Anaphylaxis Presenting as Macroglossia

Three days after having eaten fish, a 66-year-old woman with a known allergy to fish and a history of schizophrenia was brought to the emergency department because of macroglossia--a presentation of anaphylaxis. The patient refused airway management (intubation or cricothyrotomy) and was therefore admitted to the medical ICU for monitoring of her airway and hemodynamic status. She received corticosteroids, ranitidine, diphenhydramine, epinephrine, and oxygen (via nasal cannula).

The patient's tongue gradually shrank, and she was discharged after 9 days. She was warned never to eat fish again--to prevent not only a recurrence of macroglossia but also possible death from hemodynamic collapse. She was given a MedicAlert bracelet warning of her allergy and was also instructed in the use of an epinephrine automatic injector, should such an episode recur.

(Case and photograph courtesy of Marc S. Scheiner, MD, David S. Scheiner, MD, and Michael L. Scheiner, MD.)