Vol. 113, January Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
ANAPHYLAXIS MANIFESTED BY HYPOTENSION ALONE NICHOLAS A. VINER*
AND
ROBERT K. RHAMY
From the Division of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
Parenteral administration of drugs and contrast media is an essential part of our diagnostic and therapeutic armamentarium. A variety of untoward reactions may occur following such injections, and awareness of the problems and correct therapy are mandatory. We herein present 3 cases demonstrating severe reactions recently seen at our hospital, including 1 case with onset delayed for an hour. CASE REPORTS
Case 1. A 68-year-old black woman was hospitalized for evaluation of left flank pain and microhematuria. The patient underwent 2 uneventful excretory urograms (IVPs) as an outpatient and was hospitalized for metabolic studies after passage of a calculus. A third IVP was performed without incident. An hour after the injection, when the patient had returned to her room, she complained of some nausea and the blood pressure was 80/60, with a pulse of 80. There was no evidence of itching, urticaria, wheezing, shortness of breath or changes in the electrocardiogram or chest film. Resuscitation was done with intravenous fluid, benadryl, oxygen and reverse Trendelenberg position. The systolic blood pressure increased after each dose of epinephrine but then decreased to previous levels shortly afterward. The patient required an aramine drip to maintain systolic blood pressure at more than 100 for the next 18 hours. During this time the pulse never exceeded 100 and was generally about 80. Within 24 hours after the acute reaction the blood pressure was normal. Convalescence was uneventful. Case 2. A 35-year-old white man was evaluated for left flank pain and pyuria. An IVP was per-· formed and within minutes of the injection of 100 ml. renografin 76, facial flushing, mild abdominal urticaria noted by 1 of 3 observers and hypotension developed. Intravenous benadryl did not affect the blood pressure and normal saline was started (see figure). The blood pressure was maintained at more than 100 mm. Hg only after 9 doses of epinephrine and 4½ L saline within 14 hours. Within 24 hours the blood pressure stabilized and recovery was complete. There was no history of urography or allergy to drug or environmental factors. Case 3. A 41-year-old black woman was given 1 tRccepted for publication July 19 1974 equests for reprints· U ·t d S' · cal Center Scott A" F Ill e tates Air Force Medi62221. ' Ir orce Base, Belleville, Illinois 108
gm. benemid by mouth, followed in 30 minutes by 4.8 million units of procaine penicillin G for suspected pelvic inflammatory disease. The patient had no known allergies but became hypotensive 15 minutes after the penicillin was given without any other evidence of an allergic reaction. After 3,500 ml. saline, epinephrine and hydrocortisone given within the first 2 hours, she remained hypotensive. The total fluid therapy was 6,600 ml. within 24 hours, at each time blood pressure remained consistently greater than 100 mm. Hg. Convalescence was uneventful and the patient has subsequently become mildly hypertensive. DISCUSSION
The incidence of reactions following IVP in large series ranges near 6.8 to 8.5 per cent. 1 • 2 However, the majority of these untoward sequelae were not life-threatening and could easily be treated with symptomatic therapy or antihistamines. Severe reactions occurred at a rate of roughly 1 per 1,000 IVPs in reports by Witten and Coleman and their associates and 1 per 5,000 IVPs in the series reported by Hamm and associates. 3 The questionnaire by Pendergrass and associates revealed 31 deaths occurring in an estimated 3,831,850 IVPs or about 1 for every 122,000 examinations, while Ansell reported an incidence of 1 per 40,000 in Great Britain with the interesting observation that mortality has not decreased with the introduction of newer contrast media. 4 • 5 Adverse reactions may be manifested by dyspnea, hypotension, cyanosis, pulmonary edema, bronchospasm or convulsions. Frequently, there are multiple symptoms. One large series showed dyspnea to be the most common presenting symptom in 102 fatal urographic reactions. 6 'Coleman, W. P., Ochsner, S. F. and Watson, B. E.: Allergic reactions in 10,000 consecutive intravenous urographies. South. Med. J., 57: 1401, 1964. 'Witten, D. M., Hirsch, F. D. and Hartman, G. W.: Acute reactions to urographic contrast medium. Amer. J. Roentgen., 119: 832, 1973. •Hamm, F. C., Waterhouse, K. and Weinberg, S. R.: Dangers of excretory urography. J.A.M.A., 172: 542, 1960.
'Pendergrass, E. P., Hodes, P. J., Tondreau, R. L., Powell, C. C. and Burdick, E. D.: Further consideration of deaths and unfavorable sequelae following the admin-
istration of contrast media in urography in the United
St:tes. Amer. J. Roentgen., 74: 262, 1955.
Ansell, G.: Adverse react'
t
Invest. Radial., 5: 374 1970 JOns O contrast agents. • Hildreth, E. A. P~nde · and Ritchie D J . R' ea t· rgrass, J:I. P., Tondreau, R. L ' · ·· c 10ns w·th · t ravenous· 1 of m hassociated . m urography: discussion ology, 74: 246, 1960. ec amsms and therapy. Radi-
109
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THE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
ANAPHYLAXIS MANIFESTED BY HYPOTENSION ALONE NICHOLAS A. VINER*
AND
ROBERT K. RHAMY
From the Division of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
Parenteral administration of drugs and contrast media is an essential part of our diagnostic and therapeutic armamentarium. A variety of untoward reactions may occur following such injections, and awareness of the problems and correct therapy are mandatory. We herein present 3 cases demonstrating severe reactions recently seen at our hospital, including 1 case with onset delayed for an hour. CASE REPORTS
Case 1. A 68-year-old black woman was hospitalized for evaluation of left flank pain and microhematuria. The patient underwent 2 uneventful excretory urograms (IVPs) as an outpatient and was hospitalized for metabolic studies after passage of a calculus. A third IVP was performed without incident. An hour after the injection, when the patient had returned to her room, she complained of some nausea and the blood pressure was 80/60, with a pulse of 80. There was no evidence of itching, urticaria, wheezing, shortness of breath or changes in the electrocardiogram or chest film. Resuscitation was done with intravenous fluid, benadryl, oxygen and reverse Trendelenberg position. The systolic blood pressure increased after each dose of epinephrine but then decreased to previous levels shortly afterward. The patient required an aramine drip to maintain systolic blood pressure at more than 100 for the next 18 hours. During this time the pulse never exceeded 100 and was generally about 80. Within 24 hours after the acute reaction the blood pressure was normal. Convalescence was uneventful. Case 2. A 35-year-old white man was evaluated for left flank pain and pyuria. An IVP was per-· formed and within minutes of the injection of 100 ml. renografin 76, facial flushing, mild abdominal urticaria noted by 1 of 3 observers and hypotension developed. Intravenous benadryl did not affect the blood pressure and normal saline was started (see figure). The blood pressure was maintained at more than 100 mm. Hg only after 9 doses of epinephrine and 4½ L saline within 14 hours. Within 24 hours the blood pressure stabilized and recovery was complete. There was no history of urography or allergy to drug or environmental factors. Case 3. A 41-year-old black woman was given 1 tRccepted for publication July 19 1974 equests for reprints· U ·t d S' · cal Center Scott A" F Ill e tates Air Force Medi62221. ' Ir orce Base, Belleville, Illinois 108
gm. benemid by mouth, followed in 30 minutes by 4.8 million units of procaine penicillin G for suspected pelvic inflammatory disease. The patient had no known allergies but became hypotensive 15 minutes after the penicillin was given without any other evidence of an allergic reaction. After 3,500 ml. saline, epinephrine and hydrocortisone given within the first 2 hours, she remained hypotensive. The total fluid therapy was 6,600 ml. within 24 hours, at each time blood pressure remained consistently greater than 100 mm. Hg. Convalescence was uneventful and the patient has subsequently become mildly hypertensive. DISCUSSION
The incidence of reactions following IVP in large series ranges near 6.8 to 8.5 per cent. 1 • 2 However, the majority of these untoward sequelae were not life-threatening and could easily be treated with symptomatic therapy or antihistamines. Severe reactions occurred at a rate of roughly 1 per 1,000 IVPs in reports by Witten and Coleman and their associates and 1 per 5,000 IVPs in the series reported by Hamm and associates. 3 The questionnaire by Pendergrass and associates revealed 31 deaths occurring in an estimated 3,831,850 IVPs or about 1 for every 122,000 examinations, while Ansell reported an incidence of 1 per 40,000 in Great Britain with the interesting observation that mortality has not decreased with the introduction of newer contrast media. 4 • 5 Adverse reactions may be manifested by dyspnea, hypotension, cyanosis, pulmonary edema, bronchospasm or convulsions. Frequently, there are multiple symptoms. One large series showed dyspnea to be the most common presenting symptom in 102 fatal urographic reactions. 6 'Coleman, W. P., Ochsner, S. F. and Watson, B. E.: Allergic reactions in 10,000 consecutive intravenous urographies. South. Med. J., 57: 1401, 1964. 'Witten, D. M., Hirsch, F. D. and Hartman, G. W.: Acute reactions to urographic contrast medium. Amer. J. Roentgen., 119: 832, 1973. •Hamm, F. C., Waterhouse, K. and Weinberg, S. R.: Dangers of excretory urography. J.A.M.A., 172: 542, 1960.
'Pendergrass, E. P., Hodes, P. J., Tondreau, R. L., Powell, C. C. and Burdick, E. D.: Further consideration of deaths and unfavorable sequelae following the admin-
istration of contrast media in urography in the United
St:tes. Amer. J. Roentgen., 74: 262, 1955.
Ansell, G.: Adverse react'
t
Invest. Radial., 5: 374 1970 JOns O contrast agents. • Hildreth, E. A. P~nde · and Ritchie D J . R' ea t· rgrass, J:I. P., Tondreau, R. L ' · ·· c 10ns w·th · t ravenous· 1 of m hassociated . m urography: discussion ology, 74: 246, 1960. ec amsms and therapy. Radi-
109
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