Fixed drug eruption induced by an iodinated non-ionic X-ray contrast medium: a practical approach to identify the causative agent and to prevent its recurrence

Abstract

We describe the case of a 61-year-old physician who developed a fixed drug eruption (FDE) after i.v. administration of a non-ionic monomeric iodinated X-ray contrast medium (CM) (iopromide). During CM injection, a sensation of heat occurred, which was most intense in the right inguinal region. Four hours later, the FDE arose with a red macule of approximately 2 cm in diameter covering a dermal infiltration in the right inguinal region, and enlarged up to a final size of 15 x 8 cm, accompanied by a burning sensation. The patient's history revealed a similar reaction in the same localization and of the same clinical appearance after CM injection 1 year before. Patch testing 4 months later revealed positive reactions to iomeprol and iohexol. Iopamidol injection for another CT examination 23 months later was well tolerated. Based on these results, we suggest patch testing after CM-induced FDE, which could help to select a CM for future CT examinations. Late onset of adverse CM reactions may manifest as FDE. Patch testing within the previous skin reaction area is the diagnostic tool that should be used to confirm the suspected agent, possible cross-reacting agents and well-tolerated agents.

Fixed Drug Eruption due to Iopromide (Ultravist®)

“…Two cases have documented positive reactions to iomeprol4 and iopamidol7 on the patch test. However, in another case, the patch test could not induce a positive reaction to iopromide2, as in our case.…”

“…FDE typically has a late onset; therefore, it belongs to the category of delayed adverse contrast media induced reactions2. The majority of late skin reactions after contrast media ingestion are probably T cell-mediated allergic reactions5.…”

“…The frequency of late adverse reactions to NIM has been reported to be between 0.52~23%5. To the best of our knowledge, there have been only three reports of FDE caused by NIM; iopromide2, iomeprol4, and iopamidol7 in the English literature. Two cases have documented positive reactions to iomeprol4 and iopamidol7 on the patch test.…”

“…On re-challenge, the skin lesion occurred again on the same location. This is the reason why it has been called "fixed" drug eruption2. FDE is most commonly associated with ibuprofen, sulfonamides, naproxen, barbiturates, and tetracyclines1.…”

Letter to the editor: Diagnostic procedures and case related information in ICM-induced hypersensitivity

“…To improve the safety of ICM application both clinical studies and case reports are of great importance. Case reports should be used to exactly describe the clinical features of adverse reactions in general, and of hypersensitivity reactions in particular [3].…”