Case Presentation: A 38-year-old woman with a history of Anxiety, Depression and Endometriosis presented for outpatient Magnetic Resonance Imaging (MRI) Pelvis with contrast for evaluation of chronic pelvic pain. Her medications included Alprazolam, Bupropion, Minoxidil, Sertraline and Ethinylestradiol/Levonorgestrel, with known allergies to Penicillin, Sulfa antibiotics and Shellfish. She fasted for four hours and took Alprazolam (0.25 mg) for sedation prior to the study.Gadobutrol (8.7 mL) was administered intravenously and she immediately developed coughing however tolerated the remainder of the MRI. Approximately fifteen minutes post study, she developed lightheadedness, worsening cough, shortness of breath, nausea, vomiting and abdominal pain. On evaluation, she was hypotensive with blood pressure 88/54 mmHg, heart rate 75, hypoxic with oxygen saturation 92% on room air and appeared pale and diaphoretic. She was transferred urgently to the emergency room where she received Methylprednisolone 125 mg IV, Diphenhydramine 50 mg IV, Ondansetron 4 mg IV and Intravenous fluids due to concern for anaphylaxis. Laboratory studies revealed leukopenia (WBC 3.54 k/UL), elevated D-dimer (1.01 Ug/mL), normal BNP (< 10 pg/mL) and negative cardiac enzymes. Electrocardiogram showed normal sinus rhythm without ischemic changes. Chest X-Ray demonstrated perihilar and lower lobe predominant opacities and CT chest with contrast revealed no pulmonary embolism, interlobular septal thickening, bilateral peribronchial and lower lobe ground glass opacities suggesting pulmonary edema for which Furosemide 20mg IV was given. An echocardiogram showed normal left ventricular systolic function with normal wall motion. She received supportive care with supplemental oxygen for persistent hypoxia and additional diuretic dose, with eventual clinical improvement and later discharge.
Discussion: Non-cardiogenic pulmonary edema (NCPE) is a medical emergency caused by changes in the permeability of the pulmonary capillary membrane with or without increased hydrostatic pressure leading to edema and disrupting effective gaseous exchange with resultant acute hypoxic respiratory failure. Common causes of NCPE include acute respiratory distress syndrome, high altitude pulmonary edema, pulmonary embolism, neurogenic pulmonary edema, opioid overdose, re-expansion pulmonary edema and transfusion related acute lung injury. Gadolinium induced NCPE is a rare etiology of this clinical entity with reported incidence ranging between 0.004-0.01%.Gadolinium based contrast agents (GBCAs) are rare, heavy metals, administered intravenously during MRI scans to enhance image quality for improved visibility of inflammation, tumors and blood vessels. While common side effects of GBCAs include nausea, dizziness and headaches, rarer adverse effects include allergic reactions, nephrogenic systemic calcinosis, and gadolinium retention. NCPE as described in our case, affects less than 0.03% of individuals receiving GBCAs. Early detection and appropriate management is critical to prevent mortality. Treatment of respiratory failure associated with NCPE is mainly supportive including supplemental oxygen, diuresis and non-invasive ventilation.
Conclusions: Our case highlights that GBCAs must be used cautiously and only when necessary due to the associated risks. When GBCAs are indicated, maintaining a high index of suspicion for NCPE is crucial for early identification and treatment to improve clinical outcomes.