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Karam JD, Boulu X, Hardy G, Buron Y. Stroke-like manifestations of angioedema: A case report and the identification of a novel mutation. Rev Neurol (Paris) 2024; 180:465-467. [PMID: 38042664 DOI: 10.1016/j.neurol.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 07/21/2023] [Accepted: 10/04/2023] [Indexed: 12/04/2023]
Affiliation(s)
- J-D Karam
- Internal Medicine and Infectious Diseases, Centre Hospitalier Intercommunal Compiègne-Noyon, Compiègne, France; Internal Medicine and RECIF, CHU of Amiens Picardie, Amiens, France.
| | - X Boulu
- Internal Medicine and Infectious Diseases, Centre Hospitalier Intercommunal Compiègne-Noyon, Compiègne, France; Internal Medicine and RECIF, CHU of Amiens Picardie, Amiens, France
| | - G Hardy
- Laboratory of Molecular Genetics, Centre Hospitalier Universitaire de Grenoble Alpes, Grenoble Alpes, France
| | - Y Buron
- Department of Neurology, Centre Hospitalier Intercommunal Compiègne-Noyon, Compiègne, France
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Castellino N, Dammino E, Scollo D, Russo A, Livia F, Neri S, Avitabile T, Giardino F. Vision loss due to atypical bilateral edema of the optic nerve in a patient with hereditary angioedema: A case report. Eur J Ophthalmol 2024; 34:NP122-NP126. [PMID: 38238930 DOI: 10.1177/11206721241228003] [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: 05/04/2024]
Abstract
PURPOSE To describe a rare case of vision loss due to bilateral edema of the optic nerve in a patient with Hereditary Angioedema, treated with prophylactic C1-esterase inhibitor. METHODS A 60-year-old Caucasian male affected by Hereditary Angioedema with unknown genetic defect (HAE- UNK) was admitted to our hospital presenting bilateral vision loss (best corrected visual acuity of 20/32 in the right eye and hand motion in the left eye) during an HAE attack. Intravenous administration of C1- esterase inhibitor (C1-INH, 1500 IU, Berinert, CSL Behring) determined the resolution of facial and periorbital swelling, however visual impairment persisted, in contrast with previous attacks experienced by the patient. Fundus examination revealed a vital optic disc without papilledema in both eyes. Magnetic resonance imaging (MRI) of the head and orbits showed bilateral edema of the optic nerve sheath. Treatment with intravenous and oral steroids was ineffective. Subsequently, a prophylactic treatment strategy with subcutaneous C1-esterase inhibitor was started (7000 IU every four days). RESULTS Complete regression of edema of the optic nerves was observed by imaging at two months of follow-up after chronic treatment with C1-esterase inhibitor (7000 IU every four days). Complete restoration of visual acuity was achieved (BCVA 20/20 in both eyes) and multimodal imaging of the optic nerves demonstrated the absence of anatomical and functional damage. CONCLUSION Patients affected by HAE may show atypical presentation with edema of the optic nerves without involvement of the optic nerve head. They may significantly benefit from prophylactic and chronic treatment with C1-esterase inhibitor.
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Affiliation(s)
| | - Edoardo Dammino
- Department of Ophthalmology, University of Catania, Catania, Italy
| | - Davide Scollo
- Department of Ophthalmology, University of Catania, Catania, Italy
| | - Andrea Russo
- Department of Ophthalmology, University of Catania, Catania, Italy
| | - Francesca Livia
- Department of Ophthalmology, University of Catania, Catania, Italy
| | - Sergio Neri
- Senior Consultant, Humanitas Istituto Clinico Catanese, Catania, Italy
| | | | - Francesco Giardino
- Department of Internal Medicine, University of Catania, Italian Network for Hereditary and Acquired Angioedema (ITACA), Catania, Italy
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Mormile I, Palestra F, Petraroli A, Loffredo S, Rossi FW, Spadaro G, de Paulis A, Bova M. Neurologic and Psychiatric Manifestations of Bradykinin-Mediated Angioedema: Old and New Challenges. Int J Mol Sci 2023; 24:12184. [PMID: 37569559 PMCID: PMC10419085 DOI: 10.3390/ijms241512184] [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: 06/27/2023] [Revised: 07/21/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
Neurologic manifestations have been occasionally described in patients with bradykinin-mediated angioedema. The existing literature is currently limited to case series and case reports mainly described in the hereditary forms (HAE) concerning central nervous system (CNS) involvement. On the contrary, very little is known about peripheral and autonomic nervous system manifestations. CNS involvement in HAE may present with symptoms including severe headaches, visual disturbance, seizures, and various focal and generalized deficits. In addition, a stroke-like clinical picture may present in HAE patients. In turn, some drugs used in patients with cardiovascular and neurologic disorders, such as recombinant tissue plasminogen activator (r-tPA) and angiotensin-converting enzyme inhibitors (ACEI), may produce medication-induced angioedema, resulting in a diagnostic challenge. Finally, most patients with HAE have higher levels of psychological distress, anxiety, and depression. With this review, we aimed to provide an organized and detailed analysis of the existing literature on neurologic and psychiatric manifestations of HAE to shed light on these potentially invalidating symptoms and lay the foundation for further personalized diagnostic pathways for patients affected by this protean disease.
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Affiliation(s)
- Ilaria Mormile
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.P.); (A.P.); (S.L.); (F.W.R.); (G.S.); (M.B.)
| | - Francesco Palestra
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.P.); (A.P.); (S.L.); (F.W.R.); (G.S.); (M.B.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Angelica Petraroli
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.P.); (A.P.); (S.L.); (F.W.R.); (G.S.); (M.B.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Stefania Loffredo
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.P.); (A.P.); (S.L.); (F.W.R.); (G.S.); (M.B.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
- Institute of Experimental Endocrinology and Oncology “G. Salvatore” (IEOS), National Research Council (CNR), Via S. Pansini 5, 80131 Naples, Italy
| | - Francesca Wanda Rossi
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.P.); (A.P.); (S.L.); (F.W.R.); (G.S.); (M.B.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.P.); (A.P.); (S.L.); (F.W.R.); (G.S.); (M.B.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Amato de Paulis
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.P.); (A.P.); (S.L.); (F.W.R.); (G.S.); (M.B.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Maria Bova
- Department of Translational Medical Sciences, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy; (I.M.); (F.P.); (A.P.); (S.L.); (F.W.R.); (G.S.); (M.B.)
- Center for Basic and Clinical Immunology Research (CISI), WAO Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
- UOC Medicina 2, A.O.R.N. “Antonio Cardarelli”, Via Antonio Cardarelli, 9, 80131 Naples, Italy
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Molina-Gil J, Azofra J, González-Fernández L. Hereditary angio-oedema with C1 inhibitor deficiency type I, an unusual stroke mimic. BMJ Case Rep 2022; 15:e249040. [PMID: 35393279 PMCID: PMC8990707 DOI: 10.1136/bcr-2022-249040] [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] [Accepted: 03/21/2022] [Indexed: 11/03/2022] Open
Abstract
Hereditary angio-oedema with C1 inhibitor deficiency (C1-INH-HAE) type I is a rare immune disorder characterised by a deficit of functional C1 esterase inhibitor (C1-INH). Recurrent C1-INH-HAE attacks typically present as generalised skin swelling and abdominal pain. Neurological involvement is very unusual, with a few reports of cephalea and recurrent dizziness. We describe a woman in her 30s diagnosed with C1-INH-HAE type I who was referred to the emergency department suffering from left hemisensory syndrome, with the initial suspicion of an ischaemic stroke. A few hours after hospital admission, she presented an acute attack of facial swelling and abdominal pain, receiving intravenous C1-INH concentrate with complete resolution of all symptoms, including neurological ones. A complete aetiological study ruled out a stroke. We pointed out that C1-INH-HAE attack can be an unusual stroke mimic that responds favourably to replacement therapy.
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Affiliation(s)
- Javier Molina-Gil
- Neurology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Julián Azofra
- Allergology and Immunology, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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Jacobs J, Neeno T. The importance of recognizing and managing a rare form of angioedema: hereditary angioedema due to C1-inhibitor deficiency. Postgrad Med 2021; 133:639-650. [PMID: 33993830 DOI: 10.1080/00325481.2021.1905364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The majority of angioedema cases encountered in clinical practice are histamine-mediated (allergic); however, some cases are bradykinin-related (non-allergic) and do not respond to standard anti-allergy medications. Among bradykinin-related angioedema, hereditary angioedema (HAE) is a rare, but chronic and debilitating condition. The majority of HAE is caused by deficiency (type 1) or abnormal function (type 2) of the naturally occurring protein, C1-inhibitor (C1-INH)-a major inhibitor of proteases in the contact (kallikrein-bradykinin cascade), fibrinolytic pathway, and complement systems. Failure to recognize HAE and initiate appropriate intervention can lead to years of pain, disability, impaired quality of life (QoL) and, in cases of laryngeal involvement, it can be life-threatening. HAE must be considered in the differential diagnosis of non-urticarial angioedema, particularly for patients with a history of recurrent angioedema attacks, family history of HAE, symptom onset in childhood/adolescence, prodromal signs/symptoms before swellings, recurrent/painful abdominal symptoms, and upper airway edema. Management strategies for HAE include on-demand treatment for acute attacks, short-term prophylaxis prior to attack-triggering events/procedures, and long-term or routine prophylaxis for attack prevention. Patients should be evaluated at least annually to assess need for routine prophylaxis. HAE specific medications like plasma-derived and recombinant C1-INH products, kallikrein inhibitors, and bradykinin B2 receptor antagonists, have improved management of HAE. While the introduction of intravenous C1-INH represented a major breakthrough in routine HAE prophylaxis, some patients fail to achieve adequate control and others have psychological barriers or experience complications related to intravenous administration. Subcutaneous (SC) C1-INH, SC monoclonal antibody (mAb)-based therapies, and an oral kallikrein inhibitor offer effective alternatives for HAE attack prevention and may facilitate self-administration. HAE management should be individualized, with QoL improvement being a key goal. This can be achieved with broader availability of existing options for routine prophylaxis, including greater global availability of C1-INH(SC), mAb-based therapy, oral treatments, and multiple on-demand therapies.
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Affiliation(s)
- Joshua Jacobs
- Department of Clinical Research, Allergy and Asthma Clinical Research, Inc., Walnut Creek, CA, USA
| | - Teresa Neeno
- Department of Internal Medicine, Northern CA VA Health Care System, Martinez Outpatient Clinic, Martinez, CA, USA
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Aktas ON, Chang J, Pappalardo AA. An unusual presentation of hereditary angioedema type II with amnesia, poor concentration, and headache. Ann Allergy Asthma Immunol 2020; 125:487-488. [PMID: 32565143 DOI: 10.1016/j.anai.2020.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/08/2020] [Accepted: 06/11/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Ozge Nur Aktas
- Department of Pediatrics, University of Illinois College of Medicine, Chicago, Illinois.
| | - Jandi Chang
- Department of Pediatrics, University of Illinois College of Medicine, Chicago, Illinois
| | - Andrea A Pappalardo
- Department of Pediatrics, University of Illinois College of Medicine, Chicago, Illinois; Department of Medicine, University of Illinois College of Medicine, Chicago, Illinois
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Abstract
A 41-year-old woman presented with recurrent dizziness. After an attack of dizziness, she felt edematous sensations in her hands. However, according to photographs taken during the attack, the edema on the back of the patient's hands and fingers appeared mild. Laboratory examinations revealed a low C4 and C1 inhibitor (INH) activity. A direct sequencing analysis of C1INH revealed a pathogenic gene mutation. Based on these results, she was diagnosed with hereditary angioedema (HAE) type 1. These findings indicate that HAE can cause recurrent dizziness, and it should therefore be included in the differential diagnosis in patients with recurrent neurologic symptoms, even in the absence of severe edema.
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Affiliation(s)
- Takashi Ando
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
| | - Ryouta Torii
- Department of Neurology, Kasugai Municipal Hospital, Japan
| | | | - Toshihiro Endo
- Department of Neurology, Kasugai Municipal Hospital, Japan
| | - Amane Araki
- Department of Neurology, Kasugai Municipal Hospital, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, Kyushu University Beppu Hospital, Japan
| | - Shinichi Terao
- Department of Neurology, Kasugai Municipal Hospital, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Japan
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Farfara D, Feierman E, Richards A, Revenko AS, MacLeod RA, Norris EH, Strickland S. Knockdown of circulating C1 inhibitor induces neurovascular impairment, glial cell activation, neuroinflammation, and behavioral deficits. Glia 2019; 67:1359-1373. [PMID: 30882931 DOI: 10.1002/glia.23611] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 02/11/2019] [Accepted: 02/19/2019] [Indexed: 12/20/2022]
Abstract
The cross-talk between blood proteins, immune cells, and brain function involves complex mechanisms. Plasma protein C1 inhibitor (C1INH) is an inhibitor of vascular inflammation that is induced by activation of the kallikrein-kinin system (KKS) and the complement system. Knockout of C1INH was previously correlated with peripheral vascular permeability via the bradykinin pathway, yet there was no evidence of its correlation with blood-brain barrier (BBB) integrity and brain function. In order to understand the effect of plasma C1INH on brain pathology via the vascular system, we knocked down circulating C1INH in wild-type (WT) mice using an antisense oligonucleotide (ASO), without affecting C1INH expression in peripheral immune cells or the brain, and examined brain pathology. Long-term elimination of endogenous C1INH in the plasma induced the activation of the KKS and peritoneal macrophages but did not activate the complement system. Bradykinin pathway proteins were elevated in the periphery and the brain, resulting in hypotension. BBB permeability, extravasation of plasma proteins into the brain parenchyma, activation of glial cells, and elevation of pro-inflammatory response mediators were detected. Furthermore, infiltrating innate immune cells were observed entering the brain through the lateral ventricle walls and the neurovascular unit. Mice showed normal locomotion function, yet cognition was impaired and depressive-like behavior was evident. In conclusion, our results highlight the important role of regulated plasma C1INH as it acts as a gatekeeper to the brain via the neurovascular system. Thus, manipulation of C1INH in neurovascular disorders might be therapeutically beneficial.
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Affiliation(s)
- Dorit Farfara
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, New York
| | - Emily Feierman
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, New York
| | - Allison Richards
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, New York
| | - Alexey S Revenko
- Department of Antisense Drug Discovery, IONIS Pharmaceuticals Inc., Carlsbad, California
| | - Robert A MacLeod
- Department of Antisense Drug Discovery, IONIS Pharmaceuticals Inc., Carlsbad, California
| | - Erin H Norris
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, New York
| | - Sidney Strickland
- Patricia and John Rosenwald Laboratory of Neurobiology and Genetics, The Rockefeller University, New York, New York
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Testori A, Melamed I. Neurologic manifestations of hereditary angioedema. Ann Allergy Asthma Immunol 2017; 118:119-120. [PMID: 28007084 DOI: 10.1016/j.anai.2016.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 10/13/2016] [Accepted: 10/20/2016] [Indexed: 11/18/2022]
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Iturri Clavero F, González Uriarte A, Tamayo Medel G, Martínez Ruíz A, Manuel Gamboa Setién P. [Some comments to the letter "Controversy to use icatibant for prophylaxis in angioedema"]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:544-545. [PMID: 26100456 DOI: 10.1016/j.redar.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 05/08/2015] [Indexed: 06/04/2023]
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
| | - A Martínez Ruíz
- Servicio de Anestesiología y Reanimación, Hospital Universitario de Cruces, Baracaldo, Vizcaya, España; Facultad de Medicina y Odontología HUC, Centro doctorado, Departamento de Cirugía, Radiología y Medicina Física, Universidad del País Vasco, Leioa, Vizcaya, España
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