Case Report: Severe Contrast Media Extravasation With Compartment Syndrome

Abstract

A 16-year-old male presented to Northside Hospital Atlanta in 1989 with right lower quadrant abdominal pain suspicious for appendicitis. He had recently recovered from Epstein-Barr virus (EBV)-induced infectious mononucleosis. A contrast-enhanced CT scan was ordered. During intravenous administration of iodinated contrast, a severe extravasation occurred, producing compartment syndrome of the upper extremity and secondary soft tissue infection. The extravasation went unrecognized despite the patient's repeated complaints of pain at the IV site. A hand surgeon and an infectious disease specialist were consulted. Amputation was considered before the patient responded to aggressive antibiotic therapy. The abdominal pain that brought him to the hospital resolved on its own, consistent with EBV-associated mesenteric lymphadenitis rather than true appendicitis.

Introduction

Contrast media extravasation occurs in roughly 0.1% to 0.9% of power-injected CT studies. Most cases cause minor swelling or redness and resolve without lasting damage. Severe cases, however, can produce compartment syndrome, tissue necrosis, secondary infection, and limb loss. Severity depends on how much contrast leaks into the tissue, the chemical properties of the contrast agent, and where in the body the leak occurs.

In 1989, most hospitals were still using high-osmolality ionic contrast agents. These are considerably more toxic to tissue than the low-osmolality non-ionic agents that replaced them, because they lyse cells through osmotic injury, constrict local blood vessels, and are directly cytotoxic.

Separately, EBV-induced infectious mononucleosis is a known cause of mesenteric lymphadenitis, a self-limiting inflammation of abdominal lymph nodes that closely mimics acute appendicitis, especially in adolescents and young adults. This case involves both problems.

Case Presentation

Patient History

A 16-year-old male was referred to Northside Hospital Atlanta by his family physician, Rajendra Patel, M.D., based in Marietta, Georgia. The patient had acute right lower quadrant abdominal pain consistent with possible appendicitis, with tenderness near McBurney's point. He had recently recovered from EBV-confirmed infectious mononucleosis. Dr. Patel held privileges at Northside and continued to coordinate the patient's care throughout the hospitalization, including arranging specialist consultations.

Diagnostic Workup

The clinical picture was not definitive enough to proceed directly to surgery, so the team ordered a contrast-enhanced CT of the abdomen and pelvis. This was an early application of the technique. CT had been used for suspected appendicitis only since the late 1980s (Balthazar, 1986) and did not become routine for this purpose until the late 1990s.

An IV was started and iodinated contrast was administered. The patient recalled receiving two large syringes of contrast material.

Extravasation Event

During the injection, the patient told nursing staff that his arm hurt at the IV site. His complaints were not acted on, and the injection continued. Over the following hours, his symptoms worsened: the pain spread through his forearm and hand, the arm began to swell, and the skin turned blue-black. He described a sensation of extreme pressure, as though his hand might burst. By that evening, the pain was severe enough that he was screaming.

The clinical picture was consistent with compartment syndrome caused by large-volume contrast extravasation.

Specialist Consultation

Dr. Patel coordinated two emergent consultations:

Frank Robert Joseph, M.D. Hand and upper extremity orthopedic surgeon. Dr. Joseph trained in hand surgery under Emmanuel B. Kaplan at Mt. Sinai Hospital in New York (1982) and was a founding member of Resurgens Orthopaedics in Atlanta. He assessed the patient for compartment syndrome and whether fasciotomy or amputation was necessary.

Howard J. Cohen, M.D. Infectious disease specialist affiliated with Northside Hospital Atlanta and Emory St. Joseph's Hospital. Dr. Cohen completed his infectious disease fellowship at Yale-New Haven Medical Center (1981-1983). He was brought in to manage secondary infection that had developed in the damaged tissue.

Clinical Course

The treating team discussed amputating the affected limb to stop the spread of infection. They considered a tissue biopsy but decided against it; the tissue was so tense that cutting into it risked uncontrolled decompression or further injury.

For pain, the patient received intramuscular meperidine (Demerol) at frequent intervals. Dr. Cohen directed aggressive IV antibiotic therapy.

Over the next several days, the swelling began to go down. The arm was placed in a sling so the body could gradually reabsorb the extravasated fluid. The patient was eventually discharged with an outpatient follow-up appointment with Dr. Cohen to make sure the infection had cleared. No follow-up with Dr. Joseph was needed because the surgical crisis had passed.

Resolution of Presenting Complaint

By the time the arm crisis was over, the abdominal pain that had brought the patient to the hospital was gone. No appendectomy was performed. The patient is now 53 and has not had a recurrence of the abdominal symptoms. He still has his appendix.

Discussion

Contrast Extravasation and Compartment Syndrome

Published case reports document that severe extravasation injuries can lead to soft tissue loss, scarring, wound infection, abscess, tissue adhesion, limb contracture, and amputation. Compartment syndrome is the most commonly reported severe outcome and is more likely when larger volumes of contrast leak into anatomically tight spaces like the wrist and hand.

Three factors made this case particularly severe:

The contrast agents of 1989. High-osmolality ionic contrast was standard at the time. These agents destroy cells through osmotic pressure, constrict blood vessels locally, and are directly toxic to tissue. The low-osmolality non-ionic agents that replaced them have reduced the rate and severity of extravasation injuries.

The volume. Two large syringes' worth of contrast entering soft tissue is a lot of fluid. Volume is the primary driver of severity in extravasation injuries.

The delay. The patient reported pain at the IV site during the injection. His complaints were not acted on. ACR and ESUR guidelines both state that contrast injection should stop immediately when a patient reports pain, burning, or swelling at the injection site. Stopping early limits how much contrast enters the tissue, and that is the single most important factor in preventing a severe injury. The patient was 16, and his age may have contributed to the dismissal of his symptoms. Age-related pain dismissal in clinical settings is a documented problem in pediatric and adolescent medicine.

Secondary Infection

Secondary infection after contrast extravasation is uncommon but documented. Large volumes of contrast sitting in tissue create conditions favorable to bacterial growth: the tissue is chemically damaged, blood flow is compromised, and the local immune response is impaired. That an infectious disease specialist (Dr. Cohen) was consulted and that the patient followed up with him after discharge, but not the hand surgeon, tells us that infection was a real and ongoing concern in this case.

Probable Cause of the Abdominal Pain

The patient's recent mono provides a straightforward alternative explanation for why he was in the hospital in the first place. EBV causes widespread lymphocyte proliferation, and in the abdomen this can produce mesenteric lymphadenopathy, hepatitis, splenic enlargement, and hyperplasia of gut-associated lymphoid tissue.

Mesenteric lymphadenitis produces sudden right lower quadrant pain that looks like appendicitis. It has been mistaken for appendicitis routinely. In one case series of 70 children clinically diagnosed with appendicitis, 16% turned out to have mesenteric adenitis instead. Published case reports describe teenage patients with EBV who presented with what appeared to be appendicitis but was actually mesenteric lymphadenitis caused by the virus.

The patient's abdominal pain resolved without surgery and has not returned in 36 years. Mesenteric lymphadenitis typically resolves on its own within 2 to 4 weeks. That timeline and outcome fit.

Retrospective Diagnosis

Putting it together, the most likely sequence of events:

1. Recent EBV infection caused mesenteric lymph nodes to swell, producing right lower quadrant pain that mimicked appendicitis.
2. The clinical team ordered a contrast-enhanced CT to confirm the diagnosis before operating. A reasonable but not yet routine choice for 1989.
3. During contrast injection, a severe extravasation occurred. The patient reported pain but was not listened to.
4. The large volume of high-osmolality ionic contrast in the tissue produced compartment syndrome and then secondary infection.
5. Aggressive antibiotics and conservative management resolved both problems without surgery on the arm.
6. The mesenteric lymphadenitis resolved on its own while the patient was hospitalized for the iatrogenic injury.

Key Lessons

Listen to the patient. Complaints of pain at the IV site during contrast injection need to be acted on immediately, regardless of the patient's age. Early recognition and stopping the injection is the most effective way to prevent a severe extravasation injury.

Consider the era. High-osmolality ionic contrast agents carried more risk of tissue injury than what is used today. Historical cases from this period should be understood in the context of the agents available at the time.

Think about mono. In adolescents and young adults with recent or concurrent EBV infection who present with right lower quadrant pain, mesenteric lymphadenitis should be on the differential. It is the most common cause of abdominal pain in EBV infection and the most frequent alternative diagnosis in patients being evaluated for appendicitis.

Infection can follow extravasation. Secondary infection is an underappreciated complication of severe extravasation and may require infectious disease consultation and prolonged antibiotics.

Outcome and Conservative Management

Most published images of contrast extravasation injuries show cases that progressed to necrosis and required surgical debridement, fasciotomy, or skin grafting. This patient's case was severe enough that amputation was discussed, but the tissue recovered without progressing to irreversible necrosis. No surgery was performed on the affected limb.

That outcome is a credit to Dr. Joseph, Dr. Cohen, and Dr. Patel. Once the severity was recognized and the right specialists were in the room, their combined work saved the arm. The case falls in a middle zone on the severity spectrum that does not get photographed or published very often: bad enough to nearly lose a limb, managed well enough that you would not know it by looking at the arm today.

Patient Epilogue

After discharge, the patient's parents asked if he wanted to sue the hospital. He was 16. He said no. The way he saw it, the extravasation itself was a known complication — it can happen to anyone. The mistake was not listening to him when he reported pain, which allowed the extravasation to continue and become severe. But the doctors who were called in fixed it and saved his arm. The mistake did not cause the problem, but it made the problem worse. The medical team corrected it. That was enough for him.

Eleven years later, in 2000, he entered the healthcare industry. He has spent the 25 years since working across providers, payers, biopharmaceutical companies, and medical device manufacturers. He has never wanted to work in any other industry.

In his words: "When things go wrong in healthcare, they can really go wrong, but occasionally providers, payers, biopharma, and medical device manufacturers can also create miracles."

A preventable injury. A successful rescue. A career in healthcare.

A Note on Patient Recall: "Radioactive Iodine" vs. "Radiographic Contrast"

The patient remembered the injected substance as "radioactive iodine." Radioactive iodine (iodine-131) is real, but it is used for thyroid conditions, not CT scans. What he received was iodinated radiographic contrast.

The most likely explanation is phonetic. "Radiographic" and "radioactive" share three syllables. A 16-year-old in a stressful hospital setting hears a nurse or tech say "radiographic iodine contrast" or just "radiographic contrast," and the brain files it as the more familiar-sounding "radioactive iodine." Over 36 years, that substitution hardens into memory. The core detail (iodine-based injectable agent) stayed accurate. Only the modifier drifted.

Physicians Referenced

Rajendra Patel, M.D. Family medicine, Marietta, Georgia. University of Newcastle School of Medicine (1975); residency, Medical College of Georgia (1982). Referring physician and care coordinator. Dr. Patel evaluated the patient, referred him to Northside Hospital Atlanta, and coordinated specialist involvement throughout.

Frank Robert Joseph, M.D. (1950-2024) Hand, wrist, and shoulder surgery. Medical College of Wisconsin (1976); hand surgery fellowship, Mt. Sinai Hospital, New York City (1982). Founding member, Resurgens Orthopaedics, Atlanta, Georgia.

Howard J. Cohen, M.D. Infectious disease, Atlanta, Georgia. Medical College of Georgia (1977); infectious disease fellowship, Yale-New Haven Medical Center (1981-1983). Affiliated with Northside Hospital Atlanta and Emory St. Joseph's Hospital.

References

1. Balthazar EJ. CT of the abdomen and pelvis for assessment of suspected appendicitis. Radiology. 1986.
2. Rud B, et al. Computed tomography for diagnosis of acute appendicitis in adults. Cochrane Database Syst Rev. 2019.
3. European Society of Urogenital Radiology (ESUR). Intravenous contrast medium extravasation: systematic review and updated ESUR Contrast Media Safety Committee Guidelines. Eur Radiol. 2022;32:3486-3500.
4. American College of Radiology (ACR). Manual on Contrast Media: Extravasation of Contrast Media.
5. CT contrast extravasation in the upper extremity: Strategies for management. Int J Surg. 2010;8(5):384-386.
6. Kim SH, et al. Computed tomography contrast media extravasation: treatment algorithm and immediate treatment by squeezing with multiple slit incisions. J Plast Reconstr Aesthet Surg. 2021;74(6):1369-1375.
7. Helbling R, et al. Acute Nonspecific Mesenteric Lymphadenitis: More Than "No Need for Surgery." Biomed Res Int. 2017;2017:9784565.
8. Longfield JN, et al. Abdominal complications of infectious mononucleosis. Postgrad Med. 1988;83(3):175-178, 181-182, 184.
9. AlMudaiheem FA, et al. An insidious case of infectious mononucleosis presenting with acute appendicitis diagnosed postoperatively: a case report. J Surg Case Rep. 2021;2021(3):rjab039.
10. Ridder GJ, et al. Pseudoappendicitis preceding infectious mononucleosis. Pediatr Infect Dis J. 1998;17(12):1171-1173.
11. Liu X, et al. Epstein-Barr virus infection mimicking acute appendicitis: a case report. J Med Case Rep. 2023.
12. Curci R, et al. Extravasation of radiographic contrast material and compartment syndrome in the hand: a case report. Cases J. 2009;2:9159.

This case report was reconstructed from patient recollection 36 years after the event, corroborated by publicly available physician records and published medical literature. No original medical records were available for review. The specific contrast agent, exact volumes, antibiotic regimens, and precise timeline are inferred from the patient's account and what was standard practice in 1989.