SUDDEN ONSET FACIAL SWELLING IN A PATIENT WITH IDIOPATHIC PULMONARY FIBROSIS MIMICKING ANGIOEDEMA

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Subcutaneous emphysema (SE) is a well known complication that can be seen following thoracic surgical procedures. Angioedema is a localized swelling of subcutaneous tissue usually the face, tongue and upper airway. We present a case of SE of the face initially mistaken for angioedema. CASE PRESENTATION: A 69 year old male, recently diagnosed with Idiopathic Pulmonary Fibrosis (IPF) after a robotic-assisted thoracoscopic biopsy of the left upper & lower lobes, a month prior presented to his primary care physician with complaints of low grade fever & non productive cough. He was treated for acute bronchitis with a course of azithromycin & prednisone which he reported to have completed. He presented to the emergency department, 4 days after completion of the antibiotic course with 1 day history of increasing shortness of breath & 2 days of worsening facial & neck swelling (Figure 1). He also had severe coughing fits days prior. Notably he denied any tongue swelling, stridor or throat tightness. There was initial concern for allergic reaction causing angioedema & was treated with IV methylprednisolone & an H1/H2 blocker in the ED. Exam showed stable vitals, diffuse crackles as well as palpable crepitus in the chest, neck and face. A subsequent chest X-ray showed extensive SE, pneumomediastinum & a small right sided pneumothorax (PTX) (Figure 2). Patient was admitted to ICU for close monitoring. A computed tomography scan of the chest demonstrated extensive SE involving chest, neck, and face; It also showed deep connective tissue space involvement (Figure 3). The small right PTX was stable. Patient was seen by thoracic Surgery who recommended conservative management. Patient remained stable & was discharged home after 3 days. DISCUSSION: Given that his small PTX was on the contralateral side of his biopsy it is unlikely that this was a post surgical complication 1 month post operatively. It is more likely that this patient had small subpleural bleb that ruptured causing air to enter the subcutaneous tissues. SE is most commonly due to an air leak from lung parenchyma, but other causes have been described such as after esophageal resections or airway trauma. This is usually a self-limited & benign complication, in rare instances stridor & respiratory collapse have also been described. This patient’s recent antibiotic exposure raised concern for angioedema. Angioedema has different causes including allergic reactions & can cause rapid swelling of the face & upper airway structures. Angioedema may be life threatening if airway structures are involved or if it is in association with anaphylaxis. CONCLUSIONS: Rapid facial swelling has a limited differential, which includes angioedema and SE, careful history and physical is vital to make the diagnosis. . Reference #1: Abu-Omar Y, Catarino P. Progressive subcutaneous emphysema and respiratory arrest, J R Soc Med 2002,95: 90-91 Reference #2: Kim YS, Risk factors for extensive subcutaneous emphysema after closed-tube throacostomy for spontaneous pneumothorax Reference #3: Loverde D, Files DC, Krishnaswamy G. Angioedema. Crit Care med 2017 Apr;45(4):725-735 DISCLOSURES: No relevant relationships by Kristoffer Neu, source=Web Response No relevant relationships by Muhammad Salick, source=Web Response No relevant relationships by Ali Wazir, source=Web Response No relevant relationships by Robert Wilcott, source=Web Response