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Excerpt
The patient was a 46-year-old white woman who underwent right modified radical mastectomy as a result of infiltrative ductal carcinoma. She had a history of postoperative metastasis in the L4 vertebra, which was cured successfully after administration of chemotherapy and radiotherapy. She had no cardiac or pulmonary disease and was a nonsmoker. Breast reconstruction was performed with a pedicled transverse rectus abdominis flap. Dextran 40 was administered at a dose of 10 ml per kilogram on the second postoperative day because of partial ischemic changes observed in the flap. After dextran 40 administration, the patient had some nonspecific signs and symptoms such as nausea with vomiting and fever. Ten hours later the patient developed dyspnea and chest pain, which were increased the following day. Chest radiography showed bilateral pleural effusion with bilateral reticulonodular radiopacities that were interpreted as pneumonic infiltration. The patient did not have hemoptysis or pleuritic chest pain, and there were no signs of heart failure. The complete blood count revealed leukocytosis (16,400 cells per cubic millimeter), whereas the cultures for sputum and pleural fluid aspirate were negative. On the fourth postoperative day, dyspnea increased along with partial oxygen pressure, and breathing room air decreased to 45.5 mmHg. It did not increase to more than 60 mmHg while 100% oxygen was being administered. Partial carbon dioxide pressure was 29.6 mmHg, and pH was 7.53. The patient’s respiratory rate was 30 breaths per minute, and the patient was afebrile. Lymphangitic carcinomatosis resulting from breast carcinoma was considered; however, it was not supported by the cytology of the effusion fluid, tumor markers (CEA and CA-15.3), and systemic screening for metastasis. The patient’s history of allergic reactions indicated the possibility of dextran-induced severe pulmonary edema going into adult respiratory distress syndrome. Dextran infusion was discontinued and a bolus of 250 mg prednisolone was administered intravenously. There was an abrupt amelioration of the symptoms and we decided to withhold more invasive diagnostic and therapeutic approaches. The patient recovered gradually during the course of the following week and was discharged on completion of her breast reconstruction.
Severe pulmonary edema with respiratory failure is not the typical allergic reaction that is expected when dextran is used. In most cases the pulmonary complications are anaphylactic, occurring within minutes of dextran administration, accompanied by bronchospasm and hypotension. Although there is a generalized increase in vascular permeability, pulmonary edema is not seen and chest radiographs are typically normal. 3 Severe pulmonary edema resulting from dextran infusion is quite rare and when it occurs it may progress into adult respiratory distress syndrome. 4,5 In these cases, reaction has a protracted course, ranging from several hours to a few days, and therefore may cause confusion in the differential diagnosis of other postoperative pulmonary complications. Pulmonary edema in a postoperative patient may be related to a number of causes, including left ventricular dysfunction, aspiration, sepsis, trauma, and drugs. Moreover, atypical pneumonia, pulmonary embolism, and lymphoreticular tumor metastasis may need to be ruled out.
