eMedicine Specialties > Allergy and Immunology > Urticaria and Angioedema

Angioedema: Differential Diagnoses & Workup

Author: Maurice Reid, MD, Staff Physician, Department of Emergency Medicine, University of Maryland Medical System
Coauthor(s): Brian Euerle, MD, FACEP, Associate Professor, Department of Emergency Medicine, Director of Emergency Ultrasound Program, University of Maryland School of Medicine; Mary Elizabeth Bollinger, DO, Associate Professor, Department of Pediatrics, Interim Chief, Division of Pediatric Pulmonology and Allergy, University of Maryland School of Medicine
Contributor Information and Disclosures

Updated: Oct 20, 2008

Differential Diagnoses

Anaphylaxis
Hymenoptera Stings

Other Problems to Be Considered

Allergic
Inhalants
Bites and stings
Natural rubber latex
Foods (eg, milk, eggs, peanuts, tree nuts, soy, wheat, seafood, sulfites)

Drugs
ACE inhibitors
Beta-lactam antibiotics
Sulfonamides
Aspirin/nonsteroidal anti-inflammatory drugs
Insulin
Dilantin
Streptokinase

Viral infections
Herpes simplex
Hepatitis B
Hepatitis C
Mononucleosis
Coxsackieviruses A and B

Bacterial infections
Dental caries/abscesses
Pharyngitis
Tonsillitis
Sinusitis
Otitis media
Upper respiratory infection
Urinary tract infection

Parasitic infections
Ascaris species
Strongyloides species
Echinococcus species
Toxocara species
Fasciola species
Filaria species
Schistosoma species

Workup

Laboratory Studies

  • Laboratory evaluation of the complement system is essential to diagnose HAE or AAE.
    • In type I HAE, C1-INH and C4 levels are low. C4 levels are low during an attack; they may be normal in between attacks.
    • In type II HAE, which is characterized by normal levels of C1-INH that is dysfunctional, a functional or qualitative assay of C1-INH must be performed before the diagnosis can be excluded. C4 levels are low during an attack.
    • In type III HAE, C1-INH levels and function and C4 levels are normal at all times.
    • In HAE and AAE, C4 levels are low during angioedema episodes but may be normal in between episodes. C4 can be used for screening between angioedema episodes, with the understanding that a normal level does not rule out the diagnosis.
    • To differentiate between AAE and HAE, the C1q level should be measured. The hallmarks of AAE are low C1q, C2, C4, and C1-INH levels. In HAE, C1q levels are usually normal or only slightly decreased. Levels of C1q are rarely less than 50% of the normal values in HAE; in AAE, C1q levels are less than 10% of the normal values.
  • Complete blood cell count: Leukocytosis should be absent. If leukocytosis is present, an infectious etiology should be sought. The white blood cell count may be elevated secondary to hemoconcentration.
  • Electrolytes: Abnormalities may be present secondary to vomiting and diarrhea. Prerenal renal failure can also result from intravascular volume depletion.
  • If time permits, a blood sample should be submitted for a type and crossmatch and for determination of the prothrombin time and activated partial thromboplastin time before surgical airway intervention is instituted.

Imaging Studies

  • Plain abdominal films may show a "stacked coin" or "thumbprint" appearance of the intestines.
  • A chest film may show pleural effusion.
  • A soft tissue neck film may show soft tissue swelling.
  • A CT scan image of the abdomen may show severe edema of the bowel wall.

Procedures

  • Airway protection is the most important consideration in patients with angioedema. In cases of possible airway compromise, early intervention with intubation may be preferred. Intubation may be exceedingly difficult, and advanced techniques (eg, fiberoptic intubation) may be necessary. In severe cases of laryngeal edema, a surgical airway must be created via cricothyrotomy or tracheotomy.

More on Angioedema

Overview: Angioedema
Differential Diagnoses & Workup: Angioedema
Treatment & Medication: Angioedema
Follow-up: Angioedema
Multimedia: Angioedema
References
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References

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Further Reading

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Keywords

angioneurotic edema, oedema, laryngeal edema, hereditary angioedema, HAE, acquired angioedema, AAE, allergic reactions, hereditary angioneurotic edema, airway obstruction, swelling

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Contributor Information and Disclosures

Author

Maurice Reid, MD, Staff Physician, Department of Emergency Medicine, University of Maryland Medical System
Maurice Reid, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Brian Euerle, MD, FACEP, Associate Professor, Department of Emergency Medicine, Director of Emergency Ultrasound Program, University of Maryland School of Medicine
Brian Euerle, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Institute of Ultrasound in Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Mary Elizabeth Bollinger, DO, Associate Professor, Department of Pediatrics, Interim Chief, Division of Pediatric Pulmonology and Allergy, University of Maryland School of Medicine
Mary Elizabeth Bollinger, DO is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, and American College of Allergy, Asthma and Immunology
Disclosure: Merck Honoraria Speaking and teaching; Merck Consulting fee Consulting; Novartis Honoraria Speaking and teaching

Medical Editor

Stephen C Dreskin, MD, PhD, Director of Allergy, Asthma, and Immunology Practice, Professor of Medicine, Departments of Internal Medicine and Immunology, University of Colorado Health Sciences Center
Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American Association of Neuropathologists, American Association of Ophthalmic Pathologists, American Association of Oral and Maxillofacial Surgeons, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology
Disclosure: Genentech Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Samuel R Marney, Jr, MD, Director, Associate Professor, Department of Internal Medicine, Division of Allergy and Immunology, Vanderbilt University School of Medicine
Samuel R Marney, Jr, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, and Tennessee Medical Association
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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