Cerebellar haemorrhage triggered by allergic reaction to maintenance haemodialysis in a patient with eosinophilia

Background

Various substances can cause allergic reactions during a dialysis session, including dialyser membranes, sterilising agents, disinfectants, antiseptics, medications and all aspects of the dialysis circuit that interface with the blood.1 2 The symptoms of an allergic reaction include pruritus, erythema, flushing, syncope, nasal conjunctivitis, urticaria, and angio-oedema. Additionally, during dialysis treatment, peripheral blood shows transient changes, such as increased eosinophils, neutrophils and IgE and decreased platelets, even during normal dialysis treatment in patients without allergies.3 4

Peripheral blood eosinophilia (PBE) is a common finding in patients undergoing haemodialysis (HD) and has been reported to have a prevalence of 13%–52%.3 5 In eosinophilia, abnormalities in the coagulation system were thought to exist (eg, elevation of fibrinogen, fibrin degradation products, platelet number and beta thromboglobulin).6 Such abnormalities, along with fluctuations in blood pressure during dialysis, increase the likelihood of stroke.

Case presentation

We present the case of a woman in her 80s undergoing three maintenance HD sessions in a week, using 750 U/hour of unfractionated heparin through an arteriovenous fistula. She had a history of eosinophilia, hypertension, transient ischaemic attack, reflux oesophagitis, hypothyroidism and chronic kidney disease due to membranous nephropathy. She also had a history of allergy to vonoprazan and omeprazole and showed chronic allergic symptoms, such as generalised itching, redness and a burning sensation in the precordium. Previously, allergen-specific IgE testing was carried out. This patient had positive responses to multiple allergens like cat, dog, wheat, cedar pollen and house mould. Antinuclear antibodies, anti-dsDNA antibody, antineutrophil cytoplasmic antibody, rheumatoid factor or jypocomplementemia was negative as autoimmune disease screen. Approximately 1 month after dialysis treatment initiation, thrombi were observed in the dialysis membrane (NF-1.3US: polymethylmethacrylate membrane) at several sessions. Therefore, the dialysis membrane was switched to an APS-13SA (polysulfone membrane). In the first two dialysis sessions, there were no reactions after switching the membrane. However, in the third session, the patient developed headache, dyspnoea and vomiting with severe hypotension immediately after HD was started.

Investigations and follow-up

The patient discontinued dialysis treatment because of severe nausea and headaches, and a brain CT and MRI revealed a cerebellar haemorrhage (figure 1). The haemorrhage was mild, and her consciousness was clear. At the time of attack, there was no obvious neurological sign like limb ataxia, dysarthria, nystagmus, abnormal gaze or facial weakness. During the HD session there was no high blood pressure even after brain attack.

Figure 1

CT and MRI obtained soon after headache, dyspnoea and vomiting with severe hypotension developed. CT image shows the area of high signal intensity in the right cerebellum. T2WI and DWI show the same lesion present in an area of signal loss. DWI, diffusion-weighted imaging; T2WI, T2-weighted imaging.

The patient was able to continue intermittent HD treatment with different anticoagulants for 2 days after the brain attack. She continued to experience recurrent dyspnoea, chest pain, headache, nausea, vomiting and hypotension during dialysis 2 weeks after the incident. The symptoms began within 20 min of HD and were almost completely resolved at the end of each dialysis session. Therefore, the dialysis membrane was changed back to an NF-1.3US, after which the symptoms disappeared. However, several months after switching the membrane, the same symptoms were observed again. Throughout the clinical course, eosinophilia was sustained (10%–20% eosinophil out of the total white blood cells).

Differential diagnosis

Severe/sustained dyspnoea, headache, nausea and vomiting soon after starting HD session are often thought to be intolerance to dialysis-related materials. Especially, both PBE and history of allergic reactions to medications are the risk for dialysis membrane allergic reaction. In the current case, these signs resulted from cerebellar haemorrhage. However, mild symptoms of dyspnoea, headache, nausea and vomiting were observed soon after starting the HD session, even a couple of months after brain attack. It is speculated that these symptoms were also caused by an allergic reaction to the dialysis membrane on the same time

Outcome and follow-up

We started the patient on 15 mg of prednisolone (PSL). Dyspnoea, headache, nausea and vomiting were disappeared from the first day of treatment. In addition to that, absolute eosinophil count was decreased to normal range (less than 500/µL). Later, the dose was tapered to 5 mg/day. Even with maintenance PSL dose (PSL 5 mg), eosinophil count was 200∼300 /µL at average. The patient was able to continue HD with the same dialysis membrane (figure 2).

Figure 2

Progress from before and after the start of dialysis and changes in the number of eosinophils. Even before the onset of brain attack, she had complained of mild nausea and had developed itching symptoms. At the time of her stroke, her nausea appeared strongly. At the time of her stroke, her headache symptoms were particularly strong, but otherwise, she had no headache symptoms. PSL, prednisolone.