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PERSISTENT ANGIOEDEMA AFTER COVID-19 VACCINATION: IS BRADYKININ TO BLAME?

https://doi.org/10.1016/j.anai.2022.08.818Get rights and content

Introduction

Bradykinin-mediated angioedema (BMA) represents a subtype of angioedema that presents with nonpruritic, non-pitting swelling of the skin and mucosal surfaces.

Case Description

A 32-year-old female presented to the Emergency Department (ED) for recurrent lip and tongue swelling after receiving the Janssen vaccination one day prior. She was treated with epinephrine with transient improvement and discharged on steroids and antihistamines. She returned to the ED multiple times and was ultimately hospitalized for recurrent angioedema. She would be trialed on additional antihistamine medications, including omalizumab, without relief. She presented to our ED and was treated with epinephrine, antihistamines, and steroids. Her labs, including C4, C1INH, C1q, tryptase, were unremarkable. She was given a dose of icatibant with immediate resolution of her angioedema.

Discussion

This case illustrates a unique presentation of BMA following the Janssen SARS-CoV-2 vaccine. Given this patient's persistent angioedema and lack of sustained clinical response to antihistamines, corticosteroids, and epinephrine, the diagnosis of BMA was made. A search for an underlying etiology, including evaluation for hereditary, acquired, and medication-induced angioedema was unremarkable. This led to a diagnosis of idiopathic bradykinin-mediated angioedema.

This case questions whether there is a particular facet of the SARS-CoV-2 vaccine, specifically, responsible for increased bradykinin levels. Homology of the bradykinin motif has been found in the SARS-CoV-2 spike protein; therefore, the antibody response to the SARS-CoV-2 protein may potentially cross-react with bradykinin protein. It is plausible that immune stimulation to the COVID-19 vaccine and subsequent generation of SARS-CoV-2 specific antibodies may have led to excess bradykinin production in our patient.

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