Abstract

Angiotensin-Converting Enzyme Inhibitors (ACEI) are commonly used to prevent cardiac remodeling in patients with ST-Segment Elevation Myocardial Infarction (STEMI). Life-threatening ACEI side effects, such as angiodema, are rare; unilateral tongue swelling is even rarer. Early recognition and diagnosis of angioedema can often be life-saving.

Keywords: Unilateral tongue angioedema; Angiotensin converting enzyme inhibitor.

Abbreviations: ACEI: Angiotensin Converting Enzyme Inhibitor.

Citation: Vijay S, Wankhade P. A rare case of angiotensin-converting enzyme inhibitor-induced unilateral tongue angioedema. J Clin Images Med Case Rep. 2023; 4(4): 2384.

Case details

A 51-year-old man with hypertension and diabetes mellitus presented with an inferior wall myocardial infarction, for which primary percutaneous intervention was done. Post-procedure, the patient was hemodynamically stable and was started on aspirin, clopidogrel, metaprolol, ramipril, and insulin. On the third day after initiation of ramipril, the patient observed difficulty speaking due to unilateral tongue swelling (Figure 1a). He denied any hives, lip swellings, flushing, facial swelling, increasing shortness of breath or stridor and having ever experienced food, drug allergies or asthma. He refuted ever having angioedema or a related symptom. The physical and systemic examinations were normal. With a provisional diagnosis of ramipril-induced angiodema, the ramipril was stopped and clinically observed in the ICU. After 48 hours, the tongue swelling resolved spontaneously (Figure Ib), and the patient was counseled to discontinue the ACEI.

Unilateral tongue angioedema caused by ACEI is extremely rare. It is caused by increased levels of angiotensin I and bradykinin, both of which cause vasodilation and swelling [1]. Although it is unknown why oedema occurs only unilaterally, it has been speculated that unilateral oedema may have been the precursor to bilateral and fulminant angioedema. Corticoste roids and antihistamines have little effect in the treatment of ACEI-induced angiodema, as the culprit here is bradykinin, not histamine [2]. It is imperative that physicians and cardiologists promptly recognize the rare occurrence of unilateral tongue angiodema as a side effect of ACEI to avoid life-threatening events.

Figure 1: (a) showed right-sided unilateral angioedema, and Figure (b) showed complete resolution of angioedema.

Declarations

Funding: Nil.

Availability of data and materials: Not applicable.

Ethical approval and consent to participate: Not applicable.

Consent for publication: The patient’s consent for publication was obtained.

Competing interests: The authors have no competing interests to declare.

References

1. Long BJ, Koyfman A, Gottlieb M. Evaluation, and management of angioedema in the emergency department. West J Emerg Med. 2019; 20: 587-600.
2. Kostis WJ, Shetty M, Chowdhury YS, Kostis J. ACE Inhibitor-Induced Angioedema: A Review. Curr Hypertens Rep. 2018; 20: 4-5.