Neck trauma serves as angioedema trigger in woman on telmisartan

Case report highlights condition as 'often forgotten' adverse reaction

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by Andrea Lobo |

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In this case study illustration, one clinician holds a gigantic magnifying glass in front of a patient's head and chest while another takes notes on a clipboard.

An 83-year-old woman suddenly developed angioedema of the airway as a result of neck trauma while being treated with telmisartan, a medication commonly used to lower blood pressure, according to a case report from the U.S.

“This case report highlights the rare and often forgotten adverse reaction of angioedema with use of angiotensin receptor blockers and confirms the finding of local trauma as a possible trigger,” the researchers wrote.

Titled “A Case of Trauma-Related Angioedema of the Airway in a Patient on an Angiotensin Receptor Blocker,” it was published in the American Journal of Case Reports.

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Woman’s throat, vocal cords seen to swell after neck trauma

Angioedema is marked by swelling attacks caused by fluid buildup in the deeper layers of the skin. Such attacks most commonly affect the face, neck, and extremities. But internal organs lined by mucous membranes — such as those comprising the gastrointestinal and respiratory tracts — also may be affected.

When angioedema affects the airways, it may cause difficulty breathing.

The condition may develop as a side effect of certain medications, such as angiotensin-converting enzyme inhibitors, called ACEIs or angiotensin receptor blockers, known as ARBs, both of which are commonly used to reduce blood pressure.

These medicines may increase the levels of bradykinin, which is a signaling molecule that causes blood vessels to widen and become more permeable, allowing fluids to leak and pool into nearby tissues. High levels of bradykinin may cause angioedema swelling attacks.

Direct local trauma has also been suggested to induce angioedema in certain situations.

“However, angioedema following local trauma in patients taking ARBs is rare in the literature,” the researchers wrote, noting that a review “revealed only 1 similar case.”

Now, researchers described the case of a woman in her early 80s who was treated at the emergency department after a fall in which she hit the left side of her jaw and neck against the edge of a chair. Following the face and neck trauma, the woman experienced shortness of breath and difficulty swallowing.

She had a history of high blood pressure, an irregular heart rhythm, and rheumatoid arthritis — an autoimmune and inflammatory disease in which the immune system attacks the joints. The woman was being treated with the ARB telmisartan (sold under the brand name Micardis), given at a daily dose of 40 mg, for several years.

On an initial examination, the woman was found to have mild respiratory distress with audible abnormal lung sounds, a normal breathing rate, and 94% oxygen saturation in the blood. A CT scan of her neck showed significant swelling, causing marked airway narrowing.

The patient was treated with dexamethasone and epinephrine, and also was intubated as doctors were concerned her airway might become compromised. During intubation, they found her throat and vocal cords were swollen.

The woman’s condition improved, and she was removed from the ventilator three days after being admitted. Her difficulty swallowing eased over time, and she was discharged on day 10 while discontinuing treatment with telmisartan. She had no recurrence of angioedema up to one year after the event.

Clinicians need to be aware of this potentially life-threatening adverse reaction and promptly discontinue ARBs in these patients to prevent recurrence.

“We hypothesize that increased levels of circulatory bradykinin in the setting of telmisartan, combined with a local release of bradykinin from trauma, was the main pathophysiologic cause of the angioedema,” the researchers wrote.

The researchers noted that the woman had no history of angioedema or allergy. Further, she had been taking telmisartan daily for several years.

“Clinicians need to be aware of this potentially life-threatening adverse reaction and promptly discontinue ARBs in these patients to prevent recurrence,” they wrote.