A 71-year-old man presented into the emergency department with a rapidly progressing swelling in his tongue. The swelling had been present for the past 5 hours. Moreover, there were no signs of flushing, urticaria, bronchospasm, rash and hypotension, which ruled out the probability of an allergic reaction. In addition to this, the patient reported that there was no family history of any similar episodes.
History of the patient revealed that he had not been exposed to any insect stings, new medications or any known food allergens. The patient was regularly taking prescription medications including aspirin, simvastatin, diltiazem, and enalapril (ACE inhibitor). After taking a thorough history of the patient, a provisional diagnosis of angiotensin-converting–enzyme (ACE) inhibitor was made.
ACE inhibitor related angioedema
Angioedema presents with a localized, nonpitting, well-demarcated, nonpruritic and non-inflammatory swelling. The swelling occurs as large erythematous areas in the subcutaneous tissue and skin. Moreover, the swelling can involve peripheral tissue, extremities, genitals, intestines, perioral or periorbital regions, oropharynx, glottis, face, tongue and lips. The condition is benign. However, can cause respiratory distress and even death if severe laryngeal edema occurs.
ACE inhibitor induced angioedema is self-limiting and localized. The swelling commonly affects the face, tongue and lips. Urticaria and pruritus are usually absent. Most cases of ACE inhibitor induced angioedema occur within the first month of starting treatment. However, onset of symptoms can be anywhere between from 1 day to 10 years. ACE inhibitors prompt a decrease in levels of angiotensin II and an increase in the level of bradykinin. Similarly, it results in increased vascular permeability and regional vasodilation.
No improvement was noted in this patient even after peripheral administration of epinephrine. methylprednisolone and diphenhydramine. In addition, a nasotracheal intubation was performed on the patient, while he was awake to prevent impending respiratory compromise. Enalpril was discontinued.
The patient’s edema resolved, the tongue returned back to its normal size. The patient was extubated the next day and there was no return of symptoms after discontinuing the ACE inhibitor.
References
Hirschy, R., Shah, T., Davis, T., & Rech, M. A. (2018). Treatment of Life-Threatening ACE-Inhibitor–Induced Angioedema. Advanced emergency nursing journal, 40(4), 267-277.
