76-Year-Old Woman With Pruritis and Lip Swelling

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Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN (J.C.S.-V., B.K.); Advisor to residents and Consultant in Allergy and Immunology, Mayo Clinic, Rochester, MN (M.A.P.). A 76-year-old woman presented to her local emergency department for evaluation of lip swelling and pruritis. She was seen earlier that morning at the outpatient clinic with symptoms of earache and mild fever. Her medical history was remarkable for seropositive rheumatoid arthritis treated with long-term immunosuppression with methotrexate and prednisone, gastroesophageal reflux disease, pulmonary fibrosis, chronic obstructive pulmonary disease, idiopathic bronchiectasis, microcytic anemia, and no penicillin allergy. Physical examination revealed a well appearing patient. Otoscopy showed a bulging right tympanicmembranewith evidence offluid.Otitis media was diagnosed, and a 7-day course of amoxicillin, 500 mg twice daily, was prescribed. The patient returned home after filling the prescription and took one amoxicillin tablet around 5 PM. About 10 minutes after ingestion, the patient noted pruritus involving her upper extremities and trunk as well as mild lip swelling. She immediately proceeded to the emergency department, where she arrived 5 minutes after symptom onset. Initial evaluation by the triage nurse revealed the following: temperature, 38.1 C; heart rate, 105 beats/min and regular; blood pressure, 91/53 mm Hg; respiratory rate, 24 breaths/min; and oxygen saturation, 94% while the patient breathed room air. The patient was in mild distress and complained of tingling in her throat. Pertinent positive examination findings included visibly swollen upper and lower lips, mild expiratory wheezing on chest auscultation, and wheals on the upper trunk. The patient was taken to a treatment room, and the attending emergency physician was called to the bedside.