Angioedema of the tongue

An 86-year-old woman presented with acute, painless, nonpruritic tongue swelling (Figure 1) that had developed 6 hours earlier. She had no symptoms of upper airway obstruction or dyspnea, but her speech was dysarthric. The results of a physical examination were normal, and she had no urticaria. The patient was hypertensive, and she had been taking an angiotensin-converting enzyme (ACE) inhibitor (benazepril) for 12 years. We diagnosed ACE-inhibitor-induced angioedema and discontinued benazepril therapy. She was given intravenous steroids and antihistamines. There was no initial improvement, but within 2 days her tongue returned to normal size. The patient was given a different antihypertensive medication, and she remained symptom-free several months later.

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Figure 1: An 86-year-old woman with acute, painless, nonpruritic tongue swelling.

Angioedema is acute, self-limited localized swelling of subcutaneous or mucosal tissue. It often affects the lips, eyelids, face, tongue, larynx or bowel, and often causes large, well-demarcated lesions that typically resolve in 2–3 days but may last 5–7 days. Angioedema affects 0.1%–0.5% of patients taking ACE inhibitors and may develop hours or years after therapy is initiated. Its onset may be idiopathic or the result of diverse causes such as nonsteroidal anti-inflammatory drugs, antibiotics, insect bites, food or environmental allergens and complement-inhibitor deficiencies. Cross reactivity with other types of ACE inhibitors is common, and a change of drug classes is necessary to prevent a recurrence. Treatments for angioedema are dependent on the underlying cause and may include antihistamines, corticosteroids, epinephrine and tranexamic acid.