Swelling of the tongue

Allergies: Swollen Tongue

Your tongue can swell for a number of reasons, most commonly due to medications, allergies, and underlying medical problems. The swelling may be referred to as angioedema, which means the swelling occurs in the deeper layers of the skin.

Sometimes, it is not only the visible part of the tongue that swells, but also the back of the tongue, the mouth, the gums, and occasionally the larynx or voice box, says Lorraine Smith, MD, of the Osborne Head and Neck Institute in Los Angeles.

The tongue is primarily a muscular structure covered by layers of cells called epithelium. Its surface is lined with taste buds, which allows us to differentiate tastes like bitter, sweet, and salty. Like the tongue, the taste buds on your tongue can swell.

Because a swollen tongue can interfere with your airways and cause serious problems with your breathing, it is usually a medical emergency that requires immediate treatment.

What Causes a Swollen Tongue?

Swelling is an important defense mechanism in our bodies. Swelling fights off harmful bacteria and parasites, and helps with injury and healing. However, inappropriate swelling or swelling that persists can be harmful.

There are multiple chemical pathways that turn swelling on and off, which are complicated and only partially understood, says Anna Feldweg, MD, a clinical instructor of medicine at Harvard Medical School and attending physician in allergy and immunology at Brigham and Women’s Hospital in Boston. A swollen tongue can happen when something — a medication, allergen (something that causes an allergic reaction), or medical problem — interferes with these pathways. Here’s a look at some common causes.

  • Medications. Many cases of a swollen tongue are the result of a reaction to a medication such as an ACE inhibitor, used to treat high blood pressure, or an NSAID, or non-steroidal anti-inflammatory drug, such as aspirin, ibuprofen , or naproxen . A swollen tongue due to a reaction to ACE inhibitors usually occurs during the first year of taking the medication, but can also happen after years of taking it, says Dr. Feldweg.
  • Allergens. In addition to allergic reactions to medications, allergic reactions to other substances — such as foods or bee stings — can cause swelling. In food allergies and bee sting allergies, the tongue can swell, but it is less common to have a swollen tongue than it is to have a swollen throat or lips.
  • Infection. Another possible cause of a swollen tongue is an infection deep inside the tongue or in the floor of the mouth. This usually develops over a day or two — more slowly than the allergic type of swelling.

Some people develop fungal infections in the mouth known as thrush. Fungal infections are caused by the fungus Candida and usually occur after a course of antibiotics. It’s the same fungus that can cause vaginal yeast infections. People with compromised immune systems, like those with HIV, also are susceptible to this yeast, also called simply candida thrush, that can cause the tongue to swell. Candida thrush can be treated with thrush medications that you swish and swallow, or swish and spit, Dr. Smith says. An oral medication often used to treat recurring thrush is fluconazole (Diflucan).

Herpes viruses also can cause infections that result in swelling of the tongue. “While there is no treatment for viral infections, recovery can sometimes be enhanced with the medicine acyclovir (Zovirax),” Smith says. Other similar drugs may also help. Herpes tongue lesions or ulcers are often extremely painful. They present as a red sore with a white overlying layer that can be wiped off with a cotton swab.

  • Medical illness. Very slow swelling of the tongue over weeks or months can occur in a condition called amyloid, a disease in which harmful amyloid proteins are deposited into tissues and organs. “With , the tongue gets bigger and bigger over time,” says Feldweg.
  • Irritants and trauma. You may find that your tongue swells if you accidentally bite it or burn your tongue with hot liquids or hot foods. Dental appliances also can irritate your tongue and cause it to swell. Tobacco is yet another irritant that can cause tongue pain and swelling.
  • Tongue cancer. Tongue cancer is a common cancer of the head and neck — more than 10,000 new cases are diagnosed in men and women in the United States each year. Highly curable if caught early, tongue cancer usually starts as a lump, ulcer, or white spot or patch on the outer layer of the tongue or a surrounding area.

“Cancer of the tongue is often painful,” Smith says. An infection tends to be self-limiting and will go away, whereas tongue lesions associated with cancer often persist and increase in size with time. Suspicious lesions need to be biopsied and treated appropriately if found to be cancerous, Smith says. “Some tongue cancers may not involve pain but any mass that persists for more than two weeks needs to be biopsied.”

Other tongue cancer symptoms include pain when chewing or swallowing, ear pain, numbness in the mouth, bleeding in the mouth, and a persistent sore throat.

A red patch on the tongue is often painless, but has a higher chance of being associated with cancer than a white patch on the tongue. But both patches need to be biopsied to get a definite diagnosis, Smith says, and to be able to apply the appropriate treatment.

Both tongue disorders and cancers of the tongue may present with swollen lymph nodes — under the chin and in the mandible region. If you have an infection, the swollen lymph nodes or swollen taste buds near the tongue will eventually go away after the infection clears. But another tongue cancer sign is if the swelling continues to progress and doesn’t go away, Smith says.

Related Conditions

In addition, a swollen tongue can be caused by:

  • Hormonal disorders such as acromegaly
  • Congenital disorders such as Beckwith Wiedemann syndrome
  • Genetic disorders such as Down syndrome and hereditary angioedema
  • Hypothyroidism, an underactive thyroid
  • Poor vitamin B12 absorption
  • Pituitary gland disorder

Treating a Swollen Tongue

Because a swollen tongue can lead to breathing problems, it should be looked at as an emergency situation. Medical personnel usually treat a dangerously swollen tongue with an injection of epinephrine, which may or may not work, depending on the cause. Once the person arrives at the hospital, “we usually give people steroids and antibiotics in the emergency room,” says Feldweg, adding that treatment for a swollen tongue ultimately depends on the cause.

If the swollen tongue is caused by a drug reaction, the person must stop taking the medication. In food allergies, foods that trigger the swelling must be avoided. Anyone who has a history of a swollen tongue due to an allergic reaction will probably be advised to carry an injectable dose of epinephrine with them, which may help control the swelling if the tongue begins to swell again. If the cause is infection or amyloid, those will be treated accordingly.

There are many different causes of a swollen tongue. Most are straightforward to treat and the swelling goes away. If your tongue swells and interferes with your breathing, you need to go to the ER for treatment. If it’s a persistent problem, see your doctor so he can determine the cause of your tongue swelling and find the most appropriate treatment.

Your tongue is a pretty important accessory—it helps you taste and swallow your food, talk non-stop to anyone who will listen, and is fun to stick out when someone annoys you. But you probably (and understandably) don’t think much about its significance until something happens to it, like when it swells up out of nowhere.

It doesn’t take long to notice when your tongue is suddenly too large for your mouth. Your first instinct might be to freak out, but fear not: “Swelling of the tongue can be caused by a variety of different problems, most of which are self-limiting and not serious,” says Clare Morrison, MD, general practitioner and medical advisor at MedExpress.

However, if the swelling happens quickly, or is severe and accompanied by throat-tightness, difficulty breathing, and dizziness or feeling faint, then you should seek medical attention right away, as it may indicate a life-threatening situation.

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Likewise if the swelling persists (say, 10 days or longer), gets worse, or you’re experiencing other concerning symptoms, such as fatigue, pain, or fever, then definitely check in with your doc for a consult.

As for what might be causing your tongue to puff up? Below, experts share 10 possible culprits.

1. Your tongue is recovering from an injury.

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“The tongue is vulnerable to trauma from the teeth, due to accidental or compulsive biting, sharp edges of broken teeth, and from dental work such as braces, false teeth, and rough fillings,” says Dr. Morrison. Hot or sharp pieces of food can cause tongue irritation and swelling too, especially if those eats are acidic (like hard sour candies) or hot and spicy (chilies and curries).

The obvious solution is to nix the causative factor of your puffy tongue (in some cases, you may need an assist from your dentist, says Dr. Morrison), while soothing the injury by sucking on an ice cube, popping ibuprofen, and using a gentle mouthwash to prevent infections.

2. Your mouthwash may be causing problems.

Certain toothpaste and mouthwash ingredients can cause tongue swelling that won’t resolve until the inciting ingredient is discontinued, says Los Angeles-based board-certified dermatologist Tsippora Shainhouse, MD. The most common culprits to cause oral contact dermatitis? Hydrogen peroxide (teeth-whitening), alcohol (mouthwashes), baking soda (toothpaste), and cinnamates (chewing gum).

If you’re not sure which ingredient is giving you ‘tude, your dermatologist can perform an allergy patch test to suss it out, adds Dr. Shainhouse.

3. It’s a sign of an allergic reaction.

Allergic reactions are caused by the immune system over-reacting to something it’s exposed to. Think: fruit, nuts, shellfish, milk, or even an insect bite. The allergic response involves the release of histamine, narrowing of small blood vessels, and the accumulation of fluid in the tissues, says Dr. Morrison. When an allergy causes swelling of the tongue, lips, and face, it’s known as angioedema.

Allergic reactions can be treated with antihistamines or oral steroids. Serious reactions can ultimately restrict breathing, which is why people who know they can react to specific foods or bites must carry an EpiPen and administer it immediately.

⚠️ If you or someone near you experiences signs of a life-threatening allergic reaction, including tongue swelling, do not hesitate to call for help. “This is an absolute emergency and 911 must be called ASAP,” says Dr. Morrison.

4. …or a side effect of certain medications.

The medications best known for causing allergic reactions—and associated tongue swelling—are blood pressure medications known as ACE-I inhibitors. “They can cause potentially life-threatening tongue swelling that can occur at any time during therapy,” says Omid Mehdizadeh, MD, otolaryngologist (ENT) and laryngologist at Providence Saint John’s Health Center in Santa Monica, California. “It doesn’t necessarily occur when first taken.”

Anti-inflammatories (like aspirin and ibuprofen) and antibiotics (penicillin, antivirals), can also trigger an allergic reaction. “If affected, it’s important to stop the offending medication,” says Dr. Morrison. Treatment must be sought right away, and depending on severity, can include antihistamines, steroids, and intramuscular adrenaline.

5. A vitamin deficiency could be to blame.

Lack of vitamin B12 and folate can cause a swollen, red, beefy-looking tongue. “You may also get tingling in the hands and feet, fatigue, and weakness,” says Dr. Morrison. Meanwhile, an iron deficiency can cause the tongue to become sore, smooth, and pale, and is likely to be accompanied by fatigue, shortness of breath, and super-pale skin.

Increasing your intake of these vitamins by eating foods like meat, fish, eggs, leafy greens, beans, and lentils, can relieve symptoms, but major vitamin and mineral deficiencies should ultimately be investigated by your doctor, says Dr. Morrison. They’ll want to look into how the deficiency arose, and replace the missing nutrients through specific supplements and dietary changes.

6. Acid reflux is irritating your tongue.

Stomach acid that travels to the throat (laryngopharyngeal reflux, or LPR), may irritate the tongue and cause swelling. “You may notice an acidic or bitter taste in your mouth, throat burning, or the sensation of a lump in your throat,” says Dr. Mehdizadeh. Steering clear of acidic or spicy foods and drinks can be help with keeping LPR in check—so can popping antacids, eating smaller, more frequent meals, and wearing looser-fitting clothes.

7. Your tongue is infected.

Bacterial infections can arise from a cut—say, from teeth biting or rubbing on the tongue—that bacteria then use as an entry point. Your tongue might feel red and sore, says Dr. Morrison, and if the infection is deep, it can cause an abscess that results in painful swelling.

Occasionally, STDs, like syphilis and gonorrhea, can affect the tongue. Bacterial infections will require a round of antibiotics from your doctor—and in the case of a large abscess, hospital admission and surgical drainage.

Viral infections of the tongue include herpes (the cold sore virus). “The first infection is the worst, and may be associated with multiple painful blisters inside the mouth, including the surface of the tongue, as well as fever and malaise,” says Dr. Morrison.

HPV (human papillomavirus) and canker sores can also mess with your tongue. These usually clear up without treatment, but medical guidance should always be sought if you’re feeling particularly awful.

8. An underactive thyroid could be stirring up symptoms.

When circulating levels of thyroid hormone are low (which is common in women, and often autoimmune-related, says Dr. Shainhouse), there are specific signs to watch out for, including fatigue, unexplained weight gain, constipation, cold-intolerance, hair thinning, and (surprise!) tongue swelling.

Fortunately, hypothyroidism can be diagnosed with a blood test. “If confirmed, it’s treated by taking prescription medication to replace the thyroid hormone,” says Dr. Morrison. From there, regular blood tests will be required to check the dose, which will be adjusted on an as-needed basis.

9. Your pituitary gland is acting up.

The pituitary gland is an itty bitty organ that’s located at the base of the brain. It makes and ships a variety of different hormones to the rest of the body, and tells other glands when to do the same. “If the pituitary gland produces too much growth hormone, there will be gradual swelling of several parts of the body, including the tongue, hands, feet, and face,” says Dr. Morrison.

Docs call this disorder acromegaly. Usually caused by a benign tumor in the pituitary gland, other symptoms can include headaches, deepening of the voice, irregular periods, skin tags, and enlarged facial features.

Because acromegaly develops slowly, you might not notice the changes to your appearance at first—but the second you suspect it to be a problem, it’s important to check in with your doctor for a blood test to confirm and subsequent treatment, as life-threatening complications can strike if left untreated, says Dr. Morrison.

10. It could be a sign of tongue cancer.

Tongue cancer starts off superficially, typically with a white or red patch, or a small lump or ulcer on the tongue. “It usually arises at the site of a previous infection with HPV, which may have occurred many years earlier,” says Dr. Morrison, and is more common in people who smoke or drink alcohol.

“If removed at this stage, it’s completely curable,” says Dr. Morrison. That’s why it’s so important to seek medical attention if you have persistent tongue soreness or a lump that won’t quit—a biopsy can determine if it’s cancerous so you can be treated right away.

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Krissy Brady Krissy is a regular contributor to Prevention, and she also writes for Cosmopolitan, Weight Watchers, Women’s Health, FitnessMagazine.com, Self.com, and Shape.com.

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Case presentation

A 76-year-old otherwise fit and healthy female presented at the Accident and Emergency Department at 2:15 am with the complaint of a mildly painful and remarkably swollen tongue that developed after eating mint chocolate. Although the patient had tenderness and the frightening swelling in the mouth causing discomfort and moderate difficulty in swallowing, she had no shortness of breath or any other complaint. She gave a medical history of rheumatic polimyalgia in the past requiring no medical treatment at present. She remembered a previous allergic reaction to mint.

On examination it was noted that a remarkable swelling was localised only on the lefthand side of the tongue (please see Figure ​Figure1).1). The tongue seemed to be suffused and a superficial non-tender ulceration was seen at the anterior quarter of the surface. There was a mild tenderness and a loss of taste on this side. The right-hand side of the tongue was completely normal. Tongue movement was normal apart from mild restriction caused by the swelling. No other pathology on the oral mucosa or in the throat was observed.

Localised swelling on the left-hand side of the tongue.

There was no skin rash or any other systemic reaction, and the vital parameters were stable. Blood results showed a mild elevation of C-reactive protein (CRP = 17) and erythrocyte sedimentation rate (ESR = 33).

As the symptoms were considered as a local allergic reaction, the patient was given 4 mg chlorphenamine orally and 100 mg hydrocortisone injection intramuscularly. The swelling responded to the medication quickly and the patient was discharged after a period of observation.

We made a follow up after one and three months. However, although the swelling had almost completely gone by the next morning and the tongue had become pain free, the follow up revealed that the healing process was indeed longer. Even after three months a scar was seen on the top of the left-hand side of the tongue (please see Figure ​Figure2).2). No other disability was reported and the sense of taste had also returned to normal.

A scar is still visible three months later.

Swollen Tongue

What is a swollen tongue?

A swollen tongue is an abnormal condition in which the entire tongue or a portion of it is enlarged, bloated or distended. Your tongue is made up of muscles and the upper surface is lined with taste buds. Your tongue helps you to talk, swallow, taste and chew.

A swollen tongue can result from infection, inflammation, allergy, genetic disorders, trauma, malignancy, metabolic diseases, and other abnormal processes. A chronically swollen tongue over a long period of time can be due to acromegaly, sarcoma, oral cancer, or Down syndrome.

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If your tongue swells up rapidly, this could be a sign of an allergy or a life-threatening anaphylactic reaction. An anaphylactic reaction is characterized by a swollen tongue (and swelling in general) combined with hives, itching, shortness of breath, and rapid breathing (more that about 16 breaths per minute for an adult). The reaction is sudden, severe, and can include respiratory distress. Seek immediate medical care (call 911) if you, or someone you are with, have any of these symptoms.

What other symptoms might occur with a swollen tongue?

If your tongue is swollen, you may also be experiencing other symptoms depending on the underlying disease, disorder or condition. Other common symptoms include tongue pain, tongue lesion, difficulty chewing, and difficulty swallowing.

Allergy symptoms that may occur along with a swollen tongue

A swollen tongue may occur with other signs and symptoms of an allergic reaction including:

  • Abdominal pain or cramps

  • Mild cough

  • Mild diarrhea

  • Mild vomiting

  • Sneezing and runny nose

Other symptoms that may occur along with a swollen tongue

A swollen tongue may occur with other symptoms including:

  • Burning feeling

  • Change in texture, such as the tongue surface becoming smooth

  • Change in tongue color (usually darker colors)

  • Fever

  • General edema (swelling)

  • Goiter

  • Headache

  • Spitting blood due to trauma

  • Symptoms of hypothyroidism (fatigue, weight gain, dry skin, hair loss, puffy eyes, depression, and menstrual abnormalities)

  • Tongue or mouth pain and soreness

Serious symptoms that might indicate a life-threatening condition

In some cases, a swollen tongue can indicate a serious or life-threatening condition called an anaphylactic reaction that can rapidly develop into anaphylactic shock and death. Seek immediate medical care (call 911) if you, or someone you are with, have any of these symptoms:

  • Bluish coloration of the lips or fingernails

  • Change in level of consciousness or alertness, such as passing out or unresponsiveness

  • Coughing up blood

  • Difficulty swallowing

  • Feeling like your throat is tight

  • General edema (swelling) around the eyes and lips

  • Hives or rash

  • Intense distress

  • Itching in the throat or mouth

  • Low blood pressure (hypotension)

  • Nausea or vomiting

  • Respiratory or breathing problems, such as shortness of breath, difficulty breathing, labored breathing, wheezing, not breathing, and choking

What causes a swollen tongue?

A swollen tongue is a symptom of a variety of diseases, disorders and conditions. Some causes of a swollen tongue are serious, even life threatening, such as an anaphylactic reaction. Other causes may be relatively mild, such as a small cut when you have bitten your tongue.

Bacterial, yeast and viral infections can lead to glossitis, which is a condition characterized by your tongue swelling and changing color. Other causes of a swollen tongue include a variety of irritants and exposure to very hot foods or beverages, spicy foods, tobacco, and alcohol. A swollen tongue can also be a side effect of having no teeth (edentulism) and certain medications.

Infections that cause a swollen tongue

Potential infectious causes of a swollen tongue include:

  • Herpes simplex virus infection

  • Strep infection (bacterial infection)

  • Syphilis

  • Yeast infection

Allergic causes of a swollen tongue

A swollen tongue can be due to mild and serious allergies and allergic reactions including:

  • Insect bite allergy, such as from a bee sting

  • Drug allergy (penicillin or codeine)

  • Food allergy

  • Anaphylactic allergic reaction

Irritants and trauma can cause a swollen tongue

A swollen tongue can arise from irritants and trauma including:

  • Biting the tongue

  • Burning the tongue, such as with hot liquids, hot food, or spicy food

  • Dental appliances

  • Tobacco

Other causes of a swollen tongue

A swollen tongue can be due to a variety of other diseases, disorders and conditions including:

  • Acromegaly (hormonal disorder)

  • Beckwith Wiedemann syndrome (congenital disorder)

  • Down syndrome

  • Hereditary angioedema (serious genetic disorder that causes periodic swelling of the throat and other areas)

  • Hypothyroidism (underactive thyroid)

  • Lymphangioma (birth defect)

  • Oral neurofibroma (benign tumor possibly due to an inherited disorder called neurofibromatosis type 1)

  • Pellagra (skin lesions and other problems caused by deficiency in vitamin B3, which is also known as niacin)

  • Pernicious anemia (decrease in red blood cells due to poor vitamin B12 absorption)

  • Pituitary gland disorder

  • Sarcoma (soft tissue cancerous tumor)

  • Tongue cancer

Questions for diagnosing the cause of a swollen tongue

To help diagnose the underlying cause of a swollen tongue, your licensed health care practitioner will ask you several questions related to your symptoms. Questions asked during your examination generally include:

  • Is the whole tongue swollen or just a portion of the tongue?

  • When did the tongue swelling start?

  • How long has the tongue swelling lasted? Does it come and go?

  • Did you eat any foods or have contact with any unusual substances before the swelling started (for example, seafood, shellfish, latex, or an insect bite)?

  • Have you had any recent infections or injuries to the mouth?

  • Do you have any pain or other symptoms?

What are the potential complications of a swollen tongue?

Complications associated with a swollen tongue can be progressive and vary depending on the underlying cause. Because a swollen tongue can be due to serious diseases, failure to seek treatment can result in complications and permanent damage. It is important to contact your health care provider when you experience any kind of persistent swelling or other unusual symptoms. Once the underlying cause is diagnosed, it is important to follow the treatment plan you and your health care practitioner design specifically for you to lower your risk of potential complications including:

  • Difficulty swallowing

  • Difficulty breathing (blocking the airway)

  • Discomfort

  • Surgery to remove the tongue due to a serious infection or malignant condition

  • Respiratory arrest from anaphylactic shock

Treating a Swollen Tongue

My daughter was just taken to the ER with a swollen tongue. It was so bad that she could not talk. How serious is this, and how do we treat it?

— Victoria, Virginia

Swelling or angioedema of the tongue must always be taken seriously because if the swelling spreads back in the throat, it can interfere with or even entirely obstruct the airway. Also, some swelling progresses very rapidly (sometimes within minutes), although that is not always the case.

There are different things that can trigger swelling of the tongue. In children, a food allergy, medication allergy (including over-the-counter medications for fever and headache like aspirin or ibuprofen), or an inherited condition called hereditary angioedema should be considered. In adults, the same list applies; additional causes include medications (especially ACE inhibitors for high blood pressure) and other swelling problems, such as acquired angioedema and idiopathic angioedema, or a newly described condition known as hereditary angioedema with normal C1 inhibitor (more about testing for these below). The hereditary conditions run in families, so asking relatives on both sides if they ever had problems with sudden swelling would be useful. Unusual causes for swelling of the tongue include infection, trauma, or an insect sting, although these are usually relatively obvious.

When tongue swelling is caused by a food allergy (which is not that common), there are usually other symptoms that accompany it, such as itching, hives, facial swelling, wheezing, vomiting, and others.

Tongue swelling should be treated with an injection of epinephrine (the treatment for a severe allergic reaction) if the tongue is constricting the airway. Epinephrine will not work if the cause is not allergic, however. If the swelling is less severe, it is usually treated with antihistamines and corticosteroids. These medications are typically continued for a few days, until the episode resolves.

Anyone with tongue swelling (especially before the cause has been determined) should be given a prescription for an epinephrine self-injector pen (the two available brands are Epipen and Twinject) and taught how to use it. Make sure that you and your daughter understand how to use the self-injector pen and use a practice pen several times, so that if you ever need the real thing, you will not fumble around or use it incorrectly.

The next step is trying to figure out the cause of the tongue swelling, because that is the best way to prevent it from happening again. Foods, drinks, candies, and medications taken in the few hours before the onset of swelling should be reviewed. Any trauma to the mouth or dental work can trigger attacks of hereditary angioedema, so events just before the onset of swelling should also be reviewed.

Allergies to medicines are simply treated by stopping the medication and labeling your daughter’s medical record sufficiently to make sure she never receives the culprit drug again. If the cause is unclear, however, then an allergist should evaluate your daughter, as this is one of the conditions that allergists specialize in.

It would be very helpful if the doctors in the emergency department had tested your daughter’s complement 4 (or C4) level at the time she had symptoms. This test screens for problems caused by abnormalities in blood proteins, called complement proteins, which control inflammation in our bodies. If C4 was not checked at that time, then please ask your primary care clinician to check a C4 level, a C1 inhibitor antigenic level, and a C1q level, even before you see the allergist. A low value in any of these tests suggests a disorder of the complement proteins, and this is helpful to know when performing further tests to determine the precise problem.

Acutely Swollen Tongue in a Middle-Aged Woman

Discussion

The answer is D: medication-induced angioedema, likely from the angiotensin-converting enzyme (ACE) inhibitor lisinopril. ACE inhibitor–associated angioedema is a self-limited, localized swelling that commonly affects the lips, tongue, and face. Pruritus and urticaria are usually absent.

The incidence of ACE inhibitor–associated angioedema varies from 0.1 to 6 percent.1 Most cases occur within the first month of starting treatment, with the highest incidence in the first week. However, symptom onset has been reported anywhere from one day to 10 years after starting treatment. Angioedema is more common in black persons, women, smokers, and persons with a history of seasonal allergies. Diabetes seems to decrease the risk.1 The condition is thought to be related to elevations in bradykinin and substance P levels, which cause inflammation and fluid leakage in the postcapillary venules. This leads to a well-demarcated, localized, and nonpitting subdermal edema.1

Although there have been reports of angioedema related to angiotensin receptor blockers (ARBs), the rates are similar to those in the general population. ARBs are generally considered safe in patients with a history of angioedema from ACE inhibitors.2

Angioedema should resolve after the discontinuation of the causative ACE inhibitor, and further treatment with other ACE inhibitors is contraindicated. Depending on the severity of symptoms, supportive care may be required, including treatment with epinephrine and intubation in anticipation of laryngeal obstruction.1,3

Acromegaly is caused by excess growth hormone and manifests as soft tissue and bony overgrowth. Other features include enlarged face, hands, feet, and tongue; coarsening of facial features; and development of diabetes and macroglossia. Duration of symptoms, from onset to diagnosis, is typically 12 years.4

Amyloidosis is characterized by deposition of the amyloid protein in various parts of the body. Although the kidneys, heart, and liver are the most common sites of deposition, amyloid may infiltrate the muscles and cause pseudohypertrophy of the tongue. Macroglossia may be the first manifestation of amyloidosis.5

Hypothyroidism is usually chronic and causes symptoms such as fatigue, constipation, and cold intolerance. Pale skin, sparse hair, periorbital puffiness, and macroglossia may sometimes progress to a stuporous state and generalized edema. Diagnosis is made by the presence of decreased serum thyroxine and increased thyroid-stimulating hormone levels.6 Superior vena cava syndrome is a manifestation of dilation of the veins in the upper thorax and neck, accompanied by plethora, facial edema, headache, and reduced consciousness. The condition leads to gradual and progressive swelling over days to weeks and is often caused by a malignancy directly compressing the vena cava.7

Enlarge

Summary Table

Condition Characteristics

Acromegaly

Soft tissue and bony overgrowth from excess growth hormone; insidious onset of enlarged features, including face, hands, feet, and tongue

Amyloidosis

Amyloid may infiltrate muscles and cause pseudohypertrophy of the tongue; kidneys, heart, and liver are the most common sites of deposition; usually not acute in onset

Hypothyroidism

May cause fatigue, constipation, and cold intolerance; pale skin, sparse hair, periorbital puffiness, and macroglossia may progress to a stuporous state and generalized edema; usually chronic

Medication-induced angioedema

May occur days or years after initiation of angiotensin-converting enzyme inhibitor; usually sudden-onset edema of lips, tongue, and face

Superior vena cava syndrome

Manifestation of dilation of the veins in the upper thorax and neck, accompanied by plethora, facial edema, headache, and reduced consciousness; gradual and progressive swelling over days to weeks

Condition Characteristics

Acromegaly

Soft tissue and bony overgrowth from excess growth hormone; insidious onset of enlarged features, including face, hands, feet, and tongue

Amyloidosis

Amyloid may infiltrate muscles and cause pseudohypertrophy of the tongue; kidneys, heart, and liver are the most common sites of deposition; usually not acute in onset

Hypothyroidism

May cause fatigue, constipation, and cold intolerance; pale skin, sparse hair, periorbital puffiness, and macroglossia may progress to a stuporous state and generalized edema; usually chronic

Medication-induced angioedema

May occur days or years after initiation of angiotensin-converting enzyme inhibitor; usually sudden-onset edema of lips, tongue, and face

Superior vena cava syndrome

Manifestation of dilation of the veins in the upper thorax and neck, accompanied by plethora, facial edema, headache, and reduced consciousness; gradual and progressive swelling over days to weeks

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