Point-of-Care Ultrasound on Management of Cellulitis Versus Local Angioedema in the Pediatric Emergency Department.

OBJECTIVES: To evaluate whether ultrasound can differentiate between cellulitis and angioedema from insect bites in pediatric patients. METHODS: A prospective, pre-post study in an urban pediatric emergency department of patients younger than 21 years with soft tissue swelling from insect bites without abscesses were enrolled. Treating physician's pretest opinions regarding the diagnosis and need for antibiotics were determined. Ultrasound of the affected areas was performed, and effects on management were recorded. Further imaging, medications, and disposition were at the discretion of the enrolling physician. Phone call follow-ups were made within a week of presentation. RESULTS: Among 103 patients enrolled with soft tissue swelling secondary to insect bites, ultrasound changed the management in 27 (26%) patients (95% confidence interval [CI], 18-35%). Of the patients who were indeterminate or believed to require antibiotics, ultrasound changed management in 6 (23%) of 26 patients (95% CI, 6%-40%). In those patients who were believed not to require antibiotics, ultrasound changed management in 12 (16%) 77 patients (95% CI, 7%-24%). Patients with diagnosis of local angioedema achieved symptom resolution 1.4 days sooner than patients diagnosed with cellulitis (mean, -1.389; 95% CI, -2.087 to -0.690; P < 0.001). No patient who was initially diagnosed as local angioedema received antibiotics upon patient follow-up. CONCLUSIONS: Point-of-care ultrasound changed physician management in 1 of 4 patients in the pediatric emergency department with soft tissue swelling secondary to insect bites. Ultrasound may guide the management in these patients and lead to improved antibiotic stewardship in conjunction with history and physical examination.

Bowel angioedema induced by iodinated contrast media.

We present the case of a patient with small bowel angioedema induced by iodinated contrast media during computed tomography. It is important to know this entity and to differentiate it from other intestinal diseases in order to avoid inappropriate treatment.

Angioedema late in the course of adjuvant nivolumab therapy for melanoma.

Although immune checkpoint inhibitors improve survival in cancer patients, they have also been linked with unusual side effects. The most common side effects of these agents are immune-mediated phenomena such as itching, skin rash, arthralgias, mild transaminitis and asymptomatic thyroid dysfunction. We describe herein a case of facial angioedema occurring 20 weeks after initiating adjuvant nivolumab therapy for melanoma. The patient had full resolution of symptoms with cessation of nivolumab and a short steroid course. As the causality of an association between nivolumab and angioedema seems legitimate, we expect further similar cases to surface in patients treated with immune checkpoint inhibitors. Prompt drug withdrawal and steroids are crucial to ensure favorable clinical outcomes in these patients.

Angioedema in Stroke Patients With Thrombolysis.

Background and Purpose- Oral angioedema (OA) is a rare but life-threatening complication in patients with ischemic stroke receiving intravenous thrombolysis with r-tPA (recombinant tissue-type plasminogen activator). This study intended to determine associations between thrombolysis-related OA and ischemic stroke lesion sites using a voxel-wise lesion analysis. Methods- Prospective registry data were used to identify ischemic stroke patients with thrombolysis-related OA between 2002 and 2018. For the study registry, ethics approval was obtained by the Ethics Committee of the Friedrich-Alexander Universität (FAU) Erlangen-Nürnberg (clinical registry registration: 377_17Bc). Ischemic stroke patients with thrombolysis treatment but without OA admitted in the years 2011 and 2012 comprised the control group. Ischemic lesions were manually outlined on magnetic resonance imaging (1.5T or 3T) or computed tomographic scans and transformed into stereotaxic space. We determined the lesion overlap and compared the absence or presence of OA voxel-wise between patients with and without lesions in a given voxel using the Liebermeister test. Stroke severity was rated using the National Institutes of Health Stroke Scale score, and blood pressure, heart rate, blood glucose levels, and body temperature were determined on admission. Results- Fifteen ischemic stroke patients with thrombolysis-related OA were identified. The voxel-wise analysis yielded associations between OA and ischemic lesions in the insulo-opercular region with a right hemispheric dominance. Mean blood pressure was significantly lower in patients with OA than in controls. Age, National Institutes of Health Stroke Scale scores, infarct volumes, heart rate, and blood glucose levels did not differ between patients with and without OA. Conclusions- The voxel-wise analysis linked thrombolysis-related OA to right insulo-opercular lesions. The lower blood pressure in patients with thrombolysis-related OA may reflect bradykinin effects causing vasodilatation and increasing vascular permeability.

[Isolated intestinal angioedema induced by enalapril]. / Angioedema intestinal aislado inducido por 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.

Angiotensin-converting enzyme inhibitors-induced angioedema of the small bowel mimicking postoperative complication.

Angioedema of the small bowel (ASB) is an extremely rare side effect of the angiotensin-converting enzyme inhibitors (ACEI). We present a case of ACEI-induced ASB mimicking postoperative complication. The diagnosis of ACEI-induced ASB should be considered in patients using these drugs and presenting sudden gastrointestinal symptoms and thickening of small bowel not attributable to other diseases.

[A Case Report of Acute Angioedema that Showed Dramatic Response to Administration of a C1-inactivator].

Angioedema is characterized by rapid and severe swelling of the subcutaneous and submucosal tissues. Angioedema involving the upper airway can lead to life-threatening airway obstruction, and needs prompt diagnosis and treatment. Herein, we report a case of acute angioedema which was suspected as having been caused by estrogen imbalance. A 32-year-old woman who was taking a fertility drug for infertility treatment, presented with sudden swelling of the face and neck region and breathing difficulty. Her symptoms continued to progress despite antibiotic and corticosteroid administration. We suspected hereditary angioedema (HAE), and administered a C1-inactivator, which led to immediate and dramatic resolution of the symptoms. Since the C4 and C1-inhibitor levels were normal, the possibility of HAE type III was considered. However, another possibility was that her complicated hormonal condition, including oral intake of a fertility drug, menstruation, and mental stress may have led to estrogen imbalance causing angioedema. Currently, a variety of hormone therapies is widely used ; therefore, caution is needed against the development of estrogen-dependent angioedema.

Quincke's edema and hypersensitivity pneumonitis induced by lenalidomide for multiple myeloma.

A 64-year-old man with recurrent multiple myeloma (BJP-κ type) was treated with 15 mg of lenalidomide (LEN) and dexamethasone. He developed Quincke's edema on his eyelid on day 4. Since the edema improved after withdrawal of LEN, the drug was subsequently re-administered at a decreased dose. However, the edema developed again on day 4. After withdrawal of LEN, the drug was administered again with gradually dose escalation, while confirming the absence of eyelid edema. Although edema did not develop, eosinophils and basophils were increased, and the CRP level was elevated. During the third course of LEN administration, his chest CT showed bilateral ground-glass opacity, and LEN-induced hypersensitivity pneumonitis was diagnosed. The pneumonitis resolved after LEN withdrawal and prednisolone administration. These observations suggested that Quincke's edema, eosinophilia and basophilia, CRP elevation, and hypersensitivity pneumonitis might occur due to the immunological effects of LEN, which is classified as an immunomodulatory drug.

Fatal laryngeal angioedema: a case report and a workup of angioedema in a forensic setting.

Angioedema is an episodic swelling of the deep dermis, subcutis, and/or submucosal tissue due to an increase in local vascular permeability. Swelling may involve skin, respiratory, and gastrointestinal tracts. The most commonly involved areas are the periorbital region and the lips. Here we report a case of a fatal laryngeal obstruction due to angioedema likely caused by an angiotensin-converting-enzyme inhibitor. The decedent, a 58-year-old man, was witnessed developing sudden facial swelling and acute respiratory difficulties quickly followed by unresponsiveness. His past medical history suggested that this was his second episode of angioedema without urticaria. Postmortem examination revealed a complete laryngeal obstruction in the absence of infection, neoplasm, or autoimmune disease. Postmortem computed tomography of the head and neck showed a complete obstruction of the upper airway. Based on the current understanding of the pathophysiology of different types of angioedema, we will suggest a workup of angioedema without urticaria in the forensic setting and offer readers resources they can use in their practice.

Sonographic appearance of angioedema in local allergic reactions to insect bites and stings.

Soft tissue infections and angioedema from insect bites and stings may be difficult to differentiate by inspection. We present sonographic findings of 4 cases of soft tissue swelling from insect bites and stings suggestive of angioedema. Sonographic features of soft tissue angioedema consist of thickened subcutaneous tissue layers with multiple linear, horizontal, striated, and hypoechoic lines following the tissue planes between soft tissue layers. In addition to the history and physical examination, sonographic findings may assist in differentiating between local allergic reactions and cellulitis in patients with insect bites and stings. Further study is warranted for clinical application.

[Recurrent abdominal pain and ascites in patients suffering from congenital angioedema due to C1 inhibitor deficiency. Retrospective analysis]. / Nawracajace bóle brzucha i wodobrzusze u pacjentów z wrodzonym obrzekiem naczynioruchowym na tle niedoboru C1 inhibitora. Analiza retrospektywna.

The aim of the study was the estimation of diagnostic value abdominal ultrasonography in recurrent attacks the patients suffering from hereditary angioedema. The retrospective analysis was done in 150 patients with C1 inhibitor deficiency and abdomen attack of angioedema connected with this. In 55 patients severe 2-3 days longlasting abdomen attacks with nausea, diarrhoea and weakening were the first symptoms of the illness and causing particular diagnostic problem. In 95 remaining patients abdomen attack appeared in the course of illness manifesting external angioedema of hands, feets, face, genitalia or larynx. The frequency of abdominal attacks was different from 1-15/year. Diagnostic problem was the reason of laparotomy in 19.3% of patients which did not explain the reason of symptoms. Only in 23 % of patients US of abdomen was done, which revealed the presence of ascites, which disappeared together with abdomen symptoms. US often allowed to show the place of regional angioedema usually in the most cases in intestine wall.

Unnecessary surgery for acute abdomen secondary to angiotensin-converting enzyme inhibitor use.

Acute abdominal pain is the reason for 5% to 10% of all emergency department visits. In 1 in every 9 patients, operated on for an acute abdomen, laparotomy is negative. In a minority of patients, the acute abdomen is caused by side effects of medication. We present a case of unnecessary abdominal surgery in a patient with acute abdominal pain caused by intestinal angioedema (AE), which was eventually due to angiotensin-converting enzyme inhibitor (ACE-i) use. We hope that this case report increases awareness of this underdiagnosed side effect. Emergency department physicians, surgeons, internists, and family physicians should always consider ACE-i in the differential diagnosis of unexplained abdominal pain. Since early withdrawal of the medication causing intestinal AE can prevent further complications and, in some cases, needless surgery, we propose an altered version of the known diagnostic algorithm, in which ACE-i and nonsteroidal anti-inflammatory drugs-induced AE is excluded at an early stage.

A Gut Feeling: Isolated Small Bowel Angioedema due to Angiotensin-Converting Enzyme Inhibitor.

Isolated angioedema of the small intestine is a rare adverse event in patients taking angiotensin-converting enzyme inhibitors. Here, we present a case of visceral angioedema in a 32-year-old woman who presented with left upper quadrant pain, nausea, vomiting, diarrhea, and characteristic radiographic signs of small bowel angio-edema, six months after starting lisinopril. Her symptoms improved within 48 hours of withholding the offending agent and with supportive care. We discuss the epidemiology, pathophysiology, diagnosis, and management of angiotensin-converting enzyme inhibitor- induced angioedema.

Presentation of an extraordinary colic: abdominal pain as the first and only utterance of an acquired C1-inhibitor deficiency.

C1-inhibitor deficiency is a rare disease which incorporates acute self-limiting intermittent swelling of the subcutaneous tissue and mucous membranes. Attacks most frequently affect the face and/or the upper airway. Isolated angioedema of the small bowel is an uncommon manifestation and often accompanied by diagnostic delay. In the present case, abdominal pain turned out to be the first and only utterance of an acquired C1-inhibitor deficiency, secondary to a splenic marginal zone lymphoma. Imaging showed wall thickening of the small intestine, ascites and splenomegaly. The abdominal pain and intestinal wall thickening with surrounding ascites on imaging spontaneously resolved each episode within 2-3 days. Gastrointestinal manifestations of angioedema may mimic an acute abdomen, and subsequently one-third of these patients undergo unnecessary surgery prior to a definite diagnosis. This emphasises the importance of considering the diagnosis in case of an 'extraordinary colic'.