NDT Advance Access originally published online on January 18, 2007
Nephrology Dialysis Transplantation 2007 22(4):1250-1252; doi:10.1093/ndt/gfl777
© The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Thyroiditis and iodide mumps following an angioplasty
R. S. Moisey1,
S. McPherson2,
M. Wright3 and
S. M. Orme1
1Department of Endocrinology, 2Department of Radiology and 3Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, LS1 3EX, UK
Correspondence and offprint requests to: S. M. Orme, MBChB, MD, FRCP, Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds, LS1 3EX, UK. Email: Steve.Orme{at}leedsth.nhs.uk
Keywords: contrast media; haemodialysis; iodide mumps; renal failure; thyroiditis
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Case history
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A 51-year-old man on maintenance haemodialysis developed an
acute and dramatic swelling of the thyroid and salivary glands,
following administration of iodine containing contrast media.
He underwent an aortofemoral angioplasty for peripheral vascular
disease requiring 300 ml of Visipaque® 320 contrast media;
the following day he developed a grossly enlarged, tender thyroid
with swelling and tenderness of the sub-mandibular and parotid
salivary glands (
Figure 1). He had refused haemodialysis immediately
following the procedure as he complained of back pain. He subsequently
underwent dialysis 24 h later.
He was apyrexial, his CRP was 81 mg/l (reference range <10)
and ESR 36 mm/h (RR 1–10). An ultrasound confirmed an
enlarged, oedematous thyroid and salivary glands with swelling
of surrounding soft tissue (
Figure 2). He had no dysphagia or
dyspnoea. He had no past history or family history of thyroid
disease. Initial thyroid function tests showed mild hypothyroidism
[TSH 2.1 miu/l (RR 0.2–6.0), FT4 9.7 pmol/l, (RR10.0–25.0)]
that recovered after a few days (TSH 4.2 miu/l, FT4 12.1 pmol/l).
Thyroid peroxidase antibodies and thyrotrophin-binding inhibiting
immunoglobulin were undetectable. We diagnosed acute thyroiditis
and iodide mumps secondary to the iodinated contrast media.
High-dose steroids (prednisolone 40 mg daily) were commenced
and within 48 h the swelling and pain significantly improved.
A repeat US confirmed normal size, echotexture and vascularity
of the thyroid and salivary glands (
Figure 3). His prednisolone
dosage was reduced and discontinued after a total of 2 weeks.
Serial measurements of thyroid function have remained normal.
Serum iodine levels were assayed before and during his second
haemodialysis following the angioplasty and were grossly elevated
(
Table 1). The serum iodine level was repeated 10 days later,
after a further 4 dialysis treatments and remained grossly elevated
(15,313 µg/l).
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Table 1. Serum iodine and iodide levels before and during the second treatment of haemodialysis following the angioplasty. Reference range for serum iodine 50–80 µg/l
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Discussion
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Visipaque® (Iodixanol) is a non-ionic iodine containing
contrast media favoured for its iso-molar properties. With normal
renal function, 97% is excreted unchanged in urine within 24
h. With increasing renal dysfunction, the elimination half-life
is prolonged. Iodinated contrast media contain predominately
organically-bound
iodine with only a tiny amount of inorganic
iodide. It is the
iodide that is metabolically and biologically
important. Visipaque® 320 contains 320 mg of iodine per
ml and between 25 µg to 60 µg of iodide per ml.
In uraemic patients, the retained iodine is subject to deiodination,
increasing the concentration of non-organic ‘free’
iodide [
1]. Iodide concentrations have been shown to be elevated
following the administration of iodinated contrast media in
a patient on haemodialysis [
2]. Iodixanol has a molecular weight
of 1550 Da and is readily dialysable by standard dialysis membranes
[
3]. The manufacturer recommends that patients on renal replacement
therapy undergo dialysis immediately after the use of iodixanol.
We measured iodine levels during our patient's second treatment
with haemodialysis following the procedure. The assay measures
both iodine and iodide: it was not possible to measure iodide
levels separately. The grossly elevated levels of iodine demonstrate
that the elimination of contrast media in renal failure patients
is dramatically delayed. Although iodixanol was eliminated through
the dialysis membrane (A Cobe Centurysystem 3, with a Fresenius
FX10 low flux polysulpone membrane was used at the time) the
level of iodine/iodide remained grossly elevated, despite a
total of 5 dialysis treatments following his angioplasty.
Iodide mumps is a rare complication following iodinated contrast media and was particularly dramatic in this patient. The reaction is idiosyncratic and the aetiology remains unclear. It is likely to be a reaction related to toxic accumulation of iodide in the ductal systems of the salivary glands [4], which are capable of collecting and concentrating high levels of non-organic iodide [5]. Our patient was at an increased risk because of his end-stage renal failure and the delay in dialysis for the first 24 h may have contributed further. This delay was because he had complained of back pain. It is possible that this was secondary to mild pancreatic ‘mumps’, which has an aetiology thought to be similar to iodide induced sialadenitis [6]. As his back pain was self-limiting, no further investigations were performed and we cannot confirm this. The observed transient thyroid dysfunction is a recognized complication of iodinated contrast media and is generally self-limiting [7].
The evidence for steroids is lacking but his reaction was so extreme that we treated him with high-dose prednisolone and his improvement within 48 h was dramatic. Although he underwent dialysis shortly after the steroids were commenced, his rapid recovery, in spite of persistently high levels of contrast media, suggests a benefit. Previous reports describe a rapid onset and resolution of symptoms with no treatment required [8]. One previously published case of iodide mumps and thyroid swelling in a haemodialysis patient reported no improvement with steroids, although the swelling improved rapidly following dialysis [9].
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Conclusion
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Thyroiditis and iodide mumps are rare complications following
iodinated contrast media. It was particularly dramatic in this
patient. He was at an increased risk because of his end-stage
renal failure and the delay in dialysis for the first 24 h may
have contributed further. With the addition of steroids he recovered
within 48 h and remains well. It is recommended that patients
on maintenance haemodialysis should undergo haemodialysis within
24 h of a procedure requiring iodinated contrast media.
Conflict of interest statement. None declared.
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References
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- Rendl J and Saller B. (2001) Schilddrüse und Röntgenkontrastmittel: Pathophysiologie, Häufigkeit und Prophylaxe der jodinduzierten Hyperthyreose. Dt Ärztebl 98:A402–A406.
- Talner LB, Lang JH, Brasch RC, Lasser EC. (1971) Elevated salivary iodide and salivary gland enlargement due to iodinated contrast media. Am J Roentgenol 112:380–382.[Abstract]
- Berg KJ, Rolfsen B, Stake G. (1998) Iodixanol is readily eliminated by hemodialysis. Acta Radiol 39:372–374.[Web of Science][Medline]
- Christensen J. (1995) Iodide mumps after intravascular administration of a non-ionic contrast medium. Case report and review of the literature. Acta Radiol 36:82–84.[Web of Science][Medline]
- Harden RM and Alexander WD. (1968) The salivary iodide trap in man: clinical applications. Proc R Soc Med 61:647–9.[Web of Science][Medline]
- St Amour TE, McLennan BC, Glazer HS. (1986) Pancreatic mumps: a transient reaction to IV contrast media (Case report). Am J Roentgenol 147:188–189.[Free Full Text]
- Hintze G, Blombach O, Fink H, Burkhardt U, Köbberling J. (1999) Risk of iodine-induced thyrotoxicosis after coronary angiography: an investigation in 788 unselected subjects. Eur J Endocrinol 140:264–267.[Abstract]
- Park SJ, Hong HS, Lee HK, Joh JH, Cha JG, Kim HC. (2005) Ultrasound findings of iodide mumps. British Journal of Radiology 78:164–165.[Abstract/Free Full Text]
- Berman HL. (1992) Delaney V. Iodide mumps due to low-osmolality contrast material. Am J Roentgenol 159:1099–1100.[Free Full Text]
Received for publication: 1.11.06
Accepted in revised form: 29.11.06
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