Blood pressure medication causes rare life-threatening reaction after 11 years
Lisinopril triggered sudden swelling in woman's airway and gut
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A woman in her 80s who had taken the same blood pressure medication for 11 years without issue suddenly developed a life-threatening reaction, marked by angioedema (swelling) in both her digestive tract and airway, a new case report reveals.
The rare dual presentation initially mimicked a bowel obstruction, nearly masking the true cause, which was a delayed reaction to an ACE inhibitor, used to treat high blood pressure and heart failure. Doctors warn that while this side effect usually appears within days of starting a drug, it can strike even after a decade of stable use.
“Interestingly, in our case, this patient presented with both intestinal and upper airway angioedema, a presentation rarely reported in the literature,” researchers wrote. “Clinicians must be aware of this pattern, as it might be overlooked at first glance.”
A dangerous case of dual swelling
The study, “ACE inhibitor-induced bradykinin-mediated angioedema presenting as small bowel obstruction and life-threatening airway angioedema: a rare dual presentation,” was published in BMJ Case Reports.
Angioedema refers to swelling of the skin or mucous membranes. In some cases, this can affect the intestines, leading to symptoms such as abdominal pain. Angioedema can also affect the throat and airways, which can cause life-threatening problems breathing.
There are many different types of angioedema with different underlying causes. Some forms are caused by allergic reactions, others by genetic mutations, and still others by side effects of certain medications.
A particular class of medicines called angiotensin-converting enzyme (ACE) inhibitors is a common cause of drug-induced angioedema. This complication is still comparatively rare, affecting less than 1% of patients given these drugs.
In the case study, the elderly patient sought help for sudden abdominal pain and vomiting. Imaging initially suggested a bowel obstruction. Working off that assumption, doctors managed the patient conservatively, having her not eat or drink anything by mouth, with fluids and nutrition given by a drip into her bloodstream.
However, the situation escalated the following day when she began struggling to breathe and required a ventilator. The combination of swelling in the intestines and trouble breathing led clinicians to suspect she might be experiencing some type of angioedema. She tested negative for genetic forms of angioedema.
When standard allergy treatments failed, doctors began reviewing the patient’s long list of routine medications. Among them was an ACE inhibitor called lisinopril, which she had been taking for 11 years. Suspecting that lisinopril might be responsible for her angioedema, her clinicians discontinued the medication.
ACE inhibitors can trigger swelling by increasing bradykinin levels, a signaling molecule. Because the small community hospital lacked specific bradykinin-blocking drugs, clinicians turned to infusions of fresh frozen plasma, which contains enzymes that naturally break down the molecule.
The treatment worked. One day after the plasma infusions, the patient was taken off the ventilator. She eventually resumed eating and was discharged with a strict warning to never take ACE inhibitors again.
The researchers highlighted several unusual features about this case. First, although airway swelling is a fairly common manifestation of angioedema caused by ACE inhibitors, it’s unusual for this type of drug-related angioedema to involve swelling around the intestines as well. Second, when ACE inhibitors trigger angioedema, it’s usually within a few days after starting the drug.
Most drug-induced angioedema occurs shortly after the first dose. Experiencing this reaction after 11 years of treatment is extremely uncommon, yet it serves as a critical reminder for doctors to remain vigilant, researchers noted, even when a patient has been on a medication safely for years.
