Posters
Presenting Author Academic/Professional Position
Taiwo Ajani / Resident Physician IM PGY2
Academic Level (Author 1)
Resident
Discipline/Specialty (Author 1)
Internal Medicine
Academic Level (Author 2)
Resident
Discipline/Specialty (Author 2)
Internal Medicine
Academic Level (Author 3)
Resident
Discipline/Specialty (Author 3)
Internal Medicine
Academic Level (Author 4)
Resident
Discipline/Specialty (Author 4)
Internal Medicine
Academic Level (Author 5)
Faculty
Discipline/Specialty (Author 5)
Internal Medicine
Discipline Track
Clinical Science
Abstract Type
Case Report
Abstract
Introduction: Angiotensin-converting enzyme inhibitor–induced angioedema (ACEI-AE) is a rare but potentially serious adverse effect of a widely used class of antihypertensives. It typically presents as non-pitting, non-pruritic swelling of the face, lips, tongue, or upper airway, often without associated urticaria. Although most cases occur within the first weeks of treatment, delayed presentations, sometimes after years of stable therapy, have been increasingly recognized. The condition is bradykinin-mediated and often does not respond to standard allergy medications such as antihistamines or corticosteroids.
Case Presentation: A 56-year-old woman with a medical history of hypertension, type 2 diabetes, GERD, and seasonal allergies presented to the emergency department with sudden onset of tongue swelling, perioral numbness, dysarthria, and persistent cough. She had been on lisinopril for over a decade, with recent dose escalation one month and four days prior to symptom onset. On examination, she was hypertensive and tachycardic but maintained oxygen saturation on room air and was not in respiratory distress. Physical exam revealed a swollen, erythematous tongue without deviation or stridor. Laboratory studies were notable for mild leukocytosis, hyperglycemia, and elevated CRP. Initial treatment with antihistamines and corticosteroids led to minimal improvement. However, following administration of intramuscular epinephrine, intravenous fluids, and tranexamic acid, the patient showed significant clinical response. She was admitted to the ICU for observation and discharged the following day with full resolution of symptoms and instructions to discontinue lisinopril permanently.
Discussion: This case illustrates a delayed onset of ACEI-AE after long-term lisinopril use, highlighting the need for clinicians to remain vigilant even years into therapy. The absence of urticaria and poor response to allergy-targeted treatments supported a bradykinin-mediated process. Management prioritized airway protection and supportive care, with adjunctive use of tranexamic acid, which has shown benefit in bradykinin-driven angioedema. While icatibant may also be effective, cost and access limit its routine use. The patient's rapid recovery and lack of airway compromise reflect the importance of early recognition and close monitoring in preventing complications.
Conclusions: ACEI-AE should be considered in the differential diagnosis of unexplained orofacial swelling, regardless of therapy duration. Prompt discontinuation of the ACE inhibitor, supportive care, and appropriate observation are essential. Clinicians should educate patients on the risks of recurrence and avoid re-initiation of ACE inhibitors. Alternative antihypertensive agents, such as ARBs, may be cautiously used with appropriate follow-up.
Presentation Type
Poster
Recommended Citation
Ajani, Taiwo; Loayza Pintado, Jose J.; Aller Rojas, Renzo; Aboytes Trevino, Jorge; and Lopez, Michelle, "Beyond the Expected Window: A Rare Presentation of ACEI-Associated Angioedema Two Decades into Therapy" (2026). Research Colloquium. 115.
https://scholarworks.utrgv.edu/colloquium/2025/posters/115
Included in
Beyond the Expected Window: A Rare Presentation of ACEI-Associated Angioedema Two Decades into Therapy
Introduction: Angiotensin-converting enzyme inhibitor–induced angioedema (ACEI-AE) is a rare but potentially serious adverse effect of a widely used class of antihypertensives. It typically presents as non-pitting, non-pruritic swelling of the face, lips, tongue, or upper airway, often without associated urticaria. Although most cases occur within the first weeks of treatment, delayed presentations, sometimes after years of stable therapy, have been increasingly recognized. The condition is bradykinin-mediated and often does not respond to standard allergy medications such as antihistamines or corticosteroids.
Case Presentation: A 56-year-old woman with a medical history of hypertension, type 2 diabetes, GERD, and seasonal allergies presented to the emergency department with sudden onset of tongue swelling, perioral numbness, dysarthria, and persistent cough. She had been on lisinopril for over a decade, with recent dose escalation one month and four days prior to symptom onset. On examination, she was hypertensive and tachycardic but maintained oxygen saturation on room air and was not in respiratory distress. Physical exam revealed a swollen, erythematous tongue without deviation or stridor. Laboratory studies were notable for mild leukocytosis, hyperglycemia, and elevated CRP. Initial treatment with antihistamines and corticosteroids led to minimal improvement. However, following administration of intramuscular epinephrine, intravenous fluids, and tranexamic acid, the patient showed significant clinical response. She was admitted to the ICU for observation and discharged the following day with full resolution of symptoms and instructions to discontinue lisinopril permanently.
Discussion: This case illustrates a delayed onset of ACEI-AE after long-term lisinopril use, highlighting the need for clinicians to remain vigilant even years into therapy. The absence of urticaria and poor response to allergy-targeted treatments supported a bradykinin-mediated process. Management prioritized airway protection and supportive care, with adjunctive use of tranexamic acid, which has shown benefit in bradykinin-driven angioedema. While icatibant may also be effective, cost and access limit its routine use. The patient's rapid recovery and lack of airway compromise reflect the importance of early recognition and close monitoring in preventing complications.
Conclusions: ACEI-AE should be considered in the differential diagnosis of unexplained orofacial swelling, regardless of therapy duration. Prompt discontinuation of the ACE inhibitor, supportive care, and appropriate observation are essential. Clinicians should educate patients on the risks of recurrence and avoid re-initiation of ACE inhibitors. Alternative antihypertensive agents, such as ARBs, may be cautiously used with appropriate follow-up.
