RECURRENT ANGIOEDEMA FOLLOWING ANGIOTENSIN CONVERTING ENZYME INHIBITOR DISCONTINUATION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Angiotensin converting enzyme inhibitors (ACEIs) are guideline recommended first-line treatment for hypertension. Angioedema is a recognized side effect of ACEI therapy, yet clinicians often unaware that limited case reports describe recurrent angioedema following discontinuation. This ACEI-induced occurring after discontinuing therapy. CASE PRESENTATION: An elderly male with medical history hypothyroidism, hypertension, and heart failure presented from his long-term care facility complaining face, tongue, throat swelling dysphagia voice changes starting 24 hours prior. Examination showed normal vital signs edema aforementioned areas. He denied family similar occurrences. It was reported 12 days prior he seen unilateral lip enalapril discontinued without further treatment. Medication administration record review appropriately by facility. given methylprednisolone, diphenhydramine, intramuscular epinephrine, C1 esterase inhibitor, 2 units fresh frozen plasma to admission. The patient monitored in the intensive unit due mild airway compromise but did not require invasive protection. A serum complement factor 4 level checked returned normal. discharged 5 stable condition resolution symptoms. DISCUSSION: ACEIs most common cause drug induced United States. self-limiting may involve lips, upper airway, rarely intestinal wall. Swelling said occur because inhibition on angiotensin preventing degradation vasoactive substances such as bradykinin (1). Recurrence discontinuation 46% cases one retrospective study (2). precise etiology this delayed reaction well described, though it reasonable hypothesize part, washout period must occur. adverse probability scale score (probable) (3). has been documented more commonly patients mainstay non-allergic caused offending acute management if needed. No therapy proven effective CONCLUSIONS: Increased awareness important among health providers appropriate diagnosis monitoring. While known treatment, close monitoring critical survival. Improved would also allow be cognizant potential recurrence early REFERENCE #1: Erickson DL, Coop CA. Angiotensin-converting inhibitor-associated treated c1-esterase inhibitor: report literature. Allergy Rhinol (Providence). 2016;7(3):168-171. #2: Beltrami L, Zanichelli A, Zingale Vacchini R, Carugo S, Cicardi M. Long-term follow-up 111 angiotensin-converting inhibitor-related angioedema. J Hypertens. 2011 Nov;29(11):2273-7. #3: LiverTox: Clinical Research Information Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute Diabetes Digestive Kidney Diseases; 2012-. Adverse Drug Reaction Probability Scale (Naranjo) Induced Injury. [Updated 2019 May 4]. DISCLOSURES: relevant relationships Mark Malesker, source=Web Response Shraddha Narechania, Bryton Perman,