Parenteral ferumoxytol interaction with magnetic resonance imaging: a case report, review of the literature and advisory warning
A 54-year-old male patient with nonalcoholic steatohepatitis (NASH) cirrhosis presented for surveillance with magnetic resonance imaging (MRI) of the liver to screen for hepatocellular carcinoma in the setting of a routine pre-transplant workup. The patient had iron deficiency anaemia and received parenteral ferumoxytol (second intravenous dose of 510 mg) 3 days prior to the MRI examination. MRI was performed using our institution’s standard high-risk liver protocol on a 3.0-T MRI scanner (Discovery 750w, General Electric Medical Systems, Milwaukee, WI). Pulse sequences included: axial and coronal T2-weighted single-shot fast spin echo (ssFSE), axial T2-weighted fast recovery fast spin echo (FRFSE), axial 3D in- and out-of-phase gradient recalled echo (GRE), B50 and B500 diffusion-weighted imaging with an apparent diffusion coefficient map, and pre- and dynamic post-contrast fat-suppressed 3D T1-weighted GRE sequences (LAVA), including arterial, portal venous and equilibrium phases. Gadobutrol (Gadovist, Bayer Inc., Toronto, ON) was administered to obtain the post-contrast imaging. The MRI study showed interval changes from the baseline examination performed 15 months prior. In the interval there was a marked reduction in signal intensity of the liver and spleen on T2 ssFSE sequences suggesting iron overload, which had not been present on the previous examination (Fig. ). Portahepatic lymph nodes also demonstrated low T2 signal intensity (Fig. ). Imaging findings of iron deposition in the bone marrow were revealed on T1 in-phase GRE imaging and also had not been present on the previous examination (Fig. ). Routine pre-contrast T1 GRE images demonstrated increased signal intensity in the blood pool and abdominal organs, which masked normal enhancement after gadolinium was administered (Fig. ). The constellation of findings was based on T1 and T2 shortening effects from ferumoxytol, which rendered the study non-diagnostic. The patient also had recently undergone unenhanced MRI of the brain to evaluate the progressive cognitive decline 1 day before the abdominal MRI, which demonstrated diffuse low signal intensity along the surface of the brain on T2* GRE images, findings also related to ferumoxytol administration that mimic superficial siderosis (Fig. ). The patient provided informed consent for publication.