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  IN THIS Article
 ::  Abstract
 :: Introduction
 :: Case Report
 :: Discussion
 :: Acknowledgement
 ::  References
 ::  Article Figures

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  Table of Contents     
CASE REPORT
Year : 2014  |  Volume : 60  |  Issue : 1  |  Page : 75-76

Beware of parotitis induced by iodine-containing contrast media


1 Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission08-Nov-2013
Date of Decision30-Oct-2013
Date of Acceptance08-Nov-2013
Date of Web Publication14-Mar-2014

Correspondence Address:
K Jayantee
Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.128820

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 :: Abstract 

Carotid stenting is being increasingly used for revascularization of the moderate to severe carotid stenosis and thus its complications are increasingly being recognized. We report a rare complication of induced by iodine contrast in a patient undergoing carotid stenting. s. A 51 year old man after the second stenting developed multiple small infarcts in spite of the distal device. He also had painful parotid swelling which improved within a week. One should be aware of iodine parotitis s in the patients undergoing iodinated contrast study.


Keywords: Carotid stenting, iodine, iodine contrast, infarction, mumps, parotitis


How to cite this article:
Kohat A K, Jayantee K, Phadke R V, Muthu R, Singh V, Misra U K. Beware of parotitis induced by iodine-containing contrast media. J Postgrad Med 2014;60:75-6

How to cite this URL:
Kohat A K, Jayantee K, Phadke R V, Muthu R, Singh V, Misra U K. Beware of parotitis induced by iodine-containing contrast media. J Postgrad Med [serial online] 2014 [cited 2019 Nov 15];60:75-6. Available from: http://www.jpgmonline.com/text.asp?2014/60/1/75/128820



 :: Introduction Top


Carotid artery stenting is recommended for significant stenosis in patients who are too unwell to undergo carotid endarterectomy or where local surgical expertise is suboptimal or perioperative mortality is more than 6%. Stenting is regarded as a safe procedure and the local and procedural complications like perforation, dissection, hemorrhage, distal embolization, and stroke are uncommon. To reduce distal embolization by plaque or debris, emboli protection devices are used. During angiography, use of iodine contrast may result in allergic reactions, nephropathy, and rarely parotitis. [1],[2] We report in this paper, a patient with iodine parotitis following carotid stenting.


 :: Case Report Top


A 51-year-old male, presented with left hemiparesis and left inferior quadrantanopia. He was ambulant and had mild hemiparesis (grade 4) with normal sensation. The right carotid artery was not palpable; no bruit was heard on either side. His lipid profile and liver and kidney function tests were within normal limits. Carotid Doppler revealed near total occlusion of right carotid and 75% occlusion of left carotid artery. The cervical part of right internal carotid artery (ICA) could not be visualized on magnetic resonance angiography (MRA). On magnetic resonance imaging (MRI), there was anterior and posterior watershed territory infarction on the right and anterior watershed territory infarction on the left. He underwent carotid artery stenting initially on the right side. Five days prior to stenting, dual antiplatelet cover was given. Predilation with 3.5 mm coronary balloon was done before stent placement. Self-expanding carotid stent 8-6 mm × 30 mm (Protιgι, EV-3) was placed in the right carotid artery with strict aseptic precaution under local anesthesia using distal protection (Spider x EV 3). Post-dilation was not used. Nonionic iodine dye iopamidol 370 was used during the procedure. The procedure was uneventful and patient was discharged after 4 days on aspirin, clopidogrel, statin, and antihypertensives.

Six weeks later, he underwent carotid stenting on the left side (8-6 mm × 30 mm Protιgι, EV-3) with a distal protection device (Spider x EV3). Heparin 5,000 units was given. The femoral sheath was removed the same evening. He then developed a right hemiparesis and difficulty in speaking. A repeat cranial MRI revealed multiple small infarcts in cortical and subcortical regions. He also complained of dryness of mouth, painful chewing and painful swelling of both parotid glands. His immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) for mumps virus was negative. The pain and swelling in the parotid glands subsided with conservative treatment in the next 5 days [Figure 1]. The hemiparesis also improved spontaneously within a week. The patient was discharged on aspirin, clopidogrel, an antihypertensive, and a statin.
Figure 1: Photograph of the patient showing parotid swelling (arrow)

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 :: Discussion Top


Our patient had two complications of carotid stenting: Cerebral infarction and iodine induced parotitis. The reported incidence of periprocedural stroke during carotid stenting is 4.1%. The debris from the atheromatous plaque can detach during the procedure and can lead to a transient ischemic attack, stroke, or myocardial infarction. [3] Lacunar infarction in the perforator territory is difficult to explain as most of the periprocedural emboli go to the larger cortical vessels. It is not clear at what stage the emboli were dislodged. It may be during the placement of the distal protection device or may have occurred after the procedure when the effect of heparin wore off. Guide wire crossing results in release of most of the emboli. [4] Postprocedure heparinization is another possibility that could be considered for 12-24 h, but this can increase the risk of blood brain barrier breakthrough hemorrhage in these patients with chronic bilateral ICA stenosis. Distal protection device is used to protect embolic event during predilation; however, embolism is possible during initial protection device placement or late in the postprocedure period after removal of the device. Stroke risk was seen to be higher in patients with angulation of ICA to common carotid artery more than 60° and lower in those treated with cerebral protection devices. [4] Left ICA stenting has higher stroke rate as seen in our patient too. [4]

Bilateral parotid swelling may occur in bacterial or viral parotitis, Sjogren's syndrome, diabetes, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), sarcoidosis, leprosy, lymphoproliferative diseases, cirrhosis, bulimia, Wegner's granulomatosis, drugs such as iodine, propyl thiouracil, and organophosphorus poisoning. [5] Our patient did not have clinical or investigational findings to support diagnoses other than exposure to iodine contrast. Iodine parotitis is characterized by rapid bilateral enlargement of salivary glands within a few minutes to 5 days after contrast administration. Facial nerve paralysis and enlargement of the thyroid and lacrimal glands are also described with iodide parotitis. [6] The reaction seems to be idiosyncratic or related to toxic accumulation of iodide in the ductal system of salivary glands leading to mucosal swelling, ductal obstruction, and inflammation of the salivary glands. [6] It is possible that our patient got sensitized to iodine in the first stenting and he reacted in the second stenting procedure. [7] Iodine parotitis has been described with both ionic and nonionic agents. Iodine is mainly excreted in urine and very small fraction is excreted in saliva, sweat, and tears. Impaired renal excretion leads to deposition of contrast media in the salivary glands. Our patient; however, had normal renal function but he was fasting prior to the procedure which might have resulted in dehydration making him prone to iodine toxicity. The risk for parotitis is more if the serum iodide level is more than 10 mg/100 ml. [1] There is no definitive treatment of iodine parotitis. It is a self-limiting entity and the current management is largely supportive using analgesics. Patients who have renal impairment may benefit from dialysis. Recurrence is not uncommon with subsequent administration of contrast medium. Our patient developed multiple infarcts and iodine parotitis following carotid stenting, both of which recovered spontaneously.


 :: Acknowledgement Top


We thank Mr. Rakesh Kumar Nigam for secretarial help.

 
 :: References Top

1.Capoccia L, Sbarigia E, Speziale F. Monolateral sialadenitis following iodinated contrast media administration for carotid artery stenting. Vascular 2010;18:34-6.  Back to cited text no. 1
    
2.ten Dam MA, Wetzels JF. Toxicity of contrast media: An update. Neth J Med 2008;66:416-22.  Back to cited text no. 2
    
3.Gray WA, Hopkins LN, Yadav S, Davis T, Wholey M, Atkinson R, et al. ARCHeR Trial Collaborators. Protected carotid stenting in high-surgical-risk patients: The ARCHeR results. J Vasc Surg 2006;44:258-68.  Back to cited text no. 3
    
4.Naggara O, Touzé E, Beyssen B, Trinquart L, Chatellier G, Meder JF, et al. EVA-3S Investigators. Anatomical and technical factors associated with stroke or death during carotid angioplasty and stenting: Results from the endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S) trial and systematic review. Stroke 2011;42:380-8.  Back to cited text no. 4
    
5.Lohiya R, Sangle S. Uncommon manifestation of organophosphorus poisoning. J Postgrad Med 2011;57:224-5.  Back to cited text no. 5
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6.Bohora S, Harikrishnan S, Tharakan J. Iodide mumps. Int J Cardiol 2008;130:82-3.  Back to cited text no. 6
[PUBMED]    
7.Wyplosz B, Scotté F, Lillo-Le Louët A, Chevrot A. Recurrent iodide mumps after repeated administration of contrast media. Ann Intern Med 2006;145:155-6.  Back to cited text no. 7
    


    Figures

  [Figure 1]

This article has been cited by
1 Heparin/iopamidol
Reactions Weekly. 2016; 1585(1): 137
[Pubmed] | [DOI]



 

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