Angioedema Medical Case Stud ESSAY

Angioedema Medical Case Stud

Topic 1: Differential Diagnosis

A 49 yo Caucasian female presents with new onset of tongue swelling. She reports that she was seen in her primary doctor’s office yesterday for ear pain and he diagnosed her with an ear infection and started her on an antibiotic which she took this morning (she shows you a new bottle of Augmentin). She has a history of HTN and takes 10mg lisinopril daily, she does report last dose this am. She denies Difficulty breathing, and has no known drug or food allergies. On exam you note her tongue to be moderately swollen, while her pharynx is erythematous and mildly swollen at this time. she does not appear to be in distress, but is fearful. As the AGACNP on call, you are now working up the patient for admission

Discussion should address the following:

At least two differential diagnoses
What is the working/Final diagnosis, and what is the causative agent?
What is your Treatment plan for the patient?
What is your rationale for your selected treatment options?

EXAMPLES:
At least two differential diagnoses
1. Augmentin Induced Angioedema
Augmentin is an antibiotic that belongs to the penicillin family. Some people who take Augmentin may experience severe allergic responses. People who are allergic to penicillin are more likely to experience severe skin rashes, hives, swelling of the lips, tongue, and throat, and difficulty breathing. A very serious allergic reaction to this drug is rare (MNT, 2021).
2. Ace Inhibitor Induced Angioedema
The pathogenesis of ACE-I-induced angioedema involves ACE (kininase II) inhibiting the breakdown of bradykinin and substance P, resulting in vasodilator and plasma extravasation. The side effect of angiotensin-converting enzyme (ACE) inhibitor medication is angioedema. The tongue and mucous membranes of the oropharynx are the most common sites of involvement in ACE inhibitor-related angioedema. Angioedema caused by ACE inhibitors is rarely accompanied by bronchospasm. Angioedema attacks normally occur within the first month of initiating angiotensin-converting enzyme medications, but they can take months or years to appear. Because the symptoms may be modest and self-resolving at first, determining the reason may take some time (Kostis, et al., 2018).
What is the working/Final diagnosis, and what is the causative agent?
Idiopathic Angioedema
African Americans, smokers, women, the elderly, and those with a history of drug rash, seasonal allergies, or immunosuppressive medication are more likely to develop angioedema. Angioedema can be caused by a variety of factors, however the actual cause is often unknown. Individuals may be allergic to a substance that is routinely found in low concentrations in their environment (such as penicillin in milk or pollutants in the air). It can also happen to persons who are stressed, recovering from an illness, or who have an underlying autoimmune condition. Even if you aren’t allergic to a medication, it can trigger angioedema. Swelling might happen right after you start taking a new prescription, or it can take months or even years (NHS, 2019).
What is your Treatment plan for the patient? What is your rationale for your selected treatment options?
Treatment Plan for Idiopathic Angioedema
Allergy drugs such as antihistamines and corticosteroids can be used to treat idiopathic angioedema. Antihistamines work by blocking the effects of histamine, one of the chemicals responsible for the swelling. Corticosteroids may be used when antihistamines are inadequate or ineffective at controlling an acute episode of angioedema. These agents usually reduce inflammation and reduce vascular permeability. Angioedema is linked to low levels of C1 inhibitors, a key immune system protein found in the blood. Low levels of this substance are what causes the swelling. Even if the cause of angioedema is unknown, increasing the amounts of this protein with the drugs ecallantide and icatibant can help prevent attacks. Idiopathic angioedema may be treated with cannabis, which has been found to have anti-inflammatory qualities. More study is needed before cannabis may be utilized as a treatment for idiopathic angioedema in the clinic. An Epi-pen can be used to treat a person in a life-threatening condition where swelling in the throat or mouth has obstructed the airway. The cause of angioedema must be determined through diagnostic testing, and once established, the causative agent must be removed to prevent further allergic reactions (BN, 2021).
References:
Bio News. (2021). [BN]. Idiopathic Angioedema.

Idiopathic Angioedema

Kostis, W., Chowdhury, Y., & Kostis J. (2018). ACE Inhibitor-Induced Angioedema: a Review. Curr Hypertens Rep. 20(7):55. doi: 10.1007/s11906-018-0859-x. PMID: 29884969.
Medical News Today. (2021). [MNT]. Augmentin. https://www.medicalnewstoday.com/articles/325154#about
National Health Services. (2019). [NHS]. Angioedema. https://www.nhs.uk/conditions/angioedema/causes/
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The differential are drug adverse reaction and glossitis. The final diagnosis is ACE inhibitor adverse reaction. Angioedema is an adverse reaction od Ace Inhibitors such as lisinopril. It could take years to of using it to develop. Having these symptoms in the absence of urticarial lesion should alert about the presence or angioedema. ACE-inhibitor–induced angioedema affects the upper aerodigestive tract but can. Therefore, the healthcare provider should take precaution against obstruction of the upper airway or laryngeal obstruction. Securing airway via intubation should be done in case the existence to possible airways obstruction

Randomized controlled trial conducted to evaluate using Icatibant to relief angioedema found that using icatibant shortened the time to achieve complete resolution of ACEI‐induced AE symptoms (Jeon et al., 2019). another randomized trial involving patients with ACE-inhibitor–induced angioedema shown complete resolution occur significantly more with using 30 mg of subcutaneous icatibant than after standard therapy with glucocorticoids and antihistamines (Baş Murat et al., 2015). Another RCT concluded that the median time to complete resolution of angioedema was shorter with icatibant than with the combination of steroids and antihistamines (Botnaru et al., 2017).

The rational of the treatment is Icatibant have been approved by the U.S. Food and Drug Administration (FDA) for hereditary angioedema. Even thougth, corticosteroids, antihistamines, and epinephrine have been used to treat severe angioedema, there was neither evidence to support using it for ACEI induce angioedema nor guidelines.

References

Baş Murat, Greve, J., Stelter, K., Havel, M., Ulrich, S., Rotter, N., . . . Hoffmann, T. K. (2015). A randomized trial of icatibant in ACE-Inhibitor–Induced angioedema. The New England Journal of Medicine, 372(5), 418-425. doi:http://dx.doi.org/10.1056/NEJMoa1312524

Botnaru, T., Robert, A., & Mottillo, S. (2017). Icatibant Compared to Steroids and Antihistamines for ACE-Inhibitor-Induced Angioedema. CJEM, 19(2), 159-162. doi:10.1017/cem.2016.21

Jeon, J., Lee, Y. J., & Lee, S.-Y. (2019). Effect of icatibant on angiotensin-converting enzyme inhibitor-induced angioedema: A meta-analysis of randomized controlled trials. Journal of Clinical Pharmacy and Therapeutics, 44(5), 685–692. https://doi-org.libauth.purdueglobal.edu/10.1111/jcpt.12997

Angioedema Medical Case Stud ESSAY

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