Gadolinium Toxicity

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Head Pain is a diagnostic feature of Gadolinium Deposition Disease

On May 18, 2018, Dr. Richard Semelka added Head Pain to the recently revised primary clinical diagnostic findings for Gadolinium Deposition Disease (GDD) and he described two critical diagnostic features of GDD.  First, symptoms of GDD must start within minutes to one month after administration of a gadolinium-based contrast agent (GBCA).  Second, the symptoms experienced by the patient after GBCA administration must be new, and not preexisting.

There are now 6 symptoms that stand out to Dr. Semelka as critical diagnostic findings for GDD.  He said that it is imperative that individuals have at least 3 of the symptoms, but he prefers to see 5/6 to be certain of the diagnosis.

The 6 main clinical criteria for Gadolinium Deposition Disease, as described by Dr. Semelka are:

1.  Intense burning of the skin and skin substrate.  Arising in early stage (early on after GBCA): This can be an all over feeling in the body, but often may be localized to the trunk region or distal extremities.

2.  Intense boring pain in bones or joints.  Arising in early stage (early on after GBCA):  This can be any bones or any joints. Often the joints may be peripheral but can also be large joints like the knee or hip. Any bones can have severe point pain, but rib pain is quite distinctive for the disease.

3.  Brain fog.  Arising in early stage (early on after GBCA): Many terms have been used for this: mental confusion sounds more scientific, but brain fog gets the point across well and succinctly. Brain fog is also a prominent feature of lead toxicity, which is another heavy metal toxicity.

4.  Muscle vibrations (muscle fasciculations) and skin pins and needles/tingling (early on after GBCA).  These symptoms may represent part of the same process that is causing brain fog. Muscle vibrations/twitching and pins and needles skin sensations generally reflect nerve disease (neuropathy).

5.  Head pain (early on after GBCA).  Headache is both a very common occurrence and shows tremendous variability.  GDD sufferers describe it as a head pain, and unlike any other type of head-ache they have previously experienced. These two properties provide differentiating features for this entity.  Some describe it as a burning pain and as an extreme tightness feeling (like a tight bathing cap on their head).

6.  Distal arm and leg skin/skin substrate thickening, discoloration, and pain. Arising in the subacute stage (2 weeks +): This is very much like the principal features of NSF, but generally less severe. Instead of woodiness, doughiness; instead of redness, pinkness; instead of extreme joint contractures, stiffness of joints and decreased range of motion. Skin tightness is a feature of GDD as well.  This symptom complex should be expected.

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Clinical Criteria for Gadolinium Deposition Disease has been revised

On May 12, 2018, Dr. Richard Semelka revised the primary clinical diagnostic findings for Gadolinium Deposition Disease (GDD).  While the revision is being made sooner than anticipated, Dr. Semelka said it is based on well-informed recommendations from “patient experts” on the disease, and observations from 2 physician sufferers.  There are 5 symptoms that stand out to Dr. Semelka as critical diagnostic findings for GDD.  It is imperative that individuals have at least 1 of the symptoms, but he prefers to see 4/5 to make certain of the diagnosis.  Note that a 24-hour gadolinium urine test, performed 30 days or more after an MRI with a gadolinium-based contrast agent (GBCA), is still part of the diagnostic criteria for GDD.

The revised main clinical criteria for Gadolinium Deposition Disease, as described by Dr. Semelka are:

  1. Intense burning of the skin and skin substrate.Arising in early stage (early on after GBCA): This can be an all over feeling in the body, but often may be localized to the trunk region or distal extremities.
  2. Intense boring pain in bones or joints. Arising in early stage (early on after GBCA): This can be any bones or any joints. Often the joints may be peripheral but can also be large joints like the knee or hip. Any bones can have severe point pain, but rib pain is quite distinctive for the disease.
  3. Brain fog. Arising in early stage (early on after GBCA): Many terms have been used for this: mental confusion sounds more scientific, but brain fog gets the point across well and succinctly.
  4. Muscle vibrations (muscle fasciculations) and skin pins and needles/tingling (early on after GBCA). These symptoms may represent part of the same process that is causing brain fog. Muscle vibrations/twitching and pins and needles skin sensations generally reflect nerve disease (neuropathy).
  5. Distal arm and leg skin/skin substrate thickening, discoloration, and pain. Arising in the subacute stage (2 weeks +): This is very much like the principal features of NSF, but generally less severe. Instead of woodiness, doughiness; instead of redness, pinkness; instead of extreme joint contractures, stiffness of joints and decreased range of motion. This symptom complex should be expected.

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Initial publication of symptoms of gadolinium toxicity

The results of a 9 question survey about gadolinium exposure and related symptoms in patients with normal renal function were reported in an article by Burke et al titled Self-reported gadolinium toxicity: A survey of patients with chronic symptoms.  The survey provides the initial description in the medical literature of patients with normal renal function who self-described toxicity related to administration of gadolinium-based contrast agents (GBCAs).  There were 50 respondents to the anonymous online survey.  All 50 respondents (100%) received gadolinium-based contrast with an average of 4.2 doses.  All 50 attribute their symptoms to gadolinium exposure.

Thirty-three (66%) subjects described the onset of symptoms immediately following GBCA administration and 16 (32%) within 6 weeks.  The most common symptoms included bone/joint pain and head/neck symptoms including headache, vision change, and hearing change.  Headache and bone/joint pain was described by more than 75% of the cases.  Skin changes were seen in approximately 60% of respondents.

Other symptoms reported include: flu-like symptoms (30.6%); digestive symptoms described as nausea, vomiting, diarrhea (46.9%); chest symptoms described as difficulty breathing (42.9%); generalized whole body symptoms (30.6%); and other (75.5%).

The findings of the survey showed that subjects with normal renal function might develop disease following administration of the majority of GBCAs including macrocyclic agents.

Despite the limitations of the survey, the authors said that it was their opinion “that there most likely is toxicity associated with GBCA administration in patients with normal renal function”.  They concluded that, “at the very least, this study highlights the need to further investigate the subject of patients with normal renal function who complain of severe long-lasting symptomatology following GBCA administration”.

My thoughts –
When Hubbs Grimm and I released the findings of the online symptom survey that we conducted in early 2014, we noted that the results presented in our paper should stimulate further professional investigation into gadolinium retention in all patient populations including those with normal renal function.  It is good to see that the medical community is now looking into the issue of gadolinium retention in patients with normal renal function further.

Our paper, Gadolinium Toxicity – A Survey of the Chronic Effects of Retained Gadolinium from Contrast MRIs can be found in the Research section of our website.

Sharon Williams

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Burke, L. M. B., Ramalho, M., AlObaidy, M., Chang, E., Jay, M., & Semelka, R. C. (2016). Self-Reported Gadolinium Toxicity: A Survey of Patients with Chronic Symptoms. Magnetic Resonance Imaging. http://doi.org/10.1016/j.mri.2016.05.005

Gadolinium Deposition Disease – Part of a Family of Disorders

Important News for Patients who have retained gadolinium –
A recently published article by UNC Radiologist Dr. Richard Semelka and his colleagues proposes naming the histopathologically proven presence of gadolinium in brain tissue “gadolinium storage condition”, and it describes a new entity that represents symptomatic deposition of gadolinium in individuals with normal renal function, for which they propose the designation “gadolinium deposition disease”.  The article titled: Gadolinium in Humans: A Family of Disorders, was published in AJR online.

The article is not freely available to the public at this time.   Because of that, I will provide some important information from the article for patients and their doctors below.

Gadolinium Storage Condition –
“Gadolinium storage condition” is the term proposed for gadolinium tissue deposition. The authors said, “Even in patients with normal renal function, in vivo clinical exposure to gadolinium chelates results in gadolinium incorporation into body tissues such as bone matrix or brain tissues.” (See references below.)

It appears that gadolinium accumulation varies depending on the stability of the agent used.  As with NSF, the least stable GBCAs appear to be most likely to result in gadolinium storage condition, and stable agents either do not cause it or cause it at a very low level.  The clinical significance of gadolinium tissue deposition remains incompletely understood.

Gadolinium Deposition Disease –
“Gadolinium deposition disease” is the name proposed for a disease process observed in subjects with normal or near normal renal function who develop persistent symptoms that arise hours to 2 months after the administration of gadolinium-based contrast agents (GBCAs).  In these cases, no preexistent disease or subsequently developed disease of an alternate known process is present to account for the symptoms.

The authors note that some of these patients are likely to have coexistent gadolinium storage condition, as described above, but gadolinium deposition disease is also described after a single administration of GBCA.  The causal relationship has not been fully established, but it is under investigation.

The article references our MRI Gadolinium-Toxicity support group and notes that the group has reported symptoms it considers to be consistent with the known toxic effects of gadolinium.  They also cite the results of our 2014 Symptom Survey which suggests an association between chronic effects and GBCA exposure.

The authors said, in their experience, “Symptoms of gadolinium deposition disease are similar but not identical to those observed in NSF”.   They said that their preliminary investigation has convinced them that this phenomenon is a true disease process. (more…)

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