Division of Allergology and Clinical Immunology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa.
Division of Emergency Medicine, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
S Afr Med J. 2023 Aug 3;113(8):51-57. doi: 10.7196/SAMJ.2023.v113i8.717.
Angioedema is the most common acute allergic presentation to emergency centres (EC), with hospitalisation rates increasing in high-income countries. Angioedema can complicate with life-threatening laryngeal obstruction. There are no local data; therefore, we aimed to characterise acute angioedema cases presenting to ECs and develop a simple management algorithm.
To characterise the clinical presentation, management and outcomes of acute angioedema cases presenting to ECs. Based on these findings, we developed a management algorithm for acute angioedema to improve the care of acute angioedema in South Africa (SA).
We conducted a retrospective folder review of all patients admitted to Groote Schuur Hospital (tertiary) and Mitchells Plain District Hospital (secondary) ECs from 1 June 2018 to 31 June 2020. Using ICD-10 coding, folders of adults ≥18 years with possible angioedema presenting to the ECs were screened. An allergist extracted demographics, medical history, management and outcome data for each angioedema event.
A total of 142 acute angioedema episodes were included, with a median (interquartile range) age of 42 (28 - 58) years, and 62% of patients were female. The majority (124/142, 87%) of acute angioedema EC presentations involved swelling above the shoulders, with airway involvement in 20 (14%) patients, with two patients requiring intubation. Nineteen (13%) patients required admission, with five (26%) admitted to high care/intensive care. Drug-induced angioedema was the most common cause, with 64/142 (45%) linked to a known offending drug, 42/64 (65.6%) being angiotensin-converting enzyme inhibitor (ACE-I). Critical information to guide angioedema management, including past personal/family allergy history, and duration of angioedema prior to EC visit, was not recorded in 64.7% and 37.8% of EC records, respectively. Unnecessary treatment with corticosteroids or antihistamines occurred in 19/53 (36%) and 16/53 (30%) cases with bradykinin-mediated angioedema ACE-I angioedema and hereditary angioedema). Overall, only 36/142 (25%) of angioedema patients were connected to allergy care.
Angioedema is the most common allergy presentation to two ECs in Cape Town, SA. Bradykinin-mediated angioedema secondary to ACE-I therapy is the single most common offender, and was not appropriately managed in more than a third of cases. Based on these findings, we have developed a management algorithm that easily stratifies patients into bradykinin or mast cell-mediated angioedema with a step-by-step management approach that is applicable to the SA context. Ongoing awareness and education on allergy emergencies are required to ensure accurate diagnosis of less common causes of angioedema (particularly bradykinin-mediated angioedema) and linkage to allergy specialist care.
血管性水肿是急诊中心（EC）最常见的急性过敏表现，高收入国家的住院率呈上升趋势。血管性水肿可并发危及生命的喉头阻塞。目前尚无本地数据；因此，我们旨在描述EC 就诊的急性血管性水肿病例，并制定一个简单的管理算法。
描述急性血管性水肿病例在 EC 就诊的临床特征、治疗方法和结局。根据这些发现，我们为急性血管性水肿制定了一个管理算法，以改善南非（SA）急性血管性水肿的护理。
我们对 2018 年 6 月 1 日至 2020 年 6 月 31 日期间从格罗特舒尔医院（三级）和米切尔平原区医院（二级）EC 就诊的所有≥18 岁可能患有血管性水肿的成年患者的文件夹进行回顾性审查。使用 ICD-10 编码筛选出可能患有血管性水肿的患者的文件夹。过敏专家提取了每位血管性水肿患者的人口统计学、病史、治疗和结局数据。
共纳入 142 例急性血管性水肿发作，中位（四分位距）年龄为 42（28-58）岁，62%的患者为女性。大多数（124/142，87%）急性血管性水肿 EC 就诊的表现为肩部以上肿胀，20 例（14%）患者出现气道受累，其中 2 例需要插管。19 例（13%）患者需要入院治疗，其中 5 例（26%）入院至高护理/重症监护病房。药物诱导的血管性水肿是最常见的病因，已知有 64/142 例（45%）与已知致病药物有关，64/64 例（65.6%）与血管紧张素转换酶抑制剂（ACE-I）有关。与血管性水肿管理相关的重要信息，包括既往个人/家族过敏史以及在 EC 就诊前血管性水肿的持续时间，分别有 64.7%和 37.8%的 EC 记录未记录。在 53 例（36%）缓激肽介导的血管性水肿 ACE-I 血管性水肿和遗传性血管性水肿患者中，不必要地使用了皮质类固醇或抗组胺药，在 16/53 例（30%）患者中。总体而言，仅有 36/142 例（25%）血管性水肿患者与过敏护理有关。
血管性水肿是南非开普敦两家 EC 最常见的过敏表现。缓激肽介导的 ACE-I 治疗相关血管性水肿是最常见的原因，在超过三分之一的病例中未得到适当治疗。基于这些发现，我们制定了一个管理算法，该算法可以轻松将患者分为缓激肽或肥大细胞介导的血管性水肿，并采用逐步管理方法，适用于南非的情况。需要持续开展过敏急症的认识和教育，以确保对较少见的血管性水肿病因（特别是缓激肽介导的血管性水肿）进行准确诊断，并与过敏专科护理联系起来。
