a rare , potentially fatal and usually self - limiting adverse effect of therapy with enalapril , the angioedema , is always a challenging encounter for an intensive care specialist . the unpredictability of clinical course and the risk of airway compromise with not so high end airway management gears at hand make it more challenging in a rural health setup . incidence of enalapril - induced angioedema is three times more common in population of african origin . botswana provides universal health care to its citizens , and health sector is almost completely under government management . we came across two cases in a very short window of about a month at a rural health center . a 74-year - old female was admitted to the emergency department of sekghoma memorial hospital , serowe village , botswana , past midnight with progressive swelling of her face , tongue and breathing difficulty for about 8 h. the family gave a history of change of antihypertensive medication recently . she has been started on tablet enalapril , 20 mg , once daily , orally , 2 days back . on examination , she was conscious , coherent but very anxious . on auscultation of chest , air entry was good bilaterally and there were some conducted sounds from pharynx due to excessive secretions . the tongue was grossly swollen , hard in consistency , it was wedged between the teeth and she was not able to close her mouth [ figure 1 ] . it was not possible to transfer this case to a tertiary care hospital by helicopter as there were landing issues in darkness . the patient was started on oxygen support at the rate of 5 l / min by facemask for building up her oxygen reserves in case of airway emergency . lateral view x - ray of neck was done which showed airway patency as fine [ figure 3 ] . elective blind nasal intubation as a proactive airway management was risky due to less chances of success and more risk of further airway compromise . there were no ear , nose , and throat ( ent ) specialists available for either evaluation or surgical airway management . she was injected with 100 mg of hydrocortisone , intravenously and 0.5 ml of injection adrenaline ( 1:1000 ) subcutaneously . she was observed for about 30 min in which she gradually became worse and swelling of face and tongue increased . we decided to go ahead with fresh - frozen plasma infusion under intravenous beta - blocker antihypertensive coverage . her blood group was o - positive and hospital being a peripheral center ; we had only blood storage facility where o - positive fresh - frozen plasma was not available . we decided to go ahead with transfusion of the only pint of o - negative fresh - frozen plasma available at our storage facility . injection metoprolol , 5 mg , intravenously was instituted and then we started with o - negative fresh - frozen plasma infusion intravenously , 220 ml over next 30 min . on post - fresh - frozen plasma infusion , , she recovered grossly and after 6 h she was able to close her mouth completely . the patient on arrival to intensive care unit the patient after fresh - frozen plasma transfusion lateral x - ray of neck taken to decide the airway management ace inhibitors are one from the most widely used antihypertensive worldwide , particularly for the diabetics to prevent nephropathy and in cases of left ventricular dysfunction or heart failure . soon after the development of ace inhibitors , wilkin et al . reported angioedema and proposed enhanced kinin effects from inhibition of kininase ii as the underlying mechanism . later , reports of ace inhibitor - related angioedema estimated an incidence between 1/1000 and 3/1000 . angioedema was about three times more likely to occur among black patients ( 1.62% vs. 0.55% for white patients ) and slightly more likely in women ( 0.84% vs. 0.54% for men ) . the incidence of angioedema was lower in diabetic patients ( 0.43% ) and higher in patients with renal disease ( 1.63% ) or a history of rash ( 2.48% ) . the most common sites of angioedema were the lips ( 49% ) and the face ( 52% ) . swelling of the tongue , neck , or eyelids occurred in approximately 1 of 5 patients with angioedema . the incidence of angioedema was not affected by prior or current use of ace inhibitors at randomization . they identified black race , history of drug rash , age > 65 years , and seasonal allergies as independent risk factors for angioedema related to enalapril . slater et al . reported a 14-fold higher incidence of angioedema in the 1 week compared with later time intervals . hedner et al . reported that about half of the cases occurred in the 1 week of therapy . , these patients should be carefully examined for any evidence of respiratory compromise such as stridor , a markedly enlarged tongue , symptoms of dyspnea , acutely presenting dysphagia , and drooling of saliva . lateral view x - ray of neck may be an important tool to decide about intubation . the decision of when to intubate should be made early based on standard physiologic criteria , recognizing that intubation may be difficult secondary to edema of the airway . cricothyrotomy or emergency tracheostomy is required for maintenance of the airway if oropharyngeal and nasopharyngeal intubation fails . fluid resuscitation and therapy with vasopressors may be required if the patient is hemodynamically unstable . hypotension can be seen in severe cases secondary to the extravasation of large amounts of fluid into the extravascular space . patients presenting with respiratory symptoms should immediately receive 0.5 ml epinephrine ( 1:1000 ) subcutaneously . therapy with antihistamines and steroids should be started initially in all patients , as a true allergic reaction can not be excluded . although the role of epinephrine , antihistamines , and corticosteroids is controversial in nonmast cell - mediated angioedema , i.e. ace inhibitor - related angioedema , in our case , we used all the three above - mentioned agents but there was no clinical improvement . fresh - frozen plasma has been used successfully for the treatment of resistant , life - threatening angioedema induced by ace inhibitor . the benefit of fresh - frozen plasma in this condition may be due to the effect of kininase ii in breaking down accumulated bradykinin . in this case , we used fresh - frozen plasma , and the clinical improvement was observed . we recommend that in case of life - threatening enalapril - induced angioedema in rural setup , where advanced airway management procedures may be difficult , we must give an early thought about starting fresh - frozen plasma . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
angioedema , a rare , potentially fatal and usually self - limiting adverse effect of therapy with enalapril , is always a challenging encounter for an intensive care specialist in a rural setup . here 
 , we present a 74-year - old female , who presented to the emergency department of sekgoma memorial hospital , serowe village , botswana , with progressive swelling of her face , tongue and breathing difficulty just 2 days after starting tablet enalapril . 
 she failed to respond to usual treatment with adrenaline , steroids , and h1-antihistaminic agent , but she responded well with intravenous fresh - frozen plasma infusion . 
 this helped us manage a difficult airway situation in a less equipped rural health center .