A Rare Case of ACE Inhibitor-Induced Intestinal Angioedema Presenting as a Delayed Complication in a Heart Transplant Recipient

Abstract

<h3>Introduction</h3> ACE inhibitor-induced intestinal angioedema is a rare side effect of ACEi that presents with nonspecific signs and symptoms. Although the risk of occurrence is greater early in therapy, angioedema can present at any time and thus a high index of suspicion is needed to avoid delays in diagnosis, unnecessary testing, and considerable morbidity. <h3>Case Report</h3> Our patient is a 54-year-old male with past medical history of orthotopic heart transplantation 3 years prior for history of end-stage ischemic cardiomyopathy, heparin-induced thrombocytopenia, and hypertension who presented with 3 days of crampy abdominal pain rated 4 out of 10. He also had bloating and watery diarrhea. He had no fever, nausea or vomiting. The patient had rebound tenderness on physical examination. Labs were unremarkable. GI pathogen panel was negative including C. difficile. CT showed a moderate segment of distal ileum which demonstrated acute inflammatory changes including mucosal hyperemia and mural edema on a background of moderate ascites. GI were consulted and performed colonoscopy that revealed no significant abnormalities. The patient had been on lisinopril for 3 years to treat hypertension. This was subsequently stopped due to suspicion of intestinal angioedema. His symptoms resolved within 72 hours of discontinuation. <h3>Summary</h3> Isolated intestinal angioedema secondary to ACEi is a diagnosis of exclusion that necessitates awareness among physicians, particularly in vulnerable subgroups such as heart transplant patients. Symptoms classically subside within 24 to 48 hours after discontinuation of the ACEi.