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Christiansen SC, Zuraw BL. Contact System Activation and Bradykinin Generation in Angioedema: Laboratory Assessment and Biomarker Utilization. Immunol Allergy Clin North Am 2024; 44:543-560. [PMID: 38937015 DOI: 10.1016/j.iac.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
The role of contact system activation has been clearly established in the pathogenesis of hereditary angioedema due to C1 inhibitor deficiency (HAE-C1INH). C1 inhibitor (C1INH)-protease complexes, levels of functional C1INH, plasma kallikrein activation, and cleavage of high-molecular-weight kininogen have each been associated with disease activity. More recently, HAE with normal levels of C1INH (HAE-nl-C1INH) has been recognized. Six genetic mutations have been identified which are linked to HAE-nl-C1INH phenotypes. The majority of individuals with HAE-nl-C1INH fall into the unknown category. There is substantial evidence that bradykinin generation underlies the recurrent attacks of swelling in some of these cohorts.
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Affiliation(s)
- Sandra C Christiansen
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, Mail Code 0732, La Jolla, CA 92093, USA
| | - Bruce L Zuraw
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, Mail Code 0732, La Jolla, CA 92093, USA; Medicine Service, San Diego Veterans Administration Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
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2
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Renaudineau Y, Sailler L, Puissant-Lubrano B. Quantification of C1 inhibitor activity using a chromogenic automated assay: analytical and clinical performances. Clin Chem Lab Med 2024; 0:cclm-2024-0024. [PMID: 38861040 DOI: 10.1515/cclm-2024-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/24/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVES The quantification of functional C1 inhibitor activity (fC1-INH) is an important tool to diagnose bradykinin-mediated angioedema (AE), whether hereditary or acquired. For that an accurate assay is necessary, therefore we evaluated the analytical performances of a fC1-INH chromogenic assay (Berichrom®, Siemens) performed utilizing an Optilite turbidimeter (Binding Site). METHODS fC1-INH was quantified by means of the chromogenic assay Berichrom®. Internal quality controls were used to determine the precision of the assay. Stability under various storage and matrix conditions, uncertainty, linearity, interference (of hemolysis, lipemia, and icterus), agreement with the manual Technochrom® assay, and diagnostic performances were further evaluated on samples from patients and healthy donors. RESULTS The fC1-INH Berichrom® assay presented good performances regarding intra- and inter-assay precision (CV: 1.3-4.5 % and 3.0-6.0 %, respectively), expanded uncertainty (5.5 % at normal level and 12.5 % at the clinical threshold) and linearity (rho2>0.99: range 7-130 % activity). Addition of interfering substances (hemoglobin <16 g/L, intralipid® <12 g/L, and bilirubin <1 g/L) did not affect fC1-INH quantification. fC1-INH activity from healthy donors remained stable in citrate whole blood until 4 days at room temperature, and 7 days when plasma was collected. Agreement between the automated Berichrom® assay and the manual Technochrom® assay (n=47) was excellent as obtained with both quantitative (Deming regression and Bland-Altman difference plot) and qualitative (Kappa index=1) analyses. Finally, the diagnostic performance of the quantification of fC1-INH for AE evaluated on 81 patients revealed a sensitivity of 100 %, a specificity of 97.2 %, a positive predictive value of 83.3 % and a negative predictive value of 100 %. CONCLUSIONS The automated fC1-INH Berichrom® assay showed good performance, both at the analytical and diagnostic/clinical levels that allowed its usage in a clinical laboratory for C1-INH-dependent bradykinin-mediated AE research in combination with quantitative C1-INH and C4 determinations.
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Affiliation(s)
- Yves Renaudineau
- Immunology Department Laboratory, Referral Medical Biology Laboratory, 36760 Institut Fédératif de Biologie, Toulouse University Hospital Center , Toulouse, France
| | - Laurent Sailler
- 36760 Internal Medicine, University Toulouse III , Toulouse, France
- 36760 Competence Centre CREAK, Toulouse University Hospital Center , Toulouse, France
| | - Bénédicte Puissant-Lubrano
- Immunology Department Laboratory, Referral Medical Biology Laboratory, 36760 Institut Fédératif de Biologie, Toulouse University Hospital Center , Toulouse, France
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3
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Kalmi G, Nguyen Y, Amarger S, Aubineau M, Bibes B, Blanchard-Delaunay C, Boccon-Gibod I, Bouillet L, Coppo P, Dalmas MC, Debord-Peguet S, Defendi F, Demoreuil C, Du-Thanh A, Gayet S, Hadjadj J, Jeandel PY, Launay D, Ly KH, Avoy CM, Niault M, Ollivier Y, Pelletier F, Porneuf M, Roos-Weil D, Fain O, Gobert D. Efficacy and Safety of Rituximab-Based Treatments in Angioedema With Acquired C1-Inhibitor Deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:212-222. [PMID: 37844846 DOI: 10.1016/j.jaip.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/28/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Angioedema (AE) due to acquired C1-inhibitor (C1-INH) deficiency (AAE-C1-INH) is related to excessive consumption of C1-INH or to anti-C1-INH antibodies, and is frequently associated with lymphoproliferative syndromes or monoclonal gammopathies. Standard of care for prophylactic treatment in this condition is not established. Rituximab may be effective to prevent attacks, especially if the lymphoid hemopathy is controlled, but data are scarce. OBJECTIVE To evaluate efficacy of rituximab in AAE-C1-INH. METHODS A retrospective multicenter study was carried out in France, including patients with AAE-C1-INH treated with rituximab between April 2005 and July 2019. RESULTS Fifty-five patients with AAE-C1-INH were included in the study, and 23 of them had an anti-C1-INH antibody. A lymphoid malignancy was identified in 39 patients, and a monoclonal gammopathy in 9. There was no associated condition in 7 cases. Thirty patients received rituximab alone or in association with chemotherapy (n = 25). Among 51 patients with available follow-up, 34 patients were in clinical remission and 17 patients had active AE after a median follow-up of 3.9 years (interquartile range, 1.5-7.7). Three patients died. The presence of anti-C1-INH antibodies was associated with a lower probability of AE remission (hazard ratio, 0.29 [95% CI, 0.12-0.67]; P = .004). Relapse was less frequent in patients with lymphoma (risk ratio, 0.27 [95% CI, 0.09-0.80]; P = .019) and in patients treated with rituximab and chemotherapy (risk ratio, 0.31 [95% CI, 0.12-0.79]; P = .014). CONCLUSIONS Rituximab is an efficient and well-tolerated therapeutic option in AE, especially in lymphoid malignancies and in the absence of detectable anti-C1-INH antibodies.
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Affiliation(s)
- Galith Kalmi
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France.
| | - Yann Nguyen
- Internal Medicine Department, Nord-Université Paris Cité, AP-HP, Hôpital Beaujon, Clichy-sous-Bois, France
| | - Stephanie Amarger
- Dermatology Department, University Hospital, Clermont-Ferrand, France
| | - Magali Aubineau
- Internal Medicine Department, Hospices Civils de Lyon, Lyon, France
| | - Beatrice Bibes
- Internal Medicine Department, Saint Grégoire Hospital, Rennes, France
| | | | - Isabelle Boccon-Gibod
- Internal Medicine Department, French National Reference Center for Angioedema (CREAK), Grenoble University Hospital, Grenoble, France
| | - Laurence Bouillet
- Internal Medicine Department, French National Reference Center for Angioedema (CREAK), Grenoble University Hospital, Grenoble, France; University Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, Grenoble, France; Internal Medicine Department, University Hospital La Tronche, Grenoble, France
| | - Paul Coppo
- Hematology Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | | | | | - Federica Defendi
- Immunology Department, Grenoble University Hospital, Grenoble, France
| | - Claire Demoreuil
- Internal Medicine Department, La Cavale Blanche University Hospital, Brest, France
| | - Aurélie Du-Thanh
- Dermatology Department, Montpellier University Hospital, Montpellier, France
| | - Stephane Gayet
- Internal Medicine Department, La Timone University Hospital, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Jerôme Hadjadj
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | | | - David Launay
- Internal and Immunological Medicine Department, Lille Hospital, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille University, INSERM F-59000, Lille, France
| | - Kim Heang Ly
- Internal Medicine Department, Dupuytren University Hospital, Limoges, France
| | - Chloé Mc Avoy
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Mathilde Niault
- Hematology Department, Hôpital du Scorff-Lorient, Groupe Hospitalier Bretagne Sud, Lorient, France
| | - Yann Ollivier
- Medicine Department, Cote de Nacre University Hospital, Caen, France
| | - Fabien Pelletier
- Dermatology Department, Allergology Center, Besançon University Hospital, Besançon, France
| | - Marc Porneuf
- Hematology Department, Centre Hospitalier Yves le Foll, Saint-Brieuc, France (x)Hematology Department, Sorbonne Université, AP-HP, Pitié Salpêtrière Hospital, Paris, France
| | - Damien Roos-Weil
- Hematology Department, Centre Hospitalier Yves le Foll, Saint-Brieuc, France (x)Hematology Department, Sorbonne Université, AP-HP, Pitié Salpêtrière Hospital, Paris, France
| | - Olivier Fain
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Delphine Gobert
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
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Trainotti S, Johnson F, Hahn J, Hofauer B, Greve J, Wollenberg B, Hoffmann TK, Lochbaum R. Acquired Angioedema Due to C1-Inhibitor Deficiency (AAE-C1-INH)-A Bicenter Retrospective Study on Diagnosis, Course, and Therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3772-3779. [PMID: 37716525 DOI: 10.1016/j.jaip.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 08/06/2023] [Accepted: 09/01/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Acquired angioedema with C1-inhibitor deficiency (AAE-C1-INH) is a rare condition resembling hereditary angioedema (HAE), but with late onset and low C1-inhibitor (C1-INH) due to consumption potentially caused by autoimmune diseases and mainly lymphatic malignancies. Being about 10-fold rarer than HAE, there is limited knowledge and no licensed therapy. OBJECTIVE To report clinical and biological data from a newly described population of 20 patients with AAE-C1-INH assessing diagnostic delay, AAE-C1-INH:HAE-ratio, underlying conditions, and therapeutic management in Germany. METHODS Retrospective data analysis of 20 patients from 2 angioedema centers in southern Germany. RESULTS Median age at symptoms' onset was 64 years (60% females), with predominant swellings of the face (85%) and low levels for C1-INH in almost all patients. The ratio AAE-C1-INH:HAE was 1:9.7. From symptoms' onset to diagnosis of AAE-C1-INH, the median delay was 7.5 months, and between AAE-C1-INH symptoms' onset and diagnosis of the underlying hematological condition (n = 9) it was 4 months (median). Four patients had a history of solid neoplasm, 1 had a papillary thyroid carcinoma as the only potential cause for AAE-C1-INH, with treatment of the malignancy resulting in resolution of AAE-C1-INH. All the symptomatic patients were treated with off-label on-demand icatibant subcutaneously or C1-INH concentrate intravenously, and 6 severely affected patients needed off-label long-term prophylaxis with good symptom control. CONCLUSIONS AAE-C1-INH is characterized by late-onset swellings mainly involving the face and low C1-INH levels. Diagnostic delay for AAE-C1-INH is further decreasing despite being about 10-fold rarer than HAE. Patients severely affected without underlying condition or no indication for treatment could benefit from off-label therapy.
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Affiliation(s)
- Susanne Trainotti
- Department of Otorhinolaryngology, Technical University of Munich, Munich, Germany.
| | - Felix Johnson
- University Hospital for Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Janina Hahn
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Benedikt Hofauer
- University Hospital for Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jens Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Barbara Wollenberg
- Department of Otorhinolaryngology, Technical University of Munich, Munich, Germany
| | - Thomas K Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Robin Lochbaum
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
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Lima H, Zheng J, Wong D, Waserman S, Sussman GL. Pathophysiology of bradykinin and histamine mediated angioedema. FRONTIERS IN ALLERGY 2023; 4:1263432. [PMID: 37920409 PMCID: PMC10619149 DOI: 10.3389/falgy.2023.1263432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/26/2023] [Indexed: 11/04/2023] Open
Abstract
Angioedema is characterized by swelling localized to the subcutaneous and submucosal tissues. This review provides an overview of angioedema, including the different types, triggers, and underlying pathophysiologic mechanisms. Hereditary and acquired angioedema are caused by dysregulation of the complement and kinin pathways. In contrast, drug-induced and allergic angioedema involve the activation of the immune system and release of vasoactive mediators. Recent advances in the understanding of the pathophysiology of angioedema have led to the development of targeted therapies, such as monoclonal antibodies, bradykinin receptor antagonists, and complement inhibitors, which promise to improve clinical outcomes in patients with this challenging condition. To accurately diagnose and manage angioedema, an understanding of this condition's complex and varied pathophysiology is both necessary and critical.
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Affiliation(s)
- Hermenio Lima
- LEADER Research Inc., Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Dennis Wong
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gordon L. Sussman
- Department of Medicine and Division of Clinical Immunology & Allergy, University of Toronto, Toronto, ON, Canada
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Irwin TM, Irwin TM, Longanecker A, Bodenhamer WS, Keirns CC. A Case of Refractory Angioedema. J Intensive Care Med 2023; 38:313-320. [PMID: 36514293 DOI: 10.1177/08850666221145310] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Angioedema is an acute disorder that affects mucous membranes and the deepest layers of the skin along with underlying tissue, marked by rapid swelling, large welts, and pain. There are 3 major subtypes of angioedema: mast-cell mediated, bradykinin-mediated, and multifactorial or unclear mechanism subtype. The most common subtype of bradykinin-mediated angioedema is ACE-inhibitor induced, which disproportionately affects African-Americans. It is most often self-limiting and usually responds to the withdrawal of the offending agent. The prolonged duration of angioedema is uncommon in the absence of a persistent stimulus, though it is more likely when there is an abnormality of the metabolic pathways, such as in hereditary angioedema or other gene polymorphisms affecting the complement system. We present a case of severe angioedema that persisted for over a month and required a tracheostomy to manage the airway.
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Affiliation(s)
- Thomas M Irwin
- 145762University of Kansas Cancer Center, Melanoma Project, Westwood, KS, USA
| | | | | | - William Spence Bodenhamer
- Departments of History of Medicine & Internal Medicine (Palliative Care), 12251University of Kansas School of Medicine, Kansas City, KS, USA
| | - Carla C Keirns
- Departments of History of Medicine & Internal Medicine (Palliative Care), 12251University of Kansas School of Medicine, Kansas City, KS, USA
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Oganesyan A, Gregory A, Malard F, Ghahramanyan N, Mohty M, Kazandjian D, Mekinian A, Hakobyan Y. Monoclonal gammopathies of clinical significance (MGCS): In pursuit of optimal treatment. Front Immunol 2022; 13:1045002. [PMID: 36505449 PMCID: PMC9728929 DOI: 10.3389/fimmu.2022.1045002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of clinical significance (MGCS) represents a new clinical entity referring to a myriad of pathological conditions associated with the monoclonal gammopathy of undetermined significance (MGUS). The establishment of MGCS expands our current understanding of the pathophysiology of a range of diseases, in which the M protein is often found. Aside from the kidney, the three main organ systems most affected by monoclonal gammopathy include the peripheral nervous system, skin, and eye. The optimal management of these MGUS-related conditions is not known yet due to the paucity of clinical data, the rarity of some syndromes, and limited awareness among healthcare professionals. Currently, two main treatment approaches exist. The first one resembles the now-established therapeutic strategy for monoclonal gammopathy of renal significance (MGRS), in which chemotherapy with anti-myeloma agents is used to target clonal lesion that is thought to be the culprit of the complex clinical presentation. The second approach includes various systemic immunomodulatory or immunosuppressive options, including intravenous immunoglobulins, corticosteroids, or biological agents. Although some conditions of the MGCS spectrum can be effectively managed with therapies aiming at the etiology or pathogenesis of the disease, evidence regarding other pathologies is severely limited to individual patient data from case reports or series. Future research should pursue filling the gap in knowledge and finding the optimal treatment for this novel clinical category.
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Affiliation(s)
- Artem Oganesyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia,*Correspondence: Artem Oganesyan,
| | - Andrew Gregory
- Wayne State University School of Medicine, Detroit, MI, United States
| | - Florent Malard
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Nerses Ghahramanyan
- Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Dickran Kazandjian
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, United States
| | - Arsène Mekinian
- Department of Internal Medicine (DMU i3), Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France,French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia
| | - Yervand Hakobyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
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Nimkar SV, Yelne P, Gaidhane SA, Acharya S, Kumar S, Saboo K. Acquired Refractory Angioneurotic Edema in a Known Case of Systemic Lupus Erythematosus. Cureus 2022; 14:e31382. [DOI: 10.7759/cureus.31382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 11/11/2022] [Indexed: 11/13/2022] Open
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Kesh S, Singh U, Bernstein JA. Longitudinal experience with treatment of acquired angioedema using tranexamic acid. Allergy Asthma Proc 2022; 43:413-418. [PMID: 36065111 DOI: 10.2500/aap.2022.43.220043] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Acquired angioedema (AAE) is a rare form of angioedema (AE) and is often associated with lymphoproliferative conditions and/or anti-C1 esterase inhibitor (C1-INH) antibodies without clear treatment consensus. Current treatments have been reported to have variable effectiveness with different safety concerns. A large Italian cohort of patients with AAE was previously found to respond well to tranexamic acid (TXA). Herein, we report our experience treating AAE with TXA used as prophylaxis. Objective: The objective was to describe clinical characteristics of patients with AAE and to report our experience with treating AAE with TXA. Methods: A retrospective chart review of patients with AAE (N = 13) from a large practice was conducted to assess characteristics and treatment responses. Patient demographics in addition to C1-INH quantitative, C1-INH functional, C4, and C1q levels; the presence of C1-INH antibodies; and a history of lymphoproliferative disease were extracted. The patients were also characterized by their treatment response to TXA. Results: All the patients were white, with a mean age at diagnosis of 67 years, an average body mass index of 31.3 kg/m², and a male-to-female ratio of 7:6. Nine patients had positive C1-INH antibodies. The patients were on various prophylaxis treatments before TXA, including chemotherapy that targeted malignancy, cyclophosphamide, rituximab, and plasmapheresis. Ultimately, 11 of the 13 patients were on TXA for prophylaxis. At 1, 12, and 24 months after TXA treatment, attacks decreased by 97, 86, and 99%, respectively. One patient developed a deep vein thrombosis and TXA was stopped. Conclusion: These findings demonstrated that treatment of AAE with TXA was effective as prophylaxis for AE attacks. However, potential adverse effects remain a concern, which emphasizes the need for additional options.
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Affiliation(s)
- Susamita Kesh
- From the Division of Immunology and Allergy, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Umesh Singh
- Division of Immunology/Allergy Section, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Jonathan A Bernstein
- Division of Immunology/Allergy Section, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
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10
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Kesh S, Bernstein JA. Isolated Angioedema: A Review of Classification and Update on Management. Ann Allergy Asthma Immunol 2022; 129:692-702. [PMID: 35988876 DOI: 10.1016/j.anai.2022.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this article is to review the various types of angioedema including diagnosis and treatment. DATA SOURCES PubMed search of articles in the English language various types of angioedema STUDY SELECTION: Articles on the subject matter were selected and reviewed. RESULTS Herein, a case based approach is presented for discussing the major types of angioedema including: hereditary angioedema (HAE) TypesI/II and normal complement, acquired angioedema, Angiotensin converting enzyme (ACE) induced angioedema, as well as histaminergic and non-histaminergic angioedema. Emerging treatments of HAE including targets of pre-kalikrein, DNA vector technology replacing C1INH protein, and CRIPSR technology targeting PKK among many others are explored. In addition, other causes as well as mimickers of angioedema are briefly reviewed. Finally, a novel algorithm is proposed to help guide the treating physician through the work up and management of patients with suspected idiopathic angioedema unresponsive to conventional therapy with antihistamines. CONCLUSION Over the years, many strides have been made in both understanding the pathophysiology of various types of angioedema as well as expansion of treatment options. It is important for clinicians to be aware of current and emerging treatment options. We provide a novel practical algorithm to guide clinicians in challenging cases of idiopathic angioedema refractory to antihistamines.
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Affiliation(s)
- Susamita Kesh
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, Division of Immunology and Allergy
| | - Jonathan A Bernstein
- University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section; Bernstein Allergy Group.
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Verschueren J, Schrijvers R, Goffin KE, Put N, Tousseyn T, Dierickx D, Gheysens O. Acquired C1-inhibitor deficiency due to splenic marginal zone lymhoma: Case Report. Acta Clin Belg 2021; 76:402-405. [PMID: 32228367 DOI: 10.1080/17843286.2020.1746552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We present the case of a 67-year-old woman who suffered recurrent episodes of angioedema of the face and larynx. After thorough biochemical investigations, an acquired deficiency of C1-INH was suspected. To evaluate a potential underlying malignancy, a whole-body FDG-PET/CT was performed and showed solely a marked splenomegaly pointing towards a splenic marginal zone lymphoma, which was confirmed by pathological examination.With this case, we discuss the pathophysiology, diagnosis and management of recurrent acquired angioedema attacks as the first presentation of an underlying lymphoproliferative disease.
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Affiliation(s)
- Jolien Verschueren
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Rik Schrijvers
- General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Karolien E. Goffin
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Natalie Put
- Oncology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Daan Dierickx
- Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
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12
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Wonnaparhown A, Stefanovic A, Lugar P, Hostetler HP. Acquired angioedema in B cell lymphoproliferative disease: A retrospective case series. Clin Exp Immunol 2021; 206:378-383. [PMID: 34586637 DOI: 10.1111/cei.13667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/02/2021] [Accepted: 09/22/2021] [Indexed: 01/08/2023] Open
Abstract
Acquired angioedema due to C1-inhibitor (C1-INH) deficiency (AAE-C1-INH) is rare and is associated with underlying lymphoproliferative diseases. C1-INH deficiency may be due to neoplastic over-consumption of C1-INH and the generation of anti-C1-INH autoantibodies. Uncovering an occult malignancy can lead to earlier oncology referral and improvement of angioedema after treatment of the underlying lymphoproliferative disorder. We characterized seven patients with C1-INH-AAE that highlights the importance of recognizing the association between C1-INH-AAE and underlying malignancy. In acute attacks, patients may be resistant to C1-INH therapy due to the presence of anti-C1-INH autoantibodies or rapid complement consumption, and may respond better to icatibant or ecallantide, which directly affect bradykinin. Treatment of the underlying malignancy also improves AAE-C1-INH symptoms and supports the role of lymphoproliferative B cells in AAE-C1-INH pathophysiology. Monitoring levels of C4, C1-INH function and level, and C1q may be predictive of AAE-C1-INH control and be used as surrogates for treatment efficacy. With close monitoring, low-dose danazol can be effective for long-term prophylaxis. Annual evaluation in AAE-C1-INH is recommended if an underlying malignancy is not found, as angioedema may precede the development of malignancy by several years. Our single-center study has aided in standardization of comprehensive AAE-C1-INH diagnosis, treatment, and monitoring strategies towards future therapeutic clinical trials.
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Affiliation(s)
- Alex Wonnaparhown
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Alexandra Stefanovic
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Patricia Lugar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Haley P Hostetler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Shi Y, Wang C. Where we are with acquired angioedema due to C1 inhibitor deficiency: A systematic literature review. Clin Immunol 2021; 230:108819. [PMID: 34358691 DOI: 10.1016/j.clim.2021.108819] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 11/29/2022]
Abstract
Acquired angioedema due to C1 inhibitor deficiency (C1-INH-AAE) is a rare disease characterized by adult-onset recurrent non-urticarial angioedema with low levels of C1-INH. It is associated with lymphoproliferative disorders, and treatments are off-label with variable success. We conducted a systematic literature review to include patients with C1-INH-AAE identified in PubMed and Embase databases between January 2006 and February 2021. Clinical features of these patients were summarized, and factors associated with disease remission were explored. A total of 121 patients were included in the current study with a median age at diagnosis of 64 years and 45.5% being male. An associated disease was recorded in 94 patients (77.7%), and lymphoproliferative disorder was the most reported (59/94, 62.8%). Anti-C1-INH autoantibodies were present in 45 of 71 patients (63.4%). Factors impacting disease remissions included age (odds ratio [OR] 0.951, 95% confidence interval [CI] 0.909-0.994, p = 0.027), male (OR 0.327, 95% CI 0.124-0.866, p = 0.025), presence of monoclonal gammopathy (OR 0.133, 95% CI 0.041-0.429, p = 0.001), requirement of specific on-demand treatment (OR 0.216, 95% CI 0.066-0.709, p = 0.012) and rituximab use (OR 2.865, 95% CI 1.038-7.911, p = 0.042). A total of nine patients (7.4%) died at last follow up and most were unrelated to C1-INH-AAE. Our results imply that C1-INH-AAE is primarily associated with underlying B or plasma cell abnormalities, and clone-directed therapies could be promising options for its long-term management.
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Affiliation(s)
- Yiyun Shi
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Chen Wang
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
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Solé D, Spindola MAC, Aun MV, Araújo Azi LMTD, Bernd LAG, Garcia DB, Capelo AV, Cumino DDO, Lacerda AE, Lima LC, Morato EF, Nunes RR, Rubini NDPM, da Silva J, Tardelli MA, Watanabe AS, Curi EF, Sano F. [Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2020; 70:642-661. [PMID: 33308829 PMCID: PMC9373683 DOI: 10.1016/j.bjan.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/19/2020] [Accepted: 08/11/2020] [Indexed: 11/30/2022]
Abstract
This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.
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Affiliation(s)
- Dirceu Solé
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Maria Anita Costa Spindola
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Marcelo Vivolo Aun
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital Universitário, São Paulo, SP, Brazil
| | - Liana Maria Tôrres de Araújo Azi
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brasil.
| | - Luiz Antonio Guerra Bernd
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Daniela Bianchi Garcia
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Infantil Pequeno Príncipe, Curitiba, PR, Brasil
| | - Albertina Varandas Capelo
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal do Rio de Janeiro, Hospital Universitário Gaffrée e Guinle, Rio de Janeiro, RJ, Brazil
| | - Débora de Oliveira Cumino
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Infantil Sabará, São Paulo, SP, Brazil
| | - Alex Eustáquio Lacerda
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Luciana Cavalcanti Lima
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Instituto Medicina Integral Prrofessor Fernando Figueira, Recife, PE, Brazil
| | - Edelton Flávio Morato
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Rogean Rodrigues Nunes
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Geral de Fortaleza (HGF), Departamento de Anestesia, Fortaleza, CE, Brazil
| | - Norma de Paula Motta Rubini
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Jane da Silva
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Maria Angela Tardelli
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil
| | - Alexandra Sayuri Watanabe
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Erick Freitas Curi
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal do Espírito Santo, Vitória, ES, Brasil
| | - Flavio Sano
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Hospital Nipo Brasileiro, São Paulo, SP, Brasil
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Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33308829 PMCID: PMC9373683 DOI: 10.1016/j.bjane.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.
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16
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Belbézier A, Bocquet A, Bouillet L. Idiopathic Angioedema: Current Challenges. J Asthma Allergy 2020; 13:137-144. [PMID: 32368100 PMCID: PMC7173836 DOI: 10.2147/jaa.s205709] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 03/13/2020] [Indexed: 11/23/2022] Open
Abstract
The etiological diagnosis of isolated recurrent angioedema poses problems because it must often be done urgently. Angioedema secondary to nonspecific mast cell activation (MC-AE) is the most frequent form and is usually mild. Bradykinin mediated angioedema (BK-AE) is rarer but potentially fatal in the absence of the correct treatment. Few biological markers exist. The C1-inhibitor (C1-inh) functional assay can exclude AE due to C1-inh deficiency. Genetic diagnoses of hereditary AE due to abnormal C1-inh AE have progressed with four currently known mutations. However, determining the physiopathological mechanism leading to some isolated AE cases is sometimes very difficult. In such cases, therapeutic tests are then the only solution: antihistamines at high doses and omalizumab for suspected MC-AE, icatibant for suspected AE-BK. Identifying new markers would be a great help.
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Affiliation(s)
- Aude Belbézier
- National Reference Center for Angioedema (CREAK), Department of Internal Medicine/Clinical Immunology, Grenoble Alpes University Hospital, Grenoble, France
| | - Alexis Bocquet
- National Reference Center for Angioedema (CREAK), Department of Internal Medicine/Clinical Immunology, Grenoble Alpes University Hospital, Grenoble, France
| | - Laurence Bouillet
- National Reference Center for Angioedema (CREAK), Department of Internal Medicine/Clinical Immunology, Grenoble Alpes University Hospital, Grenoble, France
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Abstract
Angioedema is a localized swelling of the skin and submucosal tissues and is generally benign and self-limiting. However, it can be life threatening if angioedema involves the upper airway, resulting in airway obstruction. Airway protection would be critical and lifesaving in patients with angioedema irrespective of the underlying etiology. Detailed history and physical examination can help identify the underlying mechanism of angioedema in an individual patient (ie, mast-cell versus bradykinin-mediated angioedema). Treatment of angioedema depends on the underlying etiology. Mast cell-mediated angioedema is generally responsive to steroids, antihistamines, and epinephrine (when indicated), unlike bradykinin-mediated disease. [Pediatr Ann. 2019;48(12):e473-e478.].
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Singh A, Jindal AK, Joshi V, Anjani G, Rawat A. An updated review on phenocopies of primary immunodeficiency diseases. Genes Dis 2019; 7:12-25. [PMID: 32181272 PMCID: PMC7063430 DOI: 10.1016/j.gendis.2019.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/28/2019] [Accepted: 09/04/2019] [Indexed: 02/07/2023] Open
Abstract
Primary immunodeficiency diseases (PIDs) refer to a heterogenous group of disorders characterized clinically by increased susceptibility to infections, autoimmunity and increased risk of malignancies. These group of disorders present with clinical manifestations similar to PIDs with known genetic defects but have either no genetic defect or have a somatic mutation and thus have been labelled as “Phenocopies of PIDs”. These diseases have been further subdivided into those associated with somatic mutations and those associated with presence of auto-antibodies against various cytokines. In this review, we provide an update on clinical manifestations, diagnosis and management of these diseases.
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Affiliation(s)
- Ankita Singh
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur K Jindal
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vibhu Joshi
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gummadi Anjani
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Rawat
- Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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19
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Kanchongkittiphon W, Kabil N, Bacharier LB, Kitcharoensakkul M. Ecallantide: An alternative treatment of refractory angioedema in adolescents with systemic lupus erythematosus. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:1115-1116. [PMID: 31541765 DOI: 10.1016/j.jaip.2019.08.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 08/28/2019] [Accepted: 08/30/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Watcharoot Kanchongkittiphon
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Mo; Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nora Kabil
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Mo
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Mo
| | - Maleewan Kitcharoensakkul
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Mo; Division of Rheumatology, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Mo.
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20
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Long BJ, Koyfman A, Gottlieb M. Evaluation and Management of Angioedema in the Emergency Department. West J Emerg Med 2019; 20:587-600. [PMID: 31316698 PMCID: PMC6625683 DOI: 10.5811/westjem.2019.5.42650] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 05/09/2019] [Accepted: 05/28/2019] [Indexed: 01/14/2023] Open
Abstract
Angioedema is defined by non-dependent, non-pitting edema that affects several different sites and is potentially life-threatening due to laryngeal edema. This narrative review provides emergency physicians with a focused overview of the evaluation and management of angioedema. Two primary forms include histamine-mediated and bradykinin-mediated angioedema. Histamine-mediated forms present similarly to anaphylaxis, while bradykinin-mediated angioedema presents with greater face and oropharyngeal involvement and higher risk of progression. Initial evaluation and management should focus on evaluation of the airway, followed by obtaining relevant historical features, including family history, medications, and prior episodes. Histamine-mediated angioedema should be treated with epinephrine intramuscularly, antihistaminergic medications, and steroids. These medications are not effective for bradykinin-mediated forms. Other medications include C1-INH protein replacement, kallikrein inhibitor, and bradykinin receptor antagonists. Evidence is controversial concerning the efficacy of these medications in an acute episode, and airway management is the most important intervention when indicated. Airway intervention may require fiberoptic or video laryngoscopy, with preparation for cricothyrotomy. Disposition is dependent on patient's airway and respiratory status, as well as the sites involved.
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Affiliation(s)
- Brit Jeffrey Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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21
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Bouillet L, Defendi F, Hardy G, Cesbron JY, Boccon-Gibod I, Deroux A, Mansard C, Launay D, Gompel A, Floccard B, Jaussaud R, Beaudouin E, Armengol G, Olliver Y, Gayet S, Du Than A, Sailler L, Guez S, Sarrat A, Sorin L, de Moreuil C, Pelletier F, Javaud N, Marmion N, Fain O, Fauré J, Dumestre-Pérard C. Diagnostic biologique des angioedèmes bradykiniques : les recommandations du CREAK. Presse Med 2019; 48:55-62. [DOI: 10.1016/j.lpm.2018.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 06/01/2018] [Accepted: 06/25/2018] [Indexed: 02/08/2023] Open
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Leru PM, Anton VF, Bumbea H. Nine year follow-up of a rare case of angioedema due to acquired C1-inhibitor deficiency with late onset and good response to attenuated androgen. Allergy Asthma Clin Immunol 2018; 14:69. [PMID: 30386386 PMCID: PMC6201569 DOI: 10.1186/s13223-018-0274-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 07/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Angioedema due to acquired deficiency of C1-inhibitor (C1-INH-AAE) is a rare disease sharing some clinical and laboratory similarities with hereditary angioedema, but with late onset and no positive family history. The underlining cause may be malignant or due to autoimmune diseases, but some cases remain idiopathic. Case presentation We report a case of a 75 year old woman suffering from recurrent episodes of angioedema since the age of 66, considered first induced by treatment with angiotensin-converting-enzyme inhibitors (ACEI). She continued to have angioedema attacks during 6 years after discontinuation of ACEI, until evaluation in our clinic in 2014, when C1 inhibitor esterase (C1-INH) deficiency was confirmed. The extended medical evaluation for inflammatory, allergic, autoimmune and neoplasic diseases was negative. C1-INH and complement fraction C4 plasma levels were significantly decreased at all measurements, but no diagnostic criteria for diseases known to induce C1-INH deficiency could be found. We first initiated daily prophylactic treatment with tranexamic acid, with no amelioration after 3 months. During the last and most severe attack, with the first facial and laryngeal edema, we have switched to attenuated androgen danazol. The evolution was very good, with prompt remission of angioedema and significant increase of C1-INH and C4 plasma levels after 2 weeks of daily danazol use. She completed 3 years of continuous treatment with low daily maintenance dose of danazol (ongoing), with no angioedema attack. We closely monitored C1-INH and C4 plasma levels, possible danazol side effects and any signs suggesting late onset of C1-INH deficiency causal disease. Conclusion We reported a particular case of rare angioedema due to acquired deficiency of C1-inhibitor, which has no clear cause after long follow-up, but good response to attenuated androgen. We concluded that the awareness of angioedema due to C1-INH deficiency should be increased within medical community and therapeutic options should be more clearly indicated and available for all diagnosed cases.
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Affiliation(s)
- Polliana Mihaela Leru
- 1Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari, no. 8, District 5, 050474 Bucharest, Romania.,2Internal Medicine Department, Colentina Clinical Hospital, Sos. Stefan cel Mare, no. 19-21, District 2, 020125 Bucharest, Romania
| | - Vlad Florin Anton
- 2Internal Medicine Department, Colentina Clinical Hospital, Sos. Stefan cel Mare, no. 19-21, District 2, 020125 Bucharest, Romania
| | - Horia Bumbea
- 1Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari, no. 8, District 5, 050474 Bucharest, Romania.,3Emergency University Hospital, Splaiul Independentei, no. 169, District 5, 050098 Bucharest, Romania
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[Acquired C1 esterase inhibitor deficiency via bradykinin-mediated angioedema: Four cases]. Ann Dermatol Venereol 2018; 145:598-602. [PMID: 29673745 DOI: 10.1016/j.annder.2018.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 09/25/2017] [Accepted: 02/13/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acquired C1-esterase inhibitor (C1-INH) deficiency angioedema (C1-INH-AAE) is a form of bradykinin-mediated angioedema. This rare disorder is due to acquired consumption of C1-INH, hyperactivation of the classic pathway of human complement, and potentially fatal recurrent angioedema symptoms. Clinical symptoms of C1-INH-AAE are very similar to those of hereditary angioedema (HAE) but usually appear after the fourth decade of life and induce abdominal pain less frequently. Laboratory tests are essential in establishing the diagnosis with low levels or abnormal structure and function of C1-INH. Most patients present C1-INH autoantibodies. Furthermore, C1q is reduced in AAE, contrary to HAE. The long-term prognosis is determined by associated hematologic malignancies. PATIENTS AND METHODS We report 4 cases of C1-INH-AAE associated with lymphoproliferative disorders referred to the Reference Centre for Angioedema of Besançon, France. The patients were aged between 60 and 77 years. C1 INH antibodies were found in three patients. Symptoms were triggered by angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) in 3 patients. Hematologic malignancy was present at diagnosis (one case of chronic lymphoid leukemia) or was diagnosed during follow-up (one case of indolent marginal zone non-Hodgkin lymphoma and two cases of monoclonal gammopathy). DISCUSSION C1-INH-AAE induced by ACE inhibitors or ARBs may be associated with hematologic malignancies. This form of revelation does not necessarily indicate a diagnosis of ACE or ARBs angioedema, and screening should therefore be performed for C1 Inh and C1q. An underlying hematologic malignancy should be routinely sought and the long-term prognosis determined.
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Kumar N, Surendran D, Bammigatti C. Angioedema as the presenting feature of systemic lupus erythematosus. BMJ Case Rep 2018; 2018:bcr-2018-224222. [PMID: 29593002 DOI: 10.1136/bcr-2018-224222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A young female in her early 20s presented with low-grade fever for 1 month, puffiness of face and abdominal distension for 15 days. Evaluation revealed pancytopenia with normocellular marrow, hypocomplementaemia and Coomb's positive haemolytic anaemia. She had angioedema with laryngospasm and worsening facial oedema which had dramatic response to steroids. Further workup lead to a diagnosis of systemic lupus erythematosus with neuropsychiatric involvement. Treatment with pulse steroids and cyclophosphamide resulted in dramatic improvement of her symptoms with no recurrence of angioedema during her follow-up visits.
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Affiliation(s)
- Naveen Kumar
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Deepanjali Surendran
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Chanaveerappa Bammigatti
- Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Refractory Abdominal Pain in a Patient with Chronic Lymphocytic Leukemia: Be Wary of Acquired Angioedema due to C1 Esterase Inhibitor Deficiency. Case Rep Hematol 2018; 2018:7809535. [PMID: 29545957 PMCID: PMC5818943 DOI: 10.1155/2018/7809535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/01/2017] [Accepted: 11/19/2017] [Indexed: 01/09/2023] Open
Abstract
Acquired angioedema due to C1 inhibitor deficiency (C1INH-AAE) is a rare and potentially fatal syndrome of bradykinin-mediated angioedema characterized by episodes of angioedema without urticaria. It typically manifests with nonpitting edema of the skin and edema in the gastrointestinal (GI) tract mucosa or upper airway. Edema of the upper airway and tongue may lead to life-threatening asphyxiation. C1INH-AAE is typically under-diagnosed because of its rarity and its propensity to mimic more common abdominal conditions and allergic reactions. In this article, we present the case of a 62-year-old male with a history of recently diagnosed chronic lymphocytic leukemia (CLL) who presented to our hospital with recurrent abdominal pain, initially suspected to have Clostridium difficile colitis and diverticulitis. He received a final diagnosis of acquired angioedema due to C1 esterase inhibitor deficiency due to concomitant symptoms of lip swelling, cutaneous nonpitting edema of his lower extremities, and complement level deficiencies. He received acute treatment with C1 esterase replacement and icatibant and was maintained on C1 esterase infusions. He also underwent chemotherapy for his underlying CLL and did not experience further recurrence of his angioedema.
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Abstract
The bradykinin B2 receptor antagonist icatibant is effective in angiotensin-converting enzyme inhibitor-induced angioedema. The drug is not approved officially for this indication and has to be administered in an emergency situation off-label. Corticosteroids or antihistamines do not seem to work in this condition. The effectiveness of C1-esterase-inhibitor in angiotensin-converting enzyme-induced angioedema must be verified in a double-blind study.
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Affiliation(s)
- Murat Bas
- Clinic of Otorhinolaryngology, Klinikum rechts der Isar, Technische Universität München, Ismaninger St 22, 81675 Munich, Germany.
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27
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Christiansen SC, Zuraw BL. Laboratory Approaches for Assessing Contact System Activation. Immunol Allergy Clin North Am 2017; 37:527-539. [DOI: 10.1016/j.iac.2017.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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28
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Abstract
Acquired angioedema due to C1-INH deficiency (C1-INH-AAE) can occur when there are acquired (not inherited) deficiencies of C1-INH. A quantitative or functional C1-INH deficiency with negative family history and low C1q is diagnostic of C1-INH-AAE. The most common conditions associated with C1-INH-AAE are autoimmunity and B-cell lymphoproliferative disorders. A diagnosis of C1-INH-AAE can precede a diagnosis of lymphoproliferative disease and confers an increased risk for developing non-Hodgkin lymphoma. Treatment focuses on symptom control with therapies that regulate bradykinin activity (C1-INH concentrate, icatibant, ecallantide, tranexamic acid, androgens) and treatment of any underlying conditions.
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Affiliation(s)
- Iris M Otani
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, UCSF Medical Center, 400 Parnassus Avenue, Box 0359, San Francisco, CA 94143, USA.
| | - Aleena Banerji
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Cox 201 Allergy Associates, Boston, MA 02114, USA
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29
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Abstract
Angioedema, as a distinct disease entity, often becomes a clinical challenge for physicians, because it may cause a life-threatening condition, whereas prompt and accurate laboratory diagnostics may not be available. Although the bedside diagnosis needs to be established based on clinical symptoms and signs, family history, and the therapeutic response, later, laboratory tests are available. Currently, only for five out of the nine different types of angioedema can be diagnosed by laboratory testing, and these occur only in a minority of the patient population. Hereditary angioedema with C1-inhibitor (C1-INH) deficiency type I can be diagnosed by the low C1-INH function and concentration, whereas in type II, C1-INH function is low, but its concentration is normal or even elevated. C1q concentration is normal in both forms. Acquired angioedema with C1-INH deficiency type I is characterized by the low C1-INH function and concentration; however, C1q concentration is also low, and autoantibodies against C1-INH cannot be detected. Complement profile of acquired angioedema with C1-INH deficiency type II is similar to that of type I, but in this form, autoantibodies against C1-INH are present. Hereditary angioedema due to a mutation of the coagulation factor XII can be diagnosed exclusively by mutation analysis of FXII gene. Diagnostic metrics are not available for idiopathic histaminergic acquired angioedema, idiopathic non-histaminergic acquired angioedema, acquired angioedema related to angiotensin-converting enzyme inhibitor, and hereditary angioedema of unknown origin; these angioedemas can be diagnosed by medical and family history, clinical symptoms, and therapeutic response and by excluding the forms previously described. Several potential biomarkers of angioedema are used to date only in research. In the future, they could be utilized into the clinical practice to improve the differential diagnosis, therapy, as well as the prognosis of angioedema.
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30
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Bas M. Evidence and evidence gaps of medical treatment of non-tumorous diseases of the head and neck. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2016; 15:Doc02. [PMID: 28025602 PMCID: PMC5169075 DOI: 10.3205/cto000129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Unfortunately, the treatment of numerous otolaryngological diseases often lacks of evidence base because appropriate studies are missing. Whereas sufficient high-quality trials exist for the specific immunotherapy of allergic rhinitis and in a limited measure also for the angiotensin-converting enzyme inhibitor induced angioedema, the evidence for Menière’s disease or for pharmacotherapy of postoperative laryngeal edema is rather poor. This contribution will discuss the trial situation and evidence of the respective diseases.
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Affiliation(s)
- Murat Bas
- Department of Otolaryngology, Technische Universität München, Germany
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31
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Farkas H, Varga L, Moldovan D, Obtulowicz K, Shirov T, Machnig T, Feuersenger H, Edelman J, Williams-Herman D, Rojavin M. Assessment of inhibitory antibodies in patients with hereditary angioedema treated with plasma-derived C1 inhibitor. Ann Allergy Asthma Immunol 2016; 117:508-513. [PMID: 27788880 DOI: 10.1016/j.anai.2016.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/10/2016] [Accepted: 08/23/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Limited data are available regarding C1 inhibitor (C1-INH) administration and anti-C1-INH antibodies. OBJECTIVE To assess the incidence of antibody formation during treatment with pasteurized, nanofiltered plasma-derived C1-INH (pnfC1-INH) in patients with hereditary angioedema with C1-INH deficiency (C1-INH-HAE) and the comparative efficacy of pnfC1-INH in patients with and without antibodies. METHODS In this multicenter, open-label study, patients with C1-INH-HAE (≥12 years of age) were given 20 IU/kg of pnfC1-INH per HAE attack that required treatment and followed up for 9 months. Blood samples were taken at baseline (day of first attack) and months 3, 6, and 9 and analyzed for inhibitory anti-C1-INH antibody (iC1-INH-Ab) and noninhibitory anti-C1-INH antibodies (niC1-INH-Abs). RESULTS The study included 46 patients (69.6% female; mean age, 38.9 years; all white) who received 221 on-site pnfC1-INH infusions; most patients received 6 or fewer infusions. No patient tested positive (titer ≥1:50) for iC1-INH-Ab at any time during the study. Thirteen patients (28.2%) had detectable niC1-INH-Abs in 1 or more samples. Nine patients (19.6%) had detectable niC1-INH-Abs at baseline; 3 of these had no detectable antibodies after baseline. Of 10 patients (21.7%) with 1 or more detectable result for niC1-INH-Abs after baseline, 6 had detectable niC1-INH-Abs at baseline. Mean times to symptom relief onset and complete symptom resolution per patient were similar for those with or without anti-niC1-INH-Abs. CONCLUSION Administration of pnfC1-INH was not associated with iC1-INH-Ab formation in this population. Noninhibitory antibodies were detected in some patients but fluctuated during the study independently of pnfC1-INH administration and appeared to have no effect on pnfC1-INH efficacy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01467947.
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32
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Misra L, Khurmi N, Trentman TL. Angioedema: Classification, management and emerging therapies for the perioperative physician. Indian J Anaesth 2016; 60:534-41. [PMID: 27601734 PMCID: PMC4989802 DOI: 10.4103/0019-5049.187776] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Angioedema is a rare condition which manifests as sudden localised, non-pitting swelling of certain body parts including skin and mucous membranes. It is vital that anaesthesiologists understand this condition, as it may present suddenly in the perioperative period with airway compromise. To identify literature for this review, the authors searched the PubMed, Medline, Embase, Scopus and Web of Science databases for English language articles covering a 10-year period, 2006 through 2016. Angioedema can be either mast-cell mediated or bradykinin-induced. Older therapies for histaminergic symptoms are well known to anaesthesiologists (e.g., adrenaline, anti-histamines and steroids), whereas older therapies for bradykinin-induced symptoms include plasma and attenuated androgens. New classes of drugs for bradykinin-induced symptoms are now available, including anti-bradykinin, plasma kallikrein inhibitor and C1 esterase inhibitors. These can be used prophylactically or as rescue medications. Anaesthesiologists are in a unique position to coordinate perioperative care for this complex group of patients.
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Affiliation(s)
- Lopa Misra
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
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33
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Gobert D, Paule R, Ponard D, Levy P, Frémeaux-Bacchi V, Bouillet L, Boccon-Gibod I, Drouet C, Gayet S, Launay D, Martin L, Mekinian A, Leblond V, Fain O. A nationwide study of acquired C1-inhibitor deficiency in France: Characteristics and treatment responses in 92 patients. Medicine (Baltimore) 2016; 95:e4363. [PMID: 27537564 PMCID: PMC5370791 DOI: 10.1097/md.0000000000004363] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Acquired angioedema (AAE) due to C1-inhibitor (C1INH) deficiency is rare. Treatment options for acute attacks are variable and used off-label. Successful treatment of the associated lymphoma with rituximab seems to prevent acute attacks in subjects with AAE. The aim of this study was to describe AAE manifestations, its associated diseases, and patients' responses to treatments in a representative cohort.A retrospective nationwide study was conducted in France. The inclusion criteria were recurrent angioedema attacks and an acquired decrease in functional C1INH <50% of the reference value.A total of 92 cases were included, with a median age at onset of 62 years. Facial edema and abdominal pain were the most frequent symptoms. Fifteen patients were hospitalized in the intensive care unit because of laryngeal edema, and 1 patient died. Anti-C1INH antibodies were present in 43 patients. The associated diseases were primarily non-Hodgkin lymphoma (n = 44, with 24 splenic marginal zone lymphomas) and monoclonal gammopathy of undetermined significance (n = 24). Three patients had myeloma, 1 had amyloid light-chain (of immunoglobulin) (AL) amyloidosis, 1 patient had a bronchial adenocarcinoma, and 19 patients had no associated disease. Icatibant relieved the symptoms in all treated patients (n = 26), and plasma-derived C1INH concentrate in 19 of 21 treated patients. Six patients experienced thromboembolic events under tranexamic acid prophylaxis. Rituximab prevented angioedema in 27 of 34 patients as a monotherapy or in association with chemotherapy. Splenectomy controlled AAE in 7 patients treated for splenic marginal zone lymphoma. After a median follow-up of 4.2 years, angioedema was on remission in 52 patients.AAE cases are primarily associated with indolent lymphoma-especially splenic marginal zone lymphoma-and monoclonal gammopathy of undetermined significance but not with autoimmune diseases or other conditions. Icatibant and plasma-derived C1INH concentrate control attacks; splenectomy and immunochemotherapy prevent angioedema in lymphoma setting.
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Affiliation(s)
- Delphine Gobert
- Internal Medicine Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, DHU i2B, Paris 6 University, Paris
- Correspondence: Delphine Gobert, Internal Medicine Department, Hôpital Saint Antoine, 184 Rue Du Faubourg Saint Antoine, 75571 Paris Cedex 12, France (e-mail: )
| | - Romain Paule
- Hematology Department, Pitié Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 6 University, Paris
| | - Denise Ponard
- Immunology Laboratory, University Hospital, Grenoble
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
| | - Pierre Levy
- Public Health Department, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris 6 University
| | - Véronique Frémeaux-Bacchi
- Immunology Laboratory, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris 5 University, Paris
| | - Laurence Bouillet
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Joint Unit 1036 CNRS-CEA-INSERM, University Grenoble Alpes
- Internal Medicine Department, University Hospital, Grenoble
| | - Isabelle Boccon-Gibod
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Joint Unit 1036 CNRS-CEA-INSERM, University Grenoble Alpes
- Internal Medicine Department, University Hospital, Grenoble
| | - Christian Drouet
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Université Joseph Fourier Grenoble, GREPI/AGIM CNRS FRE 3405, Grenoble
| | - Stéphane Gayet
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Internal Medicine Department, La Conception Hospital, AP-HM, Marseille
| | - David Launay
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Internal Medicine and Clinical Immunology Department, Lille University Hospital
- LIRIC, INSERM UMR 995, EA2686, Lille
| | - Ludovic Martin
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Dermatology Department, L’UNAM Université, University Hospital, Angers, France
| | - Arsène Mekinian
- Internal Medicine Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, DHU i2B, Paris 6 University, Paris
| | - Véronique Leblond
- Hematology Department, Pitié Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 6 University, Paris
| | - Olivier Fain
- Internal Medicine Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, DHU i2B, Paris 6 University, Paris
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
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Castelli R, Wu MA, Arquati M, Zanichelli A, Suffritti C, Rossi D, Cicardi M. High prevalence of splenic marginal zone lymphoma among patients with acquired C1 inhibitor deficiency. Br J Haematol 2016; 172:902-8. [PMID: 26728240 DOI: 10.1111/bjh.13908] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/09/2015] [Indexed: 12/17/2022]
Abstract
Marginal zone lymphoma represents about 10% of all non-Hodgkin lymphomas (NHLs). 33% of patients with acquired angioedema (AAE) due to acquired C1-inhibitor (C1-INH) deficiency (C1-INH-AAE) have or will develop NHLs. C1-INH-AAE is a rare condition. We report the follow-up of 72 C1-INH-AAE patients, followed for a median of 15 years (range 1-24). Median age was 71 (range 64-79) years; median age at onset of angioedema symptoms was 57·5 (range 50-66) years and it was 63 [range 45-80) years at diagnosis]. Twenty patients were diagnosed with low-grade non-follicular B-cell lymphomas (75% were splenic MZL), one with follicular and three with high-grade lymphomas (two diffuse large B-cell lymphomas and one mantle cell lymphoma). Fifteen NHLs were diagnosed at onset of AAE or thereafter (3 months to 7 years), eight had already been diagnosed at onset of angioedema. Two of 24 patients remain on watchful wait. Thirthen of 24 received chemotherapy, two received rituximab. Three underwent splenectomy. All 18 patients receiving therapy for NHL experienced post-treatment reduction in AAE symptoms. Our study suggests that clonal B-cell proliferation is the pathology underlying AAE leading to production of C1-INH-neutralizing autoantibodies and to NHLs. The post-germinal centre origin of NHL suggests that immune stimulation may contribute to lymphomagenesis.
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Affiliation(s)
- Roberto Castelli
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
| | - Maddalena Alessandra Wu
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
| | - Massimo Arquati
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
| | - Andrea Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
| | - Chiara Suffritti
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
| | - Davide Rossi
- Division of Haematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital Milan, University of Milan, Milan, Italy
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35
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Fain O, Gobert D, Khau CA, Mekinian A, Javaud N. [Acquired angioedema]. Presse Med 2014; 44:48-51. [PMID: 25535166 DOI: 10.1016/j.lpm.2014.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 07/12/2014] [Accepted: 09/22/2014] [Indexed: 10/24/2022] Open
Abstract
Acquired angioedema are rare. They are associated with monoclonal gammapathies of uncertain significance (MGUS) or lymphomas. They give the same symptoms as the hereditary form and the same laryngeal risk. They are characterized by a low level of C4, C1Inh and C1q. They are linked to the consumption of C1Inh by the lymphoid cells or to the presence of anti-C1Inh autoantibodies. They must be treated by symptomatic treatment when attack occur (C1Inh concentrate and icatibant). The use of rituximab needs to prove its efficiency.
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Affiliation(s)
- Olivier Fain
- AP-HP, DHU i2B, université Paris 6, hôpital Saint-Antoine, centre de références des angioedèmes à kinines (CREAK), service de médecine interne, 75012 Paris, France.
| | - Delphine Gobert
- AP-HP, DHU i2B, université Paris 6, hôpital Saint-Antoine, centre de références des angioedèmes à kinines (CREAK), service de médecine interne, 75012 Paris, France
| | - Cam Anh Khau
- AP-HP, DHU i2B, université Paris 6, hôpital Saint-Antoine, centre de références des angioedèmes à kinines (CREAK), service de médecine interne, 75012 Paris, France
| | - Arsène Mekinian
- AP-HP, DHU i2B, université Paris 6, hôpital Saint-Antoine, centre de références des angioedèmes à kinines (CREAK), service de médecine interne, 75012 Paris, France
| | - Nicolas Javaud
- AP-HP, université Paris 7, urgences, hôpital Louis-Mounier, 92700 Colombes, France
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36
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Kaur R, Williams AA, Swift CB, Caldwell JW. Rituximab therapy in a patient with low grade B-cell lymphoproliferative disease and concomitant acquired angioedema. J Asthma Allergy 2014; 7:165-7. [PMID: 25506230 PMCID: PMC4259552 DOI: 10.2147/jaa.s68548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Acquired angioedema is often associated with significant morbidity. An underlying lymphatic malignancy, autoimmune disorder, adenocarcinoma, or other malignancy may be present. Screening for these disorders should occur in all patients with acquired angioedema as treatment may result in resolution of angioedema.
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Affiliation(s)
- Ravdeep Kaur
- Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Aerik Anthony Williams
- Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Catherine Baker Swift
- Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Jason W Caldwell
- Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, USA
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Pasquet F, Pavic M, Ninet J, Hot A. [Auto-immune diseases and cancers. Second part: auto-immune diseases complicating cancers and their treatment]. Rev Med Interne 2014; 35:656-63. [PMID: 25106665 DOI: 10.1016/j.revmed.2014.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 01/27/2014] [Accepted: 04/14/2014] [Indexed: 12/18/2022]
Abstract
Autoimmune diseases may reveal or occur during the course of a neoplasia or its treatment. Autoimmune cytopenia, especially haemolytic anaemia, is common in lymphoproliferative disorders such as chronic lymphoid leukemia. The link between cancer and myositis is well established. Dermatomyositis is associated with an increased relative risk of cancer of 3.4 to 4.4. A combination of detection of antibodies against p155 and TEP-computed tomography may be the best approach to ascertain the presence of occult malignancy in patients with dermatomyositis. A cutaneous or a systemic vascularitis may reveal a cancer, most often a haematological malignancy such as hairy cell leukemia. Paraneoplastic polyarthritis have been described in particular with adenocardinoma of the lungs. Underlying neoplasia should be considered in male smokers patients with new onset polyarthritis and poor health status. The prevalence of autoimmune conditions in myelodysplastic syndromes is 10 to 30%. Vasculitis and relapsing polychondritis are the most commonly reported manifestations. Immune manifestations can also be related to treatment. The most common treatment complications are autoimmune haemolytic anaemia with fludarabine and thyroiditis related to interferon and cervical radiotherapy.
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Affiliation(s)
- F Pasquet
- Service de médecine interne-oncologie, hôpital d'instruction des armées Desgenettes, 108, boulevardd Pinel, 69003 Lyon, France.
| | - M Pavic
- Service de médecine interne-oncologie, hôpital d'instruction des armées Desgenettes, 108, boulevardd Pinel, 69003 Lyon, France
| | - J Ninet
- Service de médecine interne, hôpital Édouard-Hérriot, 5, place d'Arsonval, 69003 Lyon cedex 03, France
| | - A Hot
- Service de médecine interne, hôpital Édouard-Hérriot, 5, place d'Arsonval, 69003 Lyon cedex 03, France
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38
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Tohani A, Chua I, Grigoriadou S, Buckland MS, Longhurst HJ. Acquired C1 inhibitor deficiency: should we monitor for associated antibody deficiency? Ann Allergy Asthma Immunol 2014; 112:265-7. [PMID: 24565597 DOI: 10.1016/j.anai.2013.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 12/24/2013] [Accepted: 12/30/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Arun Tohani
- Department of Immunopathology, Barts Health NHS Trust, Royal London Hospital, London, England
| | - Ignatius Chua
- Department of Immunopathology, Barts Health NHS Trust, Royal London Hospital, London, England
| | - Sofia Grigoriadou
- Department of Immunopathology, Barts Health NHS Trust, Royal London Hospital, London, England
| | - Matthew S Buckland
- Department of Immunopathology, Barts Health NHS Trust, Royal London Hospital, London, England
| | - Hilary J Longhurst
- Department of Immunopathology, Barts Health NHS Trust, Royal London Hospital, London, England.
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39
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Moellman JJ, Bernstein JA, Lindsell C, Banerji A, Busse PJ, Camargo CA, Collins SP, Craig TJ, Lumry WR, Nowak R, Pines JM, Raja AS, Riedl M, Ward MJ, Zuraw BL, Diercks D, Hiestand B, Campbell RL, Schneider S, Sinert R. A consensus parameter for the evaluation and management of angioedema in the emergency department. Acad Emerg Med 2014; 21:469-84. [PMID: 24730413 PMCID: PMC4100605 DOI: 10.1111/acem.12341] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 11/01/2013] [Accepted: 11/06/2013] [Indexed: 11/28/2022]
Abstract
Despite its relatively common occurrence and life-threatening potential, the management of angioedema in the emergency department (ED) is lacking in terms of a structured approach. It is paramount to distinguish the different etiologies of angioedema from one another and more specifically differentiate histaminergic-mediated angioedema from bradykinin-mediated angioedema, especially in lieu of the more novel treatments that have recently become available for bradykinin-mediated angioedema. With this background in mind, this consensus parameter for the evaluation and management of angioedema attempts to provide a working framework for emergency physicians (EPs) in approaching the patient with angioedema in terms of diagnosis and management in the ED. This consensus parameter was developed from a collaborative effort among a group of EPs and leading allergists with expertise in angioedema. After rigorous debate, review of the literature, and expert opinion, the following consensus guideline document was created. The document has been endorsed by the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM).
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Affiliation(s)
- Joseph J Moellman
- The Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
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40
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[Skin manifestations of monoclonal gammopathies]. Rev Med Interne 2013; 35:28-38. [PMID: 24070793 DOI: 10.1016/j.revmed.2013.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 08/19/2013] [Accepted: 08/21/2013] [Indexed: 01/01/2023]
Abstract
Whatever their aetiology, monoclonal gammopathies can be associated to several clinical features. Mechanisms are various and sometimes unknown. Skin is frequently involved and may represent a challenging diagnosis. Indeed, skin manifestations are either the presenting features and isolated, or at the background of a systemic syndrome. Our objective was to review the various skin manifestations that have been associated with monoclonal gammopathies.
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41
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Bafunno V, Divella C, Sessa F, Tiscia GL, Castellano G, Gesualdo L, Margaglione M, Montinaro V. De novo homozygous mutation of the C1 inhibitor gene in a patient with hereditary angioedema. J Allergy Clin Immunol 2013; 132:748-750.e3. [DOI: 10.1016/j.jaci.2013.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 04/02/2013] [Accepted: 04/03/2013] [Indexed: 11/15/2022]
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Zuraw BL, Bernstein JA, Lang DM, Craig T, Dreyfus D, Hsieh F, Khan D, Sheikh J, Weldon D, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. A focused parameter update: Hereditary angioedema, acquired C1 inhibitor deficiency, and angiotensin-converting enzyme inhibitor–associated angioedema. J Allergy Clin Immunol 2013; 131:1491-3. [DOI: 10.1016/j.jaci.2013.03.034] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 03/11/2013] [Accepted: 03/14/2013] [Indexed: 11/26/2022]
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Angioedema with normal C1q and C1 inhibitor: an atypical presentation of Waldenström macroglobulinemia. Int J Hematol 2013; 97:654-6. [PMID: 23591717 DOI: 10.1007/s12185-013-1330-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 04/09/2013] [Accepted: 04/09/2013] [Indexed: 10/26/2022]
Abstract
Angioedema is a recurrent, non-pitting, non-pruritic, transitory swelling due to transient increase of endothelial permeability in the capillaries of the deep cutaneous and mucosal layers. Angioedema is generally categorized based on etiology, and characteristic lab findings are associated with each category. Cases of acquired angioedema associated with myeloproliferative disorders have been described in the literature, but these have been associated with a characteristic low C1q, a defining laboratory finding in acquired angioedema. Here we present a case of 68-year-old female with acquired angioedema that was not associated with low C1q, but was found to have Waldenström disease. Her angioedema responded dramatically to combination therapy consisting of bortezomib, rituximab, and dexamethasone.
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Small bowel angioedema due to acquired C1 inhibitor deficiency: a case report and overview. Eur J Gastroenterol Hepatol 2013; 25:507-13. [PMID: 23255023 DOI: 10.1097/meg.0b013e32835c94ff] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acquired angioedema is a rare disorder caused by an acquired deficiency of C1 inhibitor. It is characterized by nonpitting, nonpruritic subcutaneous or submucosal edema of the skin, or of the respiratory or gastrointestinal tract. When localized in the gastrointestinal tract, it can cause severe abdominal pain, mimicking an acute surgical abdomen, or chronic recurrent pain of moderate intensity. We report a case of a 48-year-old man presenting with recurrent episodes of hypotension and abdominal pain. Computed tomography of the abdomen showed edema of the small bowel. The first determinations of C1 inhibitor level and activity, measured in a symptom-free period, were normal. Repetition of the laboratory tests in the acute phase, however, showed a low C1 inhibitor level. Further diagnostic work-up indicated an acquired C1 inhibitor deficiency caused by a monoclonal gammopathy. He was treated with tranexamic acid as prophylaxis for his frequent attacks and to date, he has remained symptom free. Acquired C1 inhibitor deficiency is a rare cause of angioedema and is, among others, related to autoantibodies and abnormal B-cell proliferation, for example monoclonal gammopathy. The diagnosis of acquired C1 inhibitor deficiency is made on the basis of the medical history and on the level and activity of plasma C4, C1q, and C1 inhibitor. In case of high suspicion and a normal C1 inhibitor activity, it is recommended to repeat this test during an angioedema attack. Early diagnosis is important for the treatment of severe, potentially life-threatening attacks and to start prophylactic treatment in patients with frequent or severe angioedema attacks.
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Castelli R, Zanichelli A, Cicardi M, Cugno M. Acquired C1-inhibitor deficiency and lymphoproliferative disorders: a tight relationship. Crit Rev Oncol Hematol 2013; 87:323-32. [PMID: 23490322 DOI: 10.1016/j.critrevonc.2013.02.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/11/2013] [Accepted: 02/14/2013] [Indexed: 11/18/2022] Open
Abstract
Angioedema due to the acquired deficiency of C1-inhibitor is a rare disease known as acquired angioedema (AAE), which was first described in a patient with high-grade lymphoma and is frequently associated with lymphoproliferative diseases, including expansion of B cell clones producing anti-C1-INH autoantibodies, monoclonal gammopathy of uncertain significance (MGUS) and non-Hodgkin lymphoma (NHL). AAE is clinically similar to hereditary angioedema (HAE), and is characterized by recurrent episodes of sub-cutaneous and sub-mucosal edema. It may affect the face, tongue, extremities, trunk and genitals. The involvement of the gastrointestinal tract causes bowel sub-occlusion with severe pain, vomiting and diarrhea, whereas laryngeal edema can be life-threatening. Unlike those with HAE, AAE patients usually have late-onset symptoms, do not have a family history of angioedema and present variable response to treatment due to the hyper-catabolism of C1-inhibitor. Reduced C1-inhibitor function leads to activation of the classic complement pathway with its consumption and activation of the contact system leading to the generation of the vasoactive peptide bradykinin, which increases vascular permeability and induces angioedema. Lymphoprolipherative diseases and AAE are tightly linked with either angioedema or limphoprolyferation being the first symptom. Experimental data indicate that neoplastic tissue and/or anti-C1-inhibitor antibodies induce C1-inhibitor consumption, and this is further supported by the observation that cytotoxic treatment of the lymphoproliferative diseases associated with AAE variably reverses the complement impairment and leads to a clinical improvement in angioedema symptoms.
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Affiliation(s)
- Roberto Castelli
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, Italy
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Javaud N, Karami A, Stirnemann J, Pilot F, Branellec A, Boubaya M, Chassaignon C, Adnet F, Fain, O. Bradykinin-mediated angioedema: factors prompting ED visits. Am J Emerg Med 2013; 31:124-9. [DOI: 10.1016/j.ajem.2012.06.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 06/22/2012] [Accepted: 06/23/2012] [Indexed: 10/27/2022] Open
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de Graaff LCG, van Essen M, Schipper EM, Boom H, Duschek EJJ. Unnecessary surgery for acute abdomen secondary to angiotensin-converting enzyme inhibitor use. Am J Emerg Med 2012; 30:1607-12. [PMID: 22867837 DOI: 10.1016/j.ajem.2011.10.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Accepted: 10/29/2011] [Indexed: 11/17/2022] Open
Abstract
Acute abdominal pain is the reason for 5% to 10% of all emergency department visits. In 1 in every 9 patients, operated on for an acute abdomen, laparotomy is negative. In a minority of patients, the acute abdomen is caused by side effects of medication. We present a case of unnecessary abdominal surgery in a patient with acute abdominal pain caused by intestinal angioedema (AE), which was eventually due to angiotensin-converting enzyme inhibitor (ACE-i) use. We hope that this case report increases awareness of this underdiagnosed side effect. Emergency department physicians, surgeons, internists, and family physicians should always consider ACE-i in the differential diagnosis of unexplained abdominal pain. Since early withdrawal of the medication causing intestinal AE can prevent further complications and, in some cases, needless surgery, we propose an altered version of the known diagnostic algorithm, in which ACE-i and nonsteroidal anti-inflammatory drugs-induced AE is excluded at an early stage.
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Affiliation(s)
- Laura C G de Graaff
- Department of Internal Medicine, Reinier de Graaf Group of Hospitals, 2600GA Delft, The Netherlands.
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Zanichelli A, Bova M, Coerezza A, Petraroli A, Triggiani M, Cicardi M. Icatibant treatment for acquired C1-inhibitor deficiency: a real-world observational study. Allergy 2012; 67:1074-7. [PMID: 22686628 DOI: 10.1111/j.1398-9995.2012.02853.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2012] [Indexed: 12/01/2022]
Abstract
Icatibant, a bradykinin B2 receptor antagonist, is an established treatment for acute attacks of hereditary angioedema (HAE) with C1-inhibitor (C1-INH) deficiency. We describe our experience with icatibant in eight patients with angioedema because of acquired C1-INH deficiency (AAE). Forty-eight moderate-to-severe attacks were treated with subcutaneous icatibant 30 mg; two moderate attacks resolved without treatment. The median (range) duration of treated attacks (onset to complete resolution) was 9.33 (1.67-39.00) h; durations of the untreated attacks were 72 and 96 h. Symptom improvement following icatibant treatment occurred in 0.5 (0.25-2.10) h and complete resolution in 6.75 (0.50-30.75) h. A single icatibant injection achieved complete symptom resolution in 47 attacks; one facial attack required a second injection. One peripheral attack responded less quickly than other treated attacks. Five patients reported transient injection site reactions. Icatibant appeared to provide effective symptom relief and was generally well tolerated.
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Affiliation(s)
- A. Zanichelli
- Dipartimento di Scienze Cliniche Luigi Sacco; Università degli Studi di Milano; Milano; Italy
| | - M. Bova
- Dipartimento di Medicina Clinica; Scienze Cardiovascolari ed Immunologiche; Università degli Studi di Napoli “Federico II”; Napoli; Italy
| | - A. Coerezza
- Fondazione Don Carlo Gnocchi ONLUS; Milano; Italy
| | - A. Petraroli
- Dipartimento di Medicina Clinica; Scienze Cardiovascolari ed Immunologiche; Università degli Studi di Napoli “Federico II”; Napoli; Italy
| | - M. Triggiani
- Dipartimento di Medicina Clinica; Scienze Cardiovascolari ed Immunologiche; Università degli Studi di Napoli “Federico II”; Napoli; Italy
| | - M. Cicardi
- Dipartimento di Scienze Cliniche Luigi Sacco; Università degli Studi di Milano; Milano; Italy
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Lam DH, Levy NB, Nickerson JM, Gruenberg DA, Lansigan F. Acquired Angioedema and Marginal Zone Lymphoma. J Clin Oncol 2012; 30:e151-3. [DOI: 10.1200/jco.2011.38.9957] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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50
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Maurer M, Parish LC. The dermatology view of hereditary angio-oedema: practical diagnostic and management considerations. J Eur Acad Dermatol Venereol 2012; 27:133-41. [PMID: 22568407 DOI: 10.1111/j.1468-3083.2012.04562.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hereditary angio-oedema (HAE) is characterized by recurrent, localized, non-pitting, non-pruritic, non-urticarial oedema. Nearly all patients experience skin swelling as a feature of HAE. There may be painful abdominal attacks, accompanied by nausea and vomiting. The disease is life-threatening should laryngeal oedema occur. HAE results from a deficiency or dysfunction of C1 inhibitor, a plasma protein with an important role in regulating the contact, complement and fibrinolytic systems. Effective management of HAE should include a plan for treatment of attacks, as well as routine and preprocedure prevention. Acute and prophylactic therapy with C1 inhibitor therapy for correcting the underlying deficiency in HAE is a valuable option.
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Affiliation(s)
- M Maurer
- Department of Dermatology, Venereology and Allergy, Charité - University Medicine, Berlin, Germany.
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