A Case of Prolonged Angioedema Following Cardiac Surgery: Prolonged Angioedema

Abstract Angioedema (AE) is an transient capillary leak syndrome, caused by either histamine or bradykinin, that presents as an acute non-pitting swelling of the skin, subcutaneous tissues and mucous membranes of the face, lips, tongue, upper airways and gastrointestinal tract, with or without a rash. A lack of response to anti-histamines, steroid, and epinephrine, suggests a bradykinin-mediated AE. Bradykinin-AE may be inherited, acquired or drug related. Mechanism of increased bradykinin can include decreased C1-esterase inhibitor (C1-INH) levels/activity, increased bradykinin production, or decreased bradykinin breakdown, the latter occurring during angiotensin converting enzyme inhibitor (ACEi). A 65 year old female who had coronary artery bypass grafting, which was complicated by prolonged bradykinin-AE due to ACEi, requiring prolonged endotracheal tube intubation. Treatment with a C1-esterase inhibitor (Berinert) on postoperative day 7 resulted in a dramatic improvement in airway edema/tongue swelling within 7 hours, and the patient was subsequently extubated. The case is unusual for the prolonged course of AE and the benefit of late administration of C1-INH concentrate.