Cutaneous small‐vessel vasculitis following hysterosalpingo‐foam sonography (HyFoSy)

Abstract

We present a case of diffuse skin immune reaction, diagnosed as cutaneous small‐vessel vasculitis, following assessment of tubal patency by contrast ultrasound, which appears to be the first reported case of hypersensitivity reaction to sonographic tubal patency testing, based on a literature search. A 32‐year‐old woman presented with non‐thrombocytopenic palpable purpura the day after assessment of tubal patency by two‐/three‐dimensional hysterosalpingo‐foam sonography (HyFoSy) using ExEm® Foam. During real‐time ultrasound, the observer identified flow in only the right tube when using saline with air as contrast medium; however, the same observer identified flow in both tubes after injecting ExEm Foam and the woman left the clinic without any complications. The next day, the patient was admitted with a complaint of a red‐purple skin rash noticed the same morning, associated with moderate leg pain. Slow‐motion analysis of the recorded videos and three‐dimensional ultrasound datasets showed previously unnoticed venous intravasation of ExEm Foam into the myometrial vessels. Palpable purpura is typically found in vasculitis as a result of extravasation of red cells outside the inflamed blood vessel. This previously unreported side effect of tubal patency testing by HyFoSy, its potential rare organ consequences, as well as unknown consequences of venous intravasation by foam, should be included in the informed consent prior to the examination. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Green urine sign after laparoscopic chromopertubation as an effect of severe contrast intravasation: a report of three cases

“…11 Previous reports have also described the intravasation phenomenon with the HSG procedure during the performance of hysterosalpingo-foam sonography (HyFoSy) and transvaginal four-dimensional hysterosalpingo-contrast sonography with SonoVue (TV 4D HyCoSy). [12][13][14] Ludwin et al 12 presented a case report of mild intravasation during HyFoSy using air/saline as a contrast agent. The risk factor for intravasation specified in the cited publication was unilateral occlusion of the fallopian tube.…”

“…By eliminating predisposing factors, it is possible to minimise or prevent intravasation and reduce its potential consequences. [6][7][8][9][12][13][14] Therefore, we treat the green urine sign as a complication of laparoscopic chromopertubation. This is in line with the definition of a complication as a deviation from the desired course of the medical procedure; it does not always indicate a violation of the standard of care, medical neglect, or medical malpractice.…”

“… 12 – 14 Ludwin et al. 12 presented a case report of mild intravasation during HyFoSy using air/saline as a contrast agent. The risk factor for intravasation specified in the cited publication was unilateral occlusion of the fallopian tube.…”

“…The authors suggested that information on this type of rare complication should be attached to the patient’s informed consent form. 12 …”

“…By eliminating predisposing factors, it is possible to minimise or prevent intravasation and reduce its potential consequences. 6 – 9 , 12 – 14 Therefore, we treat the green urine sign as a complication of laparoscopic chromopertubation.…”