A challenging case of bradykinin-mediated angioedema with airway obstruction: management and therapeutic strategies.

IF 0.8 Q3 MEDICINE, GENERAL & INTERNAL
Archive of clinical cases Pub Date : 2023-10-03 eCollection Date: 2023-01-01 DOI:10.22551/2023.40.1003.10260
Lisete Rolo Nunes, Mónica Palma Anselmo, Tiago Salvador Brito
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Abstract

Angioedema is a potentially life-threatening condition that can have an allergic origin, usually mediated by histamine or a non-allergic origin, mediated by bradykinin. The distinction between these origins may present a clinical challenge at first approach, especially in cases that appear as an emergency and the outcome is time dependent. The authors describe a rare case of bradykinin angioedema associated with airway obstruction and discuss the right approach and therapeutic options. A 46-year-old patient under ACE inhibitor, renin-angiotensin-aldosterone blocker and beta blocker presented with difficulty swallowing, shortness of breath and angioedema, associated with inspiratory stridor, incapacity of talking, plantar pruritus and vomits minutes after ingestion of shrimp. The symptoms did not respond to epinephrine, anti-histamines or steroids. The airway quickly became an emergency and the authors discuss the importance of airway obstruction management and having a multidisciplinary well-defined plan of approach with backup plans. Exuberant angioedema persisted leading to the suspicion of drug induced angioedema. Treatment with tranexamic acid 1g 6/6h and icatibant 30 mg 6/6h (3 doses) was started with resolution. In these cases, the rapid institution of the right pharmacological line will relate significantly to a better outcome. It is particularly important because, as their underlying physiopathologic mechanism differ, bradykinin mediated angioedema does not respond to drugs that histamine mediated angioedema does, like corticosteroids and antihistaminic. In severe and life-threatening cases icatibant and tranexamic acid have proven to be an effective therapy.

Abstract Image

缓激肽介导的血管性水肿伴气道阻塞的一个具有挑战性的病例:管理和治疗策略。
血管水肿是一种潜在的危及生命的疾病,可能有过敏性来源,通常由组胺介导,或由缓激肽介导的非过敏性来源。这些起源之间的区别可能会对最初的方法提出临床挑战,尤其是在出现紧急情况且结果取决于时间的情况下。作者描述了一例罕见的缓激肽血管性水肿伴气道阻塞的病例,并讨论了正确的治疗方法和治疗方案。一名46岁的患者在服用ACE抑制剂、肾素-血管紧张素-醛固酮阻断剂和β受体阻断剂后,出现吞咽困难、呼吸急促和血管性水肿,并伴有吸气性喘鸣、不能说话、足底瘙痒和进食虾几分钟后呕吐。这些症状对肾上腺素、抗组胺药或类固醇没有反应。气道很快成为紧急情况,作者讨论了气道阻塞管理的重要性,以及制定多学科明确的方法计划和备用计划的重要性。肿胀性血管性水肿持续存在,导致怀疑为药物诱导的血管性水肿。开始用氨甲环酸1g 6/6h和艾替班30mg 6/6h(3剂)进行治疗,并得到缓解。在这些情况下,快速制定正确的药理学路线将与更好的结果显著相关。这一点尤为重要,因为缓激肽介导的血管性水肿对组胺介导的药物(如皮质类固醇和抗组胺药)没有反应,因为它们的潜在生理病理机制不同。在严重和危及生命的情况下,艾替班和氨甲环酸已被证明是一种有效的治疗方法。
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