Diagnostic Radiology
•
•
weeks later showed no obvious abnormality of the lower extremity except for hypopigmentation in the healed areas.
Edmund A. Franken, Jr., M.D. and Jay L. Grosfeld, M.D.
DISCUSSION
Injection of water-soluble contrast medium into a foot vein in a 5-month-old infant was complicated by intense edema and vesicle formation above the site of injection. This was due to local toxic effect of contrast medium entering the lymphatic system with backflow into the skin. The method by which the contrast medium entered the lymphatics could not be determined.
The reaction in this patient was a local toxic effect due to intralymphatic contrast medium. The major channels opacified in the leg have the typical appearance of lymphatic vessels from which water-soluble contrast medium is diffusing, and the smaller channels perpendicular to the skin are characteristic of the tiny lymphatics noted on lymphangiography in dermal backflow (2). Whether the contrast medium entered the lymphatics by partial intralymphatic injection or as a result of preexisting Iymphaticovenous anastomosis cannot be determined. There is no evidence in this case for venous hypertension or other similar abnormalities in the extremity. Water-soluble iodinated contrast medium was used in past years for opacification of the lymphatics but was abandoned because of its tendency to diffuse rapidly from the lymphatic vessels into surrounding tissue, with distortion of anatomical details of the lymphatics (2, 3). Local burning pain due to such a contrast medium in the lymphatics is described (2) and local dermatitis due to oily intralymphatic contrast medium has also been reported (4). A locally intense reactionsuch as reported
Unusual Local Reaction to Iodinated Contrast Medium 1
INDEX TERMS:
Contrast media, toxicity. Urography, complications
Radiology 116:629-630, September 1975
•
•
in infants and children is a relatively safe procedure and major reactions to iodinated contrast medium are infrequently observed (1). This report describes a severe local complication occurring in an infant following intravenous injection of the contrast medium.
E
XCRETORY UROGRAPHY
CASE REPORT A 5-day-old female infant was referred to the James Whitcomb Riley Hospital for Children for an abdominal mass and fever. Physical examination demonstrated abdominal distension, a midline lower abdominal mass, and vaginal atresia. During her initial evaluation excretory urography performed after intravenous injection of 10 ml sodium diatrizoate was unaccompanied by any reaction and showed bilateral hydronephrosis secondary to a pelvic mass. Subsequent laparotomy demonstrated a pyocolpos which was drained transvaginally. Vaginoplasty and cystostomy with placement of a suprapubic catheter were performed. The infant was discharged in satisfactory condition ten days later. At no time during her life was edema or other abnormality of the legs noted. At five months of age, a follow-up excretory urogram was obtained. After blood was aspirated from a vein on the dorsum of the foot, the occluding tourniquet above the ankle was removed and 12 ml of 50 % sodium diatrizoate injected through a 23 gauge needle over approximately two minutes. Prompt calyceal opacification occurred .: Approximately three minutes after the injection the anterior tibial space. began to swell and numerous vesicles appeared. Some of the vesicles promptly ruptured and showed a hemorrhagic dermis beneath (Fig. 1). Ten minutes after the injection a roentgenogram of the involved lower leg was obtained (Fig. 2). This revealed some contrast medium in ill-defined vascular channels anterior to the tibia and in small lymphatic vessels coursing to the skin. There was no contrast medium or skin change at the site of injection. Roentgenographic opacification of the vesicles themselves indicated that contrast medium was entering these areas. The infant was treated with oral prednisone (2.0 mg/kg) for two days and local therapy in the form of Furacin dressings. Local reaction rapidly subsided (within 48 hours) and spontaneous healing by local re-epithelialization followed over a ten-day period. The infant was discharged in satisfactory condition, and examination two
Fig. 1. Photograph of left lower leg. Soft-tissue edema is evident, and numerous vesicles are present on the anterior surface of the leg. Focal dermal hemorrhage is seen in the ruptured vesicle. Fig. 2. Lateral roentgenogram of the left lower leg. There is no contrast medium at the site of injection on the foot. Poorly defined lymphatic channels are opacified anterior to the tibia, as are tiny vessels coursing perpendicularly to the involved skin.
1 From the Departments of Radiology and Surgery, Indiana University School of Medicine, Indianapolis, Ind. Accepted for publication in dk March 1 9 7 5 . ·
629
630
EDMUND
A. FRANKEN,
here must be a rare event, but has been noted by others (5). Treatment of such a complication with short-term adrenocorticosteroids to minimize the inflammatory response to the intralymphatic contrast medium and local care similar to that administered for a second degree burn are advised.
REFERENCES 1. Baker DH, Berdon WE: The use and safety of "high" dosage in pediatric urography. A survey of the Society for Pediatric Radiology. Radiology 103:371-373, May 1972
JR. AND JAY
L. GROSFELD
September 1975
2. Kuisk H: Technique of Lymphography and Principles of Interpretation. St. Louis, Warren H. Green, 1971 3. Fischer HW, Zimmerman GR: Roentgenographic visualization of lymph nodes and lymphatic channels. Am J Roentgenol 81: 517-534, Mar 1959 4. Redman HC: Dermatitis as a complication of lymphangiography. Radiology 86:323-326, Feb 1966 5. Altman DH: Personal communication. Annual meeting, Society of Pediatric Radiology, San Francisco, Calif., 22 Sep 1974
1100 W. Michigan St. Indianapolis, Ind. 46202
•
•
weeks later showed no obvious abnormality of the lower extremity except for hypopigmentation in the healed areas.
Edmund A. Franken, Jr., M.D. and Jay L. Grosfeld, M.D.
DISCUSSION
Injection of water-soluble contrast medium into a foot vein in a 5-month-old infant was complicated by intense edema and vesicle formation above the site of injection. This was due to local toxic effect of contrast medium entering the lymphatic system with backflow into the skin. The method by which the contrast medium entered the lymphatics could not be determined.
The reaction in this patient was a local toxic effect due to intralymphatic contrast medium. The major channels opacified in the leg have the typical appearance of lymphatic vessels from which water-soluble contrast medium is diffusing, and the smaller channels perpendicular to the skin are characteristic of the tiny lymphatics noted on lymphangiography in dermal backflow (2). Whether the contrast medium entered the lymphatics by partial intralymphatic injection or as a result of preexisting Iymphaticovenous anastomosis cannot be determined. There is no evidence in this case for venous hypertension or other similar abnormalities in the extremity. Water-soluble iodinated contrast medium was used in past years for opacification of the lymphatics but was abandoned because of its tendency to diffuse rapidly from the lymphatic vessels into surrounding tissue, with distortion of anatomical details of the lymphatics (2, 3). Local burning pain due to such a contrast medium in the lymphatics is described (2) and local dermatitis due to oily intralymphatic contrast medium has also been reported (4). A locally intense reactionsuch as reported
Unusual Local Reaction to Iodinated Contrast Medium 1
INDEX TERMS:
Contrast media, toxicity. Urography, complications
Radiology 116:629-630, September 1975
•
•
in infants and children is a relatively safe procedure and major reactions to iodinated contrast medium are infrequently observed (1). This report describes a severe local complication occurring in an infant following intravenous injection of the contrast medium.
E
XCRETORY UROGRAPHY
CASE REPORT A 5-day-old female infant was referred to the James Whitcomb Riley Hospital for Children for an abdominal mass and fever. Physical examination demonstrated abdominal distension, a midline lower abdominal mass, and vaginal atresia. During her initial evaluation excretory urography performed after intravenous injection of 10 ml sodium diatrizoate was unaccompanied by any reaction and showed bilateral hydronephrosis secondary to a pelvic mass. Subsequent laparotomy demonstrated a pyocolpos which was drained transvaginally. Vaginoplasty and cystostomy with placement of a suprapubic catheter were performed. The infant was discharged in satisfactory condition ten days later. At no time during her life was edema or other abnormality of the legs noted. At five months of age, a follow-up excretory urogram was obtained. After blood was aspirated from a vein on the dorsum of the foot, the occluding tourniquet above the ankle was removed and 12 ml of 50 % sodium diatrizoate injected through a 23 gauge needle over approximately two minutes. Prompt calyceal opacification occurred .: Approximately three minutes after the injection the anterior tibial space. began to swell and numerous vesicles appeared. Some of the vesicles promptly ruptured and showed a hemorrhagic dermis beneath (Fig. 1). Ten minutes after the injection a roentgenogram of the involved lower leg was obtained (Fig. 2). This revealed some contrast medium in ill-defined vascular channels anterior to the tibia and in small lymphatic vessels coursing to the skin. There was no contrast medium or skin change at the site of injection. Roentgenographic opacification of the vesicles themselves indicated that contrast medium was entering these areas. The infant was treated with oral prednisone (2.0 mg/kg) for two days and local therapy in the form of Furacin dressings. Local reaction rapidly subsided (within 48 hours) and spontaneous healing by local re-epithelialization followed over a ten-day period. The infant was discharged in satisfactory condition, and examination two
Fig. 1. Photograph of left lower leg. Soft-tissue edema is evident, and numerous vesicles are present on the anterior surface of the leg. Focal dermal hemorrhage is seen in the ruptured vesicle. Fig. 2. Lateral roentgenogram of the left lower leg. There is no contrast medium at the site of injection on the foot. Poorly defined lymphatic channels are opacified anterior to the tibia, as are tiny vessels coursing perpendicularly to the involved skin.
1 From the Departments of Radiology and Surgery, Indiana University School of Medicine, Indianapolis, Ind. Accepted for publication in dk March 1 9 7 5 . ·
629
630
EDMUND
A. FRANKEN,
here must be a rare event, but has been noted by others (5). Treatment of such a complication with short-term adrenocorticosteroids to minimize the inflammatory response to the intralymphatic contrast medium and local care similar to that administered for a second degree burn are advised.
REFERENCES 1. Baker DH, Berdon WE: The use and safety of "high" dosage in pediatric urography. A survey of the Society for Pediatric Radiology. Radiology 103:371-373, May 1972
JR. AND JAY
L. GROSFELD
September 1975
2. Kuisk H: Technique of Lymphography and Principles of Interpretation. St. Louis, Warren H. Green, 1971 3. Fischer HW, Zimmerman GR: Roentgenographic visualization of lymph nodes and lymphatic channels. Am J Roentgenol 81: 517-534, Mar 1959 4. Redman HC: Dermatitis as a complication of lymphangiography. Radiology 86:323-326, Feb 1966 5. Altman DH: Personal communication. Annual meeting, Society of Pediatric Radiology, San Francisco, Calif., 22 Sep 1974
1100 W. Michigan St. Indianapolis, Ind. 46202
