Angioedema after rt-PA infusion led to airway emergency: a case report of rescue treatment with fresh frozen plasma

Abstract The authors report the case of a 71-year-old woman presented to the Emergency Department with acute ischemic stroke. She was treated with rt-PA and interventional endovascular revascularization and developed rapidly progressing angioedema that led to emergency intubation. The standard treatment was not very effective and the swelling improved after infusion of fresh frozen plasma. Angioedema after rt-PA infusion could be a life-threatening emergency that requires quick airway management by skilled professionals. As this condition is triggered by several factors, such as unregulated histamine and bradykinin production, the traditional treatment recommended by the guidelines may not be sufficient and the use of FFP can be considered as a safe and valuable aid.

Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis / Atualização sobre reações de hipersensibilidade perioperatória: documento conjunto da Sociedade Brasileira de Anestesiologia (SBA) e Associação Brasileira de Alergia e Imunologia (ASBAI) - Parte II: etiologia e diagnóstico

Abstract This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.

Resumo Este segundo documento, escrito por especialistas da Associação Brasileira de Alergia e Imunologia (ASBAI) e da Sociedade Brasileira de Anestesiologia (SBA) interessados no tema anafilaxia perioperatória, tem por objetivo revisar os mecanismos fisiopatológicos, agentes desencadeantes (em adultos e crianças), assim como a abordagem diagnóstica durante e após o episódio. Por se tratar de uma avaliação abrangente, a identificação das medicações, antissépticos e outras substâncias usadas em cada região, registros detalhados, e nomenclatura padronizada são pontos fundamentais para a obtenção de dados epidemiológicos mais fidedignos sobre a anafilaxia perioperatória.

Update on perioperative hypersensitivity reactions: joint document of the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part I: post-crisis guidelines and treatment / Atualização sobre reações de hipersensibilidade perioperatória: documento conjunto da Sociedade Brasileira de Anestesiologia (SBA) e Associação Brasileira de Alergia e Imunologia (ASBAI) - Parte I: tratamento e orientação pós-crise

Abstract Experts from the Brazilian Association of Allergy and Immunology (ASBAI) and the Brazilian Society of Anesthesiology (SBA) interested in the issue of perioperative anaphylaxis, and aiming to strengthen the collaboration between the two societies, combined efforts to study the topic and to prepare a joint document to guide specialists in both areas. The purpose of the present series of two articles was to report the most recent evidence based on the collaborative assessment between both societies. This first article will consider the updated definitions, treatment and guidelines after a perioperative crisis. The following article will discuss the major etiologic agents, how to proceed with the investigation, and the appropriate tests.

Resumo Especialistas da Associação Brasileira de Alergia e Imunologia (ASBAI) e da Sociedade Brasileira de Anestesiologia (SBA) interessados no tema anafilaxia perioperatória reuniram-se com o objetivo de intensificar a colaboração entre as duas sociedades no estudo desse tema e elaborar um documento conjunto que possa guiar os especialistas de ambas as áreas. O objetivo desta série de dois artigos foi mostrar as evidências mais recentes alicerçadas na visão colaborativa entre as sociedades. Este primeiro artigo versará sobre as definições mais atuais, formas de tratamento e as orientações após a crise no perioperatório. No próximo artigo serão discutidos os principais agentes causais e a condução da investigação com testes apropriados.

Postoperative angioedema induced by angiotensin-converting enzyme inhibitor: case report / Angioedema pós-operatório induzido por inibidor da enzima conversora da angiotensina: relato de caso

Abstract Background and objectives: Angioedema is a potentially fatal condition that may occur at any time in the perioperative period. It may result from histamine release, hypersensitivity reaction to drugs, or be triggered by bradykinin, in non-allergic reactions of hereditary or acquired etiology. The aim of this report is to report a case of angioedema in the early postoperative period in a patient on antihypertensive medication involving angiotensin-converting enzyme inhibitors. Case report: A 67-year-old male, Afro-descendant, hypertensive, and taken enalapril maleate underwent orthopedic shoulder surgery under general anesthesia combined with brachial plexus block. The procedure lasted 3 hours uneventfully. After discharge from the post-anesthesia care unit, the patient presented with angioedema and severe airway impairment. Tracheal intubation was attempted but it was impossible due to edema affecting the lips, tongue, and oropharyngeal region Emergency cricothyroidotomy was performed. The onset of angioedema had no causal relationship with the administration of any medication; there were no cutaneous manifestations and also not response to therapy for hypersensitivity reaction to drugs, such as antihistamines, corticoid, and adrenaline. It was considered to be mediated by bradykinin, as the patient had already had two similar episodes and was on regular medication (enalapril). The evolution was satisfactory. Conclusion: Angioedema is a potentially fatal condition when it affects the airway, and should be recognized by anesthesiologists and physicians working in the emergency departments.

Resumo Justificativa e objetivos: O angioedema é uma condição potencialmente fatal que pode surgir em qualquer momento no perioperatório. Pode decorrer da liberação de histamina, em uma reação de hipersensibilidade a drogas ou ser desencadeado pela bradicinina, em reações não alérgicas, de etiologia hereditária ou adquirida. O objetivo desse relato é descrever um caso de angioedema, no pós-operatório imediato, em um paciente em uso de medicação anti-hipertensiva da classe dos inibidores da enzima conversora da angiotensina. Relato de caso: Paciente de 67 anos, masculino, negro, hipertenso e em uso do maleato de enalapril, foi submetido a cirurgia ortopédica de ombro sob anestesia geral associada a bloqueio do plexo braquial. O procedimento durou 3 horas, sem intercorrências. Após a alta da sala de recuperação pós-anestésica, apresentou angioedema com grave comprometimento das vias aéreas. Tentou-se fazer intubação traqueal, mas foi impossível devido ao edema que acometia os lábios, a língua e região orofaringeana. Fez-se a cricotireoidostomia de emergência. O aparecimento do angioedema não apresentou relação causal com a administração de qualquer medicação, não houve manifestações cutâneas e também não respondeu à terapêutica para reação de hipersensibilidade a drogas, como anti-histamínicos, corticoide e adrenalina. Foi considerado como mediado pela bradicinina, pois o paciente já havia apresentado dois episódios semelhantes e estava em uso regular de medicação (enalapril). A evolução foi satisfatória. Conclusão: O angioedema é uma condição potencialmente fatal quando atinge as vias aéreas e deve ser de conhecimento do anestesiologista e dos médicos que trabalham nos setores de emergência.

Angioedema intestinal aislado inducido por enalapril / Isolated intestinal angioedema induced by enalapril

El angioedema inducido por inhibidores de la enzima convertidora de angiotensina es una entidad poco frecuente caracterizada por edema en piel y mucosas, debido al aumento de la permeabilidad vascular provocada por la inhibición de la enzima convertidora y el subsiguiente aumento de la bradiquinina. De manera frecuente cursa con compromiso facial y de mucosas, siendo infrecuente el compromiso intestinal o de vía aérea. El angioedema intestinal puede presentarse asociado a angioedema facial o aislado, siendo este último excepcional. Cursa con episodios recurrentes de dolor, distensión abdominal y diarrea acuosa con recuperación completa en dos o tres días. Si bien es una entidad poco frecuente, el hecho de que esté asociada a fármacos utilizados con frecuencia nos hace incluirla en el diagnóstico diferencial del dolor abdominal recurrente. Presentamos un caso de angioedema intestinal aislado, asociado al uso de enalapril.

Angioedema induced by angiotensin converting enzyme inhibitors is a rare entity characterized by skin and mucosal edema, due to increased vascular permeability caused by inhibition of the converting enzyme and subsequent increase in bradykinin. It frequently presents with facial and mucosal involvement, being uncommon the intestinal or airway compromise. Intestinal angioedema may be associated with facial or isolated angioedema, the latter being exceptional. It is associated with recurrent episodes of pain, abdominal distention and watery diarrhea which complete recovery in two or three days. Although it is a rare entity, the fact that it is associated with frequently used drugs makes us include it in the differential diagnosis of recurrent abdominal pain. We report a case of isolated intestinal angioedema associated with the use of enalapril.

Mucosal-dominant pemphigus vulgaris in a captopril-taking woman with angioedema

AbstractWe describe a 39-year-old woman with an apparent captopril-induced, contact mucosal-dominant pemphigus vulgaris and angioedema, who took captopril during a bout of arterial hypertension. This exposure suggests that captopril and pathophysiology of angioedema stimulated the development of pemphigus vulgaris, which was diagnosed using the novel, indirect immunofluorescence BIOCHIP mosaic, with the modification to detect serum IgG4 autoantibodies. We discuss the patient, who experienced a chain of events leading to the active stage of pemphigus vulgaris, and review concepts of pemphigus vulgaris inducible by drugs and pathological immunity.

Reacciones medicamentosas severas en piel / Severe skin drug reactions

Las drogas son sustancias químicas que pueden interferir con el sistema inmune y a veces conducen a reacciones inusuales y severas. Éstas pueden amenazar la vida, requerir hospitalizaciones prolongadas o dejar secuelas significativas. Cerca del 2 por ciento de las reacciones cutáneas inducidas por fármacos se consideran graves. Estas son el angioedema, el shock anafiláctico, el síndrome de Stevens-Johnson (SSJ), la necrolisis epidérmica tóxica (NET), y el síndrome de hipersensibilidad (DRESS), entre otros. Requieren atención especial ya que los síntomas clínicos son heterogéneos y pueden imitar diferentes enfermedades, lo que lleva a retardar el diagnóstico correcto.

Drugs are chemicals that can interfere with the immune system and may sometimes lead to unusual and severe reactions. These can be life threatening, requiring prolonged hospitalization or have significant sequelae. About 2 per cent of drug-induced skin reactions are considered serious. They are angioedema, anaphylactic shock, the Steven-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and hypersensitivity syndrome (DRESS), among others. They require special attention because clinical symptoms are heterogeneous and can mimic different diseases, leading to a delay in the correct diagnosis.

Angiodema due to oral acitretin and isotretinoin / Angioedema por acitretina e isotretinoína oral

Angioedema may be caused by nonsteroidal antiinflammatory drugs, angiotensin- converting enzyme inhibitors, radiocontrast media, antibiotics, sea food etc. It can involve an allergic (IgE-mediated) or non-allergic hypersensitivity reaction, both with a similar clinical presentation. While angioedema due to isotretionin has been described previously, this is the first description of angiodema due to acitretin. We report two uncommon cases of palpebral and labial angiodema due to retinoids, by acitretin and oral isotretinoin respectively: a 48-year-old man with psoriasis and a 24-year-old woman with severe acne resistant to antibiotics and topical drugs. In both cases the reaction persisted through-out treatment with these drugs, but resolved quickly after discontinuation. Reintroduction of the drugs brought on angioedema again.

Angioedema pode ser causado por diversos fármacos como : antiinflamatórios não-esteroidais, inibidores da ECA, contrastes, antibióticos e frutos do mar, entre outras causas. Pode ser uma reação alérgica, mediada por IgE, ou não-alérgica, com apresentações clínicas semelhantes. Angioedema por isotretinoína já foi relatado, mas não por acitretina. Relatamos dois casos, uma com angioedema palpebral e um labial, por acitretina e isotretinoína, respectivamente: um paciente de 48 anos com psoríase e uma paciente de 24 anos com acne resistente à terapia convencional. Em ambos casos a afecção persistiu durante o tratamento, resolveu com a interrupção e recidivou com reexposição.

Naproxen induced angioedma

Although usually a benign condition, angioedema can be life-threatening if it involves the larynx. Laryngeal edema, regardless of the etiology, can progress to airway compromise and asphyxiation. We report a 36-year-old male who came in with arthralgia and developed urticaria and angioedema after being started on Naproxen

Acquired angioedema secondary to hormone replacement therapy.

Angioedema is a potentially life threatening condition and may be either inherited or acquired. The latter is rare with only a handful of cases reported in the world literature. Presenting complaints are often vague. Those most commonly described include swelling in the subcutaneous and submucosal tissues. Patients presenting with laryngeal edema have high mortality, and high clinical suspicion is necessary to avoid instrumentation, which can precipitate laryngeal spasm. We present a review of reported cases of hormonally induced hereditary angioedema, along with a report of a patient with acquired angioedema secondary to hormone replacement therapy. To the best of our knowledge, this case probably represents the first reported case of acquired angioedema secondary to hormone replacement therapy.

Polymorphisms of High-Affinity IgE Receptor and Histamine-Related Genes in Patients with ASA-Induced Urticaria/Angioedema

The pathogenic mechanism of ASA-induced urticaria/angioedema (AIU) is still poorly understood, but it has been known that histamine releasing by cutaneous mast cell activation is considered to be an important role. Considering the importance of histamine in AIU, we speculated that a genetic abnormality of histamine-related genes such as a high-affinity IgE receptor, a metabolic enzyme of histamines and histamine receptors, may be involved in the development of AIU. Enrolled in the study were 110 patients with AIU, 53 patients without ASA hypersensitivity who had various drug allergies presenting as exanthematous skin symptoms, and 99 normal healthy controls (NC). Eleven single nucleotide polymorphisms (SNPs) of the beta chain of the high-affinity IgE receptor (FCER1B) and three histamine-related genes-histamine N-methyltransferase (HNMT), histamine H1 receptor (HRH1), histamine H2 receptor (HRH2)-were screened using the SNP-IT assay based on a single base extension method. No significant differences were observed in allele and genotype frequencies, and haplotype frequencies of all the SNPs of FCER1B, HNMT, HRH1, and HRH2 among the three groups (p>0.05, respectively). These results suggest that the polymorphisms of FCER1B and the three histamine-related genes may not contribute to the development of AIU phenotype in the Korean population.

Reações adversas a drogas / Adverse reactions to drugs

Os autores apresentam quadros clínicos de lesões estomatológicas que podem ser provocadas pelo uso de medicamentos, fazendo referências aos prováveis agentes etiológicos, às características das lesões e à conduta do profissional frente às mesmas

Estudio de la frecuencia de urticaria y angioedema inducidos por aditivos de alimentos / Frecuency of urticaria and angioneurotic edema induceds by food additives

Algunos aditivos de alimentos pueden inducir urticaria y angioedema en los pacientes susceptibles. En el presente estudio se realizaron pruebas de reto oral tipo doble-ciego, controladas con palcebo, en 33 pacientes (21 de sexo femenino y 12 de sexo masculino con edad promedio de 25 años), con diagnóstico de urticaria y angioedema crónicos (más de seis semanas de duración) e historia clínica que sugería una relación entre la presentación de los síntomas y la ingestión de aditivos de alimentos, o sin causa desencadenante conocida. Las pruebas se llevaron a cabo con dosis progresivamente incrementadas (1-200 mg) de los siguientes aditivos: metabisulfito desodio, benzoato de sodio y tartrazina y lactosa como placebo. Diez de los 33 pacientes (30.3%) presentaron reacción positiva al menos a un aditivo. De las 132 pruebas, 11 (8.3%) fueron positivias (presentación de urticaria y/o angioderma): 5 (15.1%) al benzoato de soido; 4 (12.1%) a la tartrazina y 2(6%) al metabisulfito desodio. No hubo reacción positiva al placebo administrado ni se presentó ninguma reacción adversa grave. Bajo las condiciones que se usaron, las pruebas de reto oral mostraron ser prácticas, seguras y útiles en el estudio de los pacientes con urticaria y/o angioderma crónicos