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• W4387268239 abstract "SESSION TITLE: Critical Care Case Report Posters 32 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Oral barium sulfate is commonly used in videofluoroscopy and is a rare cause of anaphylaxis, with an incidence of less than one in two million.1 A handful of case reports have described anaphylaxis to barium, specifically due to two additives: carboxymethylcellulose1 and, even more rarely, carrageenan.2 We describe the case of a patient who developed circulatory collapse following barium videofluoroscopy, concerning for fatal anaphylaxis due to retained antigen. CASE PRESENTATION: A 60 year old woman was hospitalized in December with plasma cell leukemia. She received chemotherapy and her hospitalization was complicated by numerous infections, typhlitis, and dysphagia. She was evaluated via videofluoroscopy in January which she tolerated well. In March she underwent repeat videofluoroscopy during which barium was administered between 9-9:30AM. Around 12PM she became acutely aphasic in the setting of hypotension. Following administration of crystalloid and initiation of norepinephrine her blood pressure normalized and she complained of generalized abdominal pain and lightheadedness. The patient was transferred to the ICU where she endorsed dyspnea despite normal SpO2. On exam she had no skin changes, lungs were clear to auscultation, and abdomen was soft. Labs were notable for rising leukocytosis, elevated lactate and anemia. She received crystalloid, pRBCs and broad spectrum antibiotics. She was intubated and vasopressors were up-titrated to maximum doses of norepinephrine, vasopressin and phenylephrine. An arterial line was placed and mean arterial pressures (MAP) were in the 30s with extremely low diastolic pressures. Given her acute decompensation and refractory hypotension, concern was raised for anaphylaxis. IV diphenhydramine, hydrocortisone, and code dose epinephrine were administered with improvement in MAP to >70. X-ray revealed contrast in the small-bowel and toxicology was contacted due to concern for ongoing anaphylaxis in the setting of retained barium; they recommended polyethylene glycol. Unfortunately the patient was persistently hypotensive despite four vasopressors, epinephrine boluses and methylene blue. She developed fixed and dilated pupils, suggesting cerebral herniation, and ultimately expired. DISCUSSION: Several features of this case support the diagnosis of anaphylaxis including: abdominal pain, dyspnea without hypoxia, shock with severely low diastolic pressures, and robust response to epinephrine. It is important to note that the barium our patient received didn't contain carboxymethylcellulose, the more commonly cited antigen in case reports of anaphylaxis to barium formulations. It did contain carrageenan, a more rare culprit of anaphylaxis.2 Perhaps the most important feature of this case is the possibility of ongoing anaphylaxis in the setting of retained barium antigen. To this point, intestinal mast cell levels have been correlated with severity of oral antigen-induced anaphylaxis in animal models.3 Our patient's history of typhlitis raises the question of pre-existing mucosal impairment and how this may have predisposed her to such a severe reaction. CONCLUSIONS: This case demonstrates multiple clinical features that should raise suspicion for anaphylaxis. It highlights the importance of continuing to investigate adverse reactions to widely used compounds in barium solutions, including carrageenan. Finally, it is imperative to recognize the possibility of ongoing anaphylaxis in the setting of retained oral antigens and quickly identify options for eliminating them. REFERENCE #1: Muroi N, Nishibori M, Fujii T, et al. Anaphylaxis from the carboxymethylcellulose component of barium sulfate suspension. N Engl J Med. 1997;337(18):1275–1277 REFERENCE #2: TARLO, S., DOLOVICH, J., & LISTGARTEN, C. (1995). Anaphylaxis to carrageenan: A pseudo–latex allergy. Journal of Allergy and Clinical Immunology, 95(5), 933–936. https://doi.org/10.1016/s0091-6749(95)70091-9 REFERENCE #3: Ahrens, R., Osterfeld, H., Wu, D., Chen, C.-Y., Arumugam, M., Groschwitz, K., Strait, R., Wang, Y.-H., Finkelman, F. D., & Hogan, S. P. (2012). Intestinal mast cell levels control severity of oral antigen-induced anaphylaxis in mice. The American Journal of Pathology, 180(4), 1535–1546. https://doi.org/10.1016/j.ajpath.2011.12.036 DISCLOSURES: No relevant relationships by Hannah Kerman No relevant relationships by Zoe Mackay No relevant relationships by Julia Munchel" @default.
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• W4387268239 date "2023-10-01" @default.
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• W4387268239 title "LETHAL ANAPHYLAXIS AFTER VIDEO FLOUROSCOPY SWALLOW STUDY" @default.
• W4387268239 doi "https://doi.org/10.1016/j.chest.2023.07.1584" @default.
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