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A Forgotten Cause of Allergy at ER That Is Still Difficult to Diagnose and Treat at Poor Resource Setting: Angioedema after Using Angiotensin Converting Enzyme Inhibitors for 4 Years

A Forgotten Cause of Allergy at ER That Is Still Difficult to Diagnose and Treat at Poor Resource... Hindawi Case Reports in Immunology Volume 2019, Article ID 1676391, 4 pages https://doi.org/10.1155/2019/1676391 Case Report A Forgotten Cause of Allergy at ER That Is Still Difficult to Diagnose and Treat at Poor Resource Setting: Angioedema after Using Angiotensin Converting Enzyme Inhibitors for 4 Years 1 1 1 2 A. A. Nilanga Nishad , K. Arulmoly, S. A. S. Priyankara, and P. K. Abeysundara Teaching Hospital, Batticaloa, Sri Lanka North Colombo Teaching Hospital, Ragama, Sri Lanka Correspondence should be addressed to A. A. Nilanga Nishad; aanilanga@gmail.com Received 9 October 2018; Revised 4 December 2018; Accepted 16 December 2018; Published 2 January 2019 Academic Editor: Christian Drouet Copyright © 2019 A. A. Nilanga Nishad et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Angiotensin converting enzyme inhibitors (ACEi) are the most commonly used antihypertensives. er Th efore, ACEI induced angioedema (ACEi-AE) is not uncommon. Physicians tend to miss the diagnosis whenever a patient is taking the drug for years due to misbelief of “a drug that was taken for years may not be the cause for an allergic reaction or an angioedema”. But ACEi can induce angioedema aer ft many years of usage as well as sometimes aeft r stopping the drug even. Most of the emergency physicians and centers are not aware of clinical diagnosis and diagnostic criteria including available diagnostic tests and more importantly the treatment options of ACEi-AE. Therefore not only the diagnosis is delayed or missing but also proper treatment options are not practiced at many emergency rooms and at wards. 1. Introduction 2. Case Report Angioedema is a life-threatening emergency due to the vast Sixty-eight-year old farmer was transferred to Teaching Hos- number of causes. It may be presented with or without pital Batticaloa from a local hospital due to “allergic reaction”. pruritus and can be classiefi d into allergic and nonallergic On further questioning, patient is complaining of swelling forms. eTh list of the drugs responsible for angioedema is of the face including the lips and dicffi ulty in breathing with on expansion and physician should be vigilant to find out its hoarseness of voices but without swallowing difficulty. cause. Angiotensin converting enzyme inhibitors (ACEis) are He had neither skin rashes nor pruritus. Other aspects very popular and mostly preferred antihypertensives used for of his medical history did not show any abnormality and different indications but known to cause angioedema. ACEi- were notsignicfi antastothe likelycauseofhisdisease associated angioedema results from decreased degradation state. The patient could not come up with a possible food of kinins and other vasoactive peptides such as substance or contact history. He also had developed similar kind of P, thus cannot be treated with conventional antihistamines attack two months back and was treated with antihistamines and steroids. More importantly angioedema can develop aer ft and steroids that time. He was having hypertension and usingACEiforalongerperiodoftimeandevenaeft rstopping was on Enalapril vfi e milligrams two times daily for four it for sometime where medical personnel can be misled due years. Physical examination revealed a middle-aged man with to thefactthatACEicannotbethecauseasithasbeen swollen lips and lower part of the face. eTh pharynx was usedforalongtime (Figures 2and3) [1]. Wereport a also oedematous. He was dyspnoeic. eTh breath sounds were case of repeated angioedema episodes aer ft using ACEis for vesicular and there were bilateral rhonchi. The pulse rate was 4years. 88 beats per minute and respiratory rate was 24 breaths per 2 Case Reports in Immunology Histamine mediated Bradykinin mediated Swelling of lips/tongue Urticaria Itching Laryngeal swelling Facial swelling Rapid onset Abdominal pain Response to epinephrine Abdominal swelling Nausea and vomiting Peripheral swelling Hypotension/shock Wheeze Genitourinary swelling Figure 1: Distinguishing histamine-mediated versus bradykinin-mediat ed angioedema clinically (figure reproduced from Bernstein JA et al. (2017), [under the Creative Commons Attribution License/public domain]). minute, respectively. His blood pressure was 110/70 mmHg. three distinct types: hereditary angioedema (HAE), acquired All other body system examination was essentially normal. angioedema, and angiotensin-converting enzyme inhibitor A clinical assessment of Enalapril induced angioedema was (ACEi) induced angioedema [4]. Hereditary angioedema made on clinical suspicion and Enalapril was immediately (C1-INH-HAE) results from increased bradykinin produc- discontinued. He was treated with intramuscular Adrenaline tion and on the other hand ACEis block the effects of the 0.5 mg stat and intravenous hydrocortisone 200 mg stat and angiotensin-converting enzyme, which impacts the renin- monitored for respiratory compromise. He was followed up angiotensin-aldosterone pathway and diminishes the degra- with oral prednisolone 30 mg daily. We did not use C1-INH dation of Bk. er Th efore, ACEi-associated angioedema has orIcatibantasitisnot availableinSriLanka. Patientdid not been found to have resulted from decreased degradation of need to undergo further management procedures. He was Bradykinin [5]. It usually occurs without urticaria. Recurrent seen at the outpatient unit two days and one week later having angioedema is due to acquired C1-inhibitor deficiency (C1- recovered fully. eTh Naranjo probability scale indicated that INH-AAE). this adverse drug event was probable [2]. ACEi-AEareusuallylocalizedtothefaceorupperairway and upper portion of the digestive tract; they are importantly 3. Discussion not characterized by erythema, but by swelling disorders, sometimes with urticaria followed by spontaneous remission Angioedema is a life-threatening condition with swelling of (Figure 1) [7, 8]. Some other medications including nons- the skin, mucosa, and submucosal tissues commonly seen teroidal anti-inflammatory drugs, proton pump inhibitors, on lips, tongue, face, hands, or feet [3]. Patients develop selective serotonin reuptake inhibitor, and other antidepres- stridor and difficulty in breathing when it occurs in pharynx sant can also produce this kind of angioedema [9]. and larynx and rarely does it involve gastrointestinal tract ACEi-induced angioedema has been reported as a side and genitalia. It can be easily categorized as histamine- effect aeff cting 0.1–0.7% of patients and up to 1.6% in some mediated or non-histamine-mediated. It can be presented studies. Surprisingly 30 to 73% of angioedema cases recorded with or without urticaria. Histamine-mediated angioedema inemergencyroomsarecausedbyACEis[10].Astudycarried usually presents with urticaria and swelling of the body that out in United States reported an incidence of 0.2% nearly subsides within one to two days. It is also called allergic two decades ago [11]. Higher incidence has been reported angioedema, an Ig-E-mediated hypersensitivity reaction with in black patients, females, smokers, elderly, and those with a prior sensitization. historyofcoughassociatedwithACEiuse[12,13].Thenewest Bradykinin (Bk) is an inflammatory vasoactive peptide reviews suggested ACEi-induced angioedema prevalence to that leads to increased capillary permeability acting as a potent vasodilator. Bk-mediated angioedema comprises be ranging from 0.4 to 2.6 per 10,000 populations [14]. Case Reports in Immunology 3 Table 1: Diagnostic tests to help distinguish among angioedema types (table reproduced from Bernstein JA et al. (2017), [under the Creative Commons Attribution License/public domain]). Type of angioedema C1-INH concentration C1-INH function C4 concentration Tryptase concentration HAE type I Low Low Low Normal HAE type II Normal or High Low Low Normal HAE with normal C1-INH Normal Normal Normal Normal Acquired AE Low Low Low Normal ACEi-induced AE Normal Normal Normal Normal Histamine-mediated anaphylaxis Normal Normal Normal Normal or Elevated In blood drawn within 4–6 h of onset of attack. ACEi: angiotensin-converting enzyme inhibitor; AE: angioedema; C1-INH:C1inhibitor; HAE: hereditary angioedema. Angioedema Cumulative % of patients with Angioedema <=5 years (n=888) 50 1 2 34 5 Years Figure 2: Cumulative percentages of developing angioedema and other side effects of ACEI with time (Banerji et al., 2017) [6]. Angioedema Cumulative % 70 of patients with Angioedema <=5 years (n=888) Years Figure 3: Cumulative percentages of developing angioedema and other side effects of ACEI with time (Banerji et al., 2017) [6]. Even though angioedema is the second most adverse occurs in clusters until ACEi is stopped and it can occur even event of ACEi next to dry cough, it is missed a lot due to aer ft stopping the treatment as a relapse sometimes up to 6 healthcare provider believingthatitshouldcomejustaeft r months of discontinuation (Figures 2 and 3) [16]. starting theprobableantigen (ACEi).Actuallyitisnot the We have to rely more on clinical diagnosis (Figure 1) case. eTh re are so many studies and case reports reporting where most of the centers would not have enough facilities that angioedema can develop at any time after starting to diagnose the condition with plasma biochemical investi- the treatment with ACEis (Figures 2 and 3) [15]. A study gations (Table 1) [17]. following 134,945 patients for vfi e years showed that, among Bradykinin-mediated angioedema is theoretically not the patients who developed ACEi-AE, nearly 20 percent responding to conventional treatment with glucocorticos- developed it between 4th and 5th year [6]. Angioedema teroids and antihistamines. er Th efore, people have been 4 Case Reports in Immunology treated with plasma derived C1-INH (C1 esterase inhibitor), [11] N. J. Brown, W. A. Ray, M. Snowden, and M. R. Griffin, “Black Americans have an increased rate of angiotensin converting recombinant C1-INH, Ecallantide, and Icatibant [18–21]. enzyme inhibitor-associated angioedema,” Clinical Pharmacol- Unfortunatelymostofthese treatmentmodalitiesare not ogy & eTh rapeutics , vol. 60, no. 1, pp. 8–13, 1996. available in our setup. Patients may rarely need to undergo [12] L. M. Lewis, C. Graeo ff , P. Crosley et al., “Ecallantide for the endotracheal intubation and subsequent tracheostomy if the acute treatment of angiotensin-converting enzyme inhibitor- response is delayed and our patient does not need them. induced angioedema: A multicenter, randomized, controlled trial,” Annals of Emergency Medicine,vol.65,no.2,pp.204–213, Conflicts of Interest [13] H.M.Bluestein,T.A. Hoover,A.S.Banerji,C.A.Camargo ea Th uthorshavenoconflictsofinterest. Jr., A. Reshef, and P. Herscu, “Angiotensin-converting enzyme inhibitor-induced angioedema in a community hospital emer- gency department,” Annals of Allergy, Asthma & Immunology, Acknowledgments vol. 103, no. 6, pp. 502–507, 2009. eTh authors would like to thank Dr. Sanjeewa Withana of [14] E. Aygor ¨ en-Pur ¨ sun, ¨ M. Magerl, A. Maetzel, and M. Maurer, National Hospital of Sri Lanka and Mr. Indrajith Solan- “Epidemiology of Bradykinin-mediated angioedema: a system- garachchi for their contribution in writing this case report. atic investigation of epidemiological studies,” Orphanet Journal of Rare Diseases,vol.13,no.1,2018. [15] N. J. Brown, M. Snowden, and M. R. Griffin, “Recurrent References angiotensin-converting enzyme inhibitor-associated angioedema,” eJ Th ournaloftheAmerican MedicalAssociation , [1] S. H. Mahmoudpour, E. V. Baranova, P. C. Souverein, F. W. vol. 278, no. 3, pp. 232-233, 1997. Asselbergs, A. de Boer, and A. H. Maitland-van der Zee, [16] L. Beltrami, A. Zanichelli, L. Zingale, R. Vacchini, S. Carugo, “Determinants of angiotensin-converting enzyme inhibitor (ACEI) intolerance and angioedema in the UK Clinical Practice and M. Cicardi, “Long-term follow-up of 111 patients with Research Datalink,” British Journal of Clinical Pharmacology, angiotensin-converting enzyme inhibitor-related angioedema,” vol. 82, no. 6, pp. 1647–1659, 2016. Journal of Hypertension, vol. 29, no. 11, pp. 2273–2277, 2011. [2] Adverse Drug Reaction Probability Scale (Naranjo) in Drug [17] J. A. Bernstein, P. Cremonesi, T. K. Hoffmann, and J. Induced Liver Injury https://livertox.nih.gov/Narajo.html. Hollingsworth, “Angioedema in the emergency department: a practical guide to differential diagnosis and management,” [3] J. A. Bernstein and J. Moellman, “Emerging concepts in the diagnosis and treatment of patients with undifferentiated International Journal of Emergency Medicine,vol.10,no.1,2017. angioedema,” International Journal of Emergency Medicine,vol. [18] M. Cicardi, A. Banerji, F. Bracho, and A. Malbran, ´ “Icati- 5, no.1,2012. bant, a New Bradykinin-Receptor Antagonist, in Hereditary [4] B.L.Zuraw,A.Banerji,J.A.Bernstein etal.,“USHereditary Angioedema,” eTh New England Journal of Medicine ,vol.363, Angioedema Association Medical Advisory Board 2013 Rec- no.15, pp.1486-1486,2010. ommendations for the Management of Hereditary Angioedema [19] M. Ba¸s, J. Greve, K. Stelter et al., “A randomized trial of Due to C1 Inhibitor Deficiency,” Journal of Allergy and Clinical icatibant in ACE-inhibitor–induced angioedema,” The New Immunology: In Practice,vol.1,no. 5, pp.458–467,2013. England Journal of Medicine,vol.372,no.5, pp.418–425,2015. [5] S. A. Hubers, K. Kohm, S. Wei et al., “Endogenous [20] T.Hermanrud,N.Duus,A.Bygum, andE.R.Rasmussen, bradykinin and B1-B5 during angiotensin-converting enzyme “eTh Use of Plasma-Derived Complement C1-Esterase Inhibitor inhibitor–associated angioedema,” The Journal of Allergy and Concentrate (Berinert) in the Treatment of Angiotensin Con- Clinical Immunology,vol.142,no.5, pp.1636–1639.e5, 2018. verting Enzyme-Inhibitor Related Angioedema,” Case Reports [6] A.Banerji,K.G.Blumenthal, K.H.Lai,andL.Zhou, “Epi- in Emergency Medicine,vol.2016,ArticleID3930923,4pages, demiology of ACE Inhibitor Angioedema Utilizing a Large Electronic Health Record,” eJ Th ournalofAllergy andClinical [21] A. M. aTh rayil, A.H.Chanda,H.A.Shiekh,M.S.Elkhatib, Immunology: In Practice,vol.5,no. 3,pp.744–749,2017. M. Nayeemuddin, and A. A. A. Alshamandy, “Life threatening [7] C. Stone and N. J. Brown, “Angiotensin-converting Enzyme angioedema in a patient on ACE inhibitor (ACEI) confined to Inhibitor and Other Drug-associated Angioedema,” Immunol- the upper airway,” Qatar Medical Journal,vol.2014, no.2,pp. ogy and Allergy Clinics of North America,vol.37, no.3,pp.483– 92–97, 2014. 495, 2017. [8] B. L. Zuraw, J. A. Bernstein, D. M. Lang et al., “A focused parameter update: hereditary angioedema, acquired C1 inhibitor deficiency, and angiotensin-converting enzyme inhibitor-associated angioedema,” The Journal of Allergy and Clinical Immunology,vol.131,no. 6,pp.1491–1493,2013. [9] T.Morimoto, T.K. Gandhi,J.M.Fiskioetal.,“An evaluation of risk factors for adverse drug events associated with angiotensin- converting enzyme inhibitors,” JournalofEvaluationinClinical Practice,vol.10,no.4,pp.499–509, 2004. [10] N. J.Chan andA.M.S.Soliman,“AngiotensinConverting Enzyme Inhibitor-Related Angioedema: Onset, Presentation, and Management,” Annals of Otology, Rhinology & Laryngology, vol. 124, no. 2, pp. 89–96, 2015. 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A Forgotten Cause of Allergy at ER That Is Still Difficult to Diagnose and Treat at Poor Resource Setting: Angioedema after Using Angiotensin Converting Enzyme Inhibitors for 4 Years

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Hindawi Case Reports in Immunology Volume 2019, Article ID 1676391, 4 pages https://doi.org/10.1155/2019/1676391 Case Report A Forgotten Cause of Allergy at ER That Is Still Difficult to Diagnose and Treat at Poor Resource Setting: Angioedema after Using Angiotensin Converting Enzyme Inhibitors for 4 Years 1 1 1 2 A. A. Nilanga Nishad , K. Arulmoly, S. A. S. Priyankara, and P. K. Abeysundara Teaching Hospital, Batticaloa, Sri Lanka North Colombo Teaching Hospital, Ragama, Sri Lanka Correspondence should be addressed to A. A. Nilanga Nishad; aanilanga@gmail.com Received 9 October 2018; Revised 4 December 2018; Accepted 16 December 2018; Published 2 January 2019 Academic Editor: Christian Drouet Copyright © 2019 A. A. Nilanga Nishad et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Angiotensin converting enzyme inhibitors (ACEi) are the most commonly used antihypertensives. er Th efore, ACEI induced angioedema (ACEi-AE) is not uncommon. Physicians tend to miss the diagnosis whenever a patient is taking the drug for years due to misbelief of “a drug that was taken for years may not be the cause for an allergic reaction or an angioedema”. But ACEi can induce angioedema aer ft many years of usage as well as sometimes aeft r stopping the drug even. Most of the emergency physicians and centers are not aware of clinical diagnosis and diagnostic criteria including available diagnostic tests and more importantly the treatment options of ACEi-AE. Therefore not only the diagnosis is delayed or missing but also proper treatment options are not practiced at many emergency rooms and at wards. 1. Introduction 2. Case Report Angioedema is a life-threatening emergency due to the vast Sixty-eight-year old farmer was transferred to Teaching Hos- number of causes. It may be presented with or without pital Batticaloa from a local hospital due to “allergic reaction”. pruritus and can be classiefi d into allergic and nonallergic On further questioning, patient is complaining of swelling forms. eTh list of the drugs responsible for angioedema is of the face including the lips and dicffi ulty in breathing with on expansion and physician should be vigilant to find out its hoarseness of voices but without swallowing difficulty. cause. Angiotensin converting enzyme inhibitors (ACEis) are He had neither skin rashes nor pruritus. Other aspects very popular and mostly preferred antihypertensives used for of his medical history did not show any abnormality and different indications but known to cause angioedema. ACEi- were notsignicfi antastothe likelycauseofhisdisease associated angioedema results from decreased degradation state. The patient could not come up with a possible food of kinins and other vasoactive peptides such as substance or contact history. He also had developed similar kind of P, thus cannot be treated with conventional antihistamines attack two months back and was treated with antihistamines and steroids. More importantly angioedema can develop aer ft and steroids that time. He was having hypertension and usingACEiforalongerperiodoftimeandevenaeft rstopping was on Enalapril vfi e milligrams two times daily for four it for sometime where medical personnel can be misled due years. Physical examination revealed a middle-aged man with to thefactthatACEicannotbethecauseasithasbeen swollen lips and lower part of the face. eTh pharynx was usedforalongtime (Figures 2and3) [1]. Wereport a also oedematous. He was dyspnoeic. eTh breath sounds were case of repeated angioedema episodes aer ft using ACEis for vesicular and there were bilateral rhonchi. The pulse rate was 4years. 88 beats per minute and respiratory rate was 24 breaths per 2 Case Reports in Immunology Histamine mediated Bradykinin mediated Swelling of lips/tongue Urticaria Itching Laryngeal swelling Facial swelling Rapid onset Abdominal pain Response to epinephrine Abdominal swelling Nausea and vomiting Peripheral swelling Hypotension/shock Wheeze Genitourinary swelling Figure 1: Distinguishing histamine-mediated versus bradykinin-mediat ed angioedema clinically (figure reproduced from Bernstein JA et al. (2017), [under the Creative Commons Attribution License/public domain]). minute, respectively. His blood pressure was 110/70 mmHg. three distinct types: hereditary angioedema (HAE), acquired All other body system examination was essentially normal. angioedema, and angiotensin-converting enzyme inhibitor A clinical assessment of Enalapril induced angioedema was (ACEi) induced angioedema [4]. Hereditary angioedema made on clinical suspicion and Enalapril was immediately (C1-INH-HAE) results from increased bradykinin produc- discontinued. He was treated with intramuscular Adrenaline tion and on the other hand ACEis block the effects of the 0.5 mg stat and intravenous hydrocortisone 200 mg stat and angiotensin-converting enzyme, which impacts the renin- monitored for respiratory compromise. He was followed up angiotensin-aldosterone pathway and diminishes the degra- with oral prednisolone 30 mg daily. We did not use C1-INH dation of Bk. er Th efore, ACEi-associated angioedema has orIcatibantasitisnot availableinSriLanka. Patientdid not been found to have resulted from decreased degradation of need to undergo further management procedures. He was Bradykinin [5]. It usually occurs without urticaria. Recurrent seen at the outpatient unit two days and one week later having angioedema is due to acquired C1-inhibitor deficiency (C1- recovered fully. eTh Naranjo probability scale indicated that INH-AAE). this adverse drug event was probable [2]. ACEi-AEareusuallylocalizedtothefaceorupperairway and upper portion of the digestive tract; they are importantly 3. Discussion not characterized by erythema, but by swelling disorders, sometimes with urticaria followed by spontaneous remission Angioedema is a life-threatening condition with swelling of (Figure 1) [7, 8]. Some other medications including nons- the skin, mucosa, and submucosal tissues commonly seen teroidal anti-inflammatory drugs, proton pump inhibitors, on lips, tongue, face, hands, or feet [3]. Patients develop selective serotonin reuptake inhibitor, and other antidepres- stridor and difficulty in breathing when it occurs in pharynx sant can also produce this kind of angioedema [9]. and larynx and rarely does it involve gastrointestinal tract ACEi-induced angioedema has been reported as a side and genitalia. It can be easily categorized as histamine- effect aeff cting 0.1–0.7% of patients and up to 1.6% in some mediated or non-histamine-mediated. It can be presented studies. Surprisingly 30 to 73% of angioedema cases recorded with or without urticaria. Histamine-mediated angioedema inemergencyroomsarecausedbyACEis[10].Astudycarried usually presents with urticaria and swelling of the body that out in United States reported an incidence of 0.2% nearly subsides within one to two days. It is also called allergic two decades ago [11]. Higher incidence has been reported angioedema, an Ig-E-mediated hypersensitivity reaction with in black patients, females, smokers, elderly, and those with a prior sensitization. historyofcoughassociatedwithACEiuse[12,13].Thenewest Bradykinin (Bk) is an inflammatory vasoactive peptide reviews suggested ACEi-induced angioedema prevalence to that leads to increased capillary permeability acting as a potent vasodilator. Bk-mediated angioedema comprises be ranging from 0.4 to 2.6 per 10,000 populations [14]. Case Reports in Immunology 3 Table 1: Diagnostic tests to help distinguish among angioedema types (table reproduced from Bernstein JA et al. (2017), [under the Creative Commons Attribution License/public domain]). Type of angioedema C1-INH concentration C1-INH function C4 concentration Tryptase concentration HAE type I Low Low Low Normal HAE type II Normal or High Low Low Normal HAE with normal C1-INH Normal Normal Normal Normal Acquired AE Low Low Low Normal ACEi-induced AE Normal Normal Normal Normal Histamine-mediated anaphylaxis Normal Normal Normal Normal or Elevated In blood drawn within 4–6 h of onset of attack. ACEi: angiotensin-converting enzyme inhibitor; AE: angioedema; C1-INH:C1inhibitor; HAE: hereditary angioedema. Angioedema Cumulative % of patients with Angioedema <=5 years (n=888) 50 1 2 34 5 Years Figure 2: Cumulative percentages of developing angioedema and other side effects of ACEI with time (Banerji et al., 2017) [6]. Angioedema Cumulative % 70 of patients with Angioedema <=5 years (n=888) Years Figure 3: Cumulative percentages of developing angioedema and other side effects of ACEI with time (Banerji et al., 2017) [6]. Even though angioedema is the second most adverse occurs in clusters until ACEi is stopped and it can occur even event of ACEi next to dry cough, it is missed a lot due to aer ft stopping the treatment as a relapse sometimes up to 6 healthcare provider believingthatitshouldcomejustaeft r months of discontinuation (Figures 2 and 3) [16]. starting theprobableantigen (ACEi).Actuallyitisnot the We have to rely more on clinical diagnosis (Figure 1) case. eTh re are so many studies and case reports reporting where most of the centers would not have enough facilities that angioedema can develop at any time after starting to diagnose the condition with plasma biochemical investi- the treatment with ACEis (Figures 2 and 3) [15]. A study gations (Table 1) [17]. following 134,945 patients for vfi e years showed that, among Bradykinin-mediated angioedema is theoretically not the patients who developed ACEi-AE, nearly 20 percent responding to conventional treatment with glucocorticos- developed it between 4th and 5th year [6]. Angioedema teroids and antihistamines. er Th efore, people have been 4 Case Reports in Immunology treated with plasma derived C1-INH (C1 esterase inhibitor), [11] N. J. Brown, W. A. Ray, M. Snowden, and M. R. Griffin, “Black Americans have an increased rate of angiotensin converting recombinant C1-INH, Ecallantide, and Icatibant [18–21]. enzyme inhibitor-associated angioedema,” Clinical Pharmacol- Unfortunatelymostofthese treatmentmodalitiesare not ogy & eTh rapeutics , vol. 60, no. 1, pp. 8–13, 1996. available in our setup. Patients may rarely need to undergo [12] L. M. Lewis, C. Graeo ff , P. Crosley et al., “Ecallantide for the endotracheal intubation and subsequent tracheostomy if the acute treatment of angiotensin-converting enzyme inhibitor- response is delayed and our patient does not need them. induced angioedema: A multicenter, randomized, controlled trial,” Annals of Emergency Medicine,vol.65,no.2,pp.204–213, Conflicts of Interest [13] H.M.Bluestein,T.A. Hoover,A.S.Banerji,C.A.Camargo ea Th uthorshavenoconflictsofinterest. Jr., A. Reshef, and P. Herscu, “Angiotensin-converting enzyme inhibitor-induced angioedema in a community hospital emer- gency department,” Annals of Allergy, Asthma & Immunology, Acknowledgments vol. 103, no. 6, pp. 502–507, 2009. eTh authors would like to thank Dr. Sanjeewa Withana of [14] E. Aygor ¨ en-Pur ¨ sun, ¨ M. Magerl, A. Maetzel, and M. Maurer, National Hospital of Sri Lanka and Mr. Indrajith Solan- “Epidemiology of Bradykinin-mediated angioedema: a system- garachchi for their contribution in writing this case report. atic investigation of epidemiological studies,” Orphanet Journal of Rare Diseases,vol.13,no.1,2018. [15] N. J. Brown, M. Snowden, and M. R. Griffin, “Recurrent References angiotensin-converting enzyme inhibitor-associated angioedema,” eJ Th ournaloftheAmerican MedicalAssociation , [1] S. H. Mahmoudpour, E. V. Baranova, P. C. Souverein, F. W. vol. 278, no. 3, pp. 232-233, 1997. Asselbergs, A. de Boer, and A. H. Maitland-van der Zee, [16] L. Beltrami, A. Zanichelli, L. Zingale, R. Vacchini, S. Carugo, “Determinants of angiotensin-converting enzyme inhibitor (ACEI) intolerance and angioedema in the UK Clinical Practice and M. Cicardi, “Long-term follow-up of 111 patients with Research Datalink,” British Journal of Clinical Pharmacology, angiotensin-converting enzyme inhibitor-related angioedema,” vol. 82, no. 6, pp. 1647–1659, 2016. Journal of Hypertension, vol. 29, no. 11, pp. 2273–2277, 2011. [2] Adverse Drug Reaction Probability Scale (Naranjo) in Drug [17] J. A. Bernstein, P. Cremonesi, T. K. Hoffmann, and J. Induced Liver Injury https://livertox.nih.gov/Narajo.html. Hollingsworth, “Angioedema in the emergency department: a practical guide to differential diagnosis and management,” [3] J. A. Bernstein and J. Moellman, “Emerging concepts in the diagnosis and treatment of patients with undifferentiated International Journal of Emergency Medicine,vol.10,no.1,2017. angioedema,” International Journal of Emergency Medicine,vol. [18] M. Cicardi, A. Banerji, F. Bracho, and A. Malbran, ´ “Icati- 5, no.1,2012. bant, a New Bradykinin-Receptor Antagonist, in Hereditary [4] B.L.Zuraw,A.Banerji,J.A.Bernstein etal.,“USHereditary Angioedema,” eTh New England Journal of Medicine ,vol.363, Angioedema Association Medical Advisory Board 2013 Rec- no.15, pp.1486-1486,2010. ommendations for the Management of Hereditary Angioedema [19] M. Ba¸s, J. Greve, K. Stelter et al., “A randomized trial of Due to C1 Inhibitor Deficiency,” Journal of Allergy and Clinical icatibant in ACE-inhibitor–induced angioedema,” The New Immunology: In Practice,vol.1,no. 5, pp.458–467,2013. England Journal of Medicine,vol.372,no.5, pp.418–425,2015. [5] S. A. Hubers, K. Kohm, S. Wei et al., “Endogenous [20] T.Hermanrud,N.Duus,A.Bygum, andE.R.Rasmussen, bradykinin and B1-B5 during angiotensin-converting enzyme “eTh Use of Plasma-Derived Complement C1-Esterase Inhibitor inhibitor–associated angioedema,” The Journal of Allergy and Concentrate (Berinert) in the Treatment of Angiotensin Con- Clinical Immunology,vol.142,no.5, pp.1636–1639.e5, 2018. verting Enzyme-Inhibitor Related Angioedema,” Case Reports [6] A.Banerji,K.G.Blumenthal, K.H.Lai,andL.Zhou, “Epi- in Emergency Medicine,vol.2016,ArticleID3930923,4pages, demiology of ACE Inhibitor Angioedema Utilizing a Large Electronic Health Record,” eJ Th ournalofAllergy andClinical [21] A. M. aTh rayil, A.H.Chanda,H.A.Shiekh,M.S.Elkhatib, Immunology: In Practice,vol.5,no. 3,pp.744–749,2017. M. Nayeemuddin, and A. A. A. Alshamandy, “Life threatening [7] C. Stone and N. J. Brown, “Angiotensin-converting Enzyme angioedema in a patient on ACE inhibitor (ACEI) confined to Inhibitor and Other Drug-associated Angioedema,” Immunol- the upper airway,” Qatar Medical Journal,vol.2014, no.2,pp. ogy and Allergy Clinics of North America,vol.37, no.3,pp.483– 92–97, 2014. 495, 2017. [8] B. L. Zuraw, J. A. Bernstein, D. M. Lang et al., “A focused parameter update: hereditary angioedema, acquired C1 inhibitor deficiency, and angiotensin-converting enzyme inhibitor-associated angioedema,” The Journal of Allergy and Clinical Immunology,vol.131,no. 6,pp.1491–1493,2013. [9] T.Morimoto, T.K. Gandhi,J.M.Fiskioetal.,“An evaluation of risk factors for adverse drug events associated with angiotensin- converting enzyme inhibitors,” JournalofEvaluationinClinical Practice,vol.10,no.4,pp.499–509, 2004. [10] N. J.Chan andA.M.S.Soliman,“AngiotensinConverting Enzyme Inhibitor-Related Angioedema: Onset, Presentation, and Management,” Annals of Otology, Rhinology & Laryngology, vol. 124, no. 2, pp. 89–96, 2015. 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