A wide range of adverse effects such as cough and angioneurotic edema [1] may result from the use of ACE inhibitors [2]. Rarely, angioedema has been reported to occur up to 3 years after initiation of therapy [3]. We describe a patient who took captopril for 7 years before onset.

A 55-year-old woman who had taken captopril, 25 mg thrice daily, for hypertension since 21 August 1984 had two episodes of moderate tongue swelling in August and September 1991, respectively. On 14 October 1991, she awoke with a severely swollen tongue. Examination showed that she was drooling, unable to swallow or speak, and in severe respiratory distress due to upper airway obstruction. Two doses of subcutaneous epinephrine, 50 mg of intravenous diphenhydramine, and 10 whiffs of epinephrine from a metered dose inhaler were administered, but the patient showed little improvement. She was judged to have life-threatening angioedema and was rushed to a local emergency room where two additional doses of subcutaneous epinephrine together with inhaled racemic epinephrine solution and intravenous methylprednisolone were given, resulting in gradual improvement. She was hospitalized overnight and was discharged the next day with no serious sequelae. Functional assays for C1 esterase inhibitor and C4 level showed normal results. Captopril therapy was discontinued and she has had no further episodes of angioedema.

Our patient represents the longest reported duration of use of an ACE inhibitor before onset of angioedema. Episodes of angioedema resulting from ACE inhibitors may be assumed to be due to food allergy or other causes. Recognition of the true drug-induced nature of the angioneurotic edema is important, however, because withdrawal of the drug may prevent a later life-threatening attack, even in patients receiving long-term therapy.