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Dias de Castro E, Pinhal AL, Bragança M, Parente Freixo J, Martinho A. Hereditary angioedema with normal C1-inhibitor: Clinical and genetic characterization of 15 Portuguese unrelated families. Ann Allergy Asthma Immunol 2024; 132:730-736. [PMID: 38342132 DOI: 10.1016/j.anai.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 01/09/2024] [Accepted: 01/26/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Hereditary angioedema with normal C1-inhibitor (HAE-nC1-INH) is a rare genetic disease with similar phenotype to HAE-C1-INH but different genetic background. Currently, 6 subtypes are recognized, based on the underlying mutations. Several aspects need further clarification. OBJECTIVE To assess clinical features of patients with genetically characterized HAE-nC1-INH from the North of Portugal. METHODS Retrospective assessment of clinical data from all patients with HAE-nC1-INH followed at a HAE Reference Center. RESULTS A total of 41 patients were identified, 4 with no family history. The FXII mutation Thr328Lys (38 carriers) was the most prevalent. There were 3 new potentially disease-causing variants linked to HAE-nC1-INH identified (c.529+4A>G:FXII; Cys248*:Kininogen-1; and Arg261His:Plasminogen). The HAE-FXII cohort included 82% females and 71.8% symptomatic patients. Penetrance rate was significantly higher in females (81.3% vs 28.6%; P = .012). A hormonal influence was observed in 96.2% of the symptomatic females, although 62.5% remained symptomatic after oral estrogen withdrawal. Trauma and dental procedures were frequent triggers (82.6% and 45.5%, respectively). Main locations were facial (described by 96%), lips (82.1%), and eyelids (64.3%). One patient reported erythema marginatum as prodrome. Plasma-derived C1-INH was effective as short-term prophylaxis in all treated patients, but only in 80% as on-demand treatment. Icatibant was effectively used on demand in 9 patients, but with relapses in 5 (57%). CONCLUSION We described a large Portuguese series of patients with HAE-nC1-INH genetically characterized. Differences with others may contribute to improve current unmet needs and raise awareness of this rare disease. We highlighted the identification of 3 new variants (additional molecular studies are ongoing) and the report of erythema marginatum in HAE-nC1-INH.
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Affiliation(s)
- Eunice Dias de Castro
- Allergy and Clinical Immunology Department, Centro Hospitalar Universitário de S. João EPE, Porto, Portugal; Public Health and Forensic Sciences and Medical Education Department, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Ana Luísa Pinhal
- Allergy and Clinical Immunology Department, Centro Hospitalar Universitário de S. João EPE, Porto, Portugal
| | - Mariana Bragança
- Allergy and Clinical Immunology Department, Centro Hospitalar Universitário de S. João EPE, Porto, Portugal
| | - João Parente Freixo
- Center for Predictive and Preventive Genetics, Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal; Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - António Martinho
- Centro do Sangue e Transplantação de Coimbra, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
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Lagacé F, D’Aguanno K, Prosty C, Laverde-Saad A, Cattelan L, Ouchene L, Oliel S, Genest G, Doiron P, Richer V, Jfri A, O’Brien E, Lefrançois P, Powell M, Moreau L, Litvinov IV, Muntyanu A, Netchiporouk E. The Role of Sex and Gender in Dermatology - From Pathogenesis to Clinical Implications. J Cutan Med Surg 2023; 27:NP1-NP36. [PMID: 37401812 PMCID: PMC10486181 DOI: 10.1177/12034754231177582] [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] [Received: 01/05/2023] [Revised: 03/29/2023] [Accepted: 04/09/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Sex and gender have increasingly been recognized as significant risk factors for many diseases, including dermatological conditions. Historically, sex and gender have often been grouped together as a single risk factor in the scientific literature. However, both may have a distinct impact on disease incidence, prevalence, clinical presentation, severity, therapeutic response, and associated psychological distress. OBJECTIVES AND PROJECT DESCRIPTION The mechanisms that underlie differences in skin diseases between males, females, men, and women remain largely unknown. The specific objectives of this review paper are:To highlight the biological differences between males and females (sex), as well as the sociocultural differences between men and women (gender) and how they impact the integumentary system.To perform a literature review to identify important sex- and gender-related epidemiological and clinical differences for various skin conditions belonging to a range of disease categories and to discuss possible biological and sociocultural factors that could explain the observed differences.To discuss dermatological skin conditions and gender-affirming treatments within the transgender community, a population of individuals who have a gender identity which is different than the gender identity they were assigned at birth. FUTURE IMPACT With the rising number of individuals that identify as non-binary or transgender within our increasingly diverse communities, it is imperative to recognize gender identity, gender, and sex as distinct entities. By doing so, clinicians will be able to better risk-stratify their patients and select treatments that are most aligned with their values. To our knowledge, very few studies have separated sex and gender as two distinct risk factors within the dermatology literature. Our article also has the potential to help guide future prevention strategies that are patient-tailored rather than using a universal approach.
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Affiliation(s)
- François Lagacé
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | | | - Connor Prosty
- Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Alexandra Laverde-Saad
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Leila Cattelan
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Lydia Ouchene
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Sarah Oliel
- Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Genevieve Genest
- Division of Allergy and Immunology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Philip Doiron
- Division of Dermatology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vincent Richer
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - Abdulhadi Jfri
- Department of Dermatology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Elizabeth O’Brien
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Philippe Lefrançois
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Mathieu Powell
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Linda Moreau
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Ivan V. Litvinov
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Anastasiya Muntyanu
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Elena Netchiporouk
- Division of Dermatology, Faculty of Medicine, McGill University, Montréal, Québec, Canada
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3
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Longhurst HJ, Valerieva A. A Review of Randomized Controlled Trials of Hereditary Angioedema Long-Term Prophylaxis with C1 Inhibitor Replacement Therapy: Alleviation of Disease Symptoms Is Achievable. J Asthma Allergy 2023; 16:269-277. [PMID: 36922963 PMCID: PMC10010185 DOI: 10.2147/jaa.s396338] [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: 11/05/2022] [Accepted: 02/01/2023] [Indexed: 03/11/2023] Open
Abstract
Through its fluctuating disease activity and unpredictable attacks, hereditary angioedema (HAE) imposes a substantial patient burden. To minimize HAE burden and improve quality of life, treatment should involve individualized management strategies that address on-demand therapy and short-term/long-term prophylaxis. Goals of long-term prophylaxis include reducing the number, severity, and burden of HAE attacks. The best characterized forms of HAE arise from deficiency or dysfunction of C1-inhibitor (C1-INH; types I/II), and C1-INH replacement therapy is a first-line intervention for on-demand (acute) treatment of HAE attacks, short-term prophylaxis before high-risk procedures, and long-term prophylaxis. Randomized, double-blind, placebo-controlled crossover trials have shown dose-dependent efficacy with plasma-derived C1-INH (pdC1-INH) 40-60 IU/kg subcutaneously, pdC1-INH 1000 U intravenously, and recombinant human C1-INH (rhC1-INH) 50 IU/kg (maximum 4200 IU) intravenously, all administered twice weekly, as long-term prophylaxis in patients with a history of 2 to ≥4 attacks/month. Overall, up to 83% (pdC1-INH 60 IU/kg) of patients experienced an HAE attack reduction threshold of ≥70%, and up to 58% (pdC1-INH 60 IU/kg) achieved an attack reduction threshold of ≥90%. Lower-dose intravenous pdC1-INH therapy (1000 U) was seemingly less effective, with 45% of 22 patients experiencing an HAE attack reduction threshold of ≥70%, and up to 23% achieving an attack reduction threshold of ≥90%. Higher-dose intravenous rhC1-INH 50 IU/kg (maximum, 4200 IU) twice weekly was of intermediate benefit. Despite a baseline mean attack frequency of 17.9 (during the 3 months prior to study treatment) and a mean attack frequency during a 4-week placebo period of 7.2, 52% of 23 patients experienced ≥70% reduction in attack frequency and 26% of 23 patients experienced ≥90% reduction in attack frequency. The increasing patient percentages treated with C1-INH replacement therapy as long-term prophylaxis meeting these high thresholds reinforces hopes and expectations that "attack freedom" is achievable, including for those with moderate or severe disease.
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Affiliation(s)
- Hilary J Longhurst
- Department of Medicine, University of Auckland and Department of Immunology, Auckland City Hospital, Auckland, New Zealand
| | - Anna Valerieva
- Department of Allergology, Medical University of Sofia, Sofia, Bulgaria
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Muacevic A, Adler JR. Hereditary Angioedema with Normal C1 Esterase Inhibitor Refractory to Long-Term Prophylaxis: A Case Report. Cureus 2023; 15:e33800. [PMID: 36819342 PMCID: PMC9931377 DOI: 10.7759/cureus.33800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2023] [Indexed: 01/18/2023] Open
Abstract
Hereditary angioedema (HAE) was classically thought to be related to a deficiency in the C1 esterase inhibitor (C1-INH). However, HAE with a normal C1 esterase inhibitor (HAE nC1-INH) is a rare disease that has been recently characterized. In this case, we describe a woman with a 21-year history of angioedema who, in the last two years, has experienced severe exacerbations that led to the formal diagnosis of HAE nC1-INH. The patient has been treated with current HAE long-term prophylaxis (LTP) and on-demand therapies but is still experiencing severe, frequent attacks. Our case describes the timeline of this patient's presentation and provides valuable insight into the presentation and management of HAE nC1-INH.
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Muacevic A, Adler JR, Prathiraja O, Jena R, Coffie-Pierre JA, Agyei J, Silva MS, Kayani AMA, Siddiqui OS. A Comprehensive Review of Bradykinin-Induced Angioedema Versus Histamine-Induced Angioedema in the Emergency Department. Cureus 2022; 14:e32075. [PMID: 36600855 PMCID: PMC9803396 DOI: 10.7759/cureus.32075] [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] [Accepted: 11/30/2022] [Indexed: 12/05/2022] Open
Abstract
Angioedema (AE) is a condition that is frequently encountered in the emergency department (ED). It is a rare condition with localized, asymmetrical swelling of the skin and/or mucosa that is frequently nonpruritic and primarily affects locations with loose connective tissue. Physicians must have a thorough understanding of this condition since it can cause fatal airway compromise, which might be the presenting symptom. Histamine-mediated AE is the most common type of AE seen in EDs. However, ED physicians must be on the lookout for the less common bradykinin-mediated types of AE as these do not respond to the same therapy as histamine-mediated AE. Hospitals may lack specialized drugs or protocols, and many ED staff may be unable to identify or treat bradykinin-mediated AE. It is crucial to understand the pathophysiology of the various kinds of AE in order to optimize treatment. The goal of this review paper is to provide an overview of the pathophysiology, clinical manifestations, and treatment options for bradykinin and histamine-induced AE in the ED.
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Germenis AE, Rijavec M, Veronez CL. Leveraging Genetics for Hereditary Angioedema: A Road Map to Precision Medicine. Clin Rev Allergy Immunol 2021; 60:416-428. [PMID: 33507496 DOI: 10.1007/s12016-021-08836-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 12/25/2022]
Abstract
Biochemical studies performed during the last decades resulted in the development of various innovative medicinal products for hereditary angioedema (HAE). These therapeutic agents target the production or the function of bradykinin-the main mediator of HAE due to C1-inhibitor (C1-INH) deficiency. However, despite these remarkable achievements, current knowledge cannot provide convincing explanations for the clinical variability of the disease. As a consequence, treatment indications apply for drugs available for C1-INH deficiency. The advent of high-throughput next-generation sequencing technologies may assist in covering the missing part of our understanding of HAE pathogenesis. During the last 3 years alone, several new entities were added to the already described genotypes. The recent discovery of four novel target genes expands our understanding of other causes which may explain recurrent angioedema in individuals and families with normal C1-INH activity. Furthermore, new genetic technologies allowed the recognition of deep intronic variants associated with the disease, and elegant functional studies characterized new variants for the C1-INH gene. Thus, evidence has been provided regarding pathogenetic aspects remaining obscure for many years, such as the defective intracellular transport of mutant C1-INH, and environmental effect on the disease expression. Therefore, it seems that the stage for Precision Medicine era in HAE management is ready. Disease endotypes are expected to be uncovered and specified targets for therapeutic intervention will be detected, promising a more effective, individualized management of the disease.
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Affiliation(s)
- Anastasios E Germenis
- Department of Immunology and Histocompatibility, School of Medicine, University of Thessaly, 3 Panepistimiou Street, GR-41500, Biopolis Larissa, Greece.
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Camila Lopes Veronez
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, University of California San Diego, San Diego, CA, USA.,Research Service, San Diego Veterans Affairs Healthcare, San Diego, CA, USA
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7
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Emelyanov AV, Leshenkova EV, Kameneva GA. [Diagnosis and treatment of hereditary angioedema with normal C1-inhibitor level]. TERAPEVT ARKH 2020; 92:86-90. [PMID: 33720579 DOI: 10.26442/00403660.2020.12.200447] [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] [Received: 02/07/2021] [Accepted: 02/07/2021] [Indexed: 11/22/2022]
Abstract
Hereditary angioedema (HAE) with normal C1-inhibitor level is a rare potentially life-threatening disorder with autosomal dominant inheritance which was first described in 2000. Its clinical presentation is similar to HAE with C1-deficiency. The review is summarized data about its prevalence, mechanisms, genetics and diagnostic criteria. Different subtypes and treatment options (on demand, short term and long-term prophylaxis) are discussed. We describe family clinical cases of 2 female patients with normal C1-inhibitor and plasminogen gene mutation. Their features were late diagnosis (in 10 and 25 years after the onset of symptoms), family history (similar genetic mutation in 3 female members of the same family, including 1-asymtomatic) and combination of face, tongue, larynx and abdominal angioedema in patient and her sibling.
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8
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Veronez CL, Mendes AR, Leite CS, Gomes CP, Grumach AS, Pesquero JB. The Panorama of Primary Angioedema in the Brazilian Population. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:2293-2304.e5. [PMID: 33276216 DOI: 10.1016/j.jaip.2020.11.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary angioedema (PA) is a complex disorder, presenting multiple hereditary (hereditary angioedema) and acquired subtypes (acquired angioedema). Despite a very similar clinical presentation among subtypes, the differential diagnosis is limited by the difficulty to identify bradykinin-mediated PA and the lack of specific biomarkers. OBJECTIVES To report the clinical and genetic features of Brazilian patients with PA. METHODS Brazilian patients referred from 50 centers were diagnosed on the basis of clinical symptoms, C1 inhibitor (C1-INH) and C4 plasma measurements, and DNA sequencing of genes associated with hereditary angioedema. RESULTS We characterized 92 patients with acquired angioedema and 425 with HAE: 125 with C1-INH deficiency, 180 with F12 mutations, and 120 of unknown cause. Thirty-one different mutations were identified in SERPING1 and 2 in F12, in addition to 2 mutations of uncertain significance in the ANGPT1 gene. The molecular diagnosis was decisive for 34 patients with HAE without family history, and for 39% of patients with inconsistent biochemical measurements. The median delay in diagnosis was 10 years, with a maximum of 18 years for HAE with C1-INH deficiency. Androgens and tranexamic acid were the most used drugs for long-term prophylaxis in all the PA subtypes, and they were used on demand by 15% of patients. Only 10% of patients reported the use of specific medication for HAE during attacks. CONCLUSIONS Our analysis exposes a broad picture of PA diagnosis and management in a developing country. Complement measurements presented considerable inconsistencies, increasing the diagnosis delay, while patients with PA with normal C1-INH remain with an inaccurate diagnosis and unspecific treatment.
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Affiliation(s)
- Camila Lopes Veronez
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil; Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, Calif; Research Service, San Diego Veterans Affairs Healthcare, San Diego, Calif.
| | | | | | - Caio Perez Gomes
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil
| | - Anete Sevciovic Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitário Saúde ABC, Santo Andre, Brazil
| | - João Bosco Pesquero
- Department of Biophysics, Federal University of São Paulo, São Paulo, Brazil
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Angioedema without urticaria: novel findings which must be measured in clinical setting. Curr Opin Allergy Clin Immunol 2020; 20:253-260. [DOI: 10.1097/aci.0000000000000633] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Bygum A. Hereditary Angio-Oedema for Dermatologists. Dermatology 2019; 235:263-275. [PMID: 31167185 DOI: 10.1159/000500196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/08/2019] [Indexed: 11/19/2022] Open
Abstract
Among angio-oedema patients, hereditary angio-oedema (HAE) should not be overlooked. Besides skin swellings, these patients might have very painful abdominal attacks and potentially life-threatening angio-oedema of the upper airway. They will not respond to traditional anti-allergic therapy with antihistamines, corticosteroids, and adrenaline, and instead need specific drugs targeting the kallikrein-kinin pathway. Classically, patients with HAE have a quantitative or qualitative deficiency of the C1 inhibitor (C1INH) due to different mutations in SERPING1, although a new subtype with normal C1INH has been recognised more recently. This latter variant is diagnosed based on clinical features, family history, or molecular genetic testing for mutations in F12, ANGPT1,or PLG.The diagnosis of HAE is often delayed due to a general unfamiliarity with this orphan disease. However, undiagnosed patients are at an increased risk of unnecessary surgical interventions or life-threatening laryngeal swellings. Within the last decade, new and effective therapies have been developed and launched for acute and prophylactic therapy. Even more drugs are under evaluation in clinical trials. It is therefore of utmost importance that patients with HAE are diagnosed as soon as possible and offered relevant therapy with orphan drugs to reduce morbidity, prevent mortality, and improve quality of life.
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Affiliation(s)
- Anette Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark,
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Mehmood A, Abdullah HMA, Inayat F, Ullah W. Wolf in the sheep's clothing: intestinal angioedema mimicking infectious colitis. BMJ Case Rep 2018; 11:11/1/e226682. [PMID: 30567241 DOI: 10.1136/bcr-2018-226682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hereditary angioedema (HAE) is a relatively rare clinical entity that can potentially cause life-threatening airway or intestinal oedema, patients with the latter usually presents with symptoms of gastroenteritis like vomiting, diarrhoea and abdominal pain. Here, we present a unique case of a less recognised type of HAE that is type III in a patient who presented with signs and symptoms consistent with infectious colitis. She previously had similar episodes and was managed multiple times with antibiotics, with no satisfactory response. There, she underwent extensive diagnostic evaluation. On the basis of findings of further investigations on the current visit, she was eventually diagnosed with intestinal angioedema. To the best of our knowledge, the present paper represents the third reported case of type III HAE-induced intestinal angioedema. Additionally, we undertake a literature review of HAE.
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Affiliation(s)
- Asif Mehmood
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
| | | | | | - Waqas Ullah
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
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Feray S, Fain O, Kayem G, Sabourdin N, Constant I, Rigouzzo A. Repeated attacks of type III hereditary angioedema with factor XII mutation during pregnancy. Int J Obstet Anesth 2018; 36:114-118. [DOI: 10.1016/j.ijoa.2018.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/17/2018] [Accepted: 07/27/2018] [Indexed: 11/24/2022]
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13
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Zuraw BL, Christiansen SC. How we manage persons with hereditary angioedema. Br J Haematol 2016; 173:831-43. [DOI: 10.1111/bjh.14059] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Bruce L. Zuraw
- University of California, San Diego; La Jolla CA USA
- San Diego VA Health System; San Diego CA USA
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Bernstein JA, Moellman JJ. Progress in the Emergency Management of Hereditary Angioedema: Focus on New Treatment Options in the United States. Postgrad Med 2015; 124:91-100. [DOI: 10.3810/pgm.2012.05.2552] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Firinu D, Bafunno V, Vecchione G, Barca MP, Manconi PE, Santacroce R, Margaglione M, Del Giacco SR. Characterization of patients with angioedema without wheals: the importance of F12 gene screening. Clin Immunol 2015; 157:239-48. [PMID: 25744496 DOI: 10.1016/j.clim.2015.02.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/20/2015] [Indexed: 11/28/2022]
Abstract
Sporadic and familiar forms of non-histaminergic angioedema and normal C1 inhibitor encompass a group of disorders possibly caused by bradikinin. We aimed to study the subgroups of hereditary angioedema with FXII mutation (FXII-HAE), unknown genetic defect (U-HAE) and idiopathic non-histaminergic acquired angioedema (InH-AAE). We screened the F12 locus in our cohort and delineated the clinical, laboratory and genetic features. Four families carried the p.Thr309Lys mutation in F12 gene. Haplotyping confirmed the hypothesis of a common founder. Six families were affected by U-HAE and 13 patients by sporadic InH-AAE. C4 levels were significantly lower in FXII-HAE than in InH-AAE. In the FXII-HAE group, none had attacks exclusively in high estrogenic states; acute attacks were treated with icatibant. Prophylaxis with tranexamic acid reduced the attack frequency in most patients. Our study provides new data on the diagnosis, clinical features and treatment of non-histaminergic angioedema, underlying the role of the screening for F12 mutations.
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Affiliation(s)
- Davide Firinu
- Department of Medical Sciences "M. Aresu", University of Cagliari, Italy.
| | - Valeria Bafunno
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Gennaro Vecchione
- Atherosclerosis and Thrombosis Unit, I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
| | - Maria Pina Barca
- Department of Medical Sciences "M. Aresu", University of Cagliari, Italy
| | | | - Rosa Santacroce
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
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Iturri Clavero F, González Uriarte A, Tamayo Medel G, Gamboa Setién PM. [Prophylactic use of icatibant before tracheal intubation of a patient with hereditary angioedema type III. (A literature review of perioperative management of patients with hereditary angioedema type III)]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:375-381. [PMID: 24931134 DOI: 10.1016/j.redar.2014.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 12/18/2013] [Accepted: 01/28/2014] [Indexed: 06/03/2023]
Abstract
Type III hereditary angioedema is a rare familial disorder that has recently been described as a separate condition. Triggers for episodes of angioedema include surgery, dental procedures, and tracheal intubation maneuvers. Since episodes affecting the upper airway are potentially life-threatening, prophylactic treatment is recommended in these situations. The use of icatibant (Firazyr(®)), for prevention of angioedema prior to tracheal intubation, is reported in a patient with type iii hereditary angioedema. A literature review on the anesthetic management of this condition was conducted.
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Affiliation(s)
- F Iturri Clavero
- Servicio de Anestesiología y Reanimación, Hospital Universitario de Cruces, Baracaldo, Vizcaya, España.
| | - A González Uriarte
- Servicio de Anestesiología y Reanimación, Hospital Universitario de Cruces, Baracaldo, Vizcaya, España
| | - G Tamayo Medel
- Servicio de Anestesiología y Reanimación, Hospital Universitario de Cruces, Baracaldo, Vizcaya, España; Departamento de Farmacología, Universidad del País Vasco, Leioa, Vizcaya, España
| | - P M Gamboa Setién
- Servicio de Alergología, Hospital de Basurto, Basurto, Vizcaya, España
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Cicardi M, Aberer W, Banerji A, Bas M, Bernstein JA, Bork K, Caballero T, Farkas H, Grumach A, Kaplan AP, Riedl MA, Triggiani M, Zanichelli A, Zuraw B. Classification, diagnosis, and approach to treatment for angioedema: consensus report from the Hereditary Angioedema International Working Group. Allergy 2014; 69:602-16. [PMID: 24673465 DOI: 10.1111/all.12380] [Citation(s) in RCA: 408] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 01/13/2023]
Abstract
Angioedema is defined as localized and self-limiting edema of the subcutaneous and submucosal tissue, due to a temporary increase in vascular permeability caused by the release of vasoactive mediator(s). When angioedema recurs without significant wheals, the patient should be diagnosed to have angioedema as a distinct disease. In the absence of accepted classification, different types of angioedema are not uniquely identified. For this reason, the European Academy of Allergy and Clinical Immunology gave its patronage to a consensus conference aimed at classifying angioedema. Four types of acquired and three types of hereditary angioedema were identified as separate forms from the analysis of the literature and were presented in detail at the meeting. Here, we summarize the analysis of the data and the resulting classification of angioedema.
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Affiliation(s)
- M. Cicardi
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; Luigi Sacco Hospital Milan; Milan Italy
| | - W. Aberer
- Department of Dermatology; Medical University of Graz; Graz Austria
| | - A. Banerji
- Division of Rheumatology, Allergy and Immunology; Massachusetts General Hospital; Boston MA USA
| | - M. Bas
- Department of Otorhinolaryngology; Klinikum rechts der Isar; Technische Universität München; Munich Germany
| | - J. A. Bernstein
- Division of Immunology/Allergy Section; Department of Internal Medicine; University of Cincinnati College of Medicine; Cincinnati OH USA
| | - K. Bork
- Department of Dermatology; Johannes Gutenberg University; Mainz Germany
| | - T. Caballero
- Department of Allergy; Hospital La Paz Institute for Health Research (IdiPaz); Biomedical Research Network on Rare Diseases-U754 (CIBERER); Madrid Spain
| | - H. Farkas
- 3rd Department of Internal Medicine; National Angioedema Center; Semmelweis University; Budapest Hungary
| | - A. Grumach
- Department of Clinical Medicine; Faculty of Medicine ABC; Sao Paulo Brazil
| | - A. P. Kaplan
- Medical University of South Carolina; Charleston SC
| | - M. A. Riedl
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; University of California - San Diego; La Jolla CA USA
| | - M. Triggiani
- Department of Medicine; University of Salerno; Salerno Italy
| | - A. Zanichelli
- Department of Biomedical and Clinical Sciences Luigi Sacco; University of Milan; Luigi Sacco Hospital Milan; Milan Italy
| | - B. Zuraw
- Division of Rheumatology, Allergy and Immunology; Department of Medicine; University of California - San Diego; La Jolla CA USA
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Abstract
BACKGROUND Angioedema is a serious medical condition characterized by recurrent non-pitting tissue edema. Hereditary (HAE) forms of this disorder are potentially fatal. METHODS PubMED, Up to Date and Cochrane Library databases were used to identify scholarly peer reviewed original research or review articles on angioedema. Search terms used were: angioedema, HAE, ACE inhibitor induced angioedema, acquired angioedema, type III HAE (now termed HAE with normal C1-INH), diagnosis of HAE, and treatment of HAE. Inclusive dates of the search were 1946 through 2013. Articles on urticaria were excluded. RESULTS The pathophysiology, clinical manifestations, differential diagnosis and treatments of angioedema are presented. Three variants of HAE are discussed and differentiated from acquired, ACE induced and allergic types of angioedema. Emphasis is placed on understanding that HAE is mediated by bradykinin, not histamine, and is therefore unresponsive to antihistamines, corticosteroids and epinephrine. In contrast, newer therapies that replace C1-INH or block bradykinin production or action are the appropriate treatments for prophylaxis and acute treatment of HAE. CONCLUSION Recognition of HAE by primary care providers and distinguishing it from allergic histamine mediated angioedema is essential in preventing recurrent attacks and avoiding inappropriate therapy, and may be life-saving.
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Miranda AR, Ue APFD, Sabbag DV, Furlani WDJ, Souza PKD, Rotta O. Hereditary angioedema type III (estrogen-dependent) report of three cases and literature review. An Bras Dermatol 2014; 88:578-84. [PMID: 24068129 PMCID: PMC3760933 DOI: 10.1590/abd1806-4841.20131818] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 08/16/2012] [Indexed: 11/25/2022] Open
Abstract
In this article, three cases of hereditary angioedema (HAE) type III
(estrogen-dependent or with normal C1 inhibitor) are reported. The HAE was initially
described in women of the same family in association with high-leveled estrogenic
conditions such as the use of oral contraceptives and pregnancy. There is no change
in the C1 inhibitor as happens in other types of hereditary angioedema, and mutations
are observed in the encoding gene of the XII factor of coagulation in several
patients. The current diagnosis is mainly clinical and treatment consists in the
suspension of the triggering factors and control of acute symptoms. A brief review of
physiopathology, clinical features, genetic alterations and treatment are also
presented.
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Sher J, Davis-Lorton M. Angioedema with normal laboratory values: the next step. Curr Allergy Asthma Rep 2014; 13:563-70. [PMID: 23979825 DOI: 10.1007/s11882-013-0383-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
When faced with a patient with recurrent swelling, a thorough laboratory evaluation to determine the underlying etiology ensues. When the laboratory work-up is unrevealing, health care practitioners are frequently left in a quandary. This review will attempt to provide up-to-date information on how to approach the diagnosis and management of angioedema in a patient with normal laboratory values. The subtypes that will be reviewed in detail include: hereditary angioedema with normal C1 inhibitor (HAE with normal C1INH), drug-induced angioedema, and idiopathic angioedema. We present literature to aid the physician in the diagnosis and treatment of these disorders.
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Affiliation(s)
- Janelle Sher
- Rheumatology, Allergy & Immunology, Winthrop University, 120 Mineola Blvd., Suite 410, Mineola, NY, 11501, USA,
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Kiss N, Barabás E, Várnai K, Halász A, Varga LÁ, Prohászka Z, Farkas H, Szilágyi Á. Novel duplication in the F12 gene in a patient with recurrent angioedema. Clin Immunol 2013; 149:142-5. [DOI: 10.1016/j.clim.2013.08.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 07/29/2013] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
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Abstract
Until recently it was assumed that hereditary angioedema was a disease that results exclusively from a genetic deficiency of the C1 inhibitor. In 2000, families with hereditary angioedema, normal C1 inhibitor activity, and protein in plasma were described. Since then, numerous patients and families with that condition have been reported. Most of the patients were women. In many of the affected women, oral contraceptives, hormone replacement therapy containing estrogens, and pregnancies triggered the clinical symptoms. In some families mutations in the coagulation factor XII (Hageman factor) gene were detected.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Langenbeckstr. 1, 55131 Mainz, Germany.
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23
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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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Xu YY, Buyantseva LV, Agarwal NS, Olivieri K, Zhi YX, Craig TJ. Update on treatment of hereditary angioedema. Clin Exp Allergy 2013; 43:395-405. [DOI: 10.1111/cea.12080] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Y.-Y. Xu
- Department of Allergy, Peking Union Medical College Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing; China
| | - L. V. Buyantseva
- Department of Internal Medicine; Pinnacle Heal System; Harrisburg Hospital; Harrisburg; PA; USA
| | - N. S. Agarwal
- Department of Pediatrics; Weill Cornell Medical Center; New York Presbyterian Hospital; New York; NY; USA
| | | | - Y.-X. Zhi
- Department of Allergy, Peking Union Medical College Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing; China
| | - T. J. Craig
- Division of Pulmonary, Allergy and Critical Care; Medicine and Pediatrics; Milton S. Hershey Medical Center; Penn State University; Hershey; PA; USA
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25
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Busse PJ, Buckland MS. Non-histaminergic angioedema: focus on bradykinin-mediated angioedema. Clin Exp Allergy 2013; 43:385-94. [DOI: 10.1111/cea.12019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- P. J. Busse
- Clinical Immunology; Mount Sinai School of Medicine; New York; NY; USA
| | - M. S. Buckland
- Clinical Immunology; Barts and the London NHS Trust; Queen Mary University of London; London; UK
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Abstract
Hereditary Angioedema (HAE) is a rare disease and for this reason proper diagnosis and appropriate therapy are often unknown or not available for physicians and other health care providers. For this reason we convened a group of specialists that focus upon HAE from around the world to develop not only a consensus on diagnosis and management of HAE, but to also provide evidence based grades, strength of evidence and classification for the consensus. Since both consensus and evidence grading were adhered to the document meets criteria as a guideline. The outcome of the guideline is to improve diagnosis and management of patients with HAE throughout the world and to help initiate uniform care and availability of therapies to all with the diagnosis no matter where the residence of the individual with HAE exists.
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Marcos C, López Lera A, Varela S, Liñares T, Alvarez-Eire MG, López-Trascasa M. Clinical, biochemical, and genetic characterization of type III hereditary angioedema in 13 Northwest Spanish families. Ann Allergy Asthma Immunol 2012; 109:195-200.e2. [PMID: 22920075 DOI: 10.1016/j.anai.2012.05.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 05/09/2012] [Accepted: 05/16/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND A new variant of hereditary angioedema has been reported during the last decade. Three main characteristics distinguish it from classic hereditary angioedema: normal C1 inhibitor activity, predominance in women, and different genetic alterations. OBJECTIVE To assess the symptoms, laboratory findings, and treatment of a population with type III hereditary angioedema from Northwest Spain. METHODS We studied 29 patients (26 female and 3 male) from 13 different families. RESULTS The 26 female patients showed a similar clinical pattern to the classic forms of hereditary angioedema, and 22 of these patients had the estrogen-dependent phenotype. Three patients had a negative family history, and 1 of the parents was confirmed as an asymptomatic carrier in 2 of them. All had functional C1 inhibitor activity within the normal range in periods without high estrogen levels, but during attacks (in female patients) and pregnancy, activity decreased to below 50%. One male patient had normal C1 inhibitor activity during attacks, and he was initially diagnosed as having idiopathic angioedema. The C4 and antigenic C1 inhibitor levels were always normal. All studied patients had the c.1032C>A, Thr309Lys mutation in the factor XII gene. The mutation was also found in asymptomatic relatives: 5 of 6 men studied and 1 of 8 women studied. CONCLUSION Positive family history is a diagnosis criterion, but it could be lacking because there may be asymptomatic relatives, primarily males.
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Affiliation(s)
- Carmen Marcos
- Allergy Service of University Hospital Complex of Vigo, Pontevedra, Spain.
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29
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Cronin JA, Maples KM. Treatment of an acute attack of type III hereditary angioedema with ecallantide. Ann Allergy Asthma Immunol 2011; 108:61-62. [PMID: 22192969 DOI: 10.1016/j.anai.2011.09.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 09/08/2011] [Accepted: 09/28/2011] [Indexed: 11/29/2022]
Affiliation(s)
- Julia A Cronin
- Eastern Virginia Medical School, Norfolk, Virginia; Children's Hospital of the King's Daughters, Norfolk, Virginia
| | - Kelly M Maples
- Eastern Virginia Medical School, Norfolk, Virginia; Children's Hospital of the King's Daughters, Norfolk, Virginia
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30
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Abstract
Background Laryngeal angioedema may be associated with significant morbidity and even mortality. Because of the potential severity of attacks, both allergists and otolaryngologists must be knowledgeable about the recognition and treatment of laryngeal angioedema. This study describes the clinical characteristics and pathophysiology of bradykinin-mediated angioedema. Methods A literature review was conducted concerning the clinical characteristics and pathophysiology of types I and II hereditary angioedema (HAE), type III HAE, acquired C1 inhibitor (C1INH) deficiency, and angiotensin-converting enzyme (ACE) inhibitor–associated angioedema. Results The diagnosis of type I/II HAE is relatively straightforward as long as the clinician maintains a high index of suspicion. Mutations in the SERPING1 gene result in decreased secretion of functional C1INH and episodic activation of plasma kallikrein and Hageman factor (FXII) of the plasma contact system with cleavage of high molecular weight kininogen and generation of bradykinin. In contrast, there are no unequivocal criteria for making a diagnosis of type III HAE, although a minority of these patients may have a mutation in the factor XII gene. Angioedema attacks and mediator of swelling in acquired C1INH deficiency are similar to those in type I or II HAE; however, it occurs on a sporadic basis because of excessive consumption of C1INH in patients who are middle aged or older. ACE inhibitor–associated angioedema should always be considered in any patient taking an ACE inhibitor who experiences angioedema. ACE is a kininase, which when inhibited is thought to result in increased bradykinin levels. Bradykinin acts on vascular endothelial cells to enhance vascular permeability. Conclusion Laryngeal swelling is not infrequently encountered in bradykinin-mediated angioedema. Novel therapies are becoming available that for the first time provide effective treatment for bradykinin-mediated angioedema. Because the characteristics and treatment of these angioedemas are quite distinct from each other and from histamine-mediated angioedema, it is crucial that the physician be able to recognize and distinguish these swelling disorders.
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Affiliation(s)
- Bruce L. Zuraw
- Department of Medicine, University of California, San Diego, and San Diego Veteran's Affairs Medical Center, La Jolla, California
| | - Sandra C. Christiansen
- Department of Allergy, Kaiser Permanente and University of California, San Diego, California
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31
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Ferraro MF, Moreno AS, Castelli EC, Donadi EA, Palma MS, Arcuri HA, Lange AP, Bork K, Sarti W, Arruda LK. A single nucleotide deletion at the C1 inhibitor gene as the cause of hereditary angioedema: insights from a Brazilian family. Allergy 2011; 66:1384-90. [PMID: 21623829 DOI: 10.1111/j.1398-9995.2011.02658.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hereditary angioedema is an autosomal dominant disease characterized by episodes of subcutaneous and submucosal edema. It is caused by deficiency of the C1 inhibitor protein, leading to elevated levels of bradykinin. More than 200 mutations in C1 inhibitor gene have been reported. The aim of this study was to analyze clinical features of a large family with an index case of hereditary angioedema and to determine the disease-causing mutation in this family. METHODS Family pedigree was constructed with 275 individuals distributed in five generations. One hundred and sixty-five subjects were interviewed and investigated for mutation at the C1 inhibitor gene. Subjects reporting a history of recurrent episodes of angioedema and/or abdominal pain attacks underwent evaluation for hereditary angioedema. RESULTS We have identified a novel mutation at the C1 inhibitor gene, c.351delC, which is a single-nucleotide deletion of a cytosine on exon 3, resulting in frameshift with premature stop codon. Sequencing analysis of the hypothetical truncated C1 inhibitor protein allowed us to conclude that, if transcription occurs, this protein has no biological activity. Twenty-eight members of the family fulfilled diagnostic criteria for hereditary angioedema and all of them presented the c.351delC mutation. Variation in clinical presentation and severity of disease was observed among these patients. One hundred and thirty-seven subjects without hereditary angioedema did not have the c.351delC mutation. CONCLUSION The present study provides definitive evidence to link a novel genetic mutation to the development of hereditary angioedema in patients from a Brazilian family.
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Affiliation(s)
- M F Ferraro
- Department of Pediatrics, School of Medicine of Ribeirão Preto, University of São Paulo, Brazil
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32
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Les angioedèmes à bradykinine. Ann Dermatol Venereol 2011; 138:328-35; quiz 327, 336. [DOI: 10.1016/j.annder.2010.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 11/26/2010] [Accepted: 12/20/2010] [Indexed: 11/20/2022]
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33
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Vitrat-Hincky V, Gompel A, Dumestre-Perard C, Boccon-Gibod I, Drouet C, Cesbron JY, Lunardi J, Massot C, Bouillet L. Type III hereditary angio-oedema: clinical and biological features in a French cohort. Allergy 2010; 65:1331-6. [PMID: 20384613 DOI: 10.1111/j.1398-9995.2010.02368.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hereditary angio-oedema (HAE) has been associated with C1inhibitor deficiency. The first cases of type III HAE were described in patients with normal C1Inh antigenic protein level and function and normal C4 levels in 2000. This finding has been reported mostly in women with a family history and may be influenced by exogenous oestrogen exposure. OBJECTIVES The purpose of this article is to describe the clinical, biological and genetic characteristics of a French population suffering from type III HAE. PATIENTS AND METHODS We conducted a retrospective analysis of angio-oedema (AE) cases seen in the National Reference Centre of AE between 2000 and 2009. RESULTS We found 26 patients (from 15 unrelated families) with type III HAE. All but four were women and presented with typical AE attacks, exacerbated by pregnancy or oral contraceptives containing oestrogens (OC). We also found that 54.5% of women were worsened with oestrogen and 23% were oestrogen dependent. All patients improved on long-term prophylactic tranexamic acid treatment; some acute attacks improved with C1Inh concentrate infusion. All of the patients had normal C1Inh and C4 levels. C1Inh function was also normal, except in women receiving OC or during a pregnancy: transient, moderately low levels (32-74% of the normal range) were found in 18 patients tested (67%). No SERPING1 gene mutation was found. Six patients from three unrelated families were heterozygous for an F12 gene variant. CONCLUSION Diagnosis of type III HAE should be based on clinical (typical attacks, often hormonally influenced), laboratory (normal C1Inh antigenic protein) and genetic (F12 gene mutation) evidence.
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Affiliation(s)
- V Vitrat-Hincky
- Internal Medicine Department, University Hospital of Grenoble, Grenoble, France
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Ebo DG, Verweij MM, De Knop KJ, Hagendorens MM, Bridts CH, De Clerck LS, Stevens WJ. Hereditary angioedema in childhood: an approach to management. Paediatr Drugs 2010; 12:257-68. [PMID: 20593909 DOI: 10.2165/11532590-000000000-00000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Hereditary angioedema (HAE) is an inherited disorder characterized by recurrent, circumscribed, non-pitting, non-pruritic, and rather painful subepithelial swelling of sudden onset, which fades during the course of 48-72 hours, but can persist for up to 1 week. Lesions can be solitary or multiple, and primarily involve the extremities, larynx, face, esophagus, and bowel wall. Patients with HAE experience angioedema because of a defective control of the plasma kinin-forming cascade that is activated through contact with negatively charged endothelial macromolecules leading to binding and auto-activation of coagulation factor XII, activation of prekallikrein to kallikrein by factor XIIa, and cleavage of high-molecular-weight kininogen by kallikrein to release the highly potent vasodilator bradykinin. Three forms of HAE have currently been described. Type I and type II HAE are rare autosomal dominant diseases due to mutations in the C1-inhibitor gene (SERPING1). C1-inhibitor mutations that cause type I HAE occur throughout the gene and result in truncated or misfolded proteins with a deficiency in the levels of antigenic and functional C1-inhibitor. Mutations that cause type II HAE generally involve exon 8 at or adjacent to the active site, resulting in an antigenically intact but dysfunctional mutant protein. In contrast, type III HAE (also called estrogen-dependent HAE) is characterized by normal C1-inhibitor activity. The diagnosis of HAE is suggested by a positive family history, the absence of accompanying pruritus or urticaria, the presence of recurrent gastrointestinal attacks of colic, and episodes of laryngeal edema. Estrogens may exacerbate attacks, and in some patients attacks are precipitated by trauma, inflammation, or psychological stress. For type I and type II HAE, diminished C4 concentrations are highly suggestive for the diagnosis. Further laboratory diagnosis depends on demonstrating a deficiency of C1-inhibitor antigen (type I) in most kindreds, but some kindreds have an antigenically intact but dysfunctional protein (type II) and require a functional assay to establish the diagnosis. There are no particular laboratory findings in type III HAE. Prophylactic administration of either 17alpha-alkylated androgens or synthetic antifibrinolytic agents has proven useful in reducing the frequency or severity of attacks. Plasma-derived C1-inhibitor concentrate, recombinant C1-inhibitor, ecallantide (DX88; a plasma kallikrein inhibitor) and icatibant (a bradykinin B(2) receptor antagonist) have demonstrated significant efficacy in the treatment of acute attacks, whereas the C1-inhibitor concentrate has also provided a significant benefit as long-term prophylaxis. However, these drugs are not licensed in all countries and are not always readily available.
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Affiliation(s)
- Didier G Ebo
- Department of Immunology, Allergology and Rheumatology, University Hospital Antwerp, Antwerp University, Universiteitsplein 1, Antwerp, Belgium
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35
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Binkley KE. Factor XII mutations, estrogen-dependent inherited angioedema, and related conditions. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2010; 6:16. [PMID: 20667119 PMCID: PMC2920236 DOI: 10.1186/1710-1492-6-16] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Accepted: 07/28/2010] [Indexed: 11/10/2022]
Abstract
The clinical, biochemical and genetic features of the conditions known as estrogen-dependent inherited angioedema, estrogen-associated angioedema, hereditary angioedema with normal C-1 inhibitor, type III angioedema, or factor XII angioedema are reviewed. Discussion emphasizes pathogenesis, diagnosis, and management.
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Affiliation(s)
- Karen E Binkley
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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36
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Bouillet L. Hereditary angioedema in women. Allergy Asthma Clin Immunol 2010; 6:17. [PMID: 20667120 PMCID: PMC2918592 DOI: 10.1186/1710-1492-6-17] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 07/28/2010] [Indexed: 11/19/2022] Open
Abstract
Women with hereditary angioedema (HAE) are more likely to be symptomatic that men. Hormonal factors (puberty, contraception, pregnancy,....) play a significant role in the precipitation or worsening of the condition in women. So, combined contraceptive pills are not indicated and progestogen pill must be preferred. During pregnancy, attack rate can increase (38-48% of women). C1Inhibitor concentrate and tranexamic acid can be used during pregnancy. Attenuated androgens for long term prophylaxis are effective but side effects appear more often in female patients. These side effects are dose dependant and can be attenuated by titrating the dose down the lowest effective level.
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Affiliation(s)
- Laurence Bouillet
- National French Reference Centre of Angioedema, Internal Medicine Department, Grenoble University Hospital, France.
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37
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Bork K. Diagnosis and treatment of hereditary angioedema with normal C1 inhibitor. Allergy Asthma Clin Immunol 2010; 6:15. [PMID: 20667118 PMCID: PMC2919521 DOI: 10.1186/1710-1492-6-15] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 07/28/2010] [Indexed: 11/23/2022] Open
Abstract
Until recently it was assumed that hereditary angioedema is a disease that results exclusively from a genetic deficiency of the C1 inhibitor. In 2000, families with hereditary angioedema, normal C1 inhibitor activity and protein in plasma were described. Since then numerous patients and families with that condition have been reported. Most of the patients by far were women. In many of the affected women, oral contraceptives, hormone replacement therapy containing estrogens, and pregnancies triggered the clinical symptoms. Recently, in some families mutations in the coagulation factor XII (Hageman factor) gene were detected in the affected persons.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Mainz, Germany.
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38
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Abstract
Bradykinin angioedema (AE) are characterized by acute recurrent episodes of localized swelling. They are not associated with pruritus or erythema, and are short-lived (24 to 72 hours), disappearing without any sequelae. Corticosteroids are useless. Skin or mucous membranes (upper respiratory and intestinal) could be affected. Bradykinin AE can be secondary to: (1) AE associated with C1 inhibitor deficiency (hereditary or acquired); (2) drug-induced AE (converting enzyme inhibitors…); (3) type III AE type (oestrogen dependant) without C1 inhibitor deficiency. These type III AE can be associated with a gain of function mutation that markedly increases factor XII activity. Prognosis depends on the laryngeal attacks (resulting in 25 % of death in the absence of specific treatment). In case of severe attacks, icatibant (bradykinin receptor antagonist) or C1 inhibitor concentrate can be used. In case of frequent attacks, long-term therapy with danazol or tranexamic acid is effective.
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39
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Obstetrical Complications and Outcome in Two Families with Hereditary Angioedema due to Mutation in the F12 Gene. Obstet Gynecol Int 2010; 2010:957507. [PMID: 20490261 PMCID: PMC2871183 DOI: 10.1155/2010/957507] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 03/16/2010] [Accepted: 03/16/2010] [Indexed: 11/21/2022] Open
Abstract
Backgroud. Hereditary angioedema (HAE) is characterized by recurrent swelling of the skin, the abdomen (causing severe acute pain), and the airways. A recently discovered type caused by mutations in the factor XII gene (designated as HAE type III) occurs mainly in women. Estrogens may play an important role, but few obstetrical complications have been reported. Case. We report the symptoms and obstetrical complications of women in two families with HAE attributable to the p. Thr328Lys mutation in the F12 gene. Clinical manifestations included acute and severe maternal abdominal pain, with transient ascites, laryngeal edema, and fetal and neonatal deaths. Patients had normal C4 levels and a normal C1 inhibitor gene. Administration of C1-inhibitor concentration twice monthly decreased the attack rate in one mother, and its predelivery administration (1000 U) led to the delivery of healthy girls. Conclusions. Obstetricians and anesthesiologists should be aware of this rare cause of unexplained maternal ascites and in utero or fetal death associated with edema.
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De Knop KJ, Hagendorens MM, Stevens WJ, De Clerck LS, Ebo DG. Angioedema beyond histamine: an educational case series. Acta Clin Belg 2009; 64:520-8. [PMID: 20101876 DOI: 10.1179/acb.2009.089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Angioedema constitutes an important clinical problem that can cause significant morbidity and mortality. Correct management requires a prompt recognition and treatment of the acute event and identification of the underlying cause. Many cases are caused by non-allergic reactions and do not result from mediator release by degranulating mast cells and basophils, but are related to accumulation of plasma and tissue bradykinin. This case series aims primarily to describe some important causes of non-allergic bradykinin-induced angioedema. Particular emphasis is put on clinical particularities, differential diagnosis, diagnostic approach and correct therapeutic management, as bradykinin-mediated angioedema is unresponsive to antihistamines.
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Affiliation(s)
- K J De Knop
- Department of Immunology, Allergology, Rheumatology University Hospital Antwerp, University Antwerp, Belgium
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41
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Abstract
Until recently, it was assumed that hereditary angioedema was a disease resulting exclusively from a genetic deficiency of the C1 inhibitor. In 2000, families with hereditary angioedema, normal C1 inhibitor activity, and protein in plasma were described. Since then, numerous patients and families with this condition have been reported. Most of the patients were women. In many of the affected women, oral contraceptives, hormone replacement therapy containing estrogens, and pregnancies triggered the clinical symptoms. In some families, mutations in the coagulation factor XII (Hageman factor) gene were detected in the affected persons.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Mainz, Germany.
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Bork K, Wulff K, Hardt J, Witzke G, Staubach P. Hereditary angioedema caused by missense mutations in the factor XII gene: Clinical features, trigger factors, and therapy. J Allergy Clin Immunol 2009; 124:129-34. [DOI: 10.1016/j.jaci.2009.03.038] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 03/05/2009] [Accepted: 03/27/2009] [Indexed: 10/20/2022]
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43
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Grigoriadou S, Longhurst HJ. Clinical Immunology Review Series: An approach to the patient with angio-oedema. Clin Exp Immunol 2009; 155:367-77. [PMID: 19220828 DOI: 10.1111/j.1365-2249.2008.03845.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Angio-oedema is a common reason for attendance at the accident and emergency department and for referral to immunology/allergy clinics. Causative factors should always be sought, but a large proportion of patients have the idiopathic form of the disease. A minority of patients represent a diagnostic and treatment challenge. Failure to identify the more unusual causes of angio-oedema may result in life-threatening situations. Common and rare causes of angio-oedema will be discussed in this article, as well as the diagnostic and treatment pathways for the management of these patients. A comprehensive history and close monitoring of response to treatment are the most cost-effective diagnostic and treatment tools.
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Affiliation(s)
- S Grigoriadou
- Barts and The London NHS Trust, Royal London Hospital, London, UK
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44
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Patel NN, Patel DN. Hereditary angioedema with normal C1 inhibitor. Am J Med 2008; 121:949-51. [PMID: 18954838 DOI: 10.1016/j.amjmed.2008.06.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Revised: 05/14/2008] [Accepted: 06/12/2008] [Indexed: 11/19/2022]
Affiliation(s)
- Nilesh N Patel
- Department of Medicine, Citrus Valley Medical Centers, West Covina, CA 91791, USA.
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45
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Drouet C, Ponard D, Monnier N, Lunardi J, Bosson JL. Classification et diagnostic biologique des angioedèmes. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.allerg.2008.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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46
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47
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Wagenaar-Bos IG, Drouet C, Aygören-Pursun E, Bork K, Bucher C, Bygum A, Farkas H, Fust G, Gregorek H, Hack CE, Hickey A, Joller-Jemelka HI, Kapusta M, Kreuz W, Longhurst H, Lopez-Trascasa M, Madalinski K, Naskalski J, Nieuwenhuys E, Ponard D, Truedsson L, Varga L, Nielsen EW, Wagner E, Zingale L, Cicardi M, van Ham SM. Functional C1-Inhibitor diagnostics in hereditary angioedema: Assay evaluation and recommendations. J Immunol Methods 2008; 338:14-20. [DOI: 10.1016/j.jim.2008.06.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Revised: 05/07/2008] [Accepted: 06/30/2008] [Indexed: 10/21/2022]
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48
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Serrano C, Guilarte M, Tella R, Dalmau G, Bartra J, Gaig P, Cerdà M, Cardona V, Valero A. Oestrogen-dependent hereditary angio-oedema with normal C1 inhibitor: description of six new cases and review of pathogenic mechanisms and treatment. Allergy 2008; 63:735-41. [PMID: 18070231 DOI: 10.1111/j.1398-9995.2007.01579.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hereditary angio-oedema (HAE) is a rare condition in which there is a deficiency in the quantity or activity of C1 inhibitor (C1INH). Recently, an additional type of HAE with no alterations in the levels or the function of C1INH has been reported. It is defined as HAE with normal C1INH, and named type III HAE or oestrogen-dependent HAE. The aim of this study is to describe the clinical and laboratory findings of six new cases of type III HAE and to review the literature about this disease. METHODS A short description of six women with recurrent angio-oedema is provided. The characteristics of the patients are compared with the previously reported case series in a literature-based review. RESULTS The mean age of the patients at onset was 22 years (range 16-30). All of them had angio-oedema attacks during oestrogen-based contraceptive treatment and four reported episodes during pregnancy. Four patients reported a positive past family history. Two of them had experienced episodes of laryngeal oedema. None of the patients responded to corticoids or antihistamines during the attacks. Levels and functional activity of C1INH were within the normal range in all cases. CONCLUSIONS Clinical and laboratory findings mirror the observations of previous reports of oestrogen-dependent angio-oedema with normal C1INH. This is the first published series of type III HAE in Spain.
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Affiliation(s)
- C Serrano
- Unidad de Alergia, Hospital Clínic, Barcelona, Spain
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49
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Zuraw BL. Hereditary angiodema: a current state-of-the-art review, IV: short- and long-term treatment of hereditary angioedema: out with the old and in with the new? Ann Allergy Asthma Immunol 2008; 100:S13-8. [PMID: 18220147 DOI: 10.1016/s1081-1206(10)60581-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To provide a context to understand the opportunity for novel therapeutic modalities to transform the treatment of hereditary angioedema (HAE). DATA SOURCES MEDLINE and PubMed were searched to identify studies involving current treatment of HAE in the United States. STUDY SELECTION Studies were selected based on their relevance to the treatment of HAE. RESULTS The current HAE treatment strategy is far from satisfactory, and its limitations create an unmet clinical need. Current prophylactic treatment exposes patients with HAE to significant risk of adverse effects, and the efficacy of prophylactic treatment, although generally good, is far from perfect. CONCLUSIONS No specific treatment is currently available in the United States for acute HAE attacks that will reliably work, resulting in a significant unmet clinical need. The emergence of several promising drugs for the treatment of HAE attacks is, thus, an extraordinarily important development in the management of these patients.
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Affiliation(s)
- Bruce L Zuraw
- Veterans Affairs Medical Center, San Diego, California, USA.
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50
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Merk HF. [Angioedema]. Hautarzt 2007; 58:1041-5. [PMID: 18004529 DOI: 10.1007/s00105-007-1440-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Angioedema can be a symptom of anaphylaxis; it may be more hazardous that the circulatory collapse in otherwise healthy patients. Angioedema can be part of IgE- and histamine-mediated allergic reactions or part of NSAID-induced hypersensitivity with disturbances in arachidonic acid metabolism. If angioedema occurs without urticaria or other symptoms of anaphylaxis, it is usually mediated by increased bradykinin synthesis (HANE, EANE) or reduced metabolism (ACE inhibitors). These observations have led to new therapeutic approaches in HANE. Icatibant is a bradykinin-receptor-2 antagonist and blocks bradykinin-induced angioedema in HANE. How applicable this will be to ACE-inhibitor angioedema remains to be seen.
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Affiliation(s)
- H F Merk
- Universitäts-Hautklinik, RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
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