Blood pressure medicine tied to man’s severe tongue swelling

A 76-year-old man developed severe, potentially life-threatening angioedema affecting his tongue and upper airway after taking the blood pressure medication telmisartan for more than three years without previous complications, according to a case report from Japan.

The swelling was so extensive that the man’s tongue protruded from his mouth, preventing him from closing it. Doctors managed to secure his airway using an unusual technique that involved modifying a disposable flexible bronchoscope, a thin tube equipped with a camera, and using it to guide a breathing tube through his nose and into his windpipe.

The man gradually recovered after stopping telmisartan, with no recurrence of angioedema in more than three years of follow-up, which strongly supported an association between the medication and the swelling episode.

“Telmisartan-associated angioedema is considered a rare adverse effect,” researchers wrote, but this report shows that “severe tongue and upper airway angioedema may occur during telmisartan therapy even after several years of uneventful treatment.”

The report, “Severe telmisartan-associated tongue angioedema managed using a disposable fiberoptic endoscope as an intubation guide: A case report,” was published in the Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology.

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Some medications linked to swelling

Angioedema is characterized by sudden swelling in deeper layers of the skin or mucous membranes, often affecting the face, lips, tongue, or throat. When swelling involves the upper airway, it can obstruct breathing and become life-threatening.

Certain medications, including angiotensin II receptor blockers (ARBs), a class of drugs used to treat high blood pressure and other cardiovascular conditions, can cause angioedema. Although ARBs carry a lower risk of this complication than angiotensin-converting enzyme (ACE) inhibitors, another class of blood pressure medications cases of severe swelling have been reported.

The exact mechanisms through which ARBs cause angioedema are still not fully understood, but some evidence suggests they may affect bradykinin, a molecule that causes blood vessels to widen and become more permeable. This allows fluid to escape into surrounding tissues, where it can accumulate and cause the swelling characteristic of angioedema.

Here, researchers in Japan described a severe case of drug-induced angioedema in a patient taking telmisartan since July 2019 to manage high blood pressure. He had no history of taking ACE inhibitors.

In April 2023, the man developed sudden, severe tongue swelling that prevented him from closing his mouth, prompting an emergency hospital visit.

He had previously experienced swelling beneath his tongue due to a mucus retention cyst and had undergone surgery to remove his sublingual glands. However, doctors considered the new episode clinically distinct from his previous condition.

The man’s tongue was markedly swollen and protruded from his mouth. He had no hives or itching, symptoms commonly associated with allergic reactions.

Doctors used a flexible bronchoscope inserted through the man’s nose to examine his airway. The examination revealed extensive swelling extending from the base of the tongue to the epiglottis, a structure that helps prevent food and liquids from entering the airway during swallowing. The opening to the voice box was barely visible.

Because the swelling had severely narrowed the airway, doctors determined that removing the bronchoscope could make it difficult to regain access. For this reason, they kept the bronchoscope in place and modified the disposable device to guide a breathing tube into the airway through the nose.

While the initial examination had not been planned as an intubation procedure, the approach successfully secured the patient’s airway.

Doctors had also prepared for an emergency tracheostomy, a procedure that creates an opening in the neck into the windpipe to support breathing, if intubation failed. Although the initial procedure successfully secured the patient’s airway, they nevertheless performed a tracheostomy the following day because they considered prolonged airway protection necessary.

The patient received an antihistamine and a corticosteroid, but his swelling showed little improvement, suggesting the swelling was not caused by allergic angioedema. Blood tests and clinical findings also made hereditary angioedema unlikely.

Because doctors suspected drug-induced angioedema, telmisartan was discontinued on the first day of hospitalization. The swelling gradually subsided and completely resolved by day 24.

A standardized tool for evaluating potential medication-related adverse events suggested a probable association between telmisartan and the angioedema, although other explanations could not be entirely excluded.

No further angioedema episodes were reported through August 2026, more than three years after the initial event.

The researchers said the case highlights the importance of recognizing drug-induced angioedema, even after years of treatment without complications, and promptly protecting the airway when severe swelling develops. They added that the modified bronchoscope technique was an exceptional rescue measure and should not be considered a standard airway management approach.