Introduction: Severe reactions to iodinated contrast agents are uncommon, and among those, true anaphylaxis is rare. Most cases involve cutaneous or respiratory symptoms; progression to disseminated intravascular coagulation (DIC) is exceptionally unusual. A literature review by Gelbenegger et al. (2024) noted only a single previously reported case of DIC secondary to anaphylaxis. Here, we present a patient who suffered cardiac arrest shortly after contrast exposure, later found to have developed fulminant DIC.
Description: A 56-year-old woman with BRCA2-positive ovarian cancer, status post total laparoscopic hysterectomy and salpingo-oophorectomy, presented for surveillance imaging. She had completed several cycles of carboplatin/paclitaxel and had no known allergies. Immediately following contrast administration for CT imaging, she developed acute cardiovascular collapse and suffered pulseless electrical activity arrest. Return of spontaneous circulation was achieved following ACLS. She was administered corticosteroids and underwent evaluation for ECMO.
Laboratory studies revealed leukocytosis, thrombocytopenia, elevated INR, low fibrinogen, and markedly elevated d-dimer—findings consistent with acute consumptive coagulopathy. Serum tryptase was significantly elevated, supporting an anaphylactic etiology. Imaging revealed mediastinal, retroperitoneal, and soft tissue hemorrhage, but no evidence of malignancy recurrence. Despite vasopressors and massive transfusion, she progressed to refractory shock. Goals-of-care discussions led to transition to comfort measures.
Discussion: Mechanistically, anaphylaxis can trigger DIC through cytokine release, thrombin generation, and systemic endothelial injury. Prior cases of anaphylaxis-induced DIC have been reported in perioperative and obstetric settings (Kuczkowski, 2003; Yamashita & Matsumoto, 2021), but reports involving contrast-induced reactions are exceedingly rare.
This case underscores a rare but catastrophic sequence: contrast-induced anaphylaxis leading to cardiac arrest and DIC. Clinicians should maintain vigilance for coagulopathy in severe anaphylaxis and consider early serum tryptase testing to support diagnosis.
