Acute generalized exanthematous pustulosis induced by iomeprol with cross‐reactivity to other iodinated contrast agents and mild reactions after rechallenge with iopromide and oral corticosteroid premedication

Abstract

K E Y W O R D S : acute generalized exanthematous pustulosis, case report, cross-reactivity, delayed adverse drug reactions, iodinated contrast media reactions, iomeprol Hypersensitivity reactions to iodinated contrast media (ICM) are rare and occur within 1 hour after infusion, but also up to 7 days later. 1 Delayed reactions may be under-reported, because they may appear after patient discharge. 2 Reactions are usually mild to moderate, but more severe cases, including generalized acute generalized exanthematous pustulosis (AGEP), have been reported. 3,4 Patch testing helps in identifying the culprit drug in AGEP, 5 and may help in choosing an alternative therapy when a new radiological examination involving ICM infusion is required. 6 CASE REPORTAn 88-year-old patient underwent three radiological examinations requiring intravenous infusion of iomeprol within a few days for preoperative assessment of aortic stenosis and ischaemic heart disease. Prior medication included furosemide, paracetamol, and simvastatin, all of which were taken for >1 year. At 24 hours after the third injection, the patient was admitted for acute exanthema, with a temperature of 39.9 C ( Figure 1A). Numerous pustules were present on the face (Figure 1B), axillary folds, and trunk. Blood tests showed leukocytosis, at 21 g/L, with polymorphonuclear cells at 19 g/L. A skin biopsy showed an intraepidermal pustule with numerous polymorphonuclear cells.Patch testing was performed 6 months after the occurrence of AGEP. Tests with ioxitalamate (++), iohexol (+++), iomeprol (+++), iobitridol (++), iopamidol (++), ioversol (+++), iodixanol (+++) and iopromide (+) gave positive reactions. A test with amidotrizoate gave a 74MACHET ET AL.

Acute localized exanthematous pustulosis (ALEP) induced by iomeprol (Iomeron 350): A diagnostic challenge

“…To date, fewer than 20 cases of acute generalized exanthematous pustulosis caused by iodinated contrast (iopamidol, loversol, iopromide, iohexol, iodixanol, and iobitriol) have been reported. 7,8 None of them had localized presentation as in our case. ALEP is characterized by acute onset of multiple nonfollicular, sterile pustules, localized typically to the face, neck, and/or chest.…”

“…To date, fewer than 20 cases of acute generalized exanthematous pustulosis caused by iodinated contrast (iopamidol, loversol, iopromide, iohexol, iodixanol, and iobitriol) have been reported 7,8 . None of them had localized presentation as in our case.…”

Diagnosing and Managing Patients with Reactions to Radiocontrast Media

“…Maculopapular exanthem (MPE) of mild or moderate severity is by far the most common manifestation of NIHR [13•]. Other exanthems, such as severe cutaneous adverse reactions (e.g., drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) or acute generalized exanthematous pustulosis (AGEP)), are rather uncommon [18,19]. Also, erythema exsudativum multiforme, bullous fixed drug eruption, and pompholyx are exceptional and have been reported only in individual cases [19].…”

Akute Schwellung im Halsbereich nach iodhaltigem Kontrastmittel – der oft unerkannte Iodmumps anhand von drei Fallbeispielen

“…Albert Neisser beschrieb schon 1884 Jodoformexantheme, und Bruno Bloch, der frühere Vorsteher der Dermatologischen Abteilung in Basel und spätere Ordinarius in Zürich, hat 1911 eine ausführliche Arbeit über die damals so bezeichnete Jodoform-Idiosynkrasie und die dadurch ausgelöste Dermatitis publiziert [12]. Hingegen sind die anaphylaktischen Reaktionen [13] und die T-Zell-vermittelten Exantheme, wie makulopapulöse, fixe und systemische Arzneimittelexantheme [14][15][16], wie auch eine akute generalisierte exanthematische Pustulose [17] auf Röntgenkontrastmittel nicht auf das darin enthaltene Iod, sondern die jeweiligen Moleküle zurückzuführen [5,18,19].…”