Larsen C. Allergic side-effects following radiographic investigation with banum sulphate suspension. Ugeskr Laeger 1981; 143: 937-8. 3. Javors BR. Applbaum Y, Gerard P. Severe allergtc reaction: an unusual complication of barium enema. Gastrointest Radio1 1984: 9: 357-8. 4. Gelfand D. Sowers J. DePonte KA. et al. Anaphylacbc and allergic reactions during double contrast studres: is glucagon or barium suspension the allergen? Am J Roentgenol 1985; 144: 405-6. 5. Thomas AMK. Kubie AM, Britt RP. Acute angroneuratic edema following a barium meal. Br J Radral 1986: 59: 1055-6. 6. Feczko PJ, Simms SM, Bakirci N. Fatal hypersensitivity reaction during a barium enema. Am J Roentgenol 1989; 153: 275-6. 7. Janower ML. Hypersensitivity reactions after barium studies of the upper and lower gastrointestinal tract. Radiology 1986; 161: 139-40. 8. Jones SA. Anaphylaxis from rectal lubricant jelly (brief clinical observation). Am J Med 1988; 85: 890. Submitted
Journal
November
29, 1989, and accepted in revised form March 26, 1990
of Medicine
Volume
89
251
February
15, 1990, and accepted March 21. 1990
ANAPHYLACTIC REACTION TO BARIUM ENEMA Although barium sulfate used in gastrointestinal radiography is considered to be an inert material, allergic reactions including anaphylaxis have previously been reported [l-7]. We report a case of anaphylaxis during barium-enema radiography of the colon, and discuss the possible predisposing factors for this uncommon and potentially lethal reaction [6]. A 51-year-old woman complained of lower abdominal pain and intermittent hematochezia for 3 weeks. Her past history included allergic rhinitis and prior allergic reaction to sulfa antibiotics. She had undergone upper-gastrointestinal barium radiography 18 years previously for evaluation of dyspepsia, with no adverse reaction. The patient’s family history included eight close relatives with cancer, five of whom had gastrointestinal malignancies. None of her family members were known to have had any reaction to barium contrast radiography. A barium enema was performed. The ingredients in this barium mixture include barium sulfate, sodium benzoate, potassium sorbate, citric acid, sodium saccharin, ethyl maltol, vegetable gum, sorbitol, simethicone, and natural and artificial flavors. No other medications were given. After 5 to 10 minutes, the patient developed nausea, shortness of breath, diaphoresis, and then shock. She was resuscitated with epinephrine injection and intravenous fluids, corticosteroids,
dopamine, and diphenhydramine. After resuscitation, physical examination showed lethargy, moderate respiratory distress, periorbital facial edema, and urticarial rash and wheezing. The barium enema showed a carcinoma of the sigmoid colon. One week later the patient underwent left hemicolectomy for an ulcerating adenocarcinoma of the colon with local lymph node involvement. Her postoperative course was uneventful. Subsequently, after giving informed consent, the patient underwent skin-prick testing with sodium benzoate, potassium sorbate, and diluted liquid barium suspension. No cutaneous hypersensitivity was detected. The patient declined to have further provocation testing. Allergic reactions, including anaphylaxis, to barium radiography have been previously reported [l71 and are estimated to occur in one patient per 750,000 examinations [2]. These reactions have been attributed to additives in the barium sulfate suspension [l-3] or to other medications such as glucagon, anticholinergic agents, or rectal lubricants given at the time of the procedure [4,5,8]. Our patient’s severe anaphylactic reaction about 5 to 10 minutes after the start of the barium enema could have been an IgE-mediated hypersensitivity reaction to one of the barium sulfate suspension constituents. The presence of an ulcerated carcinoma in the sigmoid-descending-colon area with recent bleeding may have permitted increased absorption of the contrast material into the circulation. Our patient also had a history of allergic rhinitis and medication allergy and a history of prior sensitizing exposure to barium radiographic contrast material. Authors of other reports of severe allergic reactions including anaphylaxis with barium enema have noted this history in their patients [1,4,6,8]. Our patient probably has a family cancer syndrome, and several other family members have had barium-enema
August
1990
The American
OBSERVATIONS
radiography of the gastrointestinal tract without known allergic reaction, suggesting that inherited predisposition may not be a factor in this type of reaction. No skin test reaction was detected with diluted sodium benzoate, potassium sorbate, and whole liquid barium sulfate suspension. Although we are unable to specifically incriminate any one of the agents used in this preparation, we suspect that benzoate, saccharin, or the vegetable gum is the most likely cause because allergic reactions to these agents have previously been reported. This patient’s severe reaction to barium may have been partly attributable to three factors: first, her history of atopy and prior medication allergy; second, a prior sensitizing exposure to barium sulfate suspension; and third, possible increased absorption of allergens into the bloodstream through the recently bleeding ulcerated carcinoma in her sigmoid colon. RIAD AL-MUDALLAL, M.D. HARVEY ROSENBAUM, M.D. HOWARD J. SCHWARTZ, M.D. JAMES M. BOYLE, M.D. Saint Luke’s Hospit;, Case Western
Reserve University School of Medicine Cleveland, Ohio
1. Schwartz EE. Glick SN. Fog@ MB, et a/. Hypersensitivity reaction after barium enema examination. Am J Roentgen01 1984: 143: 10334. 2. Larsen C. Allergic side-effects following radiographic investigation with banum sulphate suspension. Ugeskr Laeger 1981; 143: 937-8. 3. Javors BR. Applbaum Y, Gerard P. Severe allergtc reaction: an unusual complication of barium enema. Gastrointest Radio1 1984: 9: 357-8. 4. Gelfand D. Sowers J. DePonte KA. et al. Anaphylacbc and allergic reactions during double contrast studres: is glucagon or barium suspension the allergen? Am J Roentgenol 1985; 144: 405-6. 5. Thomas AMK. Kubie AM, Britt RP. Acute angroneuratic edema following a barium meal. Br J Radral 1986: 59: 1055-6. 6. Feczko PJ, Simms SM, Bakirci N. Fatal hypersensitivity reaction during a barium enema. Am J Roentgenol 1989; 153: 275-6. 7. Janower ML. Hypersensitivity reactions after barium studies of the upper and lower gastrointestinal tract. Radiology 1986; 161: 139-40. 8. Jones SA. Anaphylaxis from rectal lubricant jelly (brief clinical observation). Am J Med 1988; 85: 890. Submitted
Journal
November
29, 1989, and accepted in revised form March 26, 1990
of Medicine
Volume
89
251
