eMedicine Specialties > Allergy and Immunology > Urticaria and Angioedema

Angioedema: Differential Diagnoses & Workup

Author: Huamin Henry Li, MD, PhD,, Director of Immunology, Institute for Asthma and Allergy
Contributor Information and Disclosures

Updated: Dec 21, 2009

Differential Diagnoses

Anaphylaxis
Hypersensitivity Reactions, Immediate
Drug Allergies
Latex Allergy
Food Allergies
Stinging Insect Hypersensitivity
Hymenoptera Stings
Urticaria
Hypersensitivity Reactions, Delayed

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

Most mild cases of angioedema do not require any laboratory tests.

  • Allergy skin tests or blood tests (specific to IgE)
    • Suspected allergies to food, stinging insects, latex, and antibiotics can be screened and diagnosed.
    • Value is limited for aeroallergen screening for patients with angioedema, except to establish atopic status.
  • Screening laboratory studies have limited value in most cases. For chronic or recurrent angioedema without clear triggers of cause, one may consider the following:
    • CBC with differential
    • Sedimentation rate
    • Urinalysis
    • Comprehensive metabolic profile
    • CH50 and C4
    • Thyroid studies, including thyroid autoantibody levels (antimicrosomal, antithyroglobulin) can be considered, particularly in women or in patients with a family history of thyroid disease or other autoimmune diseases.
    • With abnormal tests or if a specific medical condition is suspected, additional tests may be needed.
    • Evaluation for possible occult infection can be considered.
    • Other tests to consider if the history and physical examination findings suggest specific problems include the following:
      • C1 INH quantity and function
      • Stool analysis for ova and parasites
      • H pylori workup
      • Hepatitis B and C workup
      • Sinus radiography (if symptomatic)
      • Antinuclear antibody (ANA)
      • Rheumatoid factor
      • Cryoglobulin levels
      • Other imaging studies
    • Assays for serum histamine–releasing factors and evaluation for specific autoantibodies (anti-IgE receptor and anti-IgE) are performed by some research centers. These tests are not commercially available currently.
    • When CH50 or C4 level is low, additional tests for C1-INH function and C1q should be considered.
    • Low C1q may require additional hematological evaluation.
Elevated prothrombin fragment F1 + 2 and D-dimer are associated with acute HAE attacks.16 If it may be used in monitoring other angioedema requires additional studies.

Imaging Studies

Most angioedema patients do not need any imaging studies. When internal organ involvement is suspected, during acute attacks, the following studies can be performed:

  • Plain abdominal films may show a "stacked coin" or "thumbprint" appearance of the intestines.13
  • A chest film may show pleural effusion.
  • A soft tissue neck film may show soft tissue swelling.17
  • Abdominal ultrasound may show ascites.
  • A CT scan image of the abdomen may show severe edema of the bowel wall.18

Other Tests

  • Skin biopsy may be used to rule out other causes of skin swelling (rarely necessary).
  • Laryngoscopy can help assess the extent of laryngeal swelling.

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.

Histologic Findings

Histologic findings in angioedema are nonspecific. Significant inflammation is usually absent, skin morphology usually intact. Eosinophil infiltration is not a common feature of angioedema (except in Gleich syndrome).

More on Angioedema

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

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Further Reading

Kaplan AP. Urticaria and Angioedema. In: Adkinson Jr NF, Bochner BS, Busse WW, Holgate ST, Lemanske Jr RF, and Simons FER, eds. Middleton’s Allergy Principles and Practice. 7th ed. St. Louis, Mo: Mosby; 2009:1063-82.

Banerji A, Sheffer AL. The spectrum of chronic angioedema. Allergy Asthma Proc. 2009 Jan-Feb;30(1):11-6. Review.

Grigoriadou S, Longhurst HJ. Clinical Immunology Review Series: An approach to the patient with angio-oedema. Clin Exp Immunol. 2009 Mar;155(3):367-77.

Zuraw BL. Clinical practice. Hereditary angioedema. N Engl J Med. 2008 Sep 4;359(10):1027-36. Review.

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Keywords

angioedema, AE, angioneurotic edema, urticaria, swelling, hereditary angioedema, HAE, acquired angioedema, AAE, angiotensin converting enzyme inhibitor, ACEI, ACEI induced angioedema, AIIA, NSAID, allergic reaction

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Contributor Information and Disclosures

Author

Huamin Henry Li, MD, PhD,, Director of Immunology, Institute for Asthma and Allergy
Huamin Henry Li, MD, PhD, is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology, and MedChi
Disclosure: Dyax Consulting fee Consulting; Shire/Jerini Consulting fee Consulting; CSL Behring Consulting fee Consulting; Lev Pharma Consulting fee Consulting; Sanofi-Advantis Honoraria Speaking and teaching

Medical Editor

Stephen C Dreskin, MD, PhD, Professor of Medicine, Departments of Internal Medicine, Director of Allergy, Asthma, and Immunology Practice, 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 College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology
Disclosure: Genentech Consulting fee Consulting; American Health Insurance Plans Consulting fee Consulting; Johns Hopkins School of Public Health Consulting fee Consulting; Array BioPharma Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

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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