Late-onset angioedema due to an angiotensin-converting enzyme inhibitor

Abstract

Angioedema is a rare but potentially life-threatening adverse effect of angiotensin-converting enzyme inhibitors. A patient who presented with facial angioedema four months after initiating antihypertensive treatment with enalapril is described. Angioedema due to angiotensin-converting enzyme inhibitors usually appears during the first weeks of treatment. Late-onset angioedema is often unrecognized.

A 69-year-old man with Parkinson’s disease and essential hypertension was admitted to the emergency department because he could not open his eyes on waking from sleep (Figure 1). He was otherwise asymptomatic, with no pain, fever or airway compromise. The patient had no history of allergies and had not been exposed to insects, plants or products that may have caused an allergic reaction; laboratory tests showed no abnormalities. An ophthalmological evaluation and an orbit computed tomography scan showed normal findings except for soft tissue edema. Medications included cinitapride and lactitol for constipation, as well as levodopa and carbidopa during the past four years. Enalapril 10 mg/day had been initiated four months earlier with good blood pressure control. A diagnosis of late-onset angioedema caused by an angiotensin converting-enzyme inhibitor (ACEI) was proposed. Enalapril was withdrawn in the emergency room; during the next 24 h, the angioedema improved and the patient’s eyes could gradually be opened. He was discharged with local and systemic steroids for one week. Four weeks later, the angioedema had disappeared (Figure 2) and the patient’s hypertension was being treated with amlodipine. On the last follow-up (three months later), there had been no recurrences.

Figure 1).

Facial angioedema. Prominent swelling of the face (especially at the eyelids) that precludes eyes opening is shown

Figure 2).

Resolution of the angioedema four weeks later. Facial edema has disappeared and eyes can be opened

Angioedema is a rare but potentially life-threatening adverse effect of ACEIs. Angioedema occurs in 0.1% to 0.7% of patients on ACEIs, but the association is not always recognized (1,2). The effect is idiosyncratic and unpredictable. It is more likely to occur in black patients, those older than 65 years of age and in those with a history of drug-related rash or seasonal allergies (1). Although the onset typically occurs within the first weeks of ACEI therapy (3), cases with latencies ranging from several months to several years have been reported (4). In patients with such an atypical course, the diagnosis may be missed.