Angioedema. pdf

Physical examination revealed dysphonia, dyspnea, and tripoding. Flexible laryngoscopy revealed grape-sized uvular swelling and edema of the false vocal folds. He received another dosage of 0. Because of the severity of his symptoms, he was started on a continuous intravenous epinephrine infusion that was weaned overnight as the angioedema improved.

Serum tryptase level drawn in the ED was normal. The patient denied ingestion of peanuts before symptom onset and had no previous history of angioedema. He received his second Pfizer-BioNTech vaccine 6 months after this reaction without complications.

He reported no further episodes of angioedema in the subsequent 9 months after his first vaccination. A year-old woman with a history of episodic idiopathic urticaria, asthma, venom hypersensitivity, and Cushing syndrome on long-term low-dose corticosteroids tolerated her first Pfizer-BioNTech COVID mRNA vaccine without immediate complications.

After 1 day, she developed a pruritic, erythematous rash on her chest, throat tightness, and dyspnea, and presented to the ED where she was noted to be normotensive, tachycardic, and mildly febrile. Physical examination revealed lip and tongue angioedema, urticaria involving arms and chest, muffled voice, and decreased breath sounds.

Flexible laryngoscopy revealed edematous vocal cords. She was urgently intubated. Serum tryptase levels during symptoms were normal. She received 2 doses of 0. Owing to her symptom severity, she was started on a continuous intravenous epinephrine infusion, which was weaned after 8 hours, and her angioedema resolved by 14 hours.

She denied a previous history of angioedema and reported no further episodes in the subsequent 7 months. Urticaria has been reported to develop within 1 to 3 days after vaccination but, in these reports, there was no association with angioedema. Altogether, these cases were disparate in terms of sex, race, ethnicity, and atopic history.

All patients denied a previous history of angioedema and could not identify an alternative trigger immediately before symptom onset. This suggests, but by no means proves, causality between the vaccine administration and development of delayed urticaria and angioedema.

From the clinical history, no factor was identified that could have predicted that angioedema or the severity would develop in each case. Fortunately, all patients were successfully treated, and no deaths occurred.

Such cases of delayed angioedema seem to be rare and, interestingly, patient 2 received the second vaccine dosage without complications or delayed angioedema. Perform a scalpel-finger-bougie cricothyrotomy. The patient should continue breathing throughout the entire procedure, so you should be able to take your time a bit with this.

However, if asphyxiation occurs, the procedure should be achievable very rapidly. There is time to call for help and additional equipment. Suggested management: The awake double setup : Obtain an experienced intubator and someone competent at scalpel-finger-bougie cricothyrotomy Note: it doesn't matter whether this person is a surgeon, what matters is skill in this specific procedure.

Perform awake fiberoptic intubation. These patients often have tongue swelling, so the best approach is often nasotracheal intubation for taller patients, consider obtaining an extra-long ETT for nasotracheal intubation. During the intubation procedure, the second operator should be prepared to perform cricothyrotomy if the airway is lost. Angioedema beyond histamine: an educational case series.

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Efficacy of Treatment of Non-hereditary Angioedema. Clin Rev Allergy Immunol. Angioedema in the emergency department: a practical guide to differential diagnosis and management.

Int J Emerg Med. Rev Med Interne. Emerg Med Int. Angiotensin-converting enzyme inhibitor-induced angioedema worsened with fresh frozen plasma. Am J Emerg Med. Angiotensin-converting enzyme inhibitor-associated angioedema treated with c1-esterase inhibitor: A case report and review of the literature. Allergy Rhinol Providence. Immunol Allergy Clin North Am.

If allergic angioedema is suspected, you are likely to be referred to a specialist allergy or immunology clinic for further testing. Tests may include:. Read more about diagnosing allergies. If you are taking a medication known to cause drug-induced angioedema, your GP will withdraw that medication and prescribe an alternative. You should not stop taking any prescribed medication without advice from a health professional.

If you don't have any further episodes of angioedema, a diagnosis of drug-induced angioedema can be made. Hereditary angioedema can be diagnosed using a blood test to check the level of proteins regulated by the C1-inh gene.

A very low level would suggest hereditary angioedema. The diagnosis and management of hereditary angioedema is highly specialised and should be carried out in a specialist immunology clinic. Idiopathic angioedema is usually confirmed by a "diagnosis of exclusion". This means a diagnosis of idiopathic angioedema can only be made after all the above tests have been carried out and a cause has not been found.

As angioedema can be associated with other medical problems — such as an iron deficiency, liver diseases and problems with the thyroid gland — your doctor or specialist will undertake some simple blood tests to check for these conditions. Medication is the main treatment for angioedema, although many cases get better after a few days without treatment. Allergic angioedema and idiopathic angioedema are usually treated in the same way, using a combination of antihistamines and corticosteroids to help relieve the swelling.

Drug-induced angioedema can usually be treated by using an alternative medication to the one causing your symptoms. If you also had symptoms of anaphylaxis during an episode of angioedema, you will probably be given an adrenaline auto-injector pen in case your symptoms return.

Read more about treating anaphylaxis. Hereditary angioedema cannot be cured and does not respond to adrenaline, antihistamines or steroids, so a preventative approach is taken. A number of different medications are used to stabilise the protein levels in your blood to help prevent symptoms developing. Antihistamines work by blocking the effects of a protein called histamine, which is one of the chemicals responsible for causing your skin to swell.

A 2-week course of a non-sedating type of antihistamine which does not cause drowsiness is usually recommended — these include fexofenadine and cetirizine. Cetirizine can be bought over the counter in pharmacies and supermarkets without a prescription. If you also have urticaria hives and are being kept awake at night by itchy skin, your GP may prescribe an older type of antihistamine to take before going to bed. These types cause drowsiness and should help you sleep. A minority of people will still experience drowsiness after taking the newer type of antihistamines.

If you find yourself feeling drowsy, you should avoid:. Corticosteroids steroids work by blocking many of your immune system's actions.

In most cases, a 3 to 5 day course of steroid tablets is recommended. A steroid called prednisolone is the preferred choice. If you feel dizzy after taking prednisolone, avoid driving and operating heavy machinery. These side effects should pass once you finish the course of treatment. Steroid injections may be needed for more severe cases of angioedema. These are usually administered in hospitals or at specialist clinics by an allergy specialist or immunologist a doctor who specialises in treating conditions that affect the immune system.

Danazol is a synthetic hormone that is effective in preventing the symptoms of angioedema because it helps boost levels of the C1-inh protein. However, danazol can cause a number of unpleasant side effects if used on a long-term basis. For example, it may cause:. Due to these side effects, many people with hereditary angioedema are uneasy about using danazol on a long-term basis.

Stanozolol is a similar medication that is slightly better tolerated. Tranexamic acid is also an alternative medication to danazol.

It can be as effective as danazol, but does not cause as many side effects and is preferred for use in women. Icatibant is a relatively new medication used to treat acute short-lasting episodes of swelling. It works by blocking the effects of some of the chemicals that are responsible for causing the swelling in cases of hereditary angioedema. Purified C1-inhibitor concentrate is widely used to replace the missing protein in the blood.

It's needed for patients undergoing surgery, to prevent attacks caused by surgical trauma. It's used to treat acute attacks and is injected directly into the vein. Icatibant and C1-inhibitor concentrate will be prescribed by the specialist immunology unit caring for the patient with hereditary angioedema.

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