185) A 65 year old woman is evaluated in your office for lower extremity swelling and weakness. She reports difficulty speaking for the past three months. Her past medical history is significant for renal insufficiency and hypertension that was diagnosed 6 months ago. A TSH level that was obtained 3 weeks ago was normal. She smokes cigarettes, about 1 pack per day for the past 35 years. Her medications include Lisinopril and Hydrochlorthiazide. On physical examination, her heart rate and rhythm are regular. Lungs are clear to auscultation. She has gross edema of the lower extremities. There is no extremity weakness. Head and neck examination reveals findings as shown below:
Which of the following is most likely to be abnormal in this patient?
A) Free thyroxine
B) Serum immunoelectrophoresis
C) Rheumatoid factor
D) ACE Level
E) Bradykinin level
a
its angio edema and need to check his bradikinin level.
Ans. is E.
bbbbb
If you know the MOA of ace – this is a no brainer
Bradykinin
Unfortunately, bradykinin is a wrong answer. ACEI may cause angioedema but the diagnosis is not based on Bradykinin levels. ACEI induced angioedema is acute where as the tongue swelling described in this question is chronic ( 3 months duration). You can not expect a person to have angioedema for 3 months and still be alive.
The most appropriate answer is amyloidosis. Serum immunoelectrophoresis may reveal monoclonal gammopathy and is a supportive evidence for amyloidosis.
Note the tongue? Too large, is not it?
So, what are the causes of Macroglossia? And how would you eliminate those choices?
hypothyroidism , acromegaly, eliminate by presence of other features of these disorders.
Bradykinin level will be high due to ACEI use—>angioedema.