ACE inhibitor deemed cause of man’s angioedema: Case report
Episodes of tongue swelling eased after stopping lisinopril
A man who experienced recurrent episodes of tongue swelling was diagnosed with angioedema related to the use of an angiotensin-converting enzyme (ACE) inhibitor to treat high blood pressure, according to a case report.
The patient’s symptoms eased after stopping treatment with the medication, lisinopril, with no recurrence of angioedema attacks after one month.
“Recognising atypical presentations offers a crucial opportunity to discontinue the offending [ACE inhibitor] medication and prevent further episodes of [ACE inhibitors]-related angioedema,” the researchers wrote in the report, “Unilateral tongue swelling: an unusual presentation of angiotensin-converting enzyme inhibitor-related angioedema,” published in BMJ Case Reports.
Angioedema is characterized by swelling of the deeper layers of the skin or the mucus membranes, and can affect any part of the body. It may be triggered by any of several factors, and in rare instances may occur as a side effect of certain medications. Usually those are ACE inhibitors, which are commonly prescribed to treat hypertension (high blood pressure) and improve heart health.
ACE inhibitors reduce blood pressure by stopping the production of the hormone angiotensin II. However, they also increase the levels of bradykinin, a molecule that plays a crucial role in inflammation and that can trigger swelling.
Researchers document 4-hour swelling episode
Angioedema secondary to an ACE inhibitor most commonly affects the lips, tongue, and other structures of the mouth and larynx. Attacks should be immediately evaluated and receive appropriate treatment.
Researchers in South Africa described the case of a man in his 60s who arrived at the emergency room with acute swelling of the tongue that had progressed over four hours.
He had a history of high blood pressure and ischemic heart disease, which occurs when the heart does not get enough blood due to narrowed arteries. He was being treated with several medications, including lisinopril.
Physical examination detected a non-tender swelling of the right side of the tongue. Considering the risk of airway blockage, doctors treated the man with epinephrine and chlorpheniramine, medications often used for severe allergic reactions.
The patient reported he had restarted lisinopril a week before after interrupting treatment due to a persistent cough. This was the third time within two years that he experienced single-sided tongue swelling.
The researchers suspected ACE inhibitor-induced angioedema, considering the recent reintroduction of lisinopril and the sudden onset, resolution, and location of swelling. As ACE inhibitor-related angioedema typically does not respond well to treatments such as antihistamines, the team decided to stop that type of therapy and keep the patient under close observation.
“Identifying unusual presentations, such as unilateral tongue angioedema, can pose a diagnostic challenge for clinicians,” the researchers wrote. “Diagnosis often relies on contextual clues, including [ACE inhibitor] usage and recurrent unexplained swelling.”
The patient’s symptoms eased within a few hours, and he was discharged with the advice to follow up with his primary care physician for an alternative anti-hypertensive medication. A month later, he had switched to losartan, an angiotensin receptor blocker that is used to reduce blood pressure, with no recurrence of angioedema attacks.
“Even though [ACE inhibitor]-related angioedema is statistically rare, extensive use of this class of antihypertensive drugs requires clinicians to remain vigilant in diagnosing and treating this condition,” the researchers wrote.
The case “contributes to the understanding of [ACE inhibitor]-induced angioedema, particularly in Africa where hypertension is prevalent and [ACE inhibitor] is commonly used,” they wrote.
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