Lisinopril

Abstract

Post-operative angioedema presenting as macroglossia: case reportA 71-year-old man developed post-operative angioedema (AE) presenting as macroglossia during treatment with lisinopril for arterial hypertension.The man with a past medical history of coronary arterial disease, atrial flutter, ascending thoracic aortic dissection repair, aortic and mitral valve repair, three-vessel coronary bypass, arterial hypertension and bifascicular block, was scheduled for an elective soft tissue biopsy of the ankle with possible resection and evacuation of the accumulated blood. He had no known history of allergies, complications of anaesthesia or any family history of angioedema. He had been receiving lisinopril [route and dosage not stated] and various other concomitant medications. Following preoxygenation, anaesthesia was induced with propofol and lidocaine followed by placement of a laryngeal mask airway without any difficulty. He was then placed in right lateral position, and surgery was started. General anaesthesia was maintained with sevoflurane in a mixture of oxygen with air. Throughout the surgery, he received ketamine and his BP was supported with phenylephrine. No antibiotics were administered during the surgery. At the end of surgery, ondansetron was administered as an antiemetic. The procedure was completed uneventfully with evacuation of collected blood and soft tissue biopsy, the laryngeal mask airway was removed, and he was transferred to the post-operative recovery unit. A routine inspection of the oral cavity at the time of the laryngeal mask airway removal did not reveal any trauma to the mucosa or local oedema. In an hour after the surgery, he developed swelling of the tongue. Immediate assessment revealed a progressively worsening swelling on the left half of the tongue without any airway compromise. Haemodynamic and respiratory parameters were found to be within the normal limits. In around an hour, the whole tongue became swollen without signs of respiratory distress. A preliminary diagnosis of AE possibly due to lisinopril was made. As alternative diagnoses, IgE-mediated anaphylactic reaction and macroglossia as a result of the LMA application and patient positioning were considered even though with lower possibility.The man received treatment with dexamethasone and diphenhydramine [Benadryl]. Oxygen inhalation was also started. He was observed overnight. An endoscopic examination revealed isolated oedema of the tongue without airway compromise, trauma or haematoma. A tryptase test was subsequently performed and was found to be negative. With conservative management and observation, his condition improved with complete resolution of the oedema within 24h. No additional laboratory tests were ordered (measurement of C1 estherase inhibitor activity and the C4) at that time. He was uneventfully discharged from the hospital next morning after an overnight observation. While in the hospital, lisinopril therapy was discontinued. He was referred to his primary care practitioner for further treatment and possi...