Early cutaneous warning signs of compartment syndrome due to iohexol extravasation

Dear Editor,

A 63-year-old woman arrived at the dermatology outpatient clinic complaining of swelling, redness, and blister formation in areas of her left extremity that were painful. The patient reported taking an injection for contrast-enhanced computed tomography (CT) 1 day before the onset of lesions to assess uterine cancer. A similar occurrence occurred 3 years ago, but it went away when the injection was stopped while she was being evaluated for uterine cancer. Examining the left extremities showed edema and erythema up to the midarm, along with blister formation over the injection site, the cubital fossa [Figure 1a and b]. The hand felt warm and the radial and ulnar arteries had intact pulses. The fingers’ capillary refill time was 1 s. Except for elevated erythrocyte sedimentation rate, complete blood count with seven hemoglobin, all regular investigations and serum creatine phosphokinase were completed and found to be normal. Human immunodeficiency virus, hepatitis B virus, and hepatitis C virus viral testing turned out negative. Clinical differentials were made, comprising cellulitis, acute compartment syndrome (ACS), posttraumatic edema, and insect bite reaction. Naranjo’s Scale and the WHO ADR probability Scale were used to determine causality and the results showed that the possibility of the offending agent causing this incident was probable. Hence, the final diagnosis of impending ACS was made due to iodinated contrast media. It was not possible to measure intracompartmental pressure. For 5 days, the patient was given oral prednisolone 40 mg in addition to PPIs, paracetamol, and antihistamines (levocetrizine 5 mg). The patient was instructed to return in 6 h if symptoms continued because ACS is a surgical emergency. Few blisters remained over the cubital fossa at follow-up, although there was improvement in terms of a reduction in edema (70%), erythema (80%), and pain (90%), as measured by the Visual Analogue Scale [Figure 2]. The blister was punctured with a needle and the same course of treatment was recommended for a further 5 days. An magnetic resonance imaging was carried out to look investigate the patient’s complaint.

Figure 1.

(a) Edema and erythema over the left upper extremity up to midarm (black arrow), (b) Blisters over cubital fossa around the injection site (black arrow)

Figure 2.

Posttreatment image showing reduced edema and erythema (black arrow) and few intact blisters at the injection site (white arrow)

Iohexol is a nonionic iodine contrast agent (ICA) used in CT scans and X-rays. It is renowned for having a rather good safety profile.[1] According to the estimates, the overall incidence of hypersensitive reactions following ICA treatment is between 1% and 3%. Immediate reactions occur within 1 h, while delayed reactions (DR) occur after 1 h.[1,2] The most frequent DRs to ICA are toxic epidermal necrolysis and Stevens–Johnson syndrome. Less serious side effects, such as urticaria, skin rash, itching, and injection site eruptions, have also been reported.[2,3] Injection site responses may occur when Iohexol is administered intravenously. Pain, itching, swelling, or redness close to the injection site, like in our case, are the possible symptoms. Rarely, fluid may seep out of the blood vessel and affect surrounding tissues, causing soft-tissue damage and occasionally brachial plexopathy and ACS.[3,4,5] Since ACS is a surgical emergency, early diagnosis and treatment are essential. Before giving a contrast injection, radiologists should carefully review the patient’s allergy history and any previous reactions. Iodixanol and iobitridol can be used; both are less allergenic isoosmolar solutions. To learn more about contrast media, types of reactions, how reactions occur, the validity of ICA skin tests, and treatment options, more number of prospective studies are required.

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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.