January 9, 2025

A 68-year-old male presents with right-sided tongue swelling

By Med-Challenger · 1 minute read

A 68-year-old male presents with right-sided tongue swelling. He has hypertension and diabetes. There have been no recent medication changes or new antigen exposures. He denies any difficult breathing. His vital signs are normal. Examination of his tongue and infralingual structures are shown here.

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Treatment consists of:

Steroids, H1 blockers; discharge if stable after 2 hours of observation
Restarting ACE inhibitors 2 weeks after symptoms have resolved
H2 blockers, steroids, switch to beta blocker as antihypertensive; discharge after 6 hours of observation
Stopping ACE inhibitors and admitting to hospital to monitor for airway obstruction

The correct answer is:

Stopping ACE inhibitors and admitting to hospital to monitor for airway obstruction

Educational Objective:

Discuss presentation and management of non-severe angioedema of the oropharynx.

Key Point:

ACE inhibitors can cause a special category of angioedema, which usually resolves within 72 hours of stopping the medication. This type of angioedema reaction mimics a type I hypersensitivity reaction, but appears to be bradykinin- rather than histamine-mediated and may continue to worsen. It responds poorly to antihistamines, epinephrine and steroids.

Explanation:

In the majority of angioedema cases, no specific allergen or other cause will be found.

Since it is difficult to treat and may continue to worsen, admission for airway monitoring and aggressive airway management is recommended for cases of angioedema that may not be histamine-related.

Reference:

Barksdale AN. Allergy, Hypersensitivity, and Anaphylaxis. (Chapter 109) In: Walls R, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 1418 -1429.e2.

Moellman JJ, Bernstein JA, Lindsell C, et al; American College of Allergy, Asthma & Immunology; Society for Academic Emergency Medicine. A consensus parameter for the evaluation and management of angioedema in the emergency department. Acad Emerg Med. 2014;21(4):469-484

This question appears in Med-Challenger Emergency Medicine Review with CME

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