Case Report: A hypothesis-generating case of gadolinium retention and persistent symptoms after MRI despite normal renal function in a patient with hypermobile Ehlers-Danlos syndrome

Gadolinium-based contrast agents are commonly used to enhance magnetic resonance imaging. In 2006, Thomas Grobner identified a link between these agents and nephrogenic systemic fibrosis in patients with renal impairment. Gadolinium exposure has also been associated with acute kidney injury, skin plaques, and encephalopathy. Even in patients with normal kidney function, gadolinium may be retained in tissues for prolonged periods after contrast administration. Some patients develop persistent and varied symptoms following exposure. Although Richard Semelka and colleagues proposed the term gadolinium deposition disease, uncertainty regarding causality and pathophysiology has led to the growing adoption of the more neutral description: symptoms associated with gadolinium exposure. We describe a patient with normal renal function and Ehlos-Danlos Syndrome who developed persistent symptoms following a single gadopiclenol-enhanced magnetic resonance imaging study. Serial testing demonstrated prolonged urinary gadolinium excretion despite normal kidney function and an undetectable blood gadolinium concentration. Gadolinium remained detectable in the urine long after the expected period of elimination. The patient's clinical manifestations persisted for an extended period following exposure. We hypothesize that slow redistribution of gadolinium from retained tissue stores contributed to the prolonged urinary excretion observed in this patient. We also discuss theoretical host-susceptibility factors that may have increased her risk of gadolinium retention following gadolinium-enhanced magnetic resonance imaging. However, this case adds to the ongoing discussion regarding the clinical significance and potential mechanisms of persistent gadolinium retention in patients with normal renal function.