Angioedema After Local Trauma in a Patient on Angiotensin-Converting Enzyme Inhibitor Therapy

Abstract

Angioedema is a side effect that is often associated with the use of angiotensin-converting enzyme (ACE) inhibitor medications. These medications result in increased levels of circulating bradykinins. This case illustrates the result of a local traumatic event to the upper lip, presumably causing marked bradykinin release in a patient who was taking an ACE inhibitor. The local release of bradykinin from trauma, in addition to decreased bradykinin catabolism secondary to ACE inhibitor therapy, resulted in angioedema predominantly in the upper lip. The angioedema resolved with discontinuation of the ACE inhibitor. (J Am Board Fam Med 2008;21:577-9.)As the indications and usage of angiotensin-converting enzyme (ACE) inhibitor therapy increases, one of its potential side effects, angioedema, is becoming commonly encountered in primary care. Angioedema is a potentially life-threatening side effect of ACE inhibitor therapy, which has an estimated incidence of 0.1% up to 6%. 1 Angioedema resulting secondary to ACE inhibitor use may occur many years after therapy has been initiated. However, it most often occurs within the first week after starting therapy. 2 Up to 25% of reported cases of angioedema seem to be a result of ACE inhibitor therapy. 2 The other most common causes include allergic reactions, hereditary angioedema, C1 esterase inhibitor deficiency, and idiopathic angioedema. 2 The mechanism of action of ACE inhibitors includes the blockade of the ACE, which leads to vasodilation. Other actions of ACE inhibitors include blockade of the conversion of substance P to inactive peptides and the blockade of bradykinin degradation. The increase in circulating substance P and bradykinin, histamine release, and other mechanisms lead to vasodilatation and increased vascular permeability. 1-3 Angioedema does not resemble other forms of edema in that it does not appear in dependent areas and is often very transient and localized. 4 The most important risk factor for developing ACE inhibitor angioedema seems to be African-American race. The mechanism of this increased risk is not clear but may include bradykinin metabolism. Other risk factors include history of angioedema, allergies to seafood, and recent head or neck surgery. 2

A Case of Trauma-Related Angioedema of the Airway in a Patient on an Angiotensin Receptor Blocker

“…The available literature contains many case reports of angioedema in surgical patients, suggesting direct injury caused by perioperative trauma (eg, intubation, lumbosacral spine surgery, c-spine surgery, shoulder surgery) as a trigger for angioedema in patients taking ACEIs or angiotensin II receptor blockers [ 3 , 7 , 14 , 15 ]. However, our search in PubMed (March 10, 2023) yielded only 1 case of local trauma-related angioedema outside the perioperative period, in a patient who bit her upper lip [ 8 ]. The patient was on an ACEI; no such event is reported with ARBs in a nonsurgical setting.…”

“…Indeed, many cases of spontaneous angioedema and perioperative angioedema in patients taking ACEIs have been reported [ 7 ]. However, angioedema following local trauma in patients taking ARBs is rare in the literature, and our literature review in PubMed revealed only 1 similar case [ 8 ].…”

Pharmacogenetics of angiotensin‐converting enzyme inhibitor‐induced angioedema

“…Many non-genetic factors are associated with ACEi-A. This ADR is more prevalent in women, elderly, smokers, people with history of drug rash, chronic heart failure, coronary artery disease and seasonal allergy, local trauma, as well as patients undergoing transplantation and under immunosuppressive conditions, 14,129,130 whereas it is reported to be lower in patients with type-2 diabetes. 14 The interaction of genetic and non-genetic factors has no doubt complicated the finding of any strong genetic associations and also suggests the possibility of epigenetic dysregulation as a contributor.…”

“…This ADR is more prevalent in women, elderly, smokers, people with history of drug rash, chronic heart failure, coronary artery disease and seasonal allergy, local trauma, as well as patients undergoing transplantation and under immunosuppressive conditions, 14,129,130 whereas it is reported to be lower in patients with type-2 diabetes. This ADR is more prevalent in women, elderly, smokers, people with history of drug rash, chronic heart failure, coronary artery disease and seasonal allergy, local trauma, as well as patients undergoing transplantation and under immunosuppressive conditions, 14,129,130 whereas it is reported to be lower in patients with type-2 diabetes.…”

ACE Inhibitor-Induced Angioedema following Cervical Spine Surgery

“…ACE inhibitor-induced angioedema after cervical surgery is a rare condition. A few cases of angioedema following local trauma in patients using ACE inhibitors have been published [3–7]. We present an interesting case of severe angioedema causing airway obstruction after anterior cervical surgery in a patient using ACE inhibitors.…”