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.

Physician adjudication of angioedema diagnosis codes in a population of patients with heart failure prescribed angiotensin-converting enzyme inhibitor therapy

PURPOSE

Our objective was to calculate the positive predictive value (PPV) of the ICD-9 diagnosis code for angioedema when physicians adjudicate the events by electronic health record review. Our secondary objective was to evaluate the inter-rater reliability of physician adjudication.

METHODS

Patients from the Cardiovascular Research Network previously diagnosed with heart failure who were started on angiotensin-converting enzyme inhibitors (ACEI) during the study period (July 1, 2006 through September 30, 2015) were included. A team of two physicians per participating site adjudicated possible events using electronic health records for all patients coded for angioedema for a total of five sites. The PPV was calculated as the number of physician-adjudicated cases divided by all cases with the diagnosis code of angioedema (ICD-9-CM code 995.1) meeting the inclusion criteria. The inter-rater reliability of physician teams, or kappa statistic, was also calculated.

RESULTS

There were 38 061 adults with heart failure initiating ACEI in the study (21 489 patient-years). Of 114 coded events that were adjudicated by physicians, 98 angioedema events were confirmed for a PPV of 86% (95% CI: 80%, 92%). The kappa statistic based on physician inter-rater reliability was 0.65 (95% CI: 0.47, 0.82).

CONCLUSIONS

ICD-9 diagnosis code of 995.1 (angioneurotic edema, not elsewhere classified) is highly predictive of angioedema in adults with heart failure exposed to ACEI.

Days Needed for the Disappearance of a Cough Due to the Use of an Angiotensin-Converting Enzyme Inhibitor and Identification of Predisposing Factors Associated With Its Appearance in a Clinical Cohort of Hypertensive Patients

Our main objective was to investigate the numbers of days necessary for the disappearance of the cough caused by an angiotensin-converting enzyme inhibitor (ACEI) subsequent to the discontinuation of treatment, and to identify the associated factors that contribute to the appearance of said cough and angioneurotic edema. We studied 1101 patients with hypertension treated with an ACEI for 15 years. A multivariate analysis of binary logistic regression was performed to identify predisposing cough factors. In the 1101 patients treated with ACEI, 270 were diagnosed as having a cough caused by an ACEI (24.5%). The average numbers of days until the cough disappeared was 6.06 ± 1.58 days. The significant predisposing factors of the cough were female sex (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.31-2.39), previous diagnosis of obstructive sleep apnea (OR, 1.85; 95% CI, 1.31-2.61), and concomitant use of thiazides (OR, 1.50; 95% CI, 1.11-2.04). Statins were shown as a protective factor (OR, 0.69; 95% CI, 0.51-0.93). In the case of angioneurotic edema, 25 patients (2.3%) were diagnosed, without significant determinants. Our analysis showed that the cough disappeared in a period of ≤10 days for 96.7% of patients diagnosed with a cough, subsequent to the discontinuation of ACEI treatment. The risk factors identified for the appearance of a cough include female sex, previous obstructive sleep apnea, and concomitant use of thiazides. The use of statins was found to be a protective factor. The incidence of angioneurotic edema in our cohort is greater than that described in the literature.

Classification, diagnosis, prophylaxis, treatment tactics]

The article highlights the current understanding of the etiology and various mechanisms of development, patterns of angioneurotic edema. Detailed clinical and laboratory picture of allergic and non-allergic forms of angioedema are presented.

[Angioneuritic edema in ischaemic stroke patients treated with rt-PA]

Data of our 254 patients who were treated with rt-PA between 1st of Jan, 2011 and 31st of Dec, 2014 were processed. We focused on angioneurotic oedema as allergic complication of thrombolysis which caused life threatening respiratory obstruction in two cases. We describe these two patients' history. Out of 254 patients six (2.3%) suffered angioneurotic edema caused respiratory obstruction in two (0.90%) cases. This occurrence is approximately 1.3-5.1% in literature. Five, out of six patients who suffered from angioneurotic oedema, had been treated with ACE inhibitors or ARB before. The role of ACE inhibitors is known in metabolism of bradykinin cascade. Plasmin which present during thrombolysis, precipitates biochemical mechanisms of this potential life threatening complication. Therefore rt-PA alone can be the cause of angioedema, but it can be more frequent together with ACE inhibitors therapy.

Cystic hepatic lesions: a review and an algorithmic approach. AJR Am J Roentgenol. 2014;203:1192-1204. [PMID: 25415696 DOI: 10.2214/ajr.13.12386]

OBJECTIVE

The purpose of this article is to review the different cystic hepatic lesions, with an emphasis on the imaging features that help to differentiate them, and to propose a practical algorithm for approaching the diagnosis of these lesions.

CONCLUSION

The number and morphology of the lesions and determination of whether there is a solid component are key imaging features that are helpful for approaching the diagnosis of cystic hepatic lesions. Familiarity with these features and knowledge of the clinical associations will help the radiologist to establish a definitive diagnosis or provide a reasonable differential diagnosis.

Angioneurotic edema: a rare case of hypersensitivity to metoclopramide

The case of a 30-year-old woman who had already experienced two incidents of angioneurotic edema and urticaria caused by drugs during the acute gastroenteritis. The allergological workup revealed hypersensitivity to metoclopramide. This case documents that metoclopramide, a drug commonly used to inhibit the vomiting, may cause not only bronchospastic reaction in an asthmatic patient but also angioneurotic edema of the tongue and larynx as well as urticaria. No similar cases in the literature were found.

Hereditary and acquired angioedema: problems and progress: proceedings of the third C1 esterase inhibitor deficiency workshop and beyond

Hereditary angioedema (HAE), a rare but life-threatening condition, manifests as acute attacks of facial, laryngeal, genital, or peripheral swelling or abdominal pain secondary to intra-abdominal edema. Resulting from mutations affecting C1 esterase inhibitor (C1-INH), inhibitor of the first complement system component, attacks are not histamine-mediated and do not respond to antihistamines or corticosteroids. Low awareness and resemblance to other disorders often delay diagnosis; despite availability of C1-INH replacement in some countries, no approved, safe acute attack therapy exists in the United States. The biennial C1 Esterase Inhibitor Deficiency Workshops resulted from a European initiative for better knowledge and treatment of HAE and related diseases. This supplement contains work presented at the third workshop and expanded content toward a definitive picture of angioedema in the absence of allergy. Most notably, it includes cumulative genetic investigations; multinational laboratory diagnosis recommendations; current pathogenesis hypotheses; suggested prophylaxis and acute attack treatment, including home treatment; future treatment options; and analysis of patient subpopulations, including pediatric patients and patients whose angioedema worsened during pregnancy or hormone administration. Causes and management of acquired angioedema and a new type of angioedema with normal C1-INH are also discussed. Collaborative patient and physician efforts, crucial in rare diseases, are emphasized. This supplement seeks to raise awareness and aid diagnosis of HAE, optimize treatment for all patients, and provide a platform for further research in this rare, partially understood disorder.