Penile granulomatosis presenting as pseudoangioedema

Many conditions may present as angioedema. We report a case of a 46 year-old man presenting with intermittent episodes of penile swelling. Following a series of investigations, he was diagnosed with genital granulomatosis. Ano-genital granulomatosis is a rare chronic inflammatory condition and that can present as diffuse penile, scrotal, vulvar or ano-perineal swelling with non-caseating non-necrotising granulomas on histology.

Acute angioedema response to topical 5-fluorouracil therapy

This is a case report involving a patient who was treated with topical 5-FU cream and subsequently developed a severe case of angioedema. This case presents the possibility of anaphylaxis to topical 5-FU treatments and/or the interaction with angiotensin converting enzyme inhibitors. To our knowledge there has been no prior reported case of this reaction. We present this unusual case along with a review of the current literature on angioedema.

Various faces of Hansen's disease

Leprosy is a chronic granulomatous disease caused by Mycobacterium leproe. Leprosy once considered a taboo is still misdiagnosed and underdiagnosed. In many cases leprosy is treated as common disorders like psoriasis, pyoderma, angioedema, pre vitiligo. Leprosy can present in many diverse ways which can be confused with many treatable and non treatable, infectious and non infectious forms. Leprosy is considered on the verge of elimination. But Leprosy cases are being newly diagnosed day by day. Here we are presenting 4 atypical cases of leprosy which did not seem to have classical presentation but were diagnosed as leprosy when investigated.

Vanishing tumour of the colon ascendens due to acquired type II C1-inhibitor deficiency

We present a patient with recurrent bouts of angioedema of the lips, throat and extremities with a negative familial history for angioedema. Laboratory results confirmed an angioedema due to acquired C1-INH deficiency (or acquired angioedema, AAE). As AAE can result from underlying disease, further investigation toward malignancy was initiated. A CT-scan of the abdomen disclosed a circumferential tumour of the proximal segment of the colon ascendens which disappeared by the time an ileocolonoscopy was executed. Angioedema of the bowel has been widely reported in hereditary angioedema, whereas it is anecdotal in AAE.

[Facial angioedema after filler injections. Description of five cases]

The use of fillers for cosmetic purposes is becoming increasingly frequent. Although initially considered inert, these products produce adverse reactions around the injection site. We present 5 cases of women with a history of filler injections who presented a hard and persistent angioedema followed by local subcutaneous nodules. They were referred to the allergist for suspected allergy related angioedema without response to usual antihistamine treatment. The angioedema episodes initiated 27.6 months (range 1 to 48) after the fillers treatment. The patients underwent exacerbations and remissions of angioedema, partially relieved with oral steroids and, in 2 cases, local triamcinolone injections. Mean time from onset of symptoms to remission of angioedema was 8.75 months (range 1 to 24). Until October 2009 four patients continued into remission after 24.5 months (range 7 to 36) free of symptoms. One patient continued with exacerbations 11 months after the initial symptoms. Fillers may cause angioedema as an adverse event and should be considered in the differential diagnosis of persistent angioedema. They are only sensitive to steroid treatment and in some steroid dependent cases they respond to ciclosporin. The frequency of angioedema after filler injections among patients with angioedema in the Unit of Asthma Allergy and Clinical Immunology was 0.5%.

[Hypocomplementemic urticarial vasculitis syndrome. Successful therapy with intravenous immunoglobulins]

Autoimmune diseases can initially present as chronic urticaria. We describe the course of a patient with hypocomplementemic urticarial vasculitis syndrome (HUVS) as well as his successful treatment with high-dose intravenous immunoglobulins (IVIG). HUVS was diagnosed clinically and confirmed by histology and laboratory studies. After only one cycle with IVIG (2 g/kg) all HUVS symptoms were significantly decreased.

Angioneurotisches orolinguales Ödem nach rt-PA-Lyse eines Schlaganfalls

Angioneurotic orolingual edema associated with the use of rt-PA (recombinant tissue plasminogen activator) for systemic thrombolysis are described in the literature, but only as isolated case reports. Strangely, the rate of anaphylactic reactions to rt-PA is higher (1.9%) when they are used in the treatment of acute stroke than when they are given to treat acute myocardial infarction (0.02%). Patients who are taking ACE inhibitors seem to be at increased risk of such a potentially life-threatening event. We now report on two patients, in each of whom asymmetric angioneurotic edema was observed following successful thrombolysis with rt-PA. Both these patients were taking ACE inhibitors. It was possible to avoid intubation and ventilation in both cases. Therapy with ranitidine, clemastine, and a C1 esterase inhibitor resulted in the resolution of symptomatic angioneurotic edema within hours.

Urticaria and angio-oedema due to ziprasidone

Antipsychotic medications are commonLy associated with adverse cutaneous reactions (ACRs) in approximately 5% of patients. Angio-oedema accompanying urticaria is one of the most serious ACRs. The 36-year-old female patient who was diagnosed with ;Paranoid schizophrenia' 6 years ago, was commenced on ziprasidone 120 mg/day. On day 30 of the treatment, the patient presented urticarial papules and plaques all over the body and angio-oedema in the face. The patient was diagnosed as ;Urticaria + Angio-oedema'. The development of ACRs after the initation of ziprasidone monotherapy, disappearance of lesions after the discontinuation of this antipsychotic, and positive intradermal skin test all suggests a possible causal relationship between ACRs and ziprasidone. To our knowledge, this is the first reported case of urticaria and angio-oedema due to ziprasidone monotherapy. Ziprasidone is a valid and effective choice amongst antipsychotic medications, but this case calls for caution regarding ACRs at the time of prescribing.

C1 Inhibitor Serpin Domain Structure Reveals the Likely Mechanism of Heparin Potentiation and Conformational Disease

C1 inhibitor, a member of the serpin family, is a major down-regulator of inflammatory processes in blood. Genetic deficiency of C1 inhibitor results in hereditary angioedema, a dominantly inheritable, potentially lethal disease. Here we report the first crystal structure of the serpin domain of human C1 inhibitor, representing a previously unreported latent form, which explains functional consequences of several naturally occurring mutations, two of which are discussed in detail. The presented structure displays a novel conformation with a seven-stranded beta-sheet A. The unique conformation of the C-terminal six residues suggests its potential role as a barrier in the active-latent transition. On the basis of surface charge pattern, heparin affinity measurements, and docking of a heparin disaccharide, a heparin binding site is proposed in the contact area of the serpin-proteinase encounter complex. We show how polyanions change the activity of the C1 inhibitor by a novel "sandwich" mechanism, explaining earlier reaction kinetic and mutagenesis studies. These results may help to improve therapeutic C1 inhibitor preparations used in the treatment of hereditary angioedema, organ transplant rejection, and heart attack.

The deficiency of C1 inhibitor and its treatment

In this article, we review the traditional therapies of hereditary angioedema (HAE) that have been used for several years. Some of these therapies were proposed before the definition of the underlying defect and the understanding of the pathogenesis of the disease. We also describe new compounds under investigation at present as potential therapies for HAE. Two of these new therapies (a plasma-kallikrein inhibitor and a bradykinin B(2)-receptor antagonist) have been developed based on the understanding that the pathogenesis of symptoms was mainly due to kallikrein activation and bradykinin release.

[Practical management of C1 inhibitor deficiency]

C1 inhibitor deficiency is a rare syndrome clinically characterized by recurrent episodes of swelling of subcutaneous tissue or angioedema. It can involve the skin, upper respiratory airways and abdomen. There are two main types: hereditary and acquired. Angioedema can involve practically any part of the cutaneous surface, it can cause lethal laryngeal edema and can present as gastrointestinal obstruction. The attacks can be triggered, in general, by trauma, drugs or infections. Diagnosis is confirmed by decreased serum levels of C4 and absence or marked decrease of the level or function of C1 inhibitor. Commonly employed drugs for prophylaxis and treatment of these patients include anabolic steroids, antifibrinolytic agents, and infusion of C1 inhibitor concentrate. Fresh frozen plasma is an option to be considered for short term prophylaxis or treatment of the acute attack. It is convenient to know this syndrome as it is a potentially life-threatening disease. Diagnosis of this rare syndrome is based on clinical features and characteristic alterations of laboratory tests. The acute attack should be treated as quickly as possible. Prophylactic therapy is indicated in certain circumstances (dental procedures, oral surgery).

[Angioneurotic edema of the head and neck in association with ACE inhibitors]

BACKGROUND

ACE-inhibitors are said to cause angioneurotic edema. In spite of the fact that patients with acute angioedema of the head and neck region are usually admitted to an ENT department, there is only limited information available in the otorhinolaryngological literature on the frequency, risk of recurrent episodes and clinical significance of ACE inhibitor related angioedema.

MATERIAL AND METHODS

The medical histories of all patients admitted to our hospital due to acute angioneurotic edema during the period from 1 January 1988 to 31 December 2001 were reviewed. These were supplemented with the results of a standardized questionnaire filed out by the affected patients and of a non-affected control-group.

RESULTS

During the observation period. 121 patients were treated for acute angioneurotic edema of the head and neck region. In 34 patients (=28.1%), edema was related to permanent treatment with ACE inhibitors. The overall frequency of angioedema and the percentage of ACE inhibitor related angioedema showed a continuous increase during the study period. There was a latency from the beginning of ACE inhibitor treatment until the first manifestation of angioedema of up to 13 years. In comparison with the group of edema patients without ACE inhibitor treatment, we found a threefold risk of recurrent edema in the ACE group. Women were affected by recurrent episodes more often than men. Until now, any individual assessment of the probable risk of developing an angioneurotic edema during ACE inhibitor treatment appears to be impossible.

The therapeutic potential of a kallikrein inhibitor for treating hereditary angioedema

Hereditary angioedema (HAE) manifests as intermittent, painful attacks of submucosal oedema affecting the larynx, gastrointestinal tract or limbs. Currently, acute treatment is available in Europe but not USA, and requires intravenous administration of a pooled blood product. HAE is most likely caused by dysinhibition of the contact cascade, resulting in overproduction of bradykinin. DX-88 (ecallantide, Dyax Corp.) is a highly specific recombinant plasma kallikrein inhibitor that halts the production of bradykinin and can be dosed subcutaneously. In a placebo-controlled Phase II trial in patients with HAE, DX-88 resulted in significant improvement in symptoms compared with placebo. A Phase III trial is ongoing. This review explains the pathophysiology of HAE and the mechanism by which DX-88, a non-intravenous, nonplasma-derived therapy, might improve the disease, and discusses the clinical course of HAE and available treatments. Finally, it explores the potential value and efficacy of DX-88 in treating HAE.

Antihistamines in the treatment of chronic urticaria

Chronic urticaria is highly prevalent in the general population, and while there are multiple treatments for the disorder, the results obtained are not completely satisfactory. The second-generation H1 antihistamines remain the symptomatic treatment option of choice. Depending on the different pharmacokinetics and H1 receptor affinity of each drug substance, different concentrations in skin can be expected, together with different efficacy in relation to the histamine-induced wheal inhibition test--though this does not necessarily have repercussions upon clinical response. The antiinflammatory properties of the H1 antihistamines could be of relevance in chronic urticaria, though it is not clear to what degree they influence the final therapeutic result. Before moving on to another therapeutic level, the advisability of antihistamine dose escalation should be considered, involving increments even above those approved in the Summary of Product Characteristics. Physical urticaria, when manifesting isolatedly, tends to respond well to H1 antihistamines, with the exception of genuine solar urticaria and delayed pressure urticaria. In some cases of chronic urticaria, the combination of H2 antihistamines may prove effective--though only with common liver metabolism (CYP3A4 isoenzyme-mediated) H1 antihistamines, due to the existence of mutual metabolic interferences. The role of leukotriene antagonists associated to antihistamines in application to chronic urticaria remains to be clearly defined.

A case report of nonepisodic angioedema with eosinophilia in a Korean patient and a review of the Korean literature

Episodic angioedema with eosinophilia (EAE) is characterized by recurrent angioedema, peripheral eosinophilia, elevated serum IgM, fever, weight gain, and a benign course lacking any internal organ involvement. Dozens of cases of the nonepisodic variant (NEAE), which is limited to a single attack, have been reported in Japan. These NEAE cases normally have been less severe than the episodic type. In this paper, we describe the case of a Korean patient whose clinical and laboratory findings were consistent with NEAE, and review five other cases of EAE and NEAE reported in the Korean literature. The Korean NEAE cases outlined in this paper demonstrate that, as in Japan, NEAE is not uncommon in Korea, and also suggest that this disease exhibits a cultural predilection for Asian populations.

Angioedema without urticaria: a large clinical survey

BACKGROUND

Angioedema without major urticarial flares (hives) is poorly understood. Its causes are diverse, and little is known about its pathogenic mechanisms. We report on our 11 years of experience with this condition and propose a classification of patients affected by angioedema unaccompanied by urticaria.

METHODS

From 1993 through 2003 at our outpatient clinic, 929 consecutive patients were examined for recurrent angioedema unaccompanied by urticaria. A detailed history was taken to identify known causes of angioedema, with special attention to external allergenic agents. Each patient underwent a complete physical examination, routine laboratory tests (blood cell count, protein electrophoresis, erythrosedimentation rate, examination of stool for ova and parasites, pharyngeal and urine cultures, sinus and dental radiography, and measurements of antitissue autoantibodies and rheumatoid factor in plasma), and complement parameters (C1 inhibitor, C4 and C1q). Further testing was done when pertinent, based on clinical findings. When all results were negative, response to H1-antihistamine was considered.

RESULTS

Angioedema could not be classified in 153 patients who were lost to follow-up (16.4%). Among the 776 cases with adequate data, these types of angioedema were identified: 124 (16%) related to external agents such as a drug, insect bite or foodstuff; 85 (11%) related to treatment with angiotensin-converting enzyme inhibitor; 55 (7%) associated with an autoimmune disease or infection; and 197 (25%) caused by C1 inhibitor deficiency. In the other 315 cases (41%), the etiology was undiscovered: 254 cases (33% of the study sample) were idiopathic histaminergic; 40 (5%) were idiopathic nonhistaminergic; and 21 (3%) had other causes of peripheral or generalyzed edema.

INTERPRETATION

Our data indicated that angioedema without urticaria could be classified according to specific clinical and pathogenic characteristics, and we have suggested a work-up for patients experiencing this condition.