Aspirin-Induced Angioedema After Total Hip Arthroplasty: A Case Report

Case Diagnosis: Aspirin-Induced Angioedema After Total Hip Arthroplasty.

Case Description or Program Description: A 23-year-old female with a history of cerebral palsy who presented to inpatient rehabilitation following total hip arthroplasty. During her stay, she developed angioedema secondary to aspirin.

Setting: Acute inpatient rehabilitation

Assessment/Results: The patient demonstrated diffuse urticaria, periorbital edema, and lip edema without signs of airway compromise. Assessment of diet and medication yielded no other contributing factors. She was treated with intravenous Solumedrol and Benadryl, which tempered her allergic response. Aspirin was discontinued, and she was transitioned to Lovenox for deep vein thrombosis prophylaxis (DVT). She was discharged with a short course of oral steroids, and upon follow up in the clinic, she had complete resolution of her symptoms.

Discussion (relevance): This case highlights the importance of early recognition of angioedema in the rehabilitation setting, a potentially life-threatening condition. The immune reaction demonstrated in this case was secondary to a type IV delayed onset hypersensitivity reaction to aspirin, which is being increasingly utilized after orthopaedic intervention. The pathogenesis of non-steroidal anti-inflammatory drugs (NSAIDs) leading to angioedema is theorized to be secondary to COX-1 inhibition, which shifts arachidonic acid metabolism toward 5-lipoxygenase, thereby resulting in an increase in inflammatory leukotrienes that cause urticaria and angioedema. While steroids, antihistamines, and epinephrine can help reduce the acute inflammatory response and manage airway compromise, the mainstay of treatment is discontinuing the offending agent. A thorough assessment of new foods, medications, and soaps should be conducted. If airway compromise occurs, prompt administration of epinephrine and readiness for intubation are critical.

Conclusions: As aspirin use increases for DVT prophylaxis after orthopaedic intervention, it is paramount to be able to recognize and manage NSAID-induced angioedema in the rehabilitation setting, which may be a medical emergency. The mainstays of treatment are removing the offending agent, steroids, antihistamines, and epinephrine for airway compromise.