Autopsy case of delayed anaphylactic shock due to contrast medium

Abstract

We report an autopsy case of delayed anaphylactic shock due to contrast medium. A 17-year-old Japanese man underwent angiography using non-ionic contrast medium under the suspected diagnosis of Buerger's disease. Initial symptoms appeared 6 h after the administration of the contrast medium, and death was confirmed 11 h later. Considering the clinical course and the results of the autopsy, we concluded that the direct cause of the patient's death was severe acute circulatory failure due to a delayed allergic reaction to the contrast medium. The reported incidence of serious delayed reactions or biphasic reactions to non-ionic contrast medium is extremely low; however, we should be aware of such rare adverse reactions.

Medicolegal Implications of Biphasic Anaphylaxis

“…Because of the absence of standardized research protocols, the literature shows no agreement as to the frequency of biphasic reactions (from 1% to 23% of all anaphylactic cases), with only 11 published cases of fatalities available. [2][3][4][6][7][8][19][20][21][22][23][24][25][26][27][30][31][32][33]38,39,[44][45][46][47][48][49][60][61][62][63][64][65][66][67][68][75][76][77][78][79][80] When a medicolegal evaluation is requested by the courts, a diagnosis of biphasic anaphylaxis in a nonclinical setting proves to be very difficult and can be impossible, whether the patient survived or not. 79 In cases where the patient survived, a forensic evaluation may be needed to ascertain whether the anaphylactic event was managed correctly and to evaluate the outcome, in the event of claims for compensation due to medical malpractice.…”

“…13,79,80,[88][89][90][91][92][93][94][95][96][97][98][99] Studies of biphasic anaphylaxis make it clear that the second reaction, especially cases where death results, often appears around an hour after the primary reaction. [2][3][4][6][7][8]19,[23][24][25][26][27]30,32,33,39,[63][64][65][66][67]73,74,[77][78][79][80]86,90 In 2016, the Working Group of the Resuscitation Council (UK) proposed the following sample timing protocol for the surveillance of tryptase: (1) initial sample as soon as possible after first aid or resuscitation has started; 2) second sample at 1 to 2 hours after the onset of symptoms because its peak concentration has been reported to be reached about an hour after the primary reaction and to disappear with a half-life 2 hours; 3) third sample 24 hours later, this protocol appears to be appropriate for the surveillance of all patients suffering from anaphylaxis, including those experiencing biph...…”

“…- Nagai et al 66 reported 1 case of a teen who died after the venous administration of nonionic contrast medium (latency 8 hours—second reaction at hospital—death in hospital).…”

“…Many aspects of biphasic anaphylaxis are unclear, with many reports and studies disagreeing on epidemiology, pathophysiology, risk factors, clinical treatment, postacute phase observation, and postdischarge therapies and precautions (the majority of fatal biphasic reactions have been reported as occurring in nonhospital environments). Because of the absence of standardized research protocols, the literature shows no agreement as to the frequency of biphasic reactions (from 1% to 23% of all anaphylactic cases), with only 11 published cases of fatalities available 2–4,6–8,19–27,30–33,38,39,44–49,60–68,75–80 …”

“…Studies of biphasic anaphylaxis make it clear that the second reaction, especially cases where death results, often appears around an hour after the primary reaction 2–4,6–8,19,23–27,30,32,33,39,63–67,73,74,77–80,86,90 …”