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An Ounce of Caution: Superparamagnetic Iron Oxide Nanoparticle Based MRI Contrast Associated Anaphylaxis
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A1254 - An Ounce of Caution: Superparamagnetic Iron Oxide Nanoparticle Based MRI Contrast Associated Anaphylaxis
Author Block: A. Heckman1, K. Sacco2, A. Agarwal3, B. Hiroto1, P. K. Guru3; 1Internal Medicine, Mayo Clinic, Jacksonville, FL, United States, 2Mayo Clinic, Jacksonville, FL, United States, 3Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States.
Introduction
Superparamagnetic iron oxide nanoparticles (SPIONs) based MRI contrast agents are considered to be superior to gadolinium-based agents for diagnosis of active infections. Ferrumoxytol is the only SPIONs approved by the FDA for use in suspected septic arthritis and osteomyelitis identification. We report a rare adverse effect in this increasingly used agent.
Description
An 85-year-old Caucasian male was admitted to the hospital after sustaining a fracture of his left femur. His medical history included paroxysmal atrial fibrillation and diet controlled type 2 diabetes mellitus. He was hemodynamically stable and his laboratory tests showed hemoglobin of 9.9g/dL, leukocytosis 12.3x10(9)/L, and serum creatinine of 2.2mg/dL. He was found to have S.aureus bacteremia with suspected osteomyelitis of the left limb. Antimicrobials were administered and MRI was scheduled. Per MRI protocol, 510 mg intravenous Ferrumoxytol was administered. Twelve minutes later he became unresponsive with a blood pressure 62/30mm Hg, and was found in ventricular fibrillation which subsequently converted to pulseless electric activity. He was managed per ACLS protocol with chest compressions, defibrillation, intravenous amiodarone, and epinephrine. Return of spontaneous circulation was achieved after 15 minutes, and patient was transferred to the intensive care unit. Unfortunately, hypoxic brain injury led to withdrawal of life support per the wishes of his family. The sequence of events in the absence of other obvious causes of arrest led to the suspicion for Ferraheme-induced anaphylaxis.
Discussion
The advantage of Ferrumoxytol, the only available SPIONs as the contrast agent for MRI, is primarily based on phagocytosis by macrophages after intravenous administration. Ferrumoxytol is also approved for the treatment of iron deficiency in patients with renal failure. Both animal and human studies have reported increased sensitivity and specificity of SPIONs over gadolinium for identification of active infection and inflammation within coronary and carotid plaques. The reported adverse reactions related to ferrumoxytol are non-life threatening. While nausea and dizziness are reported on 3.1% and 2.6% of patients respectively, serious hypersensitivity reactions are reported in only 3 out of 1526 patients. Anaphylaxis is a life threatening systemic hypersensitivity to food, insect stings or medications. The diagnosis of anaphylaxis is purely clinical. A positive serum tryptase helps confirm the suspicion, though it is not required for diagnosis. The cornerstone of anaphylaxis management involves removal of the inciting antigen and immediate resuscitative measures including fluids and epinephrine.
Increased awareness for potential life threatening side effects of ferrumoxytol is warranted for immediate recognition and appropriate care.
Author Block: A. Heckman1, K. Sacco2, A. Agarwal3, B. Hiroto1, P. K. Guru3; 1Internal Medicine, Mayo Clinic, Jacksonville, FL, United States, 2Mayo Clinic, Jacksonville, FL, United States, 3Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States.
Introduction
Superparamagnetic iron oxide nanoparticles (SPIONs) based MRI contrast agents are considered to be superior to gadolinium-based agents for diagnosis of active infections. Ferrumoxytol is the only SPIONs approved by the FDA for use in suspected septic arthritis and osteomyelitis identification. We report a rare adverse effect in this increasingly used agent.
Description
An 85-year-old Caucasian male was admitted to the hospital after sustaining a fracture of his left femur. His medical history included paroxysmal atrial fibrillation and diet controlled type 2 diabetes mellitus. He was hemodynamically stable and his laboratory tests showed hemoglobin of 9.9g/dL, leukocytosis 12.3x10(9)/L, and serum creatinine of 2.2mg/dL. He was found to have S.aureus bacteremia with suspected osteomyelitis of the left limb. Antimicrobials were administered and MRI was scheduled. Per MRI protocol, 510 mg intravenous Ferrumoxytol was administered. Twelve minutes later he became unresponsive with a blood pressure 62/30mm Hg, and was found in ventricular fibrillation which subsequently converted to pulseless electric activity. He was managed per ACLS protocol with chest compressions, defibrillation, intravenous amiodarone, and epinephrine. Return of spontaneous circulation was achieved after 15 minutes, and patient was transferred to the intensive care unit. Unfortunately, hypoxic brain injury led to withdrawal of life support per the wishes of his family. The sequence of events in the absence of other obvious causes of arrest led to the suspicion for Ferraheme-induced anaphylaxis.
Discussion
The advantage of Ferrumoxytol, the only available SPIONs as the contrast agent for MRI, is primarily based on phagocytosis by macrophages after intravenous administration. Ferrumoxytol is also approved for the treatment of iron deficiency in patients with renal failure. Both animal and human studies have reported increased sensitivity and specificity of SPIONs over gadolinium for identification of active infection and inflammation within coronary and carotid plaques. The reported adverse reactions related to ferrumoxytol are non-life threatening. While nausea and dizziness are reported on 3.1% and 2.6% of patients respectively, serious hypersensitivity reactions are reported in only 3 out of 1526 patients. Anaphylaxis is a life threatening systemic hypersensitivity to food, insect stings or medications. The diagnosis of anaphylaxis is purely clinical. A positive serum tryptase helps confirm the suspicion, though it is not required for diagnosis. The cornerstone of anaphylaxis management involves removal of the inciting antigen and immediate resuscitative measures including fluids and epinephrine.
Increased awareness for potential life threatening side effects of ferrumoxytol is warranted for immediate recognition and appropriate care.
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