Repeated Subileus due to Angioedema During Renin-Angiotensin System Blockade

A 77-year-old man with membranous nephropathy was treated with triple blockade of the renin-angiotensin-aldosterone system and developed subileus six times in 5 months. The resection of his sigmoid colon uncovered angioedema. It should be noted that angiotensin-converting enzyme or angiotensin receptor blocker can cause angioedema of the intestine and induce subileus.

Development of multiple food allergies in children taking tacrolimus after heart and liver transplantation

Angioedema and chronic diarrhea in patients taking immunosuppressants are not always because of side effects and could be a new onset of food allergy. Our aim is to discuss the pathogenesis and treatment of the post-transplant development of food allergies. The first patient was receiving tacrolimus subsequent to heart transplantation and developed angioedema after consumption of dairy products at 12 months after transplantation. He was found to be allergic to multiple foods by both RAST and ImmunoCAP tests. The second patient with argininosuccinic aciduria, post-liver transplant, also received tacrolimus and developed chronic non-mucoid/bloody diarrhea at seven months following transplantation. ImmunoCAP test was positive only for egg white and peanuts. Biopsy showed eosinophilic infiltration of the mucosa from the stomach to the rectum. Elimination diets in both patients resolved the symptoms. These cases suggest a direct relationship between tacrolimus and development of food allergy.

Solar angioedema: an uncommonly recognized condition?

Solar urticaria is a well defined although uncommon photosensitivity disorder, and is said to be the underlying cause of chronic urticaria in approximately 0.5% cases. In contrast, solar angioedema is seldom reported. We describe two patients with postulated solar angioedema, associated with clinical and/or phototest features of solar urticaria. Recognition of solar provocation of angioedema has important consequences for patient management.

Soft Tissue Cervicofacial Emphysema After Dental Treatment

BACKGROUND

The development of soft tissue cervicofacial emphysema after dental treatment is a rare complication, with few descriptions in the dermatologic literature. It is usually restricted to only moderate local swelling. However, spread of larger amounts of air into deeper spaces may sometimes cause serious complications, including airway compromise due to accumulation of air in the retropharyngeal space, pneumomediastinum, and pneumopericardium. Fatal air embolism and soft tissue infections through dissemination of oral flora microorganisms along the emphysematous tracts have also been described. Therefore, early recognition is important, but the unfamiliarity of dermatologists with this condition often causes diagnostic problems. Important differential diagnoses include angioedema, soft tissue infections, and hematoma.

OBSERVATIONS

We describe 2 patients with different severity of the emphysema and airway compromise, representing the wide spectrum of its clinical expression. Our first case was remarkable, because the emphysema was massive and extended far into deep spaces, including the orbita, mediastinum, and pleural cavity. The present case is only the third report of pneumothorax associated with dental treatment published to date. The patient's condition was initially misdiagnosed and treated as angioedema.

CONCLUSIONS

Dermatologists should be aware that soft tissue emphysema can cause acute swelling of the cervicofacial region after dental procedures. Angioedema is an important differential diagnosis, because it may be caused by the use of nonsteroidal anti-inflammatory drugs or local anesthetics, which are often administered during dental treatments.

Life-threatening orolingual angioedema during thrombolysis in acute ischemic stroke

BACKGROUND

Orolingual angioedema can occur during thrombolysis with alteplase in stroke patients. However, data about its frequency, severity and the significance of concurrent use of angiotensin-converting-enzyme inhibitors (ACEi) are sparse.

OBJECTIVE

(1), to alert to the potentially life-threatening complication of orolingual angioedema. (2), to present CT-scans of the tongue which exclude lingual hematoma. (3), to estimate the frequency of orolingual angioedema. (4), to evaluate the risk associated with the concurrent use of ACEi.

METHODS

Single center, databank-based observational study on 120 consecutive patients with i. v. alteplase for acute stroke. Meta-analysis of all stroke studies on alteplase-associated angioedema, which provided detailed information about the use of ACE-inhibitors. Across studies, the Peto odds ratio of orolingual angioedema for "concurrent use of ACEi" was calculated.

RESULTS

Orolingual angioedema occurred in 2 of 120 patients (1.7%, 95% CI 0.2-5.9 %). Angioedema was mild in one, but rapidly progressive in another patient. Impending asphyxia prompted immediate intubation. CT showed orolingual swelling but no bleeding. One of 19 (5%) patients taking ACEi had orolingual angioedema, compared to 1 of 101 (1%) patients without ACEi. Medline search identified one further study about the occurrence of alteplase-associated angioedema in stroke patients stratified to the use of ACEi. Peto odds ratio of 37 (95 % CI 8-171) indicated an increased risk of alteplasetriggered angioedema for patients with ACEi (p <0.001).

CONCLUSION

Orolingual angioedema is a potentially life-threatening complication of alteplase treatment in stroke patients, especially in those with ACEi. Orolingual hematoma as differential diagnosis can be excluded by CT-scan.

[Reticular erythema signalling the onset of episodes of hereditary angioedema in a child]

INTRODUCTION

Hereditary angioedema is characterized by episodes of subcutaneous, digestive or laryngeal edema. In some cases, non-pruritic reticular erythema may precede the episodes of edema.

OBSERVATION

Every 4 to 6 weeks since infancy, a girl presented non-pruritic widespread reticular erythema, sparing the face. Two or three times every year, abdominal pain or edema of the lower limb joints followed the skin eruption. At 12 years of age, she was hospitalized because of an edema of the face associated with the eruption. Exploration of the complement confirmed the diagnosis of type I hereditary angioedema.

DISCUSSION

The mean delay before diagnosis of hereditary angioedema is of 7 years. Reticular erythema in hereditary angioedema is frequent (40p. 100 of cases) and it usually occurs early in childhood, even in the absence of any episode of angioedema. When present, these eruptions usually precede an episode of angioedema. Recognition of this eruption as a symptom of hereditary angioedema would shorten the delay before diagnosis and anticipate appropriate management of the episodes.

Angioedema acute hypersensitivity reaction to injectable hyaluronic acid

BACKGROUND

Injectable hyaluronic acid was introduced to European markets in 1996 and has demonstrated a high safety profile. We describe the first reported case of angioedema-type hypersensitivity following injection of the upper lip with non-animal-stabilized hyaluronic acid (NASHA) gel.

OBJECTIVE

To report a case and discuss a potential mechanism for and treatment of angioedema-type hypersensitivity following injection with NASHA gel into the upper lip.

METHODS AND MATERIALS

Not applicable.

RESULTS

Not applicable.

CONCLUSION

Although injectable hyaluronic acid has a high safety profile, this reaction is dramatic. Treatments and potential mechanisms are discussed.

Cutaneous Manifestations as Presenting Sign of Autoimmune Lymphoproliferative Syndrome in Childhood

Autoimmune lymphoproliferative syndrome is a disorder due to a defect of lymphocyte apoptosis, whose clinical manifestations consist of hyperplasia of lymphoid tissues and autoimmune diseases. We report on a 26-month-old child who presented with frequent eruptions of weals and angioedema without any apparent triggering factor, who subsequently developed an erythematopapular rash with a histological pattern of a lymphoplasmacellular infiltrate. Familial anamnesis revealed a history of lymphoadenomegaly and massive spleen and liver enlargement in her sister. Functional and molecular analysis led to a diagnosis of type 1a autoimmune lymphoproliferative syndrome. Immunophenotyping of the cutaneous lesion revealed the presence of an inflammatory infiltrate with a considerably high number of Langerhans cells. Cutaneous features such as urticaria, angioedema and vasculitis in children with a personal and familial history of hyperplasia of lymphoid tissues may be a presenting sign of a systemic disease, such as autoimmune lymphoproliferative syndrome.

Non-rheumatoid erosive arthritis associated with type I hereditary angioedema

Hereditary angioedema (HAE) is an autosomal dominant disease that causes recurrent attacks of non-pitting edema of soft tissues, without pruritus. This disorder can also affect internal organs. The cause of HAE consists in quantitative or qualitative defective production of C1 inhibitor (C1-INH). Many autoimmune diseases such as systemic lupus erythematosus (SLE) (or SLE-like syndromes), Sjögren's syndrome, scleroderma, thyroiditis, glomerulonephritis, and inflammatory bowel disease have been described in patients suffering from HAE. A concomitance with pure arthritis was previously reported only in two adult patients. Here, we describe for the first time the association between HAE and a non-rheumatoid erosive oligoarthritis involving hips and wrists.

Immunosuppressive Therapy with Everolimus Can Be Associated with Potentially Life-Threatening Lingual Angioedema

Everolimus has recently received approval for immunosuppressive therapy in heart transplant recipients in Austria and Germany. At our heart center we have treated 114 patients with everolimus since January 2004. Here we describe 6 cases of lingual angioedema (corresponding to 5.3% of the patients). Symptoms occurred within 2 to 41 days after initiation of therapy. In 5 out of the 6 patients, lingual angioedema disappeared with anti-allergic treatment alone. However, in one patient, two severe recurrent episodes of lingual angioedema occurred so that therapy had to be discontinued. We conclude that the potentially life-threatening condition of lingual angioedema should be considered a severe drug reaction after initiation of everolimus therapy in heart transplant recipients.

Lymphoma-associated paraneoplastic angioedema with normal C1-inhibitor activity: does danazol work?

A patient with splenic marginal zone lymphoma presented with severe, symptomatic acquired angioedema. Unlike previously reported cases, his serum levels of complement and C1 inhibitor (C1-INH) were not decreased. Nonetheless, he responded clinically to treatment with an attenuated androgen and, after therapeutic splenectomy, has been maintained asymptomatic without androgen therapy for 5 years. Thus stimulation of C1-INH synthesis may overcome paraneoplastic angioedema in patients with lymphoproliferative disorders despite the absence of typical evidence for a quantitative or qualitative defect in C1-INH. Androgens should not be withheld despite a normal level of C1-INH and complement in symptomatic patients.

Airway Compromise Due to Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema

STUDY OBJECTIVE

To evaluate the incidence of airway compromise, clinical presentation and morbidity of angiotensin-converting enzyme inhibitor (ACEI)-related angioedema (AE).

METHOD

A retrospective chart review was conducted of all patients admitted to our hospital between 1996 and 2001 with the diagnosis of AE.

RESULTS

A total of 70 charts on which a diagnosis of AE had been entered were reviewed. Of those, 45 patients (64%) had AE that was thought to be related to ACEI therapy. Of those 45 patients, 29 were women. The mean age was 62 years, and 41 (91%) were African-American. The duration of ACEI therapy before presentation varied from 1 day to 5 years postingestion. Twenty-one of 32 patients presented within 2 months of the initiation of therapy. The mean duration between the onset of symptoms and presentation to the hospital was 9 h. Lip and tongue swelling was seen in all patients. Pulmonary manifestations were noted in 17 of 45 patients (38%) [dyspnea 17 of 17 patients; stridor/respiratory failure, 5 of 17 patients; cough, 2 of 17 patients]. Dysphagia was noted in 9 of 45 patients, drooling of saliva in 8 of 45 patients, and pruritus in 6 of 45 patients. Ten of 45 patients had a history of AE. In five of those patients (50%), ACEI use was a presumed cause of the AE for the current hospital admission. Eighteen of 45 (40%) patients required ICU admission. The mean ICU length of stay was 2.2 days. Five of 45 patients required endotracheal intubation. The mean time spent receiving ventilation was 2.2 days. Discontinuation of the initiating agent and supportive care were the keys to therapy. All of our patients responded to supportive management, and there was no mortality.

CONCLUSION

Sixty-four percent of patients in this series had AE due to receiving an ACEI. The majority of the patients were African-American women. Most patients presented within 2 months of starting to receive the drug, although longer durations of therapy were not uncommon. Lip and tongue swelling was the most common airway manifestation. Based on our observations, the discontinuation of ACEI therapy and supportive management are the recommended approaches to therapy to prevent an untoward outcome.

Life threatening tongue angioedema associated with an angiotensin-converting enzyme inhibitor

We present a case with angioedema of the tongue, following 1 dose of an angiotensin-converting enzyme (ACE) inhibitor ingestion. A gradual progression of angioedema required tracheotomy despite aggressive medical treatment and illustrates the severity of this adverse reaction. Although ACE inhibitors are considered safe, emergency physicians should be alert for minor angioedema at presentation that may progress to life threatening airway compromise.

The pathogenesis of hereditary angioedema

Hereditary angioedema (HAE), which is characterized by episodic localized angioedema of the skin or mucosa, results from heterozygous deficiency of the plasma protease inhibitor, C1 inhibitor (C1INH). The most obvious biologic role of C1INH, therefore, is prevention of excessive vascular permeability. A variety of data indicate that this role is primarily a product of regulation of the contact system proteases, factor XIIa and plasma kallikrein. The C1INH deficient mouse, although it does not have episodes of cutaneous angioedema, does have increased vascular permeability which is reversed by treatment with C1INH, with the plasma kallikrein inhibitor, DX88, and with the bradykinin 2 receptor (Bk2R) antagonist, Hoe140. In addition, mice deficient in both C1INH and the Bk2R do not have increased vascular permeability. These analyses strengthen the argument that angioedema is mediated by bradykinin. This mouse also provides a system to test new potential therapeutic approaches. In addition to its role in the regulation of vascular permeability, C1INH also is an important modulator of inflammatory responses via regulation of activation of both the contact and the complement systems, and very likely via activities unrelated to protease inhibition.

Sudden upper airway obstruction in patients with hereditary angioedema

Hereditary angioedema (HAE) is clinically characterized by recurrent and self-limiting skin, intestinal, and life-threatening laryngeal edema. This study describes the age at which laryngeal edema first occurred, the time between onset and full development, and the effectiveness of therapy and prophylaxis in 123 HAE patients. 61 (49.7%) patients experienced a total of 596 laryngeal edema episodes. The ratio of laryngeal edema episodes to skin swellings and abdominal pain attacks was approximately 1:70:54 in patients who had laryngeal edema. The mean (SD) age at the first laryngeal edema was 26.2 (15.3) years. Nearly 80% of the laryngeal edemas occurred between age 11 and 45. The mean interval between onset and maximum development of laryngeal edema was 8.3 hours. A total of 354 laryngeal edemas cleared spontaneously without treatment and 208 laryngeal edemas were successfully treated with C1 inhibitor concentrate. Despite long-term prophylactic treatment with danazol, 6 patients developed subsequent laryngeal edemas. Laryngeal edema may occur at any age, although young adults are at greatest risk. In adults, the interval between onset of symptoms and acute risk of asphyxiation is usually long enough to allow for use of appropriate emergency procedures. It is essential to instruct patients and their relatives about the first signs of laryngeal edemas and the necessary procedures to follow.

Hypocomplementemic urticarial vasculitis with angioedema, a rare presentation of systemic lupus erythematosus: rapid response to rituximab

We report a case of hypocomplementemic urticarial vasculitis and recurrent angioedema in a patient with systemic lupus erythematosus unresponsive to mycophenolate mofetil, high-dose methylprednisolone, and intravenous immunoglobulin that responded rapidly to rituximab. Rituximab is a monoclonal antibody against CD20 transmembrane protein on the surface of mature and malignant B cells. No adverse effects occurred during or after therapy, and the patient was discharged from the hospital for outpatient rituximab infusion and follow-up care.

Angioneurotic edema of the upper airways and antihypertensive therapy

Angioneurotic edema is a non-pitting edema which is usually limited to the skin and the mucous membranes of the face and upper aerodigestive tract. The risk of acute upper airway obstruction makes angioneurotic edema a concern for emergency room physicians, internists and otolaryngologists because prompt recognition of the condition and immediate institution of therapy is essential for proper airway management. Angiotensin-converting enzyme (ACE) inhibitors have recently been associated with angioneurotic edema, the probable link being the reduction in angiotensin II and the potentiation of bradykinin, resulting in vasodilatation, increased vascular permeability and angioedema. We report four cases of acquired angioneurotic edema, which were probably related to ACE inhibitor use. These cases are discussed, including a review of the literature, methods of diagnosis, pathophysiology and treatment of angioedema. Care should be taken when antihypertensive ACE inhibitor treatments are started and patients should be warned of the potential risk of angioneurotic edema.

[Episodic angioedema associated with eosinophilia in relapsing erythema and swelling of the right thigh]

On March 16, 2000, a 37-year-old male was admitted to another hospital for fever, erythema of the limbs, and swelling of the right lower leg. The leukocyte count was 19,800/microliter, and the ratio of eosinophils was 61%, suggesting marked eosinophilia. Thoracic computed tomography (CT) revealed pneumonia in the left lung. However, the patient was negative for autoantibodies or parasitic antibodies. Administration of prednisolone at 80 mg/day resulted in a marked improvement of the symptoms and the eosinophilia. For diagnosis, detailed examination, and treatment, the patient was referred and admitted to our department on March 28. The dose of prednisolone was gradually decreased. On April 15, the agent was discontinued. Eosinophilia was not observed, however erythema of the limbs and swelling of the right lower leg recurred. Skin biopsy revealed in mild edema of the corium and eosinophilic infiltration, suggesting episodic angioedema associated with eosinophilia (EAE). In 1984, Greich et al. reported 4 patients with repeated angioedema, hives, and marked eosinophilia, and proposed the term EAE. Since then, more than 50 patients have been reported in Japan. Only 4 of these patients were males. We report on the present male patient together with the pathological findings.

Intravenous immunoglobulin therapy suppresses manifestations of the angioedema with hypereosinophilia syndrome

Angioedema with hypereosinophilia syndrome has a dramatic clinical presentation that may result from T-cell dysregulation and/or eosinophil dysfunction. Symptoms may be either episodic or persistent and are usually responsive to systemic glucocorticosteroid therapy. This diabetic patient had a dramatically severe presentation, responsive to high-dose steroids but relapsing when prednisone was tapered. To decrease his risks from long-term steroids, a therapeutic trial of intravenous immunoglobulin (IVIG) was tried, and a slow taper off of glucocorticosteroids achieved a prolonged remission. A brief recurrence and subsequent remission of eosinophilia and symptoms were associated with changes in the IVIG preparation lot and source. We conclude that some cases of angioedema with hypereosinophilia syndrome may be highly responsive to IVIG therapy and, furthermore, that specific sources and/or lots of IVIG may have significantly different immunoregulatory properties.

Retinal capillary angioma managed with trans-pupillary thermotherapy

Retinal capillary angioma is a tumour-like nodule of the retina and was first described in 1904 by von Hippel. This disease is characterised among the congenital syndromes known as the phakomatoses. It is the only known phakomatosis that does not exhibit skin lesions. A patient with retinal capillary angioma with leakage and haemorrhage is described and the differential diagnosis discussed. In addition, this patient was treated with trans-pupillary thermotherapy and the available therapies are summarised.

Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke

One hundred seventy-six consecutive patients treated with IV tissue plasminogen activator (tPA) for acute ischemic stroke were examined prospectively, and orolingual angioedema was found in nine (5.1%; 95% CI 2.3 to 9.5). The reaction was typically mild, transient, and contralateral to the ischemic hemisphere. Risk of angioedema was associated with angiotensin-converting enzyme inhibitors (relative risk [RR] 13.6; 95% CI 3.0 to 62.7) and signs on initial CT of ischemia in the insular and frontal cortex (RR 9.1; 95% CI 1.4 to 30.0).