When a drug does more than it needs: angio-oedema, an important adverse effect.

To cite: Ferreira MB, Rocha SM, Maia JM, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2013-201200 DESCRIPTION A 77 -year-old man, with a history of arterial hypertension, hypercholesterolaemia and obesity, presented to our emergency department with acute swelling of the tongue. He was being treated with an ACE inhibitor and a statin for the past few years and had been tolerating both well. He denied cutaneous or abdominal symptoms but admitted to having had a similar but milder episode 4 months earlier, which was treated with corticosteroids and antihistaminic drugs. On examination, massive swelling of the tongue outside the mouth was evident (figure 1), without any signs of airway obstruction. He was started on intravenous glucocorticoids, antihistaminic drugs and intramuscular epinephrine; simultaneously, the surgical department was called in the event and an emergent tracheotomy was required. Continuous monitoring was provided and no significant improvement was seen in the first 12 h. However, tongue swelling resolved over the next 24 h and he was discharged home with discontinuation of the ACE inhibitor. Two weeks later, he was completely asymptomatic (figure 2). The measurement of C1 inhibitor level was in the normal range, supporting the diagnosis of angio-oedema induced by ACE inhibitor. After a year of follow-up, no other events were reported. This case report emphasises potentially lifethreatening angio-oedema of ACE inhibitors, which are one of the most used drug classes, occurring between 0.1% and 0.5% of patients taking these drugs. This event most commonly affects the lips, tongue, face and upper airway, which may progress to airway obstruction in up to 10% of cases; rarely, massive tongue swelling and asphyxiation can occur. 2