Hello calamityjane,
Thanks for requesting me to answer this question. Although I am an
internal medicine physician, please see your primary care physician
for specific questions regarding your case – please do not use Google
Answers as a substitute for medical advice.
I will answer factual questions regarding lip and tongue swelling.
All sources will be from physician-written, peer-reviewed sources.
To be complete, I started my search by looking for the differential
diagnosis of upper lip swelling. From Dxplain (a computerized
differential diagnosis program):
Findings: Lip swelling, male, elderly (age>65)
Common diseases:
Food allergy
Chronic Urticaria
Rare diseases:
Acromegaly
Angioedema
Ascariasis
Multiple endocrine neoplasia type II
I will concentrate my discussion on the three most likely causes of
your lip and tongue swelling: food allergy, chronic urticaria, and
angioedema.
1) Urticaria
Urticaria, or hives, is a common disorder affecting up to 25 percent
of the population. The most common complaint of patients with
urticaria is pruritus that may cause difficulties with sleep or work.
Significant disability has been reported in the quality of life of
patients with chronic urticaria.
More than two-thirds of cases of urticaria are acute and self-limited.
The lesions of acute urticaria are characterized by a rapid onset and
resolution within several hours. Urticarial lesions can affect the
lips and tongue. These lesions can recur, but typically for less than
six weeks. A presumptive trigger such as a drug, food ingestion,
insect sting, or infection can occasionally be identified.
Chronic urticaria accounts for approximately 30 percent of cases. The
clinical appearance of chronic and acute urticarial lesions is usually
indistinguishable. The time to resolution of chronic lesions is
usually longer (a few to up to 36 hours), and recurrences go on for
more than six weeks. A careful history and physical examination will
occasionally uncover a probable cause for persistent chronic
urticaria; however, a definite etiology is not identified in up to 90
percent of patients.
Causes of urticaria - The following are among the potential triggers
for
urticaria:
Drugs: Identification of any new drugs, including antibiotics,
hormones, nonsteroidal antiinflammatory drugs (NSAIDS), and aspirin,
is important in determining an exogenous trigger for urticaria.
Physical contacts: Physical contact with a number of agents may result
in urticaria, including animal saliva, plant products and resins, raw
fish or vegetables, latex, and metals such as nickel. On the other
hand, detergents, soaps, and lotions are more likely to cause contact
dermatitis than urticaria.
Stinging insects: Stings from bees, wasps, or hornets often cause
local reactions characterized by induration and erythema.
Latex: Occupational, recreational, or surgical exposure to latex may
cause urticaria, angioedema, asthma, or anaphylaxis in sensitized
individuals. Urticaria may develop, for example, after blowing up
balloons.
Aeroallergens: Aeroallergens are themselves an infrequent cause of
urticaria. However, a subset of patients with sensitization to tree,
grass, or weed pollens may develop localized angioedema of the lips
after ingestion of specific fresh fruits or vegetables that share
cross-reactive epitopes with the pollen. This condition is referred to
as the oral allergy syndrome.
Foods and additives: Acute generalized urticarial reactions to foods
typically occur within 30 minutes of ingestion. Milk, egg, peanuts,
nuts, soy, and wheat are the most common agents to cause generalized
urticaria in children. In adults, fish, shellfish, nuts, and peanuts
are most often implicated. Urticarial reactions in response to food
additives and preservatives such as sulfites also have been reported.
Infections: Acute bacterial and viral infections are responsible for
many cases of acute urticaria. Bacterial toxins, immune complex
formation, and complement activation are proposed mechanisms for the
development of urticaria in this setting. Infections account for over
80 percent of cases of acute urticaria in the pediatric population.
Thyroid disease: Thyroid autoimmunity is found in patients with
chronic urticaria at a greater than expected frequency.
Familial cold autoinflammatory syndrome and Muckle-Wells syndrome: Two
rare genetic disorders, familial cold autoinflammatory syndrome, also
called familial cold urticaria, and the Muckle-Wells syndrome are
associated with episodes of urticaria.
The familial cold autoinflammatory syndrome is an autosomal dominantly
inherited disorder of periodic fever, urticaria, leukocytosis,
conjunctivitis, and muscle and skin tenderness after exposure to cold.
Urticaria followed by fever starts about seven hours after cold
exposure.
The Muckle-Wells syndrome is another periodic urticarial syndrome
associated with mutations in cryopyrin. It has a similar phenotype to
familial cold autoinflammatory syndrome except for lack of cold
sensitivity and frequent sensorineural hearing loss. The factors that
precipitate symptoms in this disorder are not known.
You noted that prednisone was prescribed – that is one of the
treatments for chronic urticaria. From UptoDate:
“Corticosteroids may cause dramatic improvement in patients with
chronic urticaria, but should only be used after a trial of maximal
doses of antihistamines. Typically 30 to 40 mg of prednisone per day
in a single early morning dose is effective in suppressing urticaria,
although some patients may require split dosing.” (3)
2) Angioedema:
Angioedema results from the release of inflammatory mediators that
facilitate dilation and enhance the permeability of capillaries and
small veins. The loss of vascular integrity allows fluid to move into
tissues.
Angioedema can be easily distinguished clinically from edema by the
following characteristics:
· Relatively rapid onset of presentation (minutes to hours)
· Asymmetric distribution
· Distribution not in dependent areas
· Involvement of lips, larynx, and bowel
· Association of some forms of angioedema with anaphylaxis
Angioedema is frequently disfiguring and frightening to the patient.
Regardless of the etiology, laryngeal edema can lead to
life-threatening airway compromise. Angioedema may also be a
premonitory or accompanying symptom to an anaphylactic or
anaphylactoid reaction. In addition, angioedema is present in up to 50
percent of patients with both acute and chronic urticaria.
Again, prednisone can be helpful in the treatment of angioedema. From
UptoDate:
“Antihistamines and corticosteroids are useful in patients with mast
cell-mediated angioedema, and will not cause harm in
complement-mediated or ACE inhibitor-induced angioedema.” (1)
3) Food Allergy:
From Merck Medicus:
“A food allergy is an exaggerated reaction in the body's immune system
to something you ate or drank.
Food allergies are more common in young children and in people who
suffer from other allergies, such as hay fever and eczema (dry skin
rash).
Reactions are varied and may occur immediately or not for several
hours. Symptoms can be mild, or they may be life threatening if
breathing problems develop.
Symptoms may include:
· swelling in the lips, face, and/or throat
· tingling in the mouth
· vomiting
· loud sounds in the intestine
· diarrhea
· congestion
· cough
· wheezing
· skin rash or hives”
MerckMedicus:
http://www.merckmedicus.com/pp/us/hcp/hcp_patient_resource_allhandouts_content_search.jsp?pg=/ppdocs/us/common/crs/crs/foodalle.htm
I will be happy to discuss the diagnosis and treatment of each of the
aforementioned diseases in separate questions. I will also be happy
to discuss some of the rarer causes of lip swelling (i.e. ascariasis,
acromegaly, multiple endocrine neoplasia type II) in separate
questions.
Please use any answer clarification before rating this answer. I will
be happy to explain or expand on any issue you may have.
Thanks,
Kevin, M.D.
Internet search strategy:
No internet search engine was used in this research. All sources were
from objective physician-written and peer reviewed sources.
Links:
Merck Medicus – Food Allergy
http://www.merckmedicus.com/pp/us/hcp/hcp_patient_resource_allhandouts_content_search.jsp?pg=/ppdocs/us/common/crs/crs/foodalle.htm
Merck Medicus – Urticaria and Angioedema
http://merck.micromedex.com/bpm/bpm.asp?page=BPM01AL08
Best Practice of Medicine – Allergic Reactions
http://merck.micromedex.com/bhg/bhg.asp?chapter=BHG01AL02§ion=report
Bibliography:
1)Bingham. Angioedema. UptoDate, 2002.
2)Bingham. Etiology and diagnosis of urticaria. UptoDate, 2002.
3)Bingham. Treatment of urticaria. UptoDate, 2002.
4)American Gastroenterological Association Medical Position Statement:
Evaluation of food allergies. UptoDate, 2002. |
