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C. Caramelo, Servicio de Nefrología, Fundación Jiménez Díaz, Av. Reyes Católicos 2, E-Madrid 28040 (Spain) ritories betwen the anterior and middle cerebral arteries, consistent with ischemic damage of toxic origin or secondary to systemic hypotension (fig. 1). The temporal relationship between the iohexol injection and the onset of symptoms and the absence of major metabolic or strucDear Sir, Myelography is associated with a low incidence of serious neurologic complications which include neuropsychiatric abnormalities, seizures, encephalopathy and focal, neurologic deficits [1-6]. Symptoms peak a few hours after the procedure and are usually transient, although they may be irreversible [3-4]. No fatalities have been recorded. We report the case of a diabetic CAPD patient who developed irreversible coma and died after iohexol myelography. A 60-year-old diabetic CAPD female patient with progressive paraparesis underwent cervical myelography with 10 ml of iohexol, which revealed spinal cord compression. She received dexamethasone before and for 48 h after the procedure. Sixteen hours after myelography, she complained of dizziness and nausea. The level of consciousness decreased and coma was present 50 h later. Neurological examination showed no other new findings. Simultaneously, the 500 ml/day residual diuresis disappeared and serum urea raised from 29.9 at admission to 60.3 mmol/l (175-355 mg/dl). There were no major abnormalities in serum sodium, potassium, glucose, osmolality or calcium. Computerized tomography of the brain showed subcortical atrophy. An electroencephalogram showed signs of moderate, diffuse brain damage. The cerebrospinal fluid was normal. The patient died 27 days later without improving consciousness. Autopsy revealed multiple symmetric ischemic encephalic lesions in watershed terFig. 1. Left occipital lobe. Left, panoramic view of the corticosub-cortical ischemic lesion, surrounding a sulcus. HE. × 40. Right, detailed view of the edge of the ischemic lesion, showing congestive blood vessels and numerous histiocytes. There is edema and reactive gliosis in the preserved parenchyma. × 70. tural brain abnormalities are consistent with iohexol-induced encephalopathy [5]. The fatal outcome may have been related to the coexistence of several risk factors for radio-contrast neurotoxicity. Cervical myelography, a seizure history, older age, female sex, dehydration and diabetes predispose to con-