Clinical discussion reply to Imane.

This evening, R.S. reported that he woke up in the morning and found that his lips were a bit swollen; a couple hours later when he looked again they had gotten bigger. The night before, his face was normal and he did not do anything out of the ordinary. Only thing he did was take his medication as usual. When his roommate noticed his lips getting bigger she was concerned and recommended getting evaluated as soon as possible. Patient stated that this has never happened to him before. There is no pain or discomfort associated with the swelling. He denies any difficulty breathing or swallowing. He is taking his PrEP medication as prescribed. The patient did notice some random rash without any itchiness. Upon collecting some more information about any new medication. The patient had confirmed that he had just started taking a new PrEP medication called Descovy. R.S. confirmed never had any drug allergy and never experienced like these symptoms before. No signs of infection present and no fever. R.S. confirmed no change of his routine diet or taking any new vitamins or supplements. Patient had confirmed no recent hospitalization or blood transfusion.

A diagnosis of Angioedema is suspected. Angioedema represents self-limited, localized swelling of submucosal or subcutaneous tissues. While the underlying etiology may be undeterminable in the emergent setting, nonhistaminergic and histaminergic angioedema respond differently to therapeutic interventions, with implications for empiric treatment (Xiao-wei Liu, & Campbell, R. L. (2019).

Differential diagnosis could include allergic reaction to food or substance, Allergic reaction to inactive ingredients in Descovy. While inactive ingredients play an important role in the formulations, they may also cause adverse effects (2019). Patient may have been experiencing some anaphylactic allergy reaction to Descovy. R.S. was sent to the nearest emergency department (ED) to be monitored for possible progression of life-threatening facial swelling. He was taken there by his roommate, a reliable source. Patient was educated not to wait and see with these types of reactions as it can become life threatening for the patient. Diagnosis was made based on history and physical findings. The patient was recommended If facial swelling occurs again; or is accompanied with neck or throat swelling, coughing or difficulty breathing, the patient instructed to rush to the closest Emergency Department immediately.

I agree with the provider’s approach in addressing this patient’s issue. Patient was started on new PrEP medication Descovy about 3 days ago. Patient denies any prior occurrence of these symptoms. R.S. denies eating anything new or different, engaging in any new activities or getting bit or exposed to anything over the last 24 hours prior to the onset of his symptoms. He denies any family history of facial swelling.

What I have learned from this case is that allergic reactions symptoms can happen at any time, and not necessarily within a few hours of taking a new medication.

References:

Sandefur, B. J., e Silva, L. O. J., Lohse, C. M., Goyal, K. A., Barbara, D. W., Castaneda-Guarderas, A., Xiao-wei Liu, & Campbell, R. L. (2019). Clinical Features and Outcomes Associated with Angioedema in the Emergency Department. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 20(5), 760–769. https://doi.org/10.5811/westjem.2019.6.42852 (Links to an external site.)

The risk of inactive ingredients in everyday drugs. (2019). Harvard Health Letter, 44(9), 6.