Allergic Quincke's edema: immunological diagnosis and treatment

2021-07-24 12:11 AM

Quincke's edema usually affects areas with loose connective tissue, such as the face, lips, mouth and throat, larynx, vagina, extremities, and genitals.

Quincke's edema is a self-limited, localized submucosal (or submucosal) swelling that results from effusion into the interstitial tissues. Quincke's edema may occur in isolation, be accompanied by urticaria, or be a component of anaphylaxis.

Quincke's edema usually affects areas with loose connective tissue, such as the face, lips, mouth and throat, larynx, vagina, extremities, and genitals. Angioedema of the bowel wall presents as severe abdominal pain.

Quincke's edema (also known as angioedema) is characterized by sudden and marked swelling of the skin and subcutaneous tissues, with itching or sometimes pain, often involving mucosal areas. semi mucosal and usually persists for 72 hours.

Clinical features

Quincke's edema is clinically manifested as swelling that appears rapidly and suddenly in the lower and upper areas of the skin and mucous membranes, mainly appearing on the tongue, lips, eyes, around the mouth, hands, and feet. legs, pharynx, and genitals. Swelling, which usually develops over minutes to hours, can be localized or diffuse, causing tenderness or mild itching or numbness due to compression of the sensory nerve. The affected area is usually pale pink, the border is not clear when rubbed or stimulated, the swelling may increase, and the color becomes pale. A single lesion of Quincke's edema due to allergy usually persists within 72 hours, disappearing without sequelae.

Some factors such as changing weather, eating fishy foods, alcoholic beverages, physical factors such as heat, cold, sunlight, scratching or rubbing, pressure, ... although not is the causative agent but may precipitate or aggravate symptoms of allergic Quincke's edema.

Taking the patient's history can reveal an association between the occurrence of Quincke's edema and exposure to foreign factors such as drugs (especially beta-lactam antibiotics, sultamides, anti-inflammatory drugs). non-steroidal anti-inflammatory drugs and contrast agents), food (seafood, eggs, milk, peanuts, ...), insect venoms (ants, bees), animal hair (dogs, cats), animal factors Physical agents (such as heat, cold, sunlight), chemicals, ... Quincke's edema usually appears within minutes to hours after exposure to the causative allergen, in rare cases may appear fulminant. within a few seconds.

Exploiting the patient's allergy history and the patient's family also often detects other allergic diseases such as eczema, allergic rhinitis, allergic conjunctivitis, bronchial asthma, ...

Paraclinical features

Skin prick tests with allergens may give positive results for allergens to which the patient is sensitive.

Quantitative testing of IgE specific to the suspected allergen can accurately determine the type of allergen to which the patient is susceptible.

Routine blood and urine tests are usually less variables in patients with Quincke's edema.

Definite Diagnosis

Based mainly on clinical manifestations and medical history, noting the association between the appearance of Quincke's edema and history of exposure to foreign factors.

Differential diagnosis

Cellulitis: often manifests as swelling, heat, redness, pain in the affected area, accompanied by high fever, infection status.

Edema due to heart failure: occurs gradually, accompanied by other manifestations of heart failure such as enlarged liver, distended neck veins, dyspnea on exertion and when lying down, a history of cardiovascular disease.

Lymphedema: hard edema, no itching, only pain sensation, concentrated in the lower extremities, appearing gradually, seen in people with a history of frequent wading.

Edema due to kidney disease: appears slowly in patients with a history of kidney disease, white edema, soft edema, concave pressure, renal function tests are abnormal.

Thrombophlebitis: in the affected area, there is often a feeling of pain, red and purple skin, there may be gangrene, Doppler ultrasound can detect thrombophlebitis.

Dermatitis: often with a red rash on the face and trunk, muscle weakness, prolonged fever, elevated creatinine kinase (CK) tests.

Treatment of angioedema due to the allergic mechanism

Specific treatment

Avoid contact with or eliminate known factors that cause or aggravate illness: stop taking medications, food, move house, change jobs, avoid the heat, cold, sunlight, ...

Consider specific desensitization therapy if the causative allergen cannot be eliminated.

Symptomatic treatment

The main classes of drugs for symptom control include adrenaline (epinephrine), antihistamines, and glucocorticoids.

Adrenalin:

Indications: for all cases of Quincke edema due to allergic mechanism with respiratory edema or hypotension.

Dosage: 0.3 - 0.5mg intramuscularly, repeat after 15-20 minutes if necessary, in severe cases repeat after 1-2 minutes. If there is no response, inject 3 - 5 ml of adrenaline solution 1/10,000 or pump through the cricothyroid membrane or endotracheal tube. One ampoule of adrenaline 1mg can be diluted with 3ml of physiological saline for nebulization in cases of upper respiratory tract edema.

Antihistamines H1:

Indications: in all cases of acute and chronic Quincke's edema due to an allergic mechanism.

Dosage and administration: see table.

Board. H1 antihistamines in the treatment of allergic angioedema

Medical

Dose, how to use

Request dose reduction

First Generation (cause drowsy)

Chlorphenamine

NL: 4mg x 3-4 times/day

TE: 0,35mg/kg/24hours

No

Diphenhydramine

NL:25-50 mgx3-4 times/day

TE:5mg/kg/24hours

Liver failure

Doxepin

NL: 25-50mgx 3 times/day

Liver failure

Hydroxyzine

NL 25-50mgx3times/day

TE: 2mg/kg/24hours

Liver failure

ketotifen

NL: 2mgx2 times/day

TE>3 Yearold: 1mgx2times/day

No

Second generation (little or no drowsiness)

Acrivatin

NL 8mgx3times/day

No

Cetirizine

NL and TE>6 yearold:5-10mgx1times/day

TE<6 yearold:5mg/day

Liver failure, renal failure

Desloratadine

NL:5mgx1time/day

Liver failure, renal failure

Ebastin

NL:10-20mgx1times/day

Liver failure, renal failure

Fexofenadine

NL:60mgx2times/day or 180mgx1times/day

Liver failure

Levocetirizine

NL:5mgx1times/day

Liver failure, renal failure

Loratadine

NL and TE>30kg:10mgx1times/day

TE<30kg:5mg/day

Liver failure

Mizolastin

NL:10mgx1time/day

renal failure

 

* NL: adult; TE: children.

Glucocorticoid:

Indications: in cases of acute and chronic angioedema to relieve symptoms and prevent recurrence of symptoms.

Dosage and administration: should use medium dose, a short course to limit side effects. Oral prednisone or prednisolone or methylprednisolone can be used 40-60mg/day (in adults) or 1mg/kg/day (in children) for 5-7 days.

Other supportive treatments:

Intubation or tracheal opacification if airway edema is life-threatening and unresponsive to medication alone.

Indicators to monitor

Clinical status.

Complete blood count (eosinophilic BC ratio).

Rate of blood sedimentation.

Specific IgE antibody levels (if possible).

Re-examination

Acute angioedema: after 3-5 days.

Chronic angioedema: after 2-4 weeks.