Pathogenesis of Drug Induced Non-Allergic Angioedema: A Review of Unusual Etiologies

Extensive Soft Tissue Swelling in the Larynx and Hypopharynx of a Young Female Patient After Haloperidol Use: A Case Report on Angioneurotic Edema

Angioneurotic edema is a potentially life-threatening condition characterized by the rapid swelling of subcutaneous and submucosal tissues of the upper respiratory and gastrointestinal tracts. It may result in laryngeal edema, thus obstructing the airway, with a potentially fatal outcome if not diagnosed early. An allergic reaction typically causes it, but certain drugs can induce or contribute to the development of angioneurotic edema in rare cases. Haloperidol is one of the most commonly used antipsychotics to treat psychiatric disorders such as schizophrenia and, in the emergency room, acute delirium and acute psychosis. While it is generally well tolerated, in rare cases, individuals may experience a severe reaction in response to haloperidol administration. Here, we present the case of angioneurotic edema associated with intramuscular haloperidol use in a 29-year-old female patient with a history of bipolar disorder and no previous history of allergy. This case report aims to raise awareness among clinicians about this rare adverse reaction associated with haloperidol use.

A Rare Case of Losartan-Induced Visceral Angioedema

The following describes a case of isolated visceral angioedema related to an angiotensin II receptor blocker (ARB) medication. Additionally, we discuss the pathophysiology of drug-induced angioedema, various presentations that can be encountered, and the leading theorized mechanisms of how renin-angiotensin-aldosterone system (RAAS) blocking medications lead to angioedema. The goal of sharing this case is to help increase awareness of the possibility of ARB-induced angioedema and to recommend keeping visceral angioedema as part of the differential diagnosis when presented with a patient who is taking an angiotensin converting enzyme inhibitor (ACEI) or ARB medication that is experiencing gastrointestinal symptoms of unclear etiology.

Angiotensin-Converting Enzyme Inhibitor-Induced Non-allergic Perioral Angioedema: A Case-Based Scoping Review

Patients with angiotensin-converting enzyme inhibitor (ACEI)-induced angioedema (ACEIIA) may visit family physicians. The aim of this article was to describe a case of delayed-onset ACEIIA and to present a concise scoping review. Using a case report and a scoping review study design, we report a case of ACEIIA, with clinically confirmed diagnosis. The symptoms resolved after replacing the offending ACEI with another antihypertensive agent. After excluding other causes of perioral swelling and discontinuation of ACEI, the patient was symptom-free within a few days thereafter. Based on this case presentation, we performed a meta-narrative scoping review including up-todate diagnosis and management of ACEIIA, based on published data in English, French, and German from inception to April 1, 2021. Patients with angioedema of unknown origin should be cautiously examined to rule out oral diseases, including allergy to dental materials and drug-induced angioedema. Clinicopathological aspects and current treatment guidelines for ACEI-associated angioedema are also presented.

Mirabegron Associated Angioedema: A Case Report

Purpose: To review a case of angioedema associated with mirabegron. Summary: A 77-year-old woman presented to the emergency department with swelling of the left anterior side of the tongue beginning 90 minutes prior to arrival. She noticed tingling on her tongue while eating a hamburger, chips, and ice cream. The patient had no history of medication-related allergies. Home medications include acetaminophen, aspirin, biotin, black cohosh, Co-enzyme Q-10, cranberry, fish oil, multivitamin, alendronate, and mirabegron all taken orally. The patient reports being on mirabegron for 3 to 4 years but recently decided to self-taper off the medication. Her initial laboratory test results were unremarkable. The patient was diagnosed with left tongue angioedema, and she received methylprednisolone, epinephrine, famotidine, and 2 units of plasma. After medication administration, the patient underwent a flexible nasopharyngeal laryngoscopy resulting in no significant angioedema in the pharynx and hypopharynx with a small area of possible edema noted on the right base of tongue/lingual tonsil. Patient's symptoms improved with medication treatment and discontinuation of mirabegron. The use of Naranjo et al. adverse-event probability scale revealed that mirabegron was the possible (score of 4) cause of the patient's left tongue angioedema. Conclusion: A 77-year-old woman developed drug induced tongue angioedema associated with mirabegron after being compliant on this medication for 3 to 4 years. Patient was self-tapering her dose of mirabegron. This patient responded well to medication treatment and discontinuation of drug. To our knowledge, this is the second case report of mirabegron induced angioedema.

Atorvastatin as a Rare Primary Cause of Drug-Induced Angioedema: A Case Report

In patients with hyperlipidemia and cardiovascular disease, statin remains the primary medication for risk reduction. Statins are primarily associated with adverse outcomes like myoglobinuria and deranged liver function tests (LFTs). Angioedema is a life-threatening reaction characterized by mucosal and submucosal swelling. It is rarely known for its association with statins. However, we present a rare case of a 59-year-old man presenting with recurrent angioedema of the face and tongue after starting on 40mg of atorvastatin, within one week of the treatment. He had no previous history of hypersensitivity and rash. He denied any food or medication allergy in the past. The Naranjo scale probability and the abrupt nature of these episodes upon starting statin and completely resolving after discontinuing the drug made statin-induced angioedema the primary diagnosis in this case.

Paliperidone palmitate-induced facial angioedema: A case report

BACKGROUND

Paliperidone palmitate is a once-monthly injectable, atypical antipsychotic. To our knowledge, there has been only one report of paliperidone palmitate-induced angioedema presenting with acute laryngeal edema with subsequent respiratory arrest. Here, we present a case report of paliperidone palmitate-induced angioedema with a relatively mild clinical presentation compared with the previously reported case, and the patient’s condition was not complicated by life-threatening anaphylaxis.

CASE SUMMARY

A 79-year-old female, who had a major neurocognitive disorder due to Alzheimer’s disease with behavioral disturbances. Paliperidone palmitate was off-label used to control her aggression, irritability, and psychosis. After induction doses (150 mg and 100 mg intramuscularly, given 1 wk apart), she developed intermittent swelling of the face, eyelids, and lips on day 17 after the initial dose, and the edema was explicitly seen on day 20. The diagnosis was paliperidone palmitate-induced angioedema. The monthly injection dose was discontinued on day 33 after the initial dose. The angioedema was subsequently alleviated, and it had completely resolved by day 40 after the initial dose.

CONCLUSION

Paliperidone palmitate-induced angioedema is a rare condition and can present with a mild, intermittent facial edema, which may be overlooked in clinical practice.

Drug-induced Angioedema: A Rare Side Effect of Rosuvastatin

Hydroxymethyl glutaryl coenzyme A reductase inhibitors (statins) are first-line medication for lowering serum cholesterol levels in the prevention of cardiovascular disease. Angioedema is the swelling of mucosa and submucosal tissue. There are no published cases of drug-induced angioedema involving rosuvastatin. We report a case of a 45-year-old female who presented with episodes of self-resolving edema of face, lips, and tongue after being on rosuvastatin. The patient denied any rash during these episodes and mentioned that self-medication with diphenhydramine did not relieve her symptoms. The patient was hemodynamically stable. The complement component 4 (C4), C1 esterase inhibitor, and complement component 1q (C1q) binding assay were within normal range. Therefore, the diagnosis of hereditary angioedema was effectively ruled out. The temporal relation between rosuvastatin and the development of angioedema and prompt resolution of symptoms after the drug discontinued suggest that rosuvastatin was the most probable culprit in the development of angioedema in our patient.