Abstract Introduction Gadolinium-based contrast agents (GBCAs) have an excellent safety record, but on rare occasions can precipitate life-threatening reactions. NCPE triggered by gadolinium is exceedingly rare, with only a handful of cases reported. We present a case of recurrent NCPE after gadobutrol exposure, highlighting diagnostic challenges and the importance of preventing re-exposure. Case Description A 68-year-old man with metastatic renal cell carcinoma (on nivolumab/ipilimumab) and chronic kidney disease underwent a gadobutrol-enhanced MRI. Within hours, he developed severe hypoxemic respiratory failure with bilateral pulmonary infiltrates on imaging. Echocardiography showed preserved ejection fraction. He was initially treated for possible contrast reaction, but post-admission was presumed multifocal pneumonia/sepsis (given fever and leukocytosis). The patient improved over several days with broad antibiotics, diuresis, corticosteroids, and BiPAP, and was discharged with a diagnosis of pneumonia and sepsis. Four months later, following another gadobutrol-enhanced MRI, he again developed acute respiratory failure about 1-hour post-contrast. He presented with pink frothy sputum and severe hypoxemia. Chest CT revealed diffuse bilateral pulmonary edema with no pulmonary embolus. Cardiac function remained normal and no infection was identified. He was managed with BiPAP, intravenous furosemide, and corticosteroids, and his respiratory status improved within 48 hours. The striking recurrence immediately after contrast confirmed gadolinium-induced NCPE. Discussion Gadolinium-induced NCPE is exceedingly rare (few cases documented). Due to the ambiguity of the first episode (misattributed to pneumonia/sepsis), it led to re-exposure and a second reaction confirming the true etiology. The mechanism suspected to be due to anaphylactoid hypersensitivity reaction causing capillary leak and acute lung injury. Immune checkpoint inhibitor pneumonitis was considered given the patient’s immunotherapy, but it typically occurs after months of treatment and presents as a subacute interstitial pneumonitis rather than abrupt edema. This case demonstrates the importance of recognizing GBCA-induced lung injury and clearly documenting the allergy. After the second episode, gadobutrol was added to the patient’s allergy list, and future contrast studies will be avoided or use alternative agents. Recurrent NCPE after gadobutrol exposure underscores a rare but serious contrast reaction that can mimic pneumonia or cardiogenic pulmonary edema. Clinicians should consider GBCA-induced lung edema in any rapid-onset respiratory failure post-MRI and avoid re-exposure to prevent potentially fatal recurrence. This abstract is funded by: None
Uppalapati et al. (Fri,) studied this question.