Category Archives: Angioedema

Facial swelling or swelling of your lips, fingers.

Intermittent Abdominal Pain and Intestinal Swelling –a Mystery?

Nice case! What makes this so unusual is angioedema usually involves the face or lips…something very visible that you know isn’t normal.  Intestinal angioedema will cause pain and bloating like your appendix only surgery won’t help that!


A recent “Think Like a Doctor”  -full link to the solved case: 

First an except from the challenge:

The Patient’s History

It started nearly two years earlier, the woman told Dr. Merai. She had been at work — she was a clerk in a bank then — and had suddenly started vomiting. As she made her way back to her desk, she felt weak and unsteady and fainted. Or that’s what everybody told her, because the next thing she knew, she was in an ambulance on the way to the hospital.

There, a CT scan showed that her small intestines were inflamed. The doctors said she might have Crohn’s disease. But after a couple of days, she started to feel better and went home. Because she felt O.K., she never followed up.

And then, it happened again — nine months later. Again she was rushed to the hospital. Again…

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How You Can Be an Expert

I want to be an expert.  Always have and always will, but now it’s a little easier than 30 years ago.  In fact, all you need now to become an expert is a little fame, a published book or memoir, and Shazam!  you’re an authority on any subject you want to write on.  So where’s the beef on my book? 

Well, that’s not exactly how an allergist becomes an expert.  I won’t bore you with the details, but doctors are trained by experience in the clinic (office) and reading about the medical conditions you have to treat….over and over again.  Eventually your training ends and what do you do then?  No more residency programs, no more allergy fellowships, and no more mentors.  I have found a valuable resource through the American Academy of Allergy, Asthma, and Immunology (AAAAI) entitled “Ask the Expert” (hey they get paid for content, not the title).  Here’s an example of a conversation about hives.  (click on the link at the end) Patients all hate hives and just from this discussion alone I propose the following take home messages:

1.       Hives are caused by allergy only 20% of the time.  We usually want an easy answer, but if that were the case you would never show up in the allergy office.  It’s important to look for the underlying cause of the hives, but in up to 50% of cases, the hives are due to autoimmunity….more on that later. 

2.       Once hives are identified, change your mindset to 6-12 months of treatment.  Hives can resolve spontaneously, but it doesn’t happen quickly. 

3.       Hives that bruise should be evaluated ASAP….no exceptions.

4.       The usual dose of antihistamines prescribed by your doctor is usually for treating hay fever.  The effective dose for treating hives may be 4 times as high; beware of feeling sleepy for several days, but that side effect will usually improve. 

5.       I try to avoid steroids because of long-term side effects, but sometimes steroids are necessary to get the itching under control.  Limit your use and look for alternative medications.  But I will warn you, it’s not always allergy!

Yes, you too, can become an expert with your health—you’ll spend a lot less time in the doctor’s office if you do!

Acute urticaria resistant to therapy.

Help….my face is swelling!



New Guidelines Detail Hereditary Angioedema Management in Women

Angioedema is a BIG problem in emergency rooms across the country and Tulsa is no exception!  Most treatment protocols use antihistamines (Benadryl) along with steroids. aughhh! 


.  She has some very common frustrations with this condition.  The REASON antihistamines & prednisone often don’t work with angioedema is because the mediator is bradykinin, not histamine! 

An international panel of gynecologists and geneticists has issued practical guidelines for managing women with hereditary angioedema caused by C1 inhibitor deficiency, or HAE-C1-INH.The condition affects between one in 10,000 and one in 50,000 individuals, and estrogen is known to worsen the course of the disease.But little information has been published on how to manage gynecologic/obstetric events in women with HAE-C1-INH, the panel writes in its report, published in the Journal of Allergy and Clinical Immunology.

Effective acute treatments include plasma-derived human C1 inhibitor concentrate (pdhC1INH), icatibant acetate, ecallantide, and recombinant human C1 inhibitor (rhC1INH), the doses of which are the same during pregnancy. PdhC1INH is recommended as first-line therapy in pregnancy.

Short-term prophylaxis (before invasive medical, surgical, or dental procedures or other events that could precipitate edematous attacks) can be provided by pdhC1INH, attenuated androgens, tranexamic acid, and fresh frozen plasma, but pdhC1INH is the treatment of choice during pregnancy.

The same drugs can be used for long-term prophylaxis, but attenuated androgens are contraindicated during pregnancy and tranexamic acid during pregnancy is medically indicated only when pdgC1INH is unavailable, Dr. Teresa Caballero from Hospital La Paz Health Research Institute in Madrid and colleagues note.

Because of the contribution of estrogen to worsening of HAE symptoms, its use for contraception and menopause should be avoided.

For similar reasons, antiestrogens like tamoxifen that may have some agonistic effects on estrogen receptors should be avoided in breast cancer patients. If possible, attenuated androgens should also be avoided as prophylaxis in these women.

The guidelines also address special features of HAE-C1-INH treatment in female patients, such as genetic counseling, infertility, abortion, lactation, and endometrial cancer.


J Allergy Clin Immunol 2011.

Interesting patient of the day!

What would you think of a teenager seen for a rash, but come to find out he has swelling of hands and lips? Not to mention, other family members have similar problems! This may be hereditary angioedema, Type III. Why is this important? Treatment is available & it’s not steroids or anti-histamines. Check this out—>