Angiotensin Converting Enzyme Inhibitor-related Angioedema: A Case of an Unexpected Death
AbstractAngioedema is an asymmetric non-pitting oedema on face, lips, tongue and mucous membranes; any delay in diagnosis and treatment can be fatal. Treatment with lisinopril as an angiotensin converting enzyme (ACE) inhibitor, can be a reason of angioedema. Here we report a case who developed oral-facial edema four years after using lisinopril/hydrochlorothiazide. Laryngeal oedema is a main cause of death in angioedema. The treatment of choice in angioedema including fresh frozen plasma, C1 inhibitor concentrations and BRK-2 antagonists (bradykinin B2 receptor antagonists) were used. In this case; a 77 years old female patient suffering from hypertension was considered. This patient was suffering two days from swelling on her face and neck. Non- allergic angioedema was distinguished in five major forms; acquired (AAO), hereditary (HAE), renin-angiotensin-aldosterone system (RAAS) blocker-dependent, pseudoallergic angioedema (PAS) and an idiopathic angioedema (IAO). She was admitted to our clinic with the diagnosis of hereditary angioedema. Patient had skin edema and life threatening laryngeal edema. In emergency department treatment was started using intravenous methylprednisolone, diphenydramine as well as inhaled and subcutaneous epinephrine simultaneously. Despite the initial treatment, the patient died due to the insufficient respiration and cardiac arrest. The patient has no history of kidney disease.
1. Kaplan AP, Greaves MW. Angioedema. J Am Acad Dermatol 2005; 53(3):373–88.2. Murinello, A., Braz, S., & Arranhado, E. (2005).Angioedema in a patient with C1 esterase inhibitor deficiency. Iranian Journal of Allergy, Asthma and Immunology,4(3), 145-148.3. National Heart, Lung, and Blood Institute National High Blood Pressure Education Program. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) Express. Bethesda, MD: May 14 2003. From NIH website. (Also published in JAMA. 2003; 289.4. Agostoni A, Cicardi M. Drug-induced angioedema without urticaria. Drug Saf 2001; 24(8):599–606.5. Hedner T, Samuelsson O, Lunde H, Lindholm L, Andren L,Wiholm BE. Angio-oedema in relation to treatment with angiotensin converting enzyme inhibitors. BMJ 1992; 304(6832):941-66. Ricketti AJ, Cleri DJ, Ramos-Bonner LS, Vernaleo JR.Hereditary angioedema presenting in late middle age after angiotensinconverting enzyme inhibitor treatment. Ann Allergy Asthma Immunol 2007; 98(4):397–401.7. Lehane RJ.Lisinopril-induced angioedma of the lip.N Y State Dent J 2013; 79(3):25-7.8. Zuraw BL, Herschbach J. Detection of C1 inhibitor mutations in patients with hereditary angioedema. J Allergy Clin Immunol 2000; 105(3):541-6.9. Sica DA, Black HR. Current concepts of pharmacotherapy in hypertension: ACE inhibitor-related angioedema: can angiotensin receptor blockers be safely used? J Clin Hypertens (Greenwich) 2002; 4(5):375–80.10. Cicardi M, Banerji A, Bracho F, Malbrán A, Rosenkranz B, Riedl M, et al. Icatibant, a new bradykininreceptor antagonist, in hereditary angioedema. N Engl J Med 2010; 363(6):532–41.11. Larisa V. Buyantseva, Niti Sardana, Timothy J Craig.Update on treatment of hereditary angioedema. Asian Pac J Allergy Immunol 2012;30:89-9812. Karim MY, Masood A. Fresh-frozen plasma as a treatment for lifethreatening ACE-inhibitor angioedema. J Allergy Clin Immunol 2002; 109(2):370–1.13. Warrier MR, Copilevitz CA, Dykewicz MS, Slavin RG.Fresh frozen plasma in the treatment of resistant angiotensin-converting enzyme inhibitor angioedema. Ann Allergy Asthma Immunol 2004; 92(5):573–5.14. Premaua M, Gibbs JG, Pratt EL, Stoughton TR, Craig TJ.Fresh frozen plasma for the treatment of hereditary angioedema. Ann Allergy Asthma Immunol 2007;98(4):383-8.15. Agostoni A, Bergamaschini L, Martignoni G, Cicardi M, Marasini B. Treatment of acute attacks of hereditary angioedema with Cl-Imhibitor concentrate. AnnAllergy 1980; 44(5):299-301.16. Bas M, Greve J, Stelter K, Bier H, Stark T, Hoffmann TK, et al. Therapeutic efficacy of icatibant in angioedema induced by angiotensin-converting enzyme inhibitors: a case series. Ann Emerg Med 2010; 56(3):278-82.