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Hyperthermia After Metrizamide Myelography

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Hyperthermia After Metrizamide Myelography 649 Hyperthermia after Metrizamide Myelography Joseph T. Latack,' Trygve O. Gabrielsen, James E. Knake, Stephen S. Gebarski, and Peter J. Yang Metrizamide is a water-soluble, nonionic, iodinated contrast Discussion agent that has gained general acceptance for myelography. Hyperthermia may be secondary to excess heat production, We present a patient who developed severe hyperthermia impairment of the heat dissipating mechanism, or loss of several hours after and apparently related to metrizamide central nervous system control of body temperature. Exces­ myelography. To our knowledge, no similar complication has sive production of heat can be seen with the use of certain been described before [1-7]. drugs that increase body activity (amphetamines, hallucino­ gens), strenuous exercise, infection, hyperthyroidism, and malignant hyperthermia [8-12]. In malignant hyperthermia, Case Report various anesthetic agents are thought to activate an under­ A 68-year-old man with carcinoma of the prostate was seen with lying metabolic defect, which results in violent muscle con­ increasing neck pain, right shoulder paresthesias, and a pathologic tractions. Large amounts of heat are produced, raising the compression fracture of the C5 vertebral body. After a C1-C2 punc­ body temperature at a rate as high as 1°C every 5 min [13]. ture, 8 ml of metrizamide in a concentration of 300 mg Ilml was Impairment of the heat-dissipating mechanism occurs with injected intrathecally in fractions under fluoroscopic control. The sweat-gland dysfunction, drugs such as anticholinergic patient moved excessively during the procedure because of his agents that inhibit sweating, hot and/or humid environment, severe neck pain . Fluoroscopic screening showed that a large amount of contrast material spilled intracranially along the clivus up to the obesity, cardiovascular disease, and extremes of age [8-13]. suprasellar cisterns. The myelogram demonstrated an anterior ex­ Loss of central nervous system control of body temperature tradural mass at the C5 level , with moderate obstruction to the usually results from hypothalamic lesions but occasionally caudad flow of the metrizamide. The patient was then stood nearly from an abnormality of the brainstem or spinal cord [14]. upright on the tilt table for 3-5 min , after which no metrizamide could Laboratory animal experiments point to the complex and be seen fluoroscopically in the intracranial or cervical regions . At the poorly understood hypothalamus as the principal thermostat conclusion of the procedure, the patient complained only of a mild of the body. Cells involved with temperature control in the headache. Prophylactic oral anticonvulsant therapy with phenytoin anterior hypothalamus have primarily a receptor function . (Dilantin) was begun because of the relatively large intracranial spill They receive information from afferent neural pathways, bac­ of metrizamide. The patient was instructed to remain still in bed with terial pyrogens, and other substances in blood , as well as his head raised 20°-30° for the next 8 hr. blood temperature itself [15]. In the posterior hypothalamus About 5 hr after the procedure, the patient developed a tempera­ ture of 40°C. Eleven hr after the myelogram, it rose to 41°C and cells receive and integrate the thermal information from the rapidly peaked at 42 .5°C. During this severe hyperthermic episode, anterior hypothalamus and then relay stimuli to the peripheral the patient became comatose, had a respiratory arrest, and required nerves that initiate shivering, sweating, vasoconstriction, and intubation. Cooling measures were begun immediately, and the pa­ other heat-regulatory maneuvers [16]. Since warm receptor tient's temperature quickly came down to 40°C and was normal 24 cells are more numerous than cold receptor cells in the hr after the myelogram. He awoke without detectable neurologic anterior hypothalamus, a destructive lesion involving the en­ abnormality when his temperature returned to normal. An apparently tire anterior hypothalamus in laboratory animals will result in traumatic lumbar puncture 8 hr postmyelography showed bloody hyperthermia [15]. A selective lesion of the medial anterior cerebrospinal fluid (CSF) with an appropriate red cell-white cell ratio, hypothalamus, where most cold receptor cells are located, normal glucose concentration, and a protein concentration of 188 produces hypothermia [14]. A lesion of the posterior hypo­ mg/dl. Cultures were negative from CSF, blood, urine, sputum, and a chronic leg sinus tract secondary to old osteomyelitis. thalamus, where signals for both heat production and dissi­ Radiation therapy to the cervical spine was started, and the patient pation originate, usually produces a poikilothermic animal, was discharged from the hospital about 1 week after admission that is, the body temperature fluctuates with the ambient without any further complaints or complications. temperature [17]. Received December 20 , 1983; accepted after revision April 11 , 1984. , All authors: Division of Neuroradiology. Department of Radiology, University of Michigan Hospitals, Ann Arbor, MI 48109. Address reprint requests to J. T. Latack. AJNR 5:649-651, September/October 1984 0195-6108/84/0505-0649 $00.00 © American Roentgen Ray Society 650 LA TACK ET AL. AJNR:5, Sept/Oct 1984 In humans, lesions of the hypothalamus may also lead to myelogram and clear 1-5 days later (40] . There is no specific thermoregulatory disorders. Postoperative hyperthermia that treatment for aseptic meningitis. The rapid appearance of clears in a few weeks is not an uncommon problem after symptoms, a temperature of 42.5°C, coma, and no definite surgery around the third ventricle (18]. Tumors, especially CSF leukocytosis in our patient make aseptic meningitis a craniopharyngiomas (19, 20], vascular accidents (21], trauma very unlikely diagnosis. (22], agenesis of the corpus callosum (23], Wernicke disease Many review articles indicate that most complications and (24], and infection (25] have all been reported to cause side effects of metrizamide are mild and self-limited (1-7]. persistent thermal regulatory disorders (26-29]. Phenothi­ Our case of severe hyperthermia after metrizamide myelog­ azine drugs, apparently acting on the posterior hypothalamus, raphy was life-threatening and had to be correctly recognized can render patients poikilothermic, and hyperthermic deaths and treated as a dire emergency. during heat waves have been reported in patients taking phenothiazine medications (30- 33]. ACKNOWLEDGMENTS The most likely cause of hyperthermia in our patient was interference with the thermoregulatory function of the hypo­ We thank Larry Junck for manuscript review and Sandra Ressler thalamus. Its occurrence 5 hr after spinal intrathecal injection for manuscript preparation. of metrizamide, when the intracranial subarachnoid concen­ tration of metrizamide could be expected to be relatively high REFERENCES (34], strongly incriminates metrizamide diffusion into the hy­ pothalamus as the cause of the hyperthermia. Since injection 1. Baker RA, Hillman BJ, McLennan JE, Strand RE, Kaufman SM . of various substances into the hypothalamus in experimental Sequelae of metrizamide myelography in 200 examinations. AJR animals can cause disturbances in temperature regulation 1978;130 : 499-502 (15-17,35, 36], and brain penetration from CSF by metriza­ 2. Bertoni JM, Schwartzman RJ , Van Horn G, Partin J. Asterixis and encephalopathy following metrizamide myelography; inves­ mide has been demonstrated (34], one can postulate similar tigations into possible mechanisms and review of the literature. penetration of metrizamide from the suprasellar cisterns into Ann Neuro/1980;9:366- 370 the hypothalamus in our patient. The metrizamide then most 3. Hauge 0 , Falkenberg H. Neuropsychologic reactions and other likely caused the described hyperthermia by acting as a side effects after metrizamide myelography. AJNR 1978;3:229- depressant or inhibitor on the warm receptor cells of the 232 anterior hypothalamus. Transependymal absorption from the 4. Oftedal S, Kayed K. Epileptic effects of water soluble contrast third ventricle into the hypothalamus is less likely because media. Acta Radiol {Suppl] (Stockh) 1973;335:45-56 only small amounts of metrizamide normally flow into the third 5. Skalpe 10. Adverse effects of water-soluble contrast media in ventricle after myelography and also because the cerebral myelography, cisternography and ventriculography. A review ventricles with their ependymal lining appear to tolerate me­ with special reference to metrizamide. Acta Radiol {Suppl] (Stockh) 1977;355:359-370 trizamide better than does the brain surface (37, 38]. 6. Sortland 0 , Lundervold A, Nesbakken R. Mental confusion and The differential diagnosis in our patient included aseptic epilepsy following cervical myelography with metrizamide. A meningitis and an infectious source of the fever. An infectious report of a case. Acta Radiol {Suppl] (Stockh) 1977;355:403- source of the fever was believed to be unlikely because of 406 negative blood, urine, CSF, sputum, and leg sinus tract cul­ 7. Gelmers HJ . Adverse side effects of metrizamide in myelography. tures. Fever of an infectious origin usually does not rise to Neuroradiology 1979;18: 119-123 42.5°C unless it involves the central nervous system, that is, 8. Austin MG , Berry JW. Observations on one hundred cases of infectious meningitis, and even then such an elevation would heatstroke. JAMA 1970;161 : 1525-1529 be very unusual. Other
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