BRIEF CLINICAL
OBSERVATIONS
usually unilateral, cystic swelling located on the anthelix of the ear. This condition occurs most commonly in men who have not had previous trauma to the lesional ear. The noninflammatory, asymptomatic, fluid-filled intracartilaginous cavity characteristically lacks an epithelial lining. The diagnosis of PCA may be suggested by the clinical features, supported by an analysis of the aspirated cystic fluid, and confirmed by histologic evaluation of a lesional biopsy specimen. Although the etiology of PCA remains unproven, several hypothesesfor the pathogenesis of this condition have been postulated. Successful treatment of PCA should result in permanent resolution of the lesion and maintain the normal architecture of the external ear.
line (rod) myopathy [3], necrotizgrown from lymph-node and spuing noninflammatory myopathy tum cultures. A second muscle bi[4], myositis ossificans [5], and pyo- opsy again disclosed the presence myositis [6]. Only one case of myo- of marked granulomatous myositis. sitis in which muscle biopsy re- Unfortunately, a muscle sample vealed mononuclear infiltrates was not cultured. Therapy consistwith multinucleated giant cells has ed of a combination of isoniazid, been previously published [7]; we rifampicin, ethambutol, and pyrahere report a case of diffuse granuzinamide. General status improved lomatous myositis possibly related rapidly and persistent apyrexia to tuberculosis in a patient infected was achieved. Signs and symptoms with HIV-l. of polymyositis gradually diminA 32-year-old native from Zaire ished and the serum CK level depresented in May 1988 with acute creased to twice the upper limit of pneumonia that was rapidly cured normal. Findings on a third muscle with amoxicillin. At that time, biopsy performed 4 weeks after iniHIV-l infection was documented tiation of therapy disclosed only by enzyme-linked immunosorbent mild inflammatory lesions without assay and Western blot. Despite a granulomas. At follow-up 12 low CD4 lymphocyte count (150/ months later, muscle weakness had mm3), a tuberculin skin test chal- disappeared and the patient relenge (10 TU) was strongly posi- turned to full activity. In our patient, the presence of PHILIP R. COHEN, M.D. tive; however, results of repeated MARC E. GROSSMAN,M.D. sputum examinations for acid-fast granulomas within the muscle durCollege of Physicians and Surgeons bacilli were negative. Clinical ex- ing an active tuberculous infection, of Columbia University amination disclosed further evi- and clinical recovery with decrease New York, New York dence of proximal muscle weakness of CK level and improvement on with tenderness. The tendon re- muscle biopsy after specific antitu1. Glamb R. Kim R. Pseudocyst of the auricle. J Am Acad Dermatol 1984; 11: 58-63. flexes were preserved and results of berculous therapy, support the tu2. Engel D. Pseudocysts of the auricle in Chinese. the remainder of the neurologic ex- berculous origin of the polymyosiArch Otolaryngol Head Neck Surg 1966; 83: 197amination were unremarkable. tis. 202. The serum creatine kinase (CK) Tuberculous infection of muscle 3. Choi S, Lam K-H, Chan K-W, Ghadially FN. NgASM. Endochondral pseudocyst of the auricle in Chinese. level was six times the upper limit has rarely been reported and usualArch Otolaryngol Head Neck Surg 1984; 110: 792-6. of normal, and electromyographic ly presents as localized muscle in4. Grabski WJ. Salasche SJ. McColloueh ML. Anneloni study showed evidence of myopa- volvement [B]. Our findings suggest VL. Pseudocyst of the auricle associatid with trauma. thy with widespread spontaneous that tuberculous polymyositis Arch Dermatol 1989; 125: 528-30. 5.Lazar RH, Heffner DK, Hughes GB. Hyams VK. fibrillations and polyphasic motormight be added to the expanding Pseudocyst of the auricle: a review of 21 cases. Otounit potentials. Light microscopic spectrum of muscular manifestalaryngol Head Neck Surg 1986; 94: 360-l. examination of a biopsy specimen tions of the acquired immunodefi6. Hansen JE. Pseudocysts of the auricle in Caucaof the quadriceps revealed granulociency syndrome, especially in the sians. Arch Otolaryngol Head Neck Surg 1967; 85: 13-4. matous myositis with epithelioid presence of muscular symptoms, in 7. Karakashian GV, Lutz-Nagey LL, Anderson R. Pseuhistiocytes, lymphocytes, and mul- HIV-infected African individuals, docyst of the auricle: compression suture therapy. J tinucleated giant cells; there was in whom tuberculosis is one of the Dermatol Surg Oncol 1987; 13: 74-5. no caseous necrosis and no acid- most frequent opportunistic infec8. Heffner DK. Hyams VJ. Cystic chondromalacia (endochondral pseudocyst) of the auricle. Arch Pathol fast bacilli or parasites were seen. tions. Lab Med 1986: 110: 740-3. The patient received no specific JACQUES POUCHOT, M.D. therapy for his polymyositis and Submitted December 21, 1988, and accepted in rePHILIPPE VINCENEUX, M.D. vised form March 21, 1990 was discharged. He was readmitted JANINE BARGE, M.D. in August 1988 with a high fever of FRANCOISE LAPARRE, M.D. 4O”C, and a marked increase in YVES BOUSSOUGANT, M.D. CHRISTOPHE MICHON, M.D. proximal muscle weakness with atHapital Louis Mourier, UniversitB TUBERCULOUS POLY MYOSITIS rophy. Serum CK level was 10 Paris VII IN HIV INFECTION times the upper limit of normal. A Colombes, France chest radiograph revealed bilateral Muscular involvement has rarely interstitial pulmonary infiltrates, 1. Dalakas MC, Pezeshkpour GH. Gravel1 M. Sever JL. associated with AIDS retrovirus. JAMA been reported in human immunoand results of bronchoalveolar la- Polymyositis 1986; 256: 2381-3. deficiency virus (HIV) infection, vage were negative for Pneumocys2. Gertner E. Thurn JR, Williams DN. eta/. Zidovudineand in most of the cases, clinical tis carinii and other organisms. associated myopathy. Am J Med 1989; 86: 814-8. features closely resemble those of Abdominal ultrasound and com- 3. Dalakas MC. Pezeshkoour GH. Flahertv M. Progressive nemakne (rod)‘myopathy associated wrth idiopathic inflammatory myopa- puterized tomography showed HIV infection. N Engl J Med 1987; 317: 1602-3. thy [l]. More recently, long-term multiple retroperitoneal lymphadPanegyres PK, Tan N. Kakulas BA. Armstrong JA, treatment with zidovudine has enopathy, and a laparotomy was 4.Hollingsworth P. Necrotising myopathy and zidovubeen associated with the develop- performed. Histologic examination dine. Lancet 1988; 2: 1050-l. ment of a polymyositis-like syn- of retroperitoneal lymph nodes re- 5. Drane WE, Tipler BM. Heterotoprc ossrfication ossificans) in acquired immune deficiency drome [2]. Other reported myo- vealed caseous necrosis and pres- (myositis syndrome. Detection by gallium scintigraphy. Clin pathies in HIV-infected patients ence of acid-fast bacilli. MycobacNucl Med 1987; 12: 433-5. are exceptional and include nema- terium tuberculosis was later 6. Gaut P. Wong PK. Meyer RD. Pyomyosths in a pa250
August
1990
The American
Journal
of Medicine
Volume
89
BRIEF CLINICAL trent with the acauired immunadeficiencv svndrome. Arch Intern Med’1988; 148: 1608-10. ~ ’ 7. Bailey RO, Turok DI, Jaufmann BP, Singh JK. Myositis and acquired immunadeficiency syndrome. Hum Pathol 1987: 18: 749-51. 6. Derkash RS. Makley JT. Isolated tuberculosisof the triceps muscle. J Bone Joint Surg [Am] 1979; 61: 948. Submitted
February
15, 1990, and accepted March 21. 1990
ANAPHYLACTIC REACTION TO BARIUM ENEMA Although barium sulfate used in gastrointestinal radiography is considered to be an inert material, allergic reactions including anaphylaxis have previously been reported [l-7]. We report a case of anaphylaxis during barium-enema radiography of the colon, and discuss the possible predisposing factors for this uncommon and potentially lethal reaction [6]. A 51-year-old woman complained of lower abdominal pain and intermittent hematochezia for 3 weeks. Her past history included allergic rhinitis and prior allergic reaction to sulfa antibiotics. She had undergone upper-gastrointestinal barium radiography 18 years previously for evaluation of dyspepsia, with no adverse reaction. The patient’s family history included eight close relatives with cancer, five of whom had gastrointestinal malignancies. None of her family members were known to have had any reaction to barium contrast radiography. A barium enema was performed. The ingredients in this barium mixture include barium sulfate, sodium benzoate, potassium sorbate, citric acid, sodium saccharin, ethyl maltol, vegetable gum, sorbitol, simethicone, and natural and artificial flavors. No other medications were given. After 5 to 10 minutes, the patient developed nausea, shortness of breath, diaphoresis, and then shock. She was resuscitated with epinephrine injection and intravenous fluids, corticosteroids,
dopamine, and diphenhydramine. After resuscitation, physical examination showed lethargy, moderate respiratory distress, periorbital facial edema, and urticarial rash and wheezing. The barium enema showed a carcinoma of the sigmoid colon. One week later the patient underwent left hemicolectomy for an ulcerating adenocarcinoma of the colon with local lymph node involvement. Her postoperative course was uneventful. Subsequently, after giving informed consent, the patient underwent skin-prick testing with sodium benzoate, potassium sorbate, and diluted liquid barium suspension. No cutaneous hypersensitivity was detected. The patient declined to have further provocation testing. Allergic reactions, including anaphylaxis, to barium radiography have been previously reported [l71 and are estimated to occur in one patient per 750,000 examinations [2]. These reactions have been attributed to additives in the barium sulfate suspension [l-3] or to other medications such as glucagon, anticholinergic agents, or rectal lubricants given at the time of the procedure [4,5,8]. Our patient’s severe anaphylactic reaction about 5 to 10 minutes after the start of the barium enema could have been an IgE-mediated hypersensitivity reaction to one of the barium sulfate suspension constituents. The presence of an ulcerated carcinoma in the sigmoid-descending-colon area with recent bleeding may have permitted increased absorption of the contrast material into the circulation. Our patient also had a history of allergic rhinitis and medication allergy and a history of prior sensitizing exposure to barium radiographic contrast material. Authors of other reports of severe allergic reactions including anaphylaxis with barium enema have noted this history in their patients [1,4,6,8]. Our patient probably has a family cancer syndrome, and several other family members have had barium-enema
August
1990
The American
OBSERVATIONS
radiography of the gastrointestinal tract without known allergic reaction, suggesting that inherited predisposition may not be a factor in this type of reaction. No skin test reaction was detected with diluted sodium benzoate, potassium sorbate, and whole liquid barium sulfate suspension. Although we are unable to specifically incriminate any one of the agents used in this preparation, we suspect that benzoate, saccharin, or the vegetable gum is the most likely cause because allergic reactions to these agents have previously been reported. This patient’s severe reaction to barium may have been partly attributable to three factors: first, her history of atopy and prior medication allergy; second, a prior sensitizing exposure to barium sulfate suspension; and third, possible increased absorption of allergens into the bloodstream through the recently bleeding ulcerated carcinoma in her sigmoid colon. RIAD AL-MUDALLAL, M.D. HARVEY ROSENBAUM, M.D. HOWARD J. SCHWARTZ, M.D. JAMES M. BOYLE, M.D. Saint Luke’s Hospit;, Case Western
Reserve University School of Medicine Cleveland, Ohio
1. Schwartz EE. Glick SN. Fog@ MB, et a/. Hypersensitivity reaction after barium enema examination. Am J Roentgen01 1984: 143: 10334. 2. Larsen C. Allergic side-effects following radiographic investigation with banum sulphate suspension. Ugeskr Laeger 1981; 143: 937-8. 3. Javors BR. Applbaum Y, Gerard P. Severe allergtc reaction: an unusual complication of barium enema. Gastrointest Radio1 1984: 9: 357-8. 4. Gelfand D. Sowers J. DePonte KA. et al. Anaphylacbc and allergic reactions during double contrast studres: is glucagon or barium suspension the allergen? Am J Roentgenol 1985; 144: 405-6. 5. Thomas AMK. Kubie AM, Britt RP. Acute angroneuratic edema following a barium meal. Br J Radral 1986: 59: 1055-6. 6. Feczko PJ, Simms SM, Bakirci N. Fatal hypersensitivity reaction during a barium enema. Am J Roentgenol 1989; 153: 275-6. 7. Janower ML. Hypersensitivity reactions after barium studies of the upper and lower gastrointestinal tract. Radiology 1986; 161: 139-40. 8. Jones SA. Anaphylaxis from rectal lubricant jelly (brief clinical observation). Am J Med 1988; 85: 890. Submitted
Journal
November
29, 1989, and accepted in revised form March 26, 1990
of Medicine
Volume
89
251
OBSERVATIONS
usually unilateral, cystic swelling located on the anthelix of the ear. This condition occurs most commonly in men who have not had previous trauma to the lesional ear. The noninflammatory, asymptomatic, fluid-filled intracartilaginous cavity characteristically lacks an epithelial lining. The diagnosis of PCA may be suggested by the clinical features, supported by an analysis of the aspirated cystic fluid, and confirmed by histologic evaluation of a lesional biopsy specimen. Although the etiology of PCA remains unproven, several hypothesesfor the pathogenesis of this condition have been postulated. Successful treatment of PCA should result in permanent resolution of the lesion and maintain the normal architecture of the external ear.
line (rod) myopathy [3], necrotizgrown from lymph-node and spuing noninflammatory myopathy tum cultures. A second muscle bi[4], myositis ossificans [5], and pyo- opsy again disclosed the presence myositis [6]. Only one case of myo- of marked granulomatous myositis. sitis in which muscle biopsy re- Unfortunately, a muscle sample vealed mononuclear infiltrates was not cultured. Therapy consistwith multinucleated giant cells has ed of a combination of isoniazid, been previously published [7]; we rifampicin, ethambutol, and pyrahere report a case of diffuse granuzinamide. General status improved lomatous myositis possibly related rapidly and persistent apyrexia to tuberculosis in a patient infected was achieved. Signs and symptoms with HIV-l. of polymyositis gradually diminA 32-year-old native from Zaire ished and the serum CK level depresented in May 1988 with acute creased to twice the upper limit of pneumonia that was rapidly cured normal. Findings on a third muscle with amoxicillin. At that time, biopsy performed 4 weeks after iniHIV-l infection was documented tiation of therapy disclosed only by enzyme-linked immunosorbent mild inflammatory lesions without assay and Western blot. Despite a granulomas. At follow-up 12 low CD4 lymphocyte count (150/ months later, muscle weakness had mm3), a tuberculin skin test chal- disappeared and the patient relenge (10 TU) was strongly posi- turned to full activity. In our patient, the presence of PHILIP R. COHEN, M.D. tive; however, results of repeated MARC E. GROSSMAN,M.D. sputum examinations for acid-fast granulomas within the muscle durCollege of Physicians and Surgeons bacilli were negative. Clinical ex- ing an active tuberculous infection, of Columbia University amination disclosed further evi- and clinical recovery with decrease New York, New York dence of proximal muscle weakness of CK level and improvement on with tenderness. The tendon re- muscle biopsy after specific antitu1. Glamb R. Kim R. Pseudocyst of the auricle. J Am Acad Dermatol 1984; 11: 58-63. flexes were preserved and results of berculous therapy, support the tu2. Engel D. Pseudocysts of the auricle in Chinese. the remainder of the neurologic ex- berculous origin of the polymyosiArch Otolaryngol Head Neck Surg 1966; 83: 197amination were unremarkable. tis. 202. The serum creatine kinase (CK) Tuberculous infection of muscle 3. Choi S, Lam K-H, Chan K-W, Ghadially FN. NgASM. Endochondral pseudocyst of the auricle in Chinese. level was six times the upper limit has rarely been reported and usualArch Otolaryngol Head Neck Surg 1984; 110: 792-6. of normal, and electromyographic ly presents as localized muscle in4. Grabski WJ. Salasche SJ. McColloueh ML. Anneloni study showed evidence of myopa- volvement [B]. Our findings suggest VL. Pseudocyst of the auricle associatid with trauma. thy with widespread spontaneous that tuberculous polymyositis Arch Dermatol 1989; 125: 528-30. 5.Lazar RH, Heffner DK, Hughes GB. Hyams VK. fibrillations and polyphasic motormight be added to the expanding Pseudocyst of the auricle: a review of 21 cases. Otounit potentials. Light microscopic spectrum of muscular manifestalaryngol Head Neck Surg 1986; 94: 360-l. examination of a biopsy specimen tions of the acquired immunodefi6. Hansen JE. Pseudocysts of the auricle in Caucaof the quadriceps revealed granulociency syndrome, especially in the sians. Arch Otolaryngol Head Neck Surg 1967; 85: 13-4. matous myositis with epithelioid presence of muscular symptoms, in 7. Karakashian GV, Lutz-Nagey LL, Anderson R. Pseuhistiocytes, lymphocytes, and mul- HIV-infected African individuals, docyst of the auricle: compression suture therapy. J tinucleated giant cells; there was in whom tuberculosis is one of the Dermatol Surg Oncol 1987; 13: 74-5. no caseous necrosis and no acid- most frequent opportunistic infec8. Heffner DK. Hyams VJ. Cystic chondromalacia (endochondral pseudocyst) of the auricle. Arch Pathol fast bacilli or parasites were seen. tions. Lab Med 1986: 110: 740-3. The patient received no specific JACQUES POUCHOT, M.D. therapy for his polymyositis and Submitted December 21, 1988, and accepted in rePHILIPPE VINCENEUX, M.D. vised form March 21, 1990 was discharged. He was readmitted JANINE BARGE, M.D. in August 1988 with a high fever of FRANCOISE LAPARRE, M.D. 4O”C, and a marked increase in YVES BOUSSOUGANT, M.D. CHRISTOPHE MICHON, M.D. proximal muscle weakness with atHapital Louis Mourier, UniversitB TUBERCULOUS POLY MYOSITIS rophy. Serum CK level was 10 Paris VII IN HIV INFECTION times the upper limit of normal. A Colombes, France chest radiograph revealed bilateral Muscular involvement has rarely interstitial pulmonary infiltrates, 1. Dalakas MC, Pezeshkpour GH. Gravel1 M. Sever JL. associated with AIDS retrovirus. JAMA been reported in human immunoand results of bronchoalveolar la- Polymyositis 1986; 256: 2381-3. deficiency virus (HIV) infection, vage were negative for Pneumocys2. Gertner E. Thurn JR, Williams DN. eta/. Zidovudineand in most of the cases, clinical tis carinii and other organisms. associated myopathy. Am J Med 1989; 86: 814-8. features closely resemble those of Abdominal ultrasound and com- 3. Dalakas MC. Pezeshkoour GH. Flahertv M. Progressive nemakne (rod)‘myopathy associated wrth idiopathic inflammatory myopa- puterized tomography showed HIV infection. N Engl J Med 1987; 317: 1602-3. thy [l]. More recently, long-term multiple retroperitoneal lymphadPanegyres PK, Tan N. Kakulas BA. Armstrong JA, treatment with zidovudine has enopathy, and a laparotomy was 4.Hollingsworth P. Necrotising myopathy and zidovubeen associated with the develop- performed. Histologic examination dine. Lancet 1988; 2: 1050-l. ment of a polymyositis-like syn- of retroperitoneal lymph nodes re- 5. Drane WE, Tipler BM. Heterotoprc ossrfication ossificans) in acquired immune deficiency drome [2]. Other reported myo- vealed caseous necrosis and pres- (myositis syndrome. Detection by gallium scintigraphy. Clin pathies in HIV-infected patients ence of acid-fast bacilli. MycobacNucl Med 1987; 12: 433-5. are exceptional and include nema- terium tuberculosis was later 6. Gaut P. Wong PK. Meyer RD. Pyomyosths in a pa250
August
1990
The American
Journal
of Medicine
Volume
89
BRIEF CLINICAL trent with the acauired immunadeficiencv svndrome. Arch Intern Med’1988; 148: 1608-10. ~ ’ 7. Bailey RO, Turok DI, Jaufmann BP, Singh JK. Myositis and acquired immunadeficiency syndrome. Hum Pathol 1987: 18: 749-51. 6. Derkash RS. Makley JT. Isolated tuberculosisof the triceps muscle. J Bone Joint Surg [Am] 1979; 61: 948. Submitted
February
15, 1990, and accepted March 21. 1990
ANAPHYLACTIC REACTION TO BARIUM ENEMA Although barium sulfate used in gastrointestinal radiography is considered to be an inert material, allergic reactions including anaphylaxis have previously been reported [l-7]. We report a case of anaphylaxis during barium-enema radiography of the colon, and discuss the possible predisposing factors for this uncommon and potentially lethal reaction [6]. A 51-year-old woman complained of lower abdominal pain and intermittent hematochezia for 3 weeks. Her past history included allergic rhinitis and prior allergic reaction to sulfa antibiotics. She had undergone upper-gastrointestinal barium radiography 18 years previously for evaluation of dyspepsia, with no adverse reaction. The patient’s family history included eight close relatives with cancer, five of whom had gastrointestinal malignancies. None of her family members were known to have had any reaction to barium contrast radiography. A barium enema was performed. The ingredients in this barium mixture include barium sulfate, sodium benzoate, potassium sorbate, citric acid, sodium saccharin, ethyl maltol, vegetable gum, sorbitol, simethicone, and natural and artificial flavors. No other medications were given. After 5 to 10 minutes, the patient developed nausea, shortness of breath, diaphoresis, and then shock. She was resuscitated with epinephrine injection and intravenous fluids, corticosteroids,
dopamine, and diphenhydramine. After resuscitation, physical examination showed lethargy, moderate respiratory distress, periorbital facial edema, and urticarial rash and wheezing. The barium enema showed a carcinoma of the sigmoid colon. One week later the patient underwent left hemicolectomy for an ulcerating adenocarcinoma of the colon with local lymph node involvement. Her postoperative course was uneventful. Subsequently, after giving informed consent, the patient underwent skin-prick testing with sodium benzoate, potassium sorbate, and diluted liquid barium suspension. No cutaneous hypersensitivity was detected. The patient declined to have further provocation testing. Allergic reactions, including anaphylaxis, to barium radiography have been previously reported [l71 and are estimated to occur in one patient per 750,000 examinations [2]. These reactions have been attributed to additives in the barium sulfate suspension [l-3] or to other medications such as glucagon, anticholinergic agents, or rectal lubricants given at the time of the procedure [4,5,8]. Our patient’s severe anaphylactic reaction about 5 to 10 minutes after the start of the barium enema could have been an IgE-mediated hypersensitivity reaction to one of the barium sulfate suspension constituents. The presence of an ulcerated carcinoma in the sigmoid-descending-colon area with recent bleeding may have permitted increased absorption of the contrast material into the circulation. Our patient also had a history of allergic rhinitis and medication allergy and a history of prior sensitizing exposure to barium radiographic contrast material. Authors of other reports of severe allergic reactions including anaphylaxis with barium enema have noted this history in their patients [1,4,6,8]. Our patient probably has a family cancer syndrome, and several other family members have had barium-enema
August
1990
The American
OBSERVATIONS
radiography of the gastrointestinal tract without known allergic reaction, suggesting that inherited predisposition may not be a factor in this type of reaction. No skin test reaction was detected with diluted sodium benzoate, potassium sorbate, and whole liquid barium sulfate suspension. Although we are unable to specifically incriminate any one of the agents used in this preparation, we suspect that benzoate, saccharin, or the vegetable gum is the most likely cause because allergic reactions to these agents have previously been reported. This patient’s severe reaction to barium may have been partly attributable to three factors: first, her history of atopy and prior medication allergy; second, a prior sensitizing exposure to barium sulfate suspension; and third, possible increased absorption of allergens into the bloodstream through the recently bleeding ulcerated carcinoma in her sigmoid colon. RIAD AL-MUDALLAL, M.D. HARVEY ROSENBAUM, M.D. HOWARD J. SCHWARTZ, M.D. JAMES M. BOYLE, M.D. Saint Luke’s Hospit;, Case Western
Reserve University School of Medicine Cleveland, Ohio
1. Schwartz EE. Glick SN. Fog@ MB, et a/. Hypersensitivity reaction after barium enema examination. Am J Roentgen01 1984: 143: 10334. 2. Larsen C. Allergic side-effects following radiographic investigation with banum sulphate suspension. Ugeskr Laeger 1981; 143: 937-8. 3. Javors BR. Applbaum Y, Gerard P. Severe allergtc reaction: an unusual complication of barium enema. Gastrointest Radio1 1984: 9: 357-8. 4. Gelfand D. Sowers J. DePonte KA. et al. Anaphylacbc and allergic reactions during double contrast studres: is glucagon or barium suspension the allergen? Am J Roentgenol 1985; 144: 405-6. 5. Thomas AMK. Kubie AM, Britt RP. Acute angroneuratic edema following a barium meal. Br J Radral 1986: 59: 1055-6. 6. Feczko PJ, Simms SM, Bakirci N. Fatal hypersensitivity reaction during a barium enema. Am J Roentgenol 1989; 153: 275-6. 7. Janower ML. Hypersensitivity reactions after barium studies of the upper and lower gastrointestinal tract. Radiology 1986; 161: 139-40. 8. Jones SA. Anaphylaxis from rectal lubricant jelly (brief clinical observation). Am J Med 1988; 85: 890. Submitted
Journal
November
29, 1989, and accepted in revised form March 26, 1990
of Medicine
Volume
89
251
