Angioedema from instant coffee

Abstract

Acute allergic angioedema is an abrupt-onset, unpredictable inflammatory reaction of the skin and mucous membranes. Without treatment, the condition may resolve within hours; however, when swallowing or breathing is affected, emergent medical attention is required. We report an atypical presentation of this condition, with a unique dietary cause. A 50-year-old man with no relevant medical history emergently presented with acute angioedema of the lower lip, without urticaria. The inflammation spread to other facial structures but gradually dissipated after subcutaneous epinephrine was administered. Despite thorough questioning of the patient, the cause of the angioedema was not determined. Five days later, during tapered prednisone therapy, the angioedema recurred, and the patient acted to reverse the attack. Instant coffee was identified as the trigger. Beverages are very rarely reported as primary causes of angioedema. To our knowledge, this is the first report of an adult with angioedema triggered not by the caffeine in coffee, but by another characteristic of it.

We report the case of a man who presented at our emergency department (ED) with angioedema of the lower lip, without urticaria. Although the cause of the condition remained undetermined upon the patient's discharge from emergency care, the offending agent was identified after a single recurrence 5 days later. We discuss the discovery of the trigger and review the relevant medical literature.

CASE REPORT

In October 2009, a 50-year-old man presented in the late morning at the employee health clinic of his employer (a hospital) with swelling of the left side of the lower lip, of 2 hours' progressive duration. The painless inflammation was disfiguring and affected his speech. He was in good general health, was taking no medications besides daily aspirin and vitamins, and had no family history of similar inflammation. The only relevant episode in his personal medical history was a localized inflammatory reaction from a wasp sting to the hand in 2005. The patient speculated that he had bitten his lip earlier that morning, but he could not specifically remember having done so. He was given topical ice and 50 mg of oral diphenhydramine. After 45 minutes and no improvement, the clinic personnel recommended that he visit either his family physician or the ED of the hospital.

At the ED, the patient repeated his assumption that he had bitten his lip. Upon visual examination, the inflammation was inconsistent with abscess. The diagnosis was angioedema without urticaria. He was given an intramuscular injection of 125 mg of methylprednisolone.

Fifteen minutes later, the patient's entire lower lip and the central portion of his tongue rapidly became asymmetrically inflamed. He was immediately given a subcutaneous injection of 0.03 mg of epinephrine, an intravenous catheter was inserted into his hand as a precaution, and he was given topical ice. He stoically declined an offer of admission to the hospital and remained under observation in the ED. During this time, his vital signs were within normal limits.

After approximately 2 hours, the inflammation began dissipating and was judged to be 25% improved. Preparations were made for the discharge examination. The ED staff thoroughly questioned the patient about his recent food intake, but no triggers were identified. Accordingly, the angioedema was attributed to an idiopathic but possibly histaminergic cause.

The patient was discharged after 4.5 hours of ED care with a prescription for a standard prednisone taper pack (beginning with two 40-mg doses). He was further instructed to take 25 mg of oral diphenhydramine on each of the next 2 evenings and then 10 mg of loratadine for 5 days, and to visit his family physician thereafter.

The patient later realized that he had not told the ED staff of his consumption that morning of a cup of instant coffee, from a newly opened jar. It had been his only intake of any foodstuff. Suspecting the coffee and challenging his reaction to it, he continued to drink single daily cups in usual amounts: 2 heaping teaspoons of coffee and 2 g of saccharine sweetener mixed into heated tap water. On the morning of the first 20-mg prednisone dose, and shortly after he had drunk a cup of the coffee, angioedema rapidly developed. The inflammation involved the left side of the lower lip and the left central portion of the tongue, abruptly spreading to the right side of the tongue but sparing the tip and the base. The patient took another 10 mg of prednisone. In an hour, the angioedema completely dissipated. He drank no more of the coffee thereafter.

After considerable discussion at the follow-up medical appointment, it was concluded that the coffee was the probable trigger. The family physician recommended against the patient's drinking more of that coffee or any from another jar with the same production codes as the first. The patient complied and, through May 2012, had experienced no more angioedema after drinking coffee.

DISCUSSION

In this patient's case, the circumstantial evidence was strong that the coffee triggered the angioedema. The absence of angio-edema in his family and personal medical histories eliminated inherited conditions from the differential diagnosis. The results of the oral challenge confirmed his personal suspicion of the culprit substance, and the absence of repeat attacks—for 2.5 years after the elimination of that trigger—excludes idiopathic causes and further supports the conclusions drawn at the time.

Acute angioedema presents with a rapid, unpredictable course that can pose merely a physical inconvenience or a life-threatening emergency for the patient (1). Clinically, challenges include accurate and timely diagnosis (2), determining whether conservative or aggressive treatment is appropriate (3), discerning the specific underlying cause or trigger of the condition (4), and counseling the patient in regard to recurrent episodes and measures for prevention and treatment. Zingale and colleagues have published a comprehensive flowchart to aid in the diagnosis of various types of angioedema that are unaccompanied by urticaria (5).

Our patient had no family history or previous personal history of angioedema. He was in good general health and had no known allergies to foodstuffs or environmental agents. Of medications that have been implicated in the immunologic triggering of angioedema, he was not taking penicillin (2), cephalosporin (2), angiotensin-converting enzyme inhibitors (5, 6), or bupropion (7), and he had never reacted adversely to aspirin (2, 8). In the absence of an identifiable environmental, dietary, or hereditary trigger, the ED personnel had to record the cause of this angioedema attack as idiopathic but possibly histaminergic (5) and trust that subsequent patient-physician interaction or the patient's own insights would reveal the trigger.

Follow-up immunologic investigation might have revealed whether the angioedema was mediated by or associated with immunoglobulin E. In cases of suspected food allergy, the official practice guidelines of the American College of Allergy, Asthma, and Immunology (9) include medical testing and oral challenges as methods by which to pinpoint and eliminate triggers of angioedema.

According to the patient, the coffee (in crystal form) was an internationally distributed brand. Upon first opening, the jar and its seal were intact, and, according to the manufacturer's code, the product would be fresh for nearly 2 more years. The patient had previously (but not recently) consumed this brand of coffee without incident. No family member experienced a reaction after drinking it. We speculate that our patient's attacks were caused by an additive or change of formulation peculiar to that jar of coffee.

Beverages are very rarely reported as primary causes of angioedema. In adults, beer (10) and other alcoholic beverages (11) have been implicated. Our search for adult cases in the world medical literature revealed a single report that involved the drinking of coffee: a woman with chronic urticaria had an anaphylactic reaction from coffee and an analgesic in combination (8). Clinicians have implicated caffeine, in coffee and from other sources, as the trigger of urticaria or anaphylaxis in children (12, 13). Workers in coffee-processing plants have experienced airborne allergies from raw coffee (14). Our patient reported no inflammatory reaction to caffeine during a lifetime of its consumption in many forms. Accordingly, we believe that this is the first report of an adult with angioedema that was triggered not by the caffeine in coffee, but by some other characteristic of it.

Acknowledgments

The authors thank Jimmie E. Lewis, MD (Kelsey-Seybold Hospital Services, Houston) and Robert I. Schwartz, RN (Emergency Department, St. Luke's Episcopal Hospital, Houston) for their care of the patient, and Prof. Dr. med. Johannes Ring (Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Munich, Germany) for communications regarding the case of the adult with coffee-induced anaphylaxis (8).