Angioedema?
CASE:
A female in her 30’s presents to the emergency department for acute onset of facial swelling, shortness of breath and a change to the sound of her voice. Although she denied any known allergic exposures, she self-administered an epi-pen at home with little improvement in her symptoms. She otherwise denied fever, cough, chest pain, abdominal pain, and vomiting. The patient stated she has a history of hereditary angioedema that required intubation in the past, as well as depression and anxiety. On exam, the patient had normal vital signs, including normal respiratory rate and oxygen saturation. She was in no acute distress but her voice was hoarse and her lips were swollen. No other oropharyngeal swelling was noted, she had clear lung sounds, and there was no rash.
DIAGNOSIS:
(Likely) Somatic Symptom Disorder
DISCUSSION:
The patient’s subjective report of her symptoms was very concerning for an impending airway emergency. Therefore, both anesthesia and ENT were consulted shortly after the patient arrived at the ED to make the safest possible plan for management of the patient’s airway. Patient was given benadryl, solumedrol, and a C1 esterase inhibitor. ENT was able to expediently execute a bedside, flexible, nasopharyngeal scope for direct visualization of the larynx. Thankfully, the patient had a widely patent airway without edema. Regardless, given that the patient continued to report concerning symptoms, and knowing that angioedema is a progressive disease, the patient was admitted to the ICU for airway monitoring. Shortly after arriving to the ICU, the patient reported her symptoms were worsening and she was intubated. Approximately 16 hours later, the patient was extubated. After extubation, the patient expressed her dissatisfaction with her care, asked to be re-intubated, and ultimately, left against medical advice (AMA), given the ICU team felt she did not need intubation.
The patient left AMA prior to speaking with the psychiatry consult service, but in retroactively reviewing the case, the psychiatry team felt there was a strong component of anxiety contributing to the patient’s reporting of her symptoms. In fact, the psychiatry team postulates that the patient’s presentation may be an example of Somatic Symptom Disorder. In brief, Somatic Symptom Disorder is diagnosed when a patient has a disproportionate amount of thoughts, feelings, and/or behaviors related to somatic symptoms and a high level of anxiety about those symptoms. By definition, the symptoms are involuntary and are not being reported for any secondary gain. The patient in this case undoubtedly had significant anxiety about her symptoms as demonstrated by her subjective report of worsening despite the objective evidence of a laryngoscopy that did not show any evidence of airway edema. The patient’s self report of worsening symptoms was so alarming to both the patient and the providers that the patient ultimately was intubated for airway protection. However, the brief amount of time that the patient was intubated speaks to how intubation was likely unnecessary in the first place.
Upon chart review, the patient had several emergency department visits with similar presentations, and, of note, multiple providers had noted the patient’s symptoms appeared to be distractible. Additionally, conversations with the patient’s outpatient providers revealed that the patient had presented to many hospitals with similar complaints and has had multiple workups that were not diagnostic for angioedema. Outpatient providers suggested that the patient is unlikely to have true hereditary angioedema, but their work-up for this diagnosis is ongoing in the outpatient setting.
In retrospect, the medications and interventions this patient received were unnecessary and therefore may have caused her more harm than provided any benefit. It is important to remember that unnecessary medical testing and interventions can be harmful to patients. For example, too many CT scans over one’s lifetime is a risk factor for developing malignancy due to the radiation exposure. Additionally, the administration of antibiotics should be carefully considered against the risk of fostering resistant bacteria.
CASE RESOLUTION:
After leaving AMA from the ICU, the patient presented to a different hospital just hours later with similar complaints and requested to be intubated. The emergency providers completed a bedside nasopharyngeal scope and reassured the patient that there was no evidence of airway edema. The patient ultimately left AMA from this emergency room visit, reporting that she had intentions of presenting to another hospital.
TAKE AWAYS:
Somatic Symptom Disorder is involuntary, related to anxiety, and is not done for secondary gain.
Adequate chart review is essential, as it may completely alter the approach to a patient’s care; however, it must be balanced against the need to rapidly execute potentially life-saving medical interventions that cannot be delayed.
While difficult to do, deciding which pieces of subjective versus objective evidence will inform your medical decision making is essential to better understanding your own medical reasoning and to informing your approach to patient care.
Unnecessary medical testing and interventions can cause harm to patients.
Author: Kaitlin Lipner, MD is a third year emergency medicine resident at Brown Emergency Medicine Residency
Faculty Reviewer: Frederick Varone, MD is an attending physician at Brown Emergency Medicine
References:
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787