Anaphylaxis to Gadobenate Dimeglumine (Multihance®): A Case Report

Abstract

Background: Gadolinium chelates are relatively safe contrast media used in MRI. Immediate severe adverse effects are exceptionally rare and mostly concern mild anaphylactoid reactions. We report a case of anaphylaxis to gadobenate dimeglumine (Gd-BOPTA, Multihance®), a gadolinium-based contrast agent. Methods: A 32-year-old female patient with a personal history of multiple sclerosis, while undergoing an MRI scan, developed bronchospasm and acute urticaria with diffuse giant pruritic plaques in the first minute of Gd-BOPTA infusion. The procedure was cancelled and acute treatment of the reaction took place. The patient reported 2 additional MRI scans with definite use of unknown contrast media in the past 2 years without any adverse effect. Blood samples were obtained 2 and 48 h after the reaction for measurement of serum tryptase concentration (Pharmacia Diagnostics, Uppsala, Sweden). Skin prick tests and intradermal tests were performed using 1:1,000, 1:100 and 1:10 dilution of the offending agent and alternative gadolinium-based agents [gadodiamide (Omniscan®) and gadoteric acid (Dotarem®)]. A group of 10 nonatopic individuals who underwent the same skin testing comprised the control group. Results: Tryptase concentration was highly elevated 2 h after the reaction (21 µg/l) compared with that at 48 h (3 µg/l). Skin prick tests in our patient were all negative, while intradermal testing with 0.03 ml of 1:100 and 1:10 preparations of Multihance showed a definite positive wheal-and-flare reaction. Skin tests to the alternative agents showed no response. In the control group, all performed tests were negative. Conclusion: We report the first case of an allergic reaction to gadobenate dimeglumine. Besides, skin testing seems to be a precious diagnostic tool which, if positive, strongly suggests a mast cell-mediated underlying mechanism.

Clinical Practice Guidelines for Diagnosis and Management of Hypersensitivity Reactions to Contrast Media

“…In some cases, positive results were detected using undiluted contrast for skin prick tests and dilutions of 1:1000 to 1:10 for intradermal tests (grade of recommendation, D) [21][22][23]109,110]. Cross-reactivity between gadolinium chelates is still unclear [22,23,111], although it appears not to exist between macrocyclic and linear substances.…”

Risk Factors in Fatal Cases of Anaphylaxis due to Contrast Media: A Forensic Evaluation

“…Another report suggesting an immunologic mechanism emphasized that the risk of immediate hypersensitivity reactions was up to 8 times higher in patients with a history of hypersensitivity to MR contrast media, the second reaction tending to be more severe than the first. However, it has been demonstrated that ionic and nonionic preparations of MR contrast agents are capable of directly inducing mast cell degranulation in vitro, which would suggest that one of the mechanisms responsible for mast cell degranulation after MR contrast medium exposure might belong to the group of nonimmunologic reactions [8,27,28,29,30,31,32,33,34,35,36]. …”

Incidental MRI Findings of Acute Gadolinium Hypersensitivity

“…Severe anaphylactoid reactions and even death have been well described in the literature [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14]. Dillman et al [1] reported a gadolinium allergy incidence of 0.4% in their pediatric population and a 7% overall incidence of severe reactions.…”