Characterization of Iodide-induced Sialadenitis: Meta-analysis of the Published Case Reports in the Medical Literature

Very rare adverse reactions to intravascular contrast media: From Kounis to sweet syndrome

Intravascular administration of contrast media may inadvertently result in adverse drug reactions (ADR) including selected hypersensitivity reactions. This review highlights some very rare ADR, aiming to alert imaging physicians to these conditions and to prompt adequate management. This is particularly relevant for Kounis syndrome, an immediate hypersensitivity reaction involving the coronary arteries. The acute management of Kounis syndrome can be challenging, as it requires continued contrast media administration, while balancing the simultaneous coronary reperfusion that requires vasodilatation with anti-allergic treatment that may involve vasoconstrictor agents. For other adverse reactions, referral to a drug allergy specialist is highly recommended to assess causality and identify safe alternatives. CLINICAL RELEVANCE STATEMENT: Cardiologists and radiologists must recognize the key symptoms of these very rare adverse reactions to contrast media to promptly initiate the appropriate therapy and refer patients for allergological evaluation, ideally within 1-6 months after the reaction.

Incidence and Risk Factors of Contrast-Induced Sialadenitis after Therapeutic Neuroendovascular Procedures

BACKGROUND AND PURPOSE

Swelling of the salivary glands, known as contrast-induced sialadenitis (CIS), is an adverse reaction to iodide contrast agents. However, the incidence and risk factors of CIS after therapeutic neuroendovascular procedures have not yet been established.

MATERIALS AND METHODS

Demographic and procedural factors that may influence the development of CIS were retrospectively analyzed to identify the incidence and risk factors of this condition. A total of 780 patients who underwent therapeutic neuroendovascular procedures between January 1, 2022 and December 31, 2022 were investigated. The risk factors affecting CIS were analyzed by using multivariate logistic regression, and the quantitative degree of association between the volume of contrast administered and occurrence of CIS was determined by using the receiver operating characteristic (ROC) curve.

RESULTS

The incidence of CIS after therapeutic neuroendovascular procedures was 4.2%. Multivariate logistic regression analysis showed that female sex (OR = 4.420, 95% CI: 1.377-14.190, P = .013), volume of contrast administered (OR = 1.007, 95% CI: 1.003-1.101, P < .001), and guiding catheter tip located within the external carotid artery (ECA) (OR = 8.701, 95% CI: 3.459-21.885, P < .001) were independently associated with CIS occurrence after therapeutic neuroendovascular procedures. The volume of contrast administered had an area under the ROC curve of 0.723 (95% CI: 0.635-0.810; P < .001), and the optimal cutoff value of the volume of contrast administered was 205 mL (sensitivity: 0.49, specificity: 0.87).

CONCLUSIONS

We observed CIS in 4.2% of our patients undergoing therapeutic neuroendovascular procedures. This represents a higher incidence than previously reported. Female sex, volume of contrast administered, and guiding catheter tip located within the ECA are associated with CIS incidence.

Adverse reactions to radiological contrast media: Prevention and treatment

Radiological contrast media, both iodinated and gadolinium-based, can lead to adverse reactions. Type A reactions are related to the pharmacological characteristics of the contrast, including side, secondary and toxic effects. Post-contrast acute kidney injury is the most frequent adverse reaction to iodinated contrast media. Less frequently, thyroid, neurological, cardiovascular, haematological, and salivary gland effects are also detected. With gadolinium-based contrast agents, nausea is the most frequent reaction, but there is also a risk of producing nephrogenic systemic fibrosis and cerebral deposits of uncertain significance. The most effective way of avoiding type A reactions is to decrease the dose and frequency of contrast media administration, especially in patients with pre-existing renal insufficiency. To prevent post-contrast acute kidney injury, adequate hydration of the patient should be maintained orally or intravenously, avoiding prolonged periods of liquid fasting. On the other hand, hypersensitivity reactions are dose-independent and clinically can range from mild cutaneous reactions to anaphylaxis. This article proposes an algorithm that differentiates between nonspecific reactions and true hypersensitivity reactions, as well as levels of severity. It also provides a treatment scheme for immediate reactions adjusted to the severity level, with a focus on the management of anaphylaxis and an early intramuscular administration of adrenaline. Finally, it sets out recommendations for the management of patients with previous hypersensitivity reactions who require elective or urgent contrast administration, favouring the use of alternative contrast media with confirmed tolerance instead of the indiscriminate use of premedication.

Contrast Induced Sialadenitis with Low Volume Non-ionic Contrast in a Patient with Cerebral Venous Sinus Thrombosis

Background: Contrast Induced Sialadenitis or Iodide Mumps refers to non-suppurative inflammation of salivary glands following intravenous iodinated contrast administration. It is a rare adverse effect of iodinated contrast with only a few cases reported worldwide. It is hypothesized to be an idiosyncratic reaction due to toxic accumulation of iodine in salivary glands. Case Report: We report a case of a 40-year-old female patient who underwent CECT brain after intravenous injection of 40ml of non-ionic iodinated contrast and developed symmetric painless swelling in bilateral submandibular triangles within five hours of contrast administration. Ultrasound with color doppler and MR imaging was performed which confirmed the diagnosis of contrast induced sialadenitis. Sialadenitis was managed conservatively and resolved slowly over eight days. Conclusion: Though it is a rare self-limiting adverse event of iodinated contrast, it must be known to the radiologist as well as the clinician to avoid unnecessary work up and manage the patient better.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03575-x.

Management of iodine contrast induced salivary gland swelling (sialadenitis): experiences from an observational study

BACKGROUND

Iodine contrast-induced sialadenitis (CIS) is an uncommon adverse effect to iodine-containing contrast exposition. There is scarce literature about its clinical course and demography.

OBJECTIVES

(1) To determine the clinical course and management of CIS. (2) To understand if CIS might be as rare as reported.

MATERIAL AND METHODS

A 2-month prospective observational study was conducted in the emergency room of a tertiary institution. ENT physicians on call received clinical formation about CIS while emergency physicians did not. During the study period, patients admitted at the emergency room matching the clinical and radiological features of CIS, were included. Information about demographics, iodine exposure, diagnostic workup, clinical course, and management was analyzed.

RESULTS

ENT physicians on call detected 4 cases, however, emergency physicians did not. Patients were aged 68-76 years and presented a bilateral submandibular gland swelling debuting 12 to 72 h after an exposure to iodinated contrast. Characteristic ultrasonographic findings supported the diagnosis and the clinical course was self-limited after 60 to 150 h.

CONCLUSIONS AND SIGNIFICANCE

Physicians' familiarity with CIS allows its detection and avoids costly and potentially harmful therapeutic/diagnostic efforts. The incidence is probably underestimated; however, further incidence studies are needed.

Iodide mumps in a patient with liver cirrhosis without renal impairment

Salivary gland enlargement following iodine-containing contrast media (ICCM), also known as iodide mumps (IM), is a rare condition characterized by swelling of submandibular glands with complete restitutio ad integrum. It manifests itself without pain, fever, dyspnea, rapid heart rate or low blood pressure. The pathogenesis is unknown, it may be an idiosyncratic reaction or toxic due to deposition of iodide in the salivary glands. IM is a condition more frequent in end stage renal disease because of iodine excretion by kidneys but it can also occur in patients without end stage renal disease. In this study, we described a 71-year-old patient with liver cirrhosis due to hepatitis B virus with normal renal function that after administration of ICCM developed IM.

Akute Schwellung im Halsbereich nach iodhaltigem Kontrastmittel – der oft unerkannte Iodmumps anhand von drei Fallbeispielen

Es werden drei Patientinnen vorgestellt, die zur Abklärung einer akuten Halsschwellung nach einer Untersuchung mit iodierten Kontrastmitteln zugewiesen wurden. Bei allen drei war ein akutes Angioödem vermutet worden, das allerdings nicht ausreichend auf Antihistaminika und Kortikosteroide ansprach. Es wurde schließlich ein sog. „Iodmumps“ oder Iod-assoziierte Sialoadenopathie diagnostiziert. Sonografisch und histologisch finden sich lediglich ein Ödem der Speicheldrüsen, hingegen keine Hinweise für eine ausgeprägte entzündliche Reaktion. Diese Komplikation ist nicht so selten und wird von Iod selbst ausgelöst, wie mit einer Provokation mit Iod-Kaliumiodid (Lugolʼscher Lösung) nachgewiesen werden konnte. Die pathophysiologisch ungeklärte Iod-assoziierte Sialoadenopathie wird somit als idiosynkratische Reaktion klassifiziert.

A case of acute bilateral iodine-induced submandibular sialadenitis: Ultrasound findings

Acute sialadenitis is a rare adverse reaction to iodine-based contrast agents. Ultrasound (US) is usually the preferred imaging method to evaluate the salivary glands; along with clinical and anamnestic data, US allows the diagnosis of contrast-induced sialadenitis. We present a case of acute bilateral submandibular sialadenitis induced by intravenous administration of iodine-based contrast media for a contrast-enhanced computed tomography scan diagnosed by US.

Iodide-induced sialadenitis following percutaneous coronary intervention: A case report

Iodide-induced sialadenitis is a rapid, painless enlargement of salivary glands following administration of iodine-based contrast agents. It has been reported numerous times in the literature; however, the pathogenesis remains unclear. This case report demonstrates how this may present following a coronary angiogram.

Recurrent neck swelling after iodinated contrast media administration

A 74-year-old male with an abdominal aortic aneurism reported 2 episodes of neck swelling 16 hours after an abdominal CT with iodinated contrast media that reappeared in a subsequent CT, although the use of pre-medication. The tests used to exclude the hypersensitivity hypothesis where negative and once a new CT where needed we decided to do it with close monitoring. We performed a facial picture and cervical ultrasound exam before and 24 hours after the exam. The neck swelling and the ultrasound findings 24 hours after the CT made the diagnosis of contrast induced sialoadenitis possible. Contrast induced sialadentis is an uncommon adverse reaction to iodinated contrast media. As it presents with neck swelling it is important to exclude a hypersensitivity reaction because it's further limitations and make a differential diagnosis.

Contrast-Induced Sialadenitis of the Sublingual Glands

Contrast-induced sialadenitis (CIS) is a rare, delayed pseudoallergic reaction from iodine containing contrast. Previously reported cases of CIS demonstrated that the two major salivary glands (parotid and submandibular) can be affected. The initial encounter of this entity can raise alarms to physicians as the differential diagnoses include serious infectious and inflammatory conditions such as Ludwig's angina and angioedema. Subsequently, it may lead to unnecessary testing and increased healthcare cost. Here we present a 60-year-old male who presented with bilateral sublingual gland swelling following exposure to iodinated contrast. With timely diagnosis by the otolaryngologist, the patient received conservative management that led to a full resolution within a few days. To date, this is the first case of CIS only involving the sublingual glands. We conclude that CIS can involve any of the major salivary glands.