A 62-year-old woman came to the emergency depar tment with bilateral, general ized swelling

of her periorbital areas. She had first noted this swelling about 2 days previously, and it s eemed to have got ten somewhat worse since it started. She

also said that she had a burning sensat ion in her mouth intermit tent ly that was worst on her tongue and the inner aspec t of her lips. She denied having had trauma, an insect bite, exposure to new foods, itching, or wheezing. No associa ted rash or symp- toms of illness were present• Her medical history included hypertension, which was well controlled with enalapril, 10 mg by mouth twice daily. She was also taking estrogen and progesterone•

Physical examinat ion revealed a well-developed, well-nourished ambulatory white woman in no acute distress who was noted to have mode ra t e swelling of

the soft t issue around both orbits. Findings of an examinat ion of the globes were unremarkable, and the oropharynx appeared normal. Visual acui ty was

noted to be normal• Vital signs were as follows: temperaturel 37.0 °

cent igrade orally; pulse, 82 beats / ra in and regular; respirat ions, 18 per minute; and blood pressure, 136/88 mm Hg.

What do you suspect?

Discussion This woman was ult imately d iagnosed as having angioedema related to the ingest ion of enalapril. Enalapril is an angiotensin enzyme inhibitor (ACEI), which is a class of widely used ant ihyper tensive medica t ions . The ACEI med ica t i ons have been t remendously popular s ince they were introduced almost 10 years age. These medicat ions work by

Lisa Molitor is Nurse Practitioner, ACORN Clinic, Brooker, Florida. For reprints, write: Lisa Molitor, ARNP, RNC, MSN, CEN, CCRN, 8404 SW 28th Place, GainesvilIe, FL 32807. J Emerg Nuts 1998;24:290-1. Copyright © 1998 by the Emergency Nurses Association. 0099-1767/98 $6.00 + 0 18/1/89105

inh ib i t ing the convers ion of ang io tens in I to angiotensin II, which is a powerful vasoconstrictor that plays a significant role among the body 's many mechanisms for mainta ining blood pressure•

Airway p a t e n c y shou ld a l w a y s be c o n s i d e r e d w h e n e v i d e n c e of any facial e d e m a exists .

One reason the ACEI medicat ions are so popular is that they have been demonst ra ted to significantly

decrease mortality in the first year after myocardial infarction• These medicat ions are also of particular

benefit to diabet ic pat ients with concomitant hyper- tension because they help prevent glomerular d isease associa ted with diabetes. In addition, they have no effect on glucose, lipids, or uric acid and work syner- gistically with diuretics. Generally the side effect pro- file of the ACEIs is very favorable, especially in comparison with that of some of the older, centrally act ing ant ihyper tensive agents and the nonselective be ta blocking agents• However, some relatively infre- quent but important side effects exist that are con- t raindicat ions to the use of ACEIs. One of the most important side effects is related to the inhibition of the inact ivat ion of bradykinin, a humoral vasodilator. In pat ients prone to this phenomenon, the ACEI agents can block the body's natural mechan i sms that are responsible for control of bradykinin metabolism. Increasing numbers of reports of "scalded mouth syn- drome" are also associa ted with ACEI use. Affected pat ients descr ibe generalized burning of the oral muscosa, especially when e a t i n g or drinking. More commonly, pat ients report a dry, pers is tent cough• Both phenomena are recognized as symptoms of bradykinin metabol ism disruption.

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Section Editor's teaching points Can the angioedema result in such severe swelling that the airway would close? This phenomenon has been reported to occur, and it certainly seems possi- ble in patients in whom ACEI-induced angioedema has developed. Airway patency should always be considered when evidence of any facial edema exists.

With more than 3000 different medications avail- able by prescription in the United States, it is no sur- prise that reports of untoward side effects are rapidly increasing. Triage and emergency nurses must stay alert to side effect profiles and drug interactions when caring for patients.

This patient did not require emergency care. She was instructed to stop taking the enalaprfl and to fol- low up with her primary care provider as soon as pos- sible. Her medication was ultimately switched to losartan, which blocks the reception of angiotensin II and thus prevents vasoconstriction, apparently with- out affecting bradykinin metabolism.

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