No abstract

Sixty two year old Caucasian man with past medical history of Hypertension, Coronary artery disease, Congestive Heart Failure (CHF) and Hypothyroidism secondary to radio-ablation of thyroid, presented to Emergency Room with complaints of shortness of breath and swelling of his neck for one day. Initial vitals on admission showed elevated BP (178/100 mm Hg) and pulse oximetry showed 92 % saturation with 2L O2 via nasal canula. Physical examination was normal except for increased neck circumference and pitting edema in both feet. Labs revealed elevated BNP at 2330 pg/ml (<125), elevated TSH at 13 uIU/ML (0.5 -5), with low T3 at 0.79 ng/ml (0.9 - 1.6). Rapid Group A streptococcal serology was negative. Patient had previous allergy to Angiotensin Converting Enzyme Inhibitor (ACEI) with lip swelling five years ago and has since been taking Angiotensin Receptor Blocker (ARB) - Losartan for Heart Failure with preserved ejection fraction (HFpEF) without any complaints, until this episode one day ago. Initial X-ray of the neck revealed epiglottic narrowing and subsequent CT scan showed uvular thickening. The uvular angioedema was likely worsened due to ARB, with possible contribution from exacerbation of diastolic heart failure and hypothyroidism. He was started on hydralazine and intravenous furosemide for CHF exacerbation in addition to continuing home medication of metoprolol and stopping Losartan. The dose of Levothyroxine was titrated for hypothyroidism. Patient was given intravenous dexamethasone, famotidine, and diphenhydramine in the hospital, with which the swelling subsided within a day and he felt symptomatically better. Oxygen was weaned off and saturation was 95 % on room air, BP was controlled at discharge. Losartan was hence stopped and he was sent home on steroid taper. Subsequent follow up at six months revealed that he did not develop any further episodes of angioedema subsequent to stopping Losartan. ARB is sometimes prescribed to patients having intolerance to ACEI. Previous reports suggest that patients who develop angioedema with ACEI, may also develop allergy with ARB, and is hence best avoided. This case illustrates that caution needs to be exercised in transitioning patients from ACEI to ARB, and that allergy may manifest as isolated uvular edema, especially in patients with multiple comorbidities.

An 80-year-old male patient presented with sepsis secondary to infected central line which was placed for native aortic valve endocarditis. He also had melena and abdominal pain prior to his presentation. Abdominal computed tomography (CT) was done, which showed cholelithiasis. Esophagogastroduodenoscopy was also done with no source of bleeding identified. Later, he developed hemodynamic instability requiring aggressive fluid resuscitation and multiple packed blood cell transfusions. In view of his hemodynamic instability, a repeat abdominal CT scan showed air droplets within the gallbladder pneumobilia, ascites, diverticulosis, and a bleeding infrahepatic hematoma measuring 6 × 10 cm, which was not on his prior scan 2 days prior. A mesenteric arteriogram was performed that identified an aneurysm of the right hepatic artery with no active bleeding; therefore, it was coiled. Due to his continued clinical decompensation, he underwent an urgent open cholecystectomy, in which serosanguineous fluid, cholecystocolic fistula, and old clot related to his previous bleed were encountered. However, control of bleeding was difficult, and the patient expired. We report this case of right hepatic artery aneurysm that we believe its etiology was related to eroding cholecystitis.