000681 - Severe anaphylactic shock triggered by gadolinium-based contrast agent during skin testing in a high-risk patient

Title

Severe anaphylactic shock triggered by gadolinium-based contrast agent during skin testing in a high-risk patient

Background

Immediate hypersensitivity reactions to gadolinium-based contrast agents (GBCAs) are considered rare but can be severe, especially in patients with a history of multiple drug-induced anaphylaxis. Skin testing is often performed to assess tolerance, although its safety and predictive value remain controversial.

Case Presentation

We report the case of a 54-year-old woman with a history of two previous anaphylactic shocks to amoxicillin and iodinated contrast media used for urography, as well as acute urticaria after amoxicillin/clavulanate. Her medical history included moderate controlled bronchial asthma, arterial hypertension, chronic gastritis, and obesity. The patient was referred for allergy evaluation prior to adrenal magnetic resonance imaging requiring gadolinium-based contrast.

Skin prick tests with Prohance® (gadoteridol) at 1:10 and undiluted concentrations were negative. Intradermal testing at 1:10 dilution was initially negative. Fifteen minutes later, the patient developed progressive local pruritus, erythema, and edema at the intradermal test site, followed by systemic symptoms including dizziness, hypotension (80/40 mmHg), hypoxemia (SpO₂ 80%), and altered general condition, consistent with anaphylactic shock.

Immediate treatment with intravenous adrenaline, hydrocortisone, dexamethasone, and fluid resuscitation was initiated, leading to rapid hemodynamic and respiratory stabilization. The patient was transferred to the intensive care unit and subsequently discharged in stable condition with strict recommendations to avoid contrast agents and to carry an epinephrine auto-injector.

Conclusion

This case highlights that gadolinium-based contrast agents can induce severe anaphylaxis even during allergy skin testing, particularly in patients with a history of multiple drug-induced hypersensitivity reactions. Extreme caution, strict indications, and emergency preparedness are mandatory when performing contrast media testing in high-risk patients.