Pediatric Angioedema

Abstract

Angioedema is a self-limited nonpitting edema generally affecting the deeper layers of the skin and mucous membranes. It is the result of increased vascular permeability causing the leakage of fluid into the skin in response to potent vasodilators released by immunologic mediators. Two main pathways are thought to be implicated in angioedema. The mast cell pathway in which preformed mediators, such as histamine, rapidly formed mediators, leukotrienes and prostaglandins, are released from mast cells through IgE or direct activation. This is the most common pathway among children, with food, medications, and infections commonly implicated. The second pathway is the kinin pathway, most notably affected by angiotensin-converting enzyme (ACE) inhibitors and hereditary forms of angioedema, which ultimately results in the formation of bradykinin, a potent vasodilator. Angioedema is being encountered with increasing frequency, particularly among children and is important to recognize and treat for its life-threatening associated manifestations such as anaphylaxis and airway obstruction. Although angioedema is still not fully understood, we have broadened our understanding of the possible causes and clinical course of angioedema. An understanding of these potential causes and mechanisms by which angioedema can occur may guide the clinician in determining the need for diagnostic testing and the extent of treatment.

Antihypertensive drug-induced angioedema causing upper airway obstruction in children

“…When those findings are present in symptomatic patients, immediate administration of epinephrine is indicated, and a formal airway evaluation should be undertaken. In general, immediate termination of the responsible drug is recommended, and symptoms generally resolve within 24-48 h of discontinuation [7]. If necessary, the medication should be replaced with an alternative drug from a different class [10].…”

“…Rather than a drug-specific effect, angioedema appears to be a class effect of all ACE inhibitors, independent of dose [7,20]. In contrast, CCB-induced angioedema appears to be related to specific drugs within the category [14,26].…”

“…Approximately 40 million patients use ACE inhibitors and these drugs remain the most common trigger of angioedema seen in emergency rooms [7,26].…”

“…Although angioedema is a well-described complication of antihypertensive agents in the adult population, its occurrence and potential for upper airway compromise has only been sporadically reported in the pediatric population. Most cases of angioedema from antihypertensive agents are mild and are treated by discontinuing the offending drug [7,11]. In this study, we report on a single institution experience of antihypertensive-induced angioedema causing upper airway obstruction in children and adolescents and review the literature on this topic.…”

The Epidemiology of Food Allergy

“…Other skin manifestations include flushing and itching of the skin and other forms of rash. Angioedema is a variant form of urticaria in which the deeper instead of the superficial layer of the skin is affected [62]. These immediate types of reactions usually occur within minutes of ingesting the food allergen, and they are mediated through the presence of existing IgE directed against the food allergen in affected individuals.…”