A patient with facial and neck swelling, dyspnea, and dysphagia

Abstract

HISTORY OF PRESENT ILLNESS A 44-year-old white woman presented to the emergency department for a 5-day history of progressive swelling of the neck and face associated with dyspnea and difficulty swallowing. The patient had a prior history of poorly differentiated carcinoma of the left breast for which she had undergone a mastectomy. This was followed by the placement of a Port-A-Cath on the left side and the administration of 6 cycles of cyclophosphamide, doxorubicin, and 5-fluorouracil. She had just received her fifth cycle of chemotherapy when the swelling began to develop. The swelling initially began on the neck and then extended to involve the face and was symmetric and bilateral. The patient specifically denied lip or tongue edema, urticarial eruption, joint pain, abdominal pain, or pruritus. The patient had a history of “mild” mental retardation, congenital hearing loss, dyslipidemia, and hypothyroidism. The patient denied a personal history of asthma, rhinitis, or prior allergic reactions. There was no prior personal or family history of angioedema. The patient was being treated with hydroxyzine, paroxetine, olanzapine, rofecoxib, synthetic thyroxine, and simvastatin. Rofecoxib, olanzapine, and simvastatin had been introduced more than 1 year ago. Examination of the patient revealed a mildly obese white woman in mild respiratory distress. She appeared dyspneic at rest. The patient had a blood pressure of 121/63 mm Hg and a heart rate of 79/min. She was afebrile. Obvious nonpitting swelling of the anterior aspect of the neck and lower third of the face was seen. The patient had a recent mastectomy scar on the left chest wall, and a Port-A-Cath had recently been placed. No obvious infection, induration, or inflammation was seen around the Port-A-Cath site. No urticaria, vasculitis, or skin eruption was observed. The patient had no tongue, lip, or uvular swelling or edema. No obvious jugular venous distension was seen. The patient was hospitalized, and treatment with intravenous steroids, diphenhydramine, and oral cimetidine. An allergy-immunology consultation was obtained. The results of the initial screening immunology tests are given in Table 1.