The n e w e ng l a n d j o u r na l of m e dic i n e

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Angioedema

Robert Matthew Bramante, M.D.

Masha Rand, M.D.
North Shore University Hospital
Manhasset, NY
rbramante@nshs.edu

A
71-year-old man presented to the emergency department with rapidly progressive tongue
swelling during the previous 5 hours. Physical examination revealed a swollen tongue and no hypotension,
rash, bronchospasm, urticaria, or flushing. There was no personal or family history of similar episodes, and
the patient had no recent exposure to known food allergens, new medications, or insect stings. His usual outpatient
medications included aspirin, simvastatin, diltiazem, and enalapril. A provisional diagnosis of angioedema associ-
ated with the use of an angiotensin-convertingenzyme (ACE) inhibitor was made. Inhibition of ACE may prompt a
decrease in the production of angiotensin II and an increase in the bradykinin level, resulting in the regional vasodi-
latation and increased vascular permeability that are characteristic of angioedema. The onset of angioedema can
occur even after long-term use of ACE inhibitors. In this patient, no improvement was noted after the parenteral ad-
ministration of diphenhydramine, methylprednisolone, and epinephrine. With the patient awake, a nasotracheal in-
tubation was performed to prevent impending respiratory compromise. Treatment with enalapril was discontinued.
The edema resolved, the tongue returned to normal size, and the patient was extubated the next day. There has been
no return of symptoms after discontinuation of the ACE inhibitor.
Copyright 2011 Massachusetts Medical Society.

e4 n engl j med 365;2 nejm.org july 14, 2011

The New England Journal of Medicine

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Copyright 2011 Massachusetts Medical Society. All rights reserved.