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Abstract
CONCLUSION Application of topical estriol ointment is an effective treatment for hereditary hemorrhagic telangiectasia (HHT) epistaxis. OBJECTIVE HHT is an autosomal-dominant disease characterized by epistaxis in more than 96% of patients. Management of this major symptom, epistaxis, has not been standardized. This study reports experience with topical application of estriol in patients with HHT. METHODS Five patients with a confirmed diagnosis of HHT who first visited the hospital between 2012 and 2013 received 0.1% estriol ointment and were guided to apply the ointment twice daily to the anterior part of both nasal cavities. Severity of epistaxis was valued using epistaxis severity score (ESS) before and 3 months after initiating therapy. RESULTS Five patients (three males, two females) received treatment. After the initiation of treatment, intensity and frequency of epistaxis became moderate in all patients. ESS decreased significantly from pre- to post-treatment (p = 0.043). No adverse events were recorded during follow-up.
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Affiliation(s)
- Kazuhiko Minami
- a Department of Head and Neck Surgery , Saitama Medical University International Medical Center , Hidaka , Saitama , Japan
| | - Tomoyuki Haji
- b Department of Communication Science and Disorders, Faculty of Health and Welfare , Prefectural University of Hiroshima , Mihara , Hiroshima , Japan
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152
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Ichimura K, Kikuchi H, Imayoshi S, Dias MS. Topical application of timolol decreases the severity and frequency of epistaxis in patients who have previously undergone nasal dermoplasty for hereditary hemorrhagic telangiectasia. Auris Nasus Larynx 2015; 43:429-32. [PMID: 26739947 DOI: 10.1016/j.anl.2015.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 10/21/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Hereditary hemorrhagic telangiectasia (HHT) is widely known to cause bleeding that is difficult to control because of the associated vascular wall fragility. Although nasal dermoplasty results in decreased severity and frequency of nasal bleeding in patients with HHT, it does not eradicate epistaxis because this procedure cannot cover the entire nasal cavity. Residual bleeding warrants additional effective therapy. Preliminary reports on the use of β-adrenergic blockers for treating epistaxis in patients with HHT encouraged us to examine their effects in HHT patients who had previously undergone nasal dermoplasty but still complained of epistaxis. METHODS We performed a prospective topical timolol, a nonselective beta blocker, application study involving 12 HHT patients who had undergone nasal dermoplasty. The observation period lasted for 3 months. RESULTS There was one improperly enrolled case in which timolol administration was discontinued. The mean score of bleeding intensity and that of bleeding frequency were markedly reduced after treatment. Two patients who had required transfusions before treatment did not need them afterward, and patients were generally satisfied with the treatment. CONCLUSION Topical timolol application was effective in decreasing epistaxis. Although no adverse effects were observed in the properly selected patients, there are contraindications to timolol application that should be kept in mind when applying this treatment.
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Affiliation(s)
- Keiichi Ichimura
- Department of Otolaryngology - Head and Neck Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi 329-0498, Japan; Ishibashi General Hospital, Shimotsuke, Tochigi 329-0596, Japan.
| | - Hisashi Kikuchi
- Department of Otolaryngology - Head and Neck Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi 329-0498, Japan
| | - Shoichiro Imayoshi
- Department of Otolaryngology - Head and Neck Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi 329-0498, Japan
| | - Mari Shimada Dias
- Department of Otolaryngology - Head and Neck Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi 329-0498, Japan
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153
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Mahfoudhi M, Khamassi K. [ Hereditary hemorrhagic telangiectasia: a diagnosis not to ignore]. Pan Afr Med J 2015; 22:40. [PMID: 26664541 PMCID: PMC4662539 DOI: 10.11604/pamj.2015.22.40.7871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/12/2015] [Indexed: 11/25/2022] Open
Affiliation(s)
- Madiha Mahfoudhi
- Service de Médecine Interne A, Hôpital Charles Nicolle, Tunis, Tunisie
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154
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Rajesh GN, Sajeer K, Nair A, Haridasan V, Sajeev CG, Krishnan MN. Device closure of pulmonary arteriovenous malformation using Amplatzer vascular plug II in hereditary hemorrhagic telangiectasia. Indian Heart J 2015; 67:455-8. [PMID: 26432734 DOI: 10.1016/j.ihj.2015.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 05/07/2015] [Accepted: 05/29/2015] [Indexed: 11/30/2022] Open
Abstract
Pulmonary arteriovenous malformations (AVM) are very rare and carry the risk of cerebral thrombo-embolism, brain abscess or pulmonary hemorrhage. The Amplatzer vascular plug II (AVP II) is a new device, used for embolization of the pulmonary AVMs. We report a case of pulmonary AVM successfully managed by using AVP II in a patient with hereditary hemorrhagic telangiectasia (HHT).
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Affiliation(s)
- Gopalan Nair Rajesh
- Additional Professor, Department of Cardiology, Government Medical College, Kozhikode, Kerala, India.
| | | | - Anishkumar Nair
- Senior Resident, Department of Cardiology, Government Medical College, Kozhikode, Kerala, India
| | - Vellani Haridasan
- Assistant Professor, Department of Cardiology, Government Medical College, Kozhikode, Kerala, India
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155
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Higa LA, McDonald J, Himes DO, Rothwell E. Life experiences of individuals with hereditary hemorrhagic telangiectasia and disclosing outside the family: a qualitative analysis. J Community Genet 2015; 7:81-9. [PMID: 26340858 DOI: 10.1007/s12687-015-0254-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 08/27/2015] [Indexed: 11/24/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT; OMIM 187300) is a disorder that affects 1:5000-1:10,000 people worldwide, with an estimated 60,000 affected individuals in the USA. Approximately 50 % of patients with HHT experience potentially life-threatening health complications such as stroke, brain abscess, or heart failure. However, the most common symptom is spontaneous and frequent nosebleeding. HHT is a hereditary condition with significant health consequences, but little is known about how individuals cope with HHT on a daily basis and how individuals share information about the disorder with social groups outside of the family. The objectives of this study were to improve understanding of the daily experiences of patients with diagnosed HHT and to investigate how they disclose their diagnosis to various social groups (friends, dating partners, employers, and coworkers) outside of their biological family. Adult patients seen at a university HHT clinic and who had been diagnosed with HHT for at least 6 months were recruited by mail. Participants completed semi-structured telephone interviews (n = 19). A qualitative content analysis of interview transcripts identified four major categories: (1) the emotional impact of HHT, (2) the social impact of HHT, (3) concerns for current and future health related to HHT, and (4) social context drives disclosure of HHT. Participants reported that although HHT was a manageable hereditary disorder, the symptoms negatively affected their daily life. It is important for health care providers to understand how individuals with rare genetic disorders are managing.
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Affiliation(s)
- Leigh Ann Higa
- Graduate Program in Genetic Counseling, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, USA
| | - Jamie McDonald
- Department of Radiology, University of Utah, Salt Lake City, UT, USA.,College of Nursing, Brigham Young University, Provo, UT, USA
| | - Deborah O Himes
- College of Nursing, Brigham Young University, Provo, UT, USA
| | - Erin Rothwell
- Graduate Program in Genetic Counseling, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, USA. .,College of Nursing, University of Utah, Salt Lake City, UT, USA.
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156
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Abstract
Cerebrospinal vascular malformations are a group of anomalies affecting the arterial wall, the capillary arteriovenous interface, or the venous and lymphatic structures. Heritability and family studies allow identification of mutations in single genes associated with rare familial conditions causing cerebral or spinal vascular malformations, as is the case in hemorrhagic hereditary telangiectasia diseases. This article reviews the genetic and epigenetic influences increasingly reported in recent years as causal factors or triggers involved in the formation and growth of cerebromedullary vascular malformations.
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Affiliation(s)
- Hortensia Alvarez
- Interventional Neuroradiology, UNC at Chapel Hill, Chapel Hill, NC 27516, USA
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157
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Nataraju KT, Mukherjee T, Doddaiah RPH, Nanjappa NG, Narasegowda L. A rare case of pulmonary arterio-venous malformation with recurrent anemia: Hereditary hemorrhagic telangiectasia. Lung India 2015; 32:384-8. [PMID: 26180392 PMCID: PMC4502207 DOI: 10.4103/0970-2113.159587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Arteriovenous malformation (AVM) is a rare vascular anomaly of the lung, which manifests predominantly as dyspnea (due to right to left shunting) and paradoxical embolism. Hereditary Hemorrhagic Telangiectasia (HHT) being a rare genetic disorder is one of the most common causes of pulmonary arteriovenous malformation (PAVM). Here we report an interesting case of recurrent anemia in an elderly female, who was subsequently found to have multiple cutaneous and mucosal telangiectasias and a large pulmonary AVM.
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Affiliation(s)
- Kamalesh Tagadur Nataraju
- Department of General Medicine, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India
| | - Tirthankar Mukherjee
- Department of General Medicine, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India
| | | | - Nagesh Gabbadi Nanjappa
- Department of General Medicine, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India
| | - Lakshmikanth Narasegowda
- Department of General Medicine, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India
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158
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Saji N, Kawarai T, Miyamoto R, Sato T, Morino H, Orlacchio A, Oki R, Kimura K, Kaji R. Exome sequencing identifies a novel intronic mutation in ENG that causes recurrence of pulmonary arteriovenous malformations. J Neurol Sci 2015; 352:29-33. [PMID: 25868896 DOI: 10.1016/j.jns.2015.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Revised: 01/16/2015] [Accepted: 02/03/2015] [Indexed: 11/16/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) occasionally can be discovered in patients with cerebrovascular disease. Pulmonary arteriovenous malformation (PAVM) is one of the complications in HHT and occasionally is causative for life-threatening embolic stroke. Several genetic defects have been reported in patients with HHT. The broad spectrum of phenotype and intrafamilial phenotype variations, including age-at-onset of vascular events, often make an early diagnosis difficult. We present here a Japanese family with a novel intronic heterozygous mutation of ENG, which was identified using whole exome sequencing (WES). The intronic mutation, IVS3+4delAGTG, results in in-frame deletion of exon 3 and would produce a shorter ENG protein lacking the extracellular forty-seven amino acid sequences, which is located within the orphan domain. Our findings highlight the importance of the domain for the downstream signaling pathway of transforming growth factor-beta and bone morphogenesis protein superfamily receptors. Considering the phenotype variations and the available treatment for vascular complications, an early diagnosis using genetic testing, including WES, should be considered for individuals at risk of HHT.
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Affiliation(s)
- Naoki Saji
- Department of Stroke Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0192, Japan.
| | - Toshitaka Kawarai
- Department of Clinical Neuroscience, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima 770-8503, Japan.
| | - Ryosuke Miyamoto
- Department of Clinical Neuroscience, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima 770-8503, Japan.
| | - Takahiro Sato
- Department of Stroke Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0192, Japan.
| | - Hiroyuki Morino
- Department of Epidemiology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan..
| | - Antonio Orlacchio
- Laboratorio di Neurogenetica, CERC-IRCCS Santa Lucia, Rome, Italy; Dipartimento di Medicina dei Sistemi, Università di Roma "Tor Vergata", Rome, Italy.
| | - Ryosuke Oki
- Department of Clinical Neuroscience, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima 770-8503, Japan.
| | - Kazumi Kimura
- Department of Stroke Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0192, Japan.
| | - Ryuji Kaji
- Department of Clinical Neuroscience, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima 770-8503, Japan.
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159
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Yanna-Schulze A. Carotid ultrasound for pulmonary arteriovenous malformation screening. Open Med (Wars) 2015; 10:285-293. [PMID: 28352707 PMCID: PMC5152993 DOI: 10.1515/med-2015-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 04/04/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE In patients with hereditary hemorrhagic telangiectasia (HHT), pulmonary arteriovenous malformations (PAVMs) can cause serious neurological complications. Our aim was to evaluate the potential of contrast-enhanced Doppler ultrasound (CE-US) of the common carotid artery as a screening test for detection of PAVMs. METHODS A total of 124 consecutive patients with HHT or a positive family history underwent screening for PAVMs with CE-US and thoracic contrast-enhanced magnetic resonance angiography (CE-MRA). CE-US was performed after receiving (D)-galactose microparticulate, and CE-MRA with gadobenate dimeglumine. Twenty-five patients with confirmed PAVMs were referred to conventional pulmonary catheter angiography (PA). Findings on CE-US and CE-MRA were evaluated using contingency tables and McNemar's test. RESULTS Using CE-MRA as the reference test, CE-US had a sensitivity of 100%, a specificity of 87%, and a negative predictive value of 100%. In 25 patients who underwent PA, PAVMs that had been diagnosed on CE-US and CE-MRA were confirmed. Of the PAVMs detected by CE-MRA, 24% were not identified on PA. CONCLUSION CE-US is a simple, minimally invasive screening method that can easily be performed in different settings. CE-US can predict PAVMs with high probability of success. CE-US may be a simple alternative to transthoracic echocardiography in the assessment of PAVMs in certain HHT-patients.
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160
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Dittus C, Streiff M, Ansell J. Bleeding and clotting in hereditary hemorrhagic telangiectasia. World J Clin Cases 2015; 3:330-337. [PMID: 25879004 PMCID: PMC4391002 DOI: 10.12998/wjcc.v3.i4.330] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/24/2014] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a relatively common inherited vascular disorder that was first described in 1864, and is notable for epistaxis, telangiectasia, and arterial venous malformations. While genetic tests are available, the diagnosis remains clinical, and is based on the Curacao criteria. Patients with HHT are at increased risk for both bleeding and clotting events. Because of these competing complications, hematologists are often faced with difficult clinical decisions. While the majority of management decisions revolve around bleeding complications, it is not infrequent for these patients to require anticoagulation for thrombosis. Any anticoagulation recommendations must take into account the bleeding risks associated with HHT. Recent reviews have found that HHT patients can be safely anticoagulated, with the most frequent complication being worsened epistaxis. Large clinical trials have shown that factor IIa and Xa inhibitors have less intracranial bleeding than warfarin, and basic coagulation research has provided a possible mechanism. This article describes the anticoagulation dilemma posed when a 62-year-old female patient with a history of bleeding events associated with HHT was diagnosed with a pulmonary embolism. The subsequent discussion focuses on the approach to anticoagulation in the HHT patient, and addresses the role of the new oral anticoagulants.
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161
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Abstract
Background: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder, which affects various internal organs and has a tendency for bleeding. It has a classic triad of mucocutaneous telangiectasias, recurrent hemorrhages and positive familial history of first-degree relative. Epistaxis or gastrointestinal telangiectasia can be fatal in a small number of cases. Case Report: A 44-year-old woman came with complaints of recurrent episodes of hematemesis and epistaxis. Patient had a family history of similar complaints. Patient underwent esophagogastroduodenoscopy (EGD), which revealed telangiectasia in the stomach. Imaging of the abdomen showed features suggestive of arteriovenous shunting. Conclusion: HHT can remain undiagnosed for a long time, and is rarely being reported in the literature with management needing a multidisciplinary approach with early inputs from a gastroenterologist.
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Affiliation(s)
- Nagesh Kamath
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Sumit Bhatia
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Harneet Singh
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Anurag Shetty
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
| | - Shiran Shetty
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
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162
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Abstract
Pulmonary vascular diseases encompass a large and diverse group of underlying pathologies ranging from venous thromboembolism to congenital malformations to inflammatory vasculitides. As a result, patients can present either acutely with dyspnea and chest pain or chronically with dyspnea on exertion, hypoxia, and right heart failure. Imaging, particularly with multidetector CT, plays a key role in the evaluation and management of patients with suspected pulmonary vascular disease and, given the widespread routine use of high-quality CT pulmonary angiography, it is imperative that radiologists be familiar these pathologies.
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Affiliation(s)
- Kristopher W Cummings
- Cardiothoracic Radiology, Mayo Clinic Arizona, 5777 E. Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Sanjeev Bhalla
- Cardiothoracic Imaging, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St Louis, 510 South Kingshighway Boulevard, Box 8131, St Louis, MO 63110, USA.
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163
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Velthuis S, Buscarini E, Gossage JR, Snijder RJ, Mager JJ, Post MC. Clinical implications of pulmonary shunting on saline contrast echocardiography. J Am Soc Echocardiogr 2015; 28:255-63. [PMID: 25623000 DOI: 10.1016/j.echo.2014.12.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Indexed: 02/07/2023]
Abstract
Pulmonary right-to-left shunting can be encountered using transthoracic contrast echocardiography (TTCE) with agitated saline. Diseases associated with pulmonary shunting on saline TTCE include hereditary hemorrhagic telangiectasia (HHT), hepatopulmonary syndrome, and some congenital heart defects after partial or complete cavopulmonary anastomosis. Furthermore, small pulmonary shunts on saline TTCE are also documented in a proportion of healthy individuals. Pulmonary shunting carries the risk for severe neurologic complications due to paradoxical embolization. In HHT, additional chest computed tomography is recommended in case of any pulmonary shunt detected on saline TTCE, to evaluate the feasibility for transcatheter embolotherapy of pulmonary arteriovenous malformations. Furthermore, antibiotic prophylaxis is advised in case of any pulmonary shunt on saline TTCE to prevent brain abscesses after procedures with risk for bacteremia. The present review provides an overview of important aspects of pulmonary shunting and its detection using saline TTCE. Furthermore, advances in understanding the clinical implications of different pulmonary shunt grades on saline TTCE are described. It appears that small pulmonary shunts on saline TTCE (grade 1) lack any clinical implication, as these shunts cannot be used as a diagnostic criterion for HHT, are not associated with an increased risk for neurologic complications, and represent pulmonary arteriovenous malformations too small for subsequent endovascular treatment. This implies that additional chest computed tomography could be safely withheld in all persons with only small pulmonary shunts on saline TTCE and sets the stage for further discussion about the need for antibiotic prophylaxis in these subjects. Besides further optimization of the current screening algorithm for the detection of pulmonary arteriovenous malformations in HHT, these observations can be of additional clinical importance in other diseases associated with pulmonary shunting and in those healthy individuals with documented small pulmonary shunts on saline TTCE.
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Affiliation(s)
- Sebastiaan Velthuis
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.
| | | | - James R Gossage
- Department of Medicine, Georgia Regents University, Augusta, Georgia
| | - Repke J Snijder
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes J Mager
- Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Martijn C Post
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
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164
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Bennesser Alaoui H, Lehraiki M, Hamaz S, El Attar N, Fakhreddine N, Serraj K. [Bevacizumab: a new success in hereditary hemorrhagic telangiectasia]. Rev Med Interne 2015; 36:623-5. [PMID: 25595875 DOI: 10.1016/j.revmed.2014.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Revised: 10/18/2014] [Accepted: 11/23/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hereditary hemorrhagic telangiectasia (HHT), is a rare, hereditary vascular dysplasia, characterized by recurrent epistaxis, mucocutaneous telangiectasias and visceral arteriovenous malformations. The vascular endothelial growth factor VEGF seems to play a crucial role in the pathogenesis of this disease. Recently bevacizumab, a humanized monoclonal VEGF inhibitor, has shown promise in treating patients with HHT. CASE REPORT A 66-year-old man, having HHT since the age of 30 years with recurrent epistaxis related to telangiectasia at the nasal septum and chronic iron deficiency anemia requiring frequent blood transfusions with iron infusions. The assessment of his disease showed septal perforation, telangiectasis in the proximal jejunum and terminal ileum, and pulmonary arteriovenous malformations. There was no improvement, despite iron infusions, repeated blood transfusions and cauterization. The patient was treated with bevacizumab at a dose of 5mg/kg/infusion every 2 weeks and was given 6 cycles. Bevacizumab, was effective without side effects. DISCUSSION It has been hypothesized that HHT is related to an imbalanced state between antiangiogenic factors and proangiogenic factors. Mutations of 3 genes are actually identified in HHT: ENG, ACVRL1, MADH4. The management of patients with HHT currently based on screening for visceral arteriovenous malformations and symptomatic measures are often disappointing. However, the angiogenic nature of this disease suggests an interesting therapy by using angiogenesis inhibitor. Therefore, bevacizumab was introduced as a potential therapy for HHT. Some clinical cases or small series report the efficacy of bevacizumab, in HHT with recurrent epistaxis, refractory iron deficiency anemia, gastrointestinal bleeding and also in liver vascular malformations with high cardiac output failure. CONCLUSION The use of modulators of angiogenesis such as bevacizumab is a possible therapeutic target in HHT.
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Affiliation(s)
| | - M Lehraiki
- Service de médecine interne, CHU Mohammed VI, Oujda, Maroc
| | - S Hamaz
- Service de médecine interne, CHU Mohammed VI, Oujda, Maroc
| | - N El Attar
- Service de médecine interne, CHU Mohammed VI, Oujda, Maroc
| | - N Fakhreddine
- Service de médecine interne, CHU Mohammed VI, Oujda, Maroc
| | - K Serraj
- Service de médecine interne, CHU Mohammed VI, Oujda, Maroc
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165
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Pousada G, Baloira A, Valverde D. Pulmonary arterial hypertension and portal hypertension in a patient with hereditary hemorrhagic telangiectasia. Med Clin (Barc) 2014; 144:261-4. [PMID: 25543221 DOI: 10.1016/j.medcli.2014.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 09/11/2014] [Accepted: 09/18/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Pulmonary arterial hypertension (PAH) is a rare disease that could be inherited with an autosomal dominant pattern. Mutations in BMPR2 gene are described in over 70% of cases, although other genes are involved in lesser extend in PAH. Hereditary hemorrhagic telangiectasia (HHT) is another rare autosomal dominant disease. PAH is a rare complication of HHT that occurs in less than 1% of cases. Liver cirrhosis with portal hypertension is also associated with the presence of PAHs in 1-2% of cases. PATIENTS We present here a patient with HHT who developed PAH shortly after showing portal hypertension. RESULTS Some genes (BMPR2, ACVRL1, ENG) seem to play an important role in PAH pathogenesis. We analyzed these genes, detecting mutations in BMPR2 gene (c.1021G>A (V341L), c.327G>A (p.Q109Q)), ACVRL1 (c.313+20C>A, c.1502+7A>G) and ENG (c.498G>A (Q166Q)). The patient also had 3 polymorphisms in the TRPC6 gene (c.1-361A>T, c.1-254C>G, c.1-218C>T). CONCLUSIONS The study of these genes will help us to identify and track individuals susceptible for developing PAH associated with other diseases.
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Affiliation(s)
- Guillermo Pousada
- Department of Biochemistry, Genetics and Immunology, Faculty of Biology, University of Vigo, Vigo, Spain; Biomedical Research Institute of Vigo (IBIV), Vigo, Spain
| | - Adolfo Baloira
- Respiratory Division, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - Diana Valverde
- Department of Biochemistry, Genetics and Immunology, Faculty of Biology, University of Vigo, Vigo, Spain; Biomedical Research Institute of Vigo (IBIV), Vigo, Spain.
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166
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Zhu Z, Han X, Qian F, Shi W, Tang W, Dong Q. "Multiple system degeneration" in hereditary hemorrhagic telangiectasia: the hepatic connection. J Neurol Sci 2014; 346:339-40. [PMID: 25179876 DOI: 10.1016/j.jns.2014.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 06/18/2014] [Accepted: 08/11/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Zhu Zhu
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Xiang Han
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Feng Qian
- Department of Health Policy, Management, and Behavior, School of Public Health, University at Albany - State University of New York, United States
| | - Wei Shi
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Weijun Tang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China.
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167
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Wee JW, Jeon YW, Eun JY, Kim HJ, Bae SB, Lee KT. Hereditary hemorrhagic telangiectasia treated with low dose intravenous bevacizumab. Blood Res 2014; 49:192-5. [PMID: 25325040 PMCID: PMC4188786 DOI: 10.5045/br.2014.49.3.192] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 12/12/2012] [Accepted: 07/09/2014] [Indexed: 12/14/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder that leads to mucocutaneous telangiectasias, epistaxis, and gastrointestinal bleeding. Depending on the severity and manifestation of the disease, various therapeutic modalities have been used, from local bleeding control to surgery or concomitant drug therapy. Several articles under review have presented guidelines for treatment of HHT with bevacizumab as a direct anti-angiogenesis strategy. Still, neither the exact optimal dose nor the minimum effective dose of intravenous bevacizumab in patients with severe HHT has been reported. A 55-year-old man presented with long-standing epistaxis, recent melena, dizziness, and a three-generation family history of chronic epistaxis, anemia, and regular blood transfusions. Treatment with argon plasma coagulation (APC) for the gastrointestinal bleeding failed to raise hemoglobin levels, we considered using the bevacizumab. We report a patient with severe HHT, who was treated with low-dose bevacizumab (2 mg/kg) and improved substantially.
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Affiliation(s)
- Jee Wan Wee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Young Woo Jeon
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jun Young Eun
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Han Jo Kim
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Sang Byung Bae
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Kyu Taek Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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168
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Moulinet T, Mohamed S, Deibener-Kaminsky J, Jankowski R, Kaminsky P. High prevalence of arterial aneurysms in hereditary hemorrhagic telangiectasia. Int J Cardiol 2014; 176:1414-6. [PMID: 25150474 DOI: 10.1016/j.ijcard.2014.08.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
Affiliation(s)
- T Moulinet
- Département de Médecine Interne et Immunologie Clinique, Pôle des Spécialités Médicales, Centre Hospitalier Universitaire de Nancy, Hôpitaux de Brabois, 54500 Vandoeuvre-lès-Nancy, France
| | - S Mohamed
- Département de Médecine Interne et Immunologie Clinique, Pôle des Spécialités Médicales, Centre Hospitalier Universitaire de Nancy, Hôpitaux de Brabois, 54500 Vandoeuvre-lès-Nancy, France
| | - J Deibener-Kaminsky
- Département de Médecine Interne et Immunologie Clinique, Pôle des Spécialités Médicales, Centre Hospitalier Universitaire de Nancy, Hôpitaux de Brabois, 54500 Vandoeuvre-lès-Nancy, France
| | - R Jankowski
- Service d'Oto Rhino Laryngologie, Pôle Tête et Cou, Centre Hospitalier Universitaire de Nancy, Hôpitaux de Brabois, 54500 Vandoeuvre-lès-Nancy, France
| | - P Kaminsky
- Département de Médecine Interne et Immunologie Clinique, Pôle des Spécialités Médicales, Centre Hospitalier Universitaire de Nancy, Hôpitaux de Brabois, 54500 Vandoeuvre-lès-Nancy, France; EA3450 «Développement - Adaptation - Handicap», Université de Lorraine, Vandoeuvre-lès-Nancy, France.
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169
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Angriman F, Ferreyro BL, Wainstein EJ, Serra MM. Pulmonary arteriovenous malformations and embolic complications in patients with hereditary hemorrhagic telangiectasia. Arch Bronconeumol 2014; 50:301-4. [PMID: 24629762 DOI: 10.1016/j.arbres.2013.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 08/08/2013] [Accepted: 08/10/2013] [Indexed: 11/19/2022]
Abstract
Patients with hereditary hemorrhagic telangiectasia (HHT) and pulmonary arteriovenous malformation (PAVM) face higher risk of embolic complications. It is not clear whether poor outcomes are related to PAVM severity or pulmonary symptoms. Furthermore, there is currently no available data on HHT patients in Argentina. We conducted a cross sectional study in a teaching hospital in Buenos Aires, Argentina. We describe baseline characteristics of HHT and compare the prevalence of embolic complications in patients with significant PAVM compared to patients without significant PAVM. One hundred and eight consecutive patients were included. Significant PAVM was defined as: contrast echocardiography grade 2 or greater; bilateral PAVM or feeding artery bigger than 3mm; or previous PAVM treatment. Primary composite outcome was defined as: cerebrovascular accident, cerebral abscess or peripheral embolism. 20% of participants had embolic complications, the most frequent one was stroke. Embolic complications were associated with significant PAVM and respiratory symptoms.
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Affiliation(s)
- Federico Angriman
- Departamento de Medicina Interna, Hospital Italiano de Buenos Aires, Universidad de Buenos Aires, Buenos Aires, Argentina.
| | - Bruno L Ferreyro
- Departamento de Medicina Interna, Hospital Italiano de Buenos Aires, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Esteban J Wainstein
- Departamento de Medicina Respiratoria, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marcelo M Serra
- Departamento de Medicina Interna, Hospital Italiano de Buenos Aires, Universidad de Buenos Aires, Buenos Aires, Argentina; Unidad de THH, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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170
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Dupuis-Girod S, Ambrun A, Decullier E, Samson G, Roux A, Fargeton AE, Rioufol C, Schwiertz V, Disant F, Chapuis F, Donazzolo Y, Paintaud G, Edery P, Faure F. ELLIPSE Study: a Phase 1 study evaluating the tolerance of bevacizumab nasal spray in the treatment of epistaxis in hereditary hemorrhagic telangiectasia. MAbs 2014; 6:794-9. [PMID: 24481211 DOI: 10.4161/mabs.28025] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a dominantly inherited genetic vascular disorder in which epistaxis is the most frequent manifestation, responsible for high morbidity. Management of this symptom has no standard, and local treatments are often aggressive. Their efficacy is variable and has not been proven. Anti-angiogenic drugs, such as bevacizumab, are a new treatment strategy. Its systemic administration in patients with HHT improves liver damage-related symptoms and epistaxis. To limit the systemic adverse effects of bevacizumab and to ease administration, a local administration seems suitable. PRIMARY OBJECTIVE To evaluate the tolerance of increasing doses of bevacizumab administered as a nasal spray in patients with HHT-related epistaxis. Secondary objectives were to study the bioavailability and efficacy of bevacizumab against epistaxis when given as a nasal spray. METHODOLOGY Phase 1, randomized, double-blind, placebo-controlled, monocentric study performed sequentially (dose escalation) on 5 groups of 8 patients. Each group was made up of 6 verum and 2 placebos. Five increasing doses of bevacizumab nasal spray (25 mg/mL) were evaluated: 12.5, 25, 50, 75 and 100 mg. RESULTS A total of 40 patients were included between October 2011 and October 2012. Bevacizumab nasal spray was well tolerated in all patients and the drug was not detected in their serum. No dose limiting toxicity was observed. No efficacy was observed at any dose in this study. CONCLUSION Based on these results, bevacizumab nasal spray is a safe treatment of epistaxis in HHT. However, a randomized Phase 2 study is needed to determine its efficacy. TRIAL REGISTRATION ClinicalTrials.gov Identifier #NCT01507480.
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Affiliation(s)
- Sophie Dupuis-Girod
- Hospices Civils de Lyon; Groupe Hospitalier Est; Service de Génétique et centre de référence pour la maladie de Rendu-Osler; Bron, France
| | - Alexis Ambrun
- Hospices Civils de Lyon; Hôpital E. Herriot; Service d'ORL; Lyon, France
| | - Evelyne Decullier
- Hospices Civils de Lyon; pôle IMER; Unité de Recherche Clinique; Lyon, France; Université de Lyon; EAM Santé Individu Société 4128; Lyon, France; Université Lyon 1; Lyon, France
| | - Géraldine Samson
- Hospices Civils de Lyon; pôle IMER; Unité de Recherche Clinique; Lyon, France; Université de Lyon; EAM Santé Individu Société 4128; Lyon, France; Université Lyon 1; Lyon, France
| | - Adeline Roux
- Hospices Civils de Lyon; pôle IMER; Unité de Recherche Clinique; Lyon, France; Université de Lyon; EAM Santé Individu Société 4128; Lyon, France; Université Lyon 1; Lyon, France
| | - Anne-Emmanuelle Fargeton
- Hospices Civils de Lyon; Groupe Hospitalier Est; Service de Génétique et centre de référence pour la maladie de Rendu-Osler; Bron, France
| | - Catherine Rioufol
- Hospices Civils de Lyon; Centre Hospitalier Lyon Sud; Unité de Pharmacie Clinique Oncologique; Pierre-Bénite, France; EMR 3738 CTO Ciblage Thérapeutique en Oncologie; UFR Lyon Sud; Pierre-Bénite, France
| | - Verane Schwiertz
- Hospices Civils de Lyon; Centre Hospitalier Lyon Sud; Unité de Pharmacie Clinique Oncologique; Pierre-Bénite, France
| | - François Disant
- Hospices Civils de Lyon; Hôpital E. Herriot; Service d'ORL; Lyon, France
| | - François Chapuis
- Hospices Civils de Lyon; pôle IMER; Unité de Recherche Clinique; Lyon, France; Université de Lyon; EAM Santé Individu Société 4128; Lyon, France; Université Lyon 1; Lyon, France
| | - Yves Donazzolo
- Eurofins-Optimed; Centre Hospitalier Lyon Sud; Pierre-Bénite, France
| | - Gilles Paintaud
- CHRU de Tours; Laboratoire de Pharmacologie-Toxicologie; Tours, France
| | - Patrick Edery
- Hospices Civils de Lyon; Groupe Hospitalier Est; Service de Génétique et centre de référence pour la maladie de Rendu-Osler; Bron, France
| | - Frederic Faure
- Hospices Civils de Lyon; Hôpital E. Herriot; Service d'ORL; Lyon, France
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171
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Rimmer J, Lund VJ. A modified technique for septodermoplasty in hereditary hemorrhagic telangiectasia. Laryngoscope 2013; 124:67-9. [PMID: 23832829 DOI: 10.1002/lary.24303] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 06/20/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Joanne Rimmer
- Department of Otolaryngology, Royal National Throat Nose and Ear Hospital, London, United Kingdom
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172
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Krowka MJ, Wiesner RH, Heimbach JK. Pulmonary contraindications, indications and MELD exceptions for liver transplantation: a contemporary view and look forward. J Hepatol 2013; 59:367-74. [PMID: 23557870 DOI: 10.1016/j.jhep.2013.03.026] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 03/21/2013] [Accepted: 03/22/2013] [Indexed: 12/11/2022]
Abstract
Pulmonary concerns in liver transplant candidates have intraoperative and outcome implications. Evolving MELD exception policies address transplant priority for problems such as hepatopulmonary syndrome, portopulmonary hypertension, and hemorrhagic hereditary telangiectasia. Other pulmonary issues such as refractory hepatic hydrothorax, advanced chronic obstructive lung disease (including alpha-1 antitrypsin deficiency) and indeterminate pulmonary nodules may affect liver transplant consideration. Herein, we discuss current pulmonary-related contraindications, indications and MELD exception policies for liver transplantation, suggesting future considerations.
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173
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Laux DW, Young S, Donovan JP, Mansfield CJ, Upton PD, Roman BL. Circulating Bmp10 acts through endothelial Alk1 to mediate flow-dependent arterial quiescence. Development 2013; 140:3403-12. [PMID: 23863480 DOI: 10.1242/dev.095307] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Blood flow plays crucial roles in vascular development, remodeling and homeostasis, but the molecular pathways required for transducing flow signals are not well understood. In zebrafish embryos, arterial expression of activin receptor-like kinase 1 (alk1), which encodes a TGFβ family type I receptor, is dependent on blood flow, and loss of alk1 mimics lack of blood flow in terms of dysregulation of a subset of flow-responsive arterial genes and increased arterial endothelial cell number. These data suggest that blood flow activates Alk1 signaling to promote a flow-responsive gene expression program that limits nascent arterial caliber. Here, we demonstrate that restoration of endothelial alk1 expression to flow-deprived arteries fails to rescue Alk1 activity or normalize arterial endothelial cell gene expression or number, implying that blood flow may play an additional role in Alk1 signaling independent of alk1 induction. To this end, we define cardiac-derived Bmp10 as the crucial ligand for endothelial Alk1 in embryonic vascular development, and provide evidence that circulating Bmp10 acts through endothelial Alk1 to limit endothelial cell number in and thereby stabilize the caliber of nascent arteries. Thus, blood flow promotes Alk1 activity by concomitantly inducing alk1 expression and distributing Bmp10, thereby reinforcing this signaling pathway, which functions to limit arterial caliber at the onset of flow. Because mutations in ALK1 cause arteriovenous malformations (AVMs), our findings suggest that an impaired flow response initiates AVM development.
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Affiliation(s)
- Derek W Laux
- Department of Biological Sciences, University of Pittsburgh, Pittsburgh, PA 15260, USA
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174
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Lacombe P, Lacout A, Marcy PY, Binsse S, Sellier J, Bensalah M, Chinet T, Bourgault-Villada I, Blivet S, Roume J, Lesur G, Blondel JH, Fagnou C, Ozanne A, Chagnon S, El Hajjam M. Diagnosis and treatment of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: An overview. Diagn Interv Imaging 2013; 94:835-48. [PMID: 23763987 DOI: 10.1016/j.diii.2013.03.014] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease is an autosomic dominant disorder, which is characterized by the development of multiple arteriovenous malformations in either the skin, mucous membranes, and/or visceral organs. Pulmonary arteriovenous malformations (PAVMs) may either rupture, and lead to life-threatening hemoptysis/hemothorax or be responsible for a right-to-left shunting leading to paradoxical embolism, causing stroke or cerebral abscess. PAVMs patients should systematically be screened as the spontaneous complication rate is high, by reaching almost 50%. Neurological complications rate is considerably higher in patients presenting with diffuse pulmonary involvement. PAVM diagnosis is mainly based upon transthoracic contrast echocardiography and CT scanner examination. The latter also allows the planification of treatments to adopt, which consists of percutaneous embolization, having replaced surgery in most of the cases. The anchor technique consists of percutaneous coil embolization of the afferent pulmonary arteries of the PAVM, by firstly placing a coil into a small afferent arterial branch closely upstream the PAVM. Enhanced contrast CT scanner is the key follow-up examination that depicts the PAVM enlargement, indicating the various mechanisms of PAVM reperfusion. When performed by experienced operators as the prime treatment, percutaneous embolization of PAVMs, is a safe, efficient and sustained therapy in the great majority of HHT patients.
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Affiliation(s)
- P Lacombe
- Radiology department, Pluridisciplinary HHT team, Ambroise-Paré Hospital, Groupement des Hôpitaux Île-de-France Ouest, Assistance Publique-Hôpitaux de Paris, Université de Versailles-Saint-Quentin-en-Yvelines, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
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175
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Ha M, Kim YJ, Kwon KA, Hahm KB, Kim MJ, Kim DK, Lee YJ, Oh SP. Gastric angiodysplasia in a hereditary hemorrhagic telangiectasia type 2 patient. World J Gastroenterol 2012; 18:1840-4. [PMID: 22553411 PMCID: PMC3332300 DOI: 10.3748/wjg.v18.i15.1840] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 01/18/2012] [Accepted: 02/08/2012] [Indexed: 02/06/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal-dominantly inherited disease that occurs in approximately one in 5000 to 8000 people. Clinical diagnosis of HHT is made when a person presents three of the following four criteria: family history, recurrent nosebleeds, mucocutaneous telangiectasis, and arteriovenous malformations (AVM) in the brain, lung, liver and gastrointestinal (GI) tract. Although epistaxis is the most common presenting symptom, AVMs affecting the lungs, brain and GI tract provoke a more serious outcome. Heterozygous mutations in endoglin, activin receptor-like kinase 1 (ACVRL1; ALK1), and SMAD4, the genes involved in the transforming growth factor-β family signaling cascade, cause HHT. We report here the case of a 63 year-old male patient who presented melena and GI bleeding episodes, proven to be caused by bleeding from multiple gastric angiodysplasia. Esophagogastroduodenoscopy revealed multiple angiodysplasia throughout the stomach. Endoscopic argon plasma coagulation was performed to control bleeding from a gastric angiodysplasia. The patient has been admitted several times with episodes of hemoptysis and hematochezia. One year ago, the patient was hospitalized due to right-sided weakness, which was caused by left basal ganglia hemorrhage as the part of HHT presentation. In family history, the patient’s mother and elder sister had died, due to intracranial hemorrhage, and his eldest son has been suffered from recurrent epistaxis for 20 years. A genetic study revealed a mutation in exon 3 of ALK1 (c.199C > T; p.Arg67Trp) in the proband and his eldest son presenting epistaxis.
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176
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Draghi F, Presazzi A, Danesino GM, de Matthaeis N, Rapaccini GL, Danesino C. Hepatic sonography in patients with hereditary hemorrhagic telangiectasia hospitalized for epistaxis. J Ultrasound 2012; 15:164-70. [PMID: 23449465 DOI: 10.1016/j.jus.2012.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by the presence of telangiectasias and arteriovenous malformations in various organs and organ systems, including the liver. The most frequent clinical manifestation of HHT is epistaxis.In 2010 (January-December inclusive) 51 patients with HHT were admitted to the ENT ward of our hospital for epistaxis, and in accordance with routine protocols, all 51 underwent abdominal ultrasonography in our department to detect hepatovascular lesions. They included 27 males (53%) and 24 (47%) females ranging in age from 11 to 86 years (mean 48.5 years). The sample was selected in an arbitrary manner to take maximum advantage of the hospital stay and monitor patients from regions other than our own.Retrospective analysis of the findings from these sonographic examinations revealed hepatic HHT in 27 (53%) of the 51 patients. Nineteen (70%) of these (age range 40-86 years, mean 63) had vascular malformations of various dimensions but no portal hypertension; the other eight (30%) (age range 39-81 years, mean 60) had vascular malformations plus portal hypertension.Our retrospective analysis indicates that a significant number of patients can have unrecognized hepatic involvement; that the appearance of hepatic lesions can be fairly unpredictable, even when the HHT has been diagnosed for years and the patients are already symptomatic; and that the hepatic lesions are frequently progressive. Therefore, regular sonographic follow-up is advisable for patients with HHT.The limitations of this study are related to the small number of patients examined and to the fact that all of them were symptomatic. Further study is therefore needed (especially in asymptomatic patients) to define the indications for hepatic sonography and the optimum examination schedule. Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by the presence of telangiectasias and arteriovenous malformations in various organs and organ systems, including the liver. The most frequent clinical manifestation of HHT is epistaxis.In 2010 (January–December inclusive) 51 patients with HHT were admitted to the ENT ward of our hospital for epistaxis, and in accordance with routine protocols, all 51 underwent abdominal ultrasonography in our department to detect hepatovascular lesions. They included 27 males (53%) and 24 (47%) females ranging in age from 11 to 86 years (mean 48.5 years). The sample was selected in an arbitrary manner to take maximum advantage of the hospital stay and monitor patients from regions other than our own.Retrospective analysis of the findings from these sonographic examinations revealed hepatic HHT in 27 (53%) of the 51 patients. Nineteen (70%) of these (age range 40–86 years, mean 63) had vascular malformations of various dimensions but no portal hypertension; the other eight (30%) (age range 39–81 years, mean 60) had vascular malformations plus portal hypertension.Our retrospective analysis indicates that a significant number of patients can have unrecognized hepatic involvement; that the appearance of hepatic lesions can be fairly unpredictable, even when the HHT has been diagnosed for years and the patients are already symptomatic; and that the hepatic lesions are frequently progressive. Therefore, regular sonographic follow-up is advisable for patients with HHT.The limitations of this study are related to the small number of patients examined and to the fact that all of them were symptomatic. Further study is therefore needed (especially in asymptomatic patients) to define the indications for hepatic sonography and the optimum examination schedule.
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Affiliation(s)
- F Draghi
- Foundation IRCCS, Policlinico San Matteo, Institute of Radiology, University of Pavia, Italy
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177
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Amanzada A, Töppler GJ, Cameron S, Schwörer H, Ramadori G. A case report of a patient with hereditary hemorrhagic telangiectasia treated successively with thalidomide and bevacizumab. Case Rep Oncol 2010; 3:463-70. [PMID: 21611144 PMCID: PMC3100268 DOI: 10.1159/000323152] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia is characterized by mucocutaneous and visceral telangiectasia and involves several organs with vascular malformations. It is an autosomal dominant disease and is distinguished into three types, which are due to mutations in different genes. The common symptom is anemia, causing a continous need of blood transfusion. Depending on the severity and disease manifestation, there are various forms of therapy ranging from local therapy activities to operations or drug therapy. Here we describe a dramatic improvement of a patient with a high transfusion frequency due to severe recurrent anemia successively treated with thalidomide and bevacizumab.
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Affiliation(s)
- Ahmad Amanzada
- Department of Gastroenterology and Endocrinology, University Clinic of the Georg August University, Göttingen, Germany
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178
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Shin JH, Park SJ, Ko GY, Yoon HK, Gwon DI, Kim JH, Sung KB. Embolotherapy for pulmonary arteriovenous malformations in patients without hereditary hemorrhagic telangiectasia. Korean J Radiol 2010; 11:312-9. [PMID: 20461185 PMCID: PMC2864858 DOI: 10.3348/kjr.2010.11.3.312] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 12/30/2009] [Indexed: 02/07/2023] Open
Abstract
Objective To evaluate the clinical and radiological outcomes of transcatheter embolotherapy for treating sporadic pulmonary arteriovenous malformations (PAVMs) that were not associated with hereditary hemorrhagic telangiectasia. Materials and Methods Between January 2001 and June 2008, thirty-five sporadic PAVMs were detected in 23 patients. The clinical follow up consisted of assessing the changes of the signs and symptoms of the PAVMs, and radiological evaluation with chest radiographs or chest CT scans. Results The lower lung regions (63%) and peripheral locations (86%) were the common locations of the PAVMs. Thirty-four PAVMs (97%) had simple architecture (one arterial feeder within a single pulmonary segment). Technical success was achieved in 33 PAVMs (94%); two cases of technical failure were due to catheterization failure (n = 1) and too large a feeding artery (17 mm) that disabled embolotherapy (n = 1). Coils and Amplatz vascular plugs were used in 30 and three PAVMs, respectively. Inadvertent placement of one coil (n = 1) and pulmonary infarction (n = 1) occurred, but no relevant symptoms developed. For the 13 patients with available data, the mean arterial O2 saturation changed significantly from 92% to 98%. Complete or near-complete involution of the sac was observed in 30 of the 33 embolized PAVMs (91%). In these 33 embolized PAVMs, the mean sac diameter significantly decreased from 17.83 mm to 0.68 mm. Conclusion Sporadic PAVMs are mostly the simple type with predominance in the lower lobe and peripheral locations. Transcatheter embolotherapy with coils or Amplatz vascular plugs is a safe and effective treatment for sporadic PAVMs and this provides excellent functional and radiological improvement.
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Affiliation(s)
- Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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179
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Lee HE, Sagong C, Yeo KY, Ko JY, Kim JS, Yu HJ. A case of hereditary hemorrhagic telangiectasia. Ann Dermatol 2009; 21:206-8. [PMID: 20523789 DOI: 10.5021/ad.2009.21.2.206] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Accepted: 11/28/2008] [Indexed: 11/08/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia, also known as Osler-Weber-Rendu disease, is an autosomal dominant disorder of the fibrovascular tissue. It is characterized by the classic triad of mucocutaneous telangiectasias, recurrent hemorrhages, and familial occurrence. The cutaneous manifestation appear clinically as punctuate, linear, or splinter-like telangiectasias of the upper body, oral, and nasal mucous membranes, and nail beds. A 73-year-old woman presented with purpuric, punctuate, and tiny macules on the finger tips of both hands and the tongue. The skin lesions were discovered about 50 years previously. She had a family history of cutaneous telangiectasia. Also, she had episodes of recurrent epistaxis, gastrointestinal bleeding, and anemia. The gastroendoscopy revealed gastric angiodysplasia of the fundus and body of the stomach. The histopathologic study showed dilated capillaries lined by flat endothelial cells in the papillary dermis. From these findings, we diagnosed this case as hereditary hemorrhagic telangiectasia, which has rarely been reported in the dermatologic literature.
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Affiliation(s)
- Ha Eun Lee
- Department of Dermatology, Hanyang University College of Medicine, Seoul, Korea
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Shimoyama Y, Kakizaki S, Katano A, Takakusaki S, Mizuide M, Ichikawa T, Sato K, Takagi H, Mori M. Hereditary hemorrhagic telangiectasia with multiple hepatic and pulmonary nodular lesions. Clin J Gastroenterol 2009; 2:131-6. [PMID: 26192179 DOI: 10.1007/s12328-008-0054-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Accepted: 11/28/2008] [Indexed: 10/21/2022]
Abstract
A 50-year-old female visited the hospital for further evaluation of multiple pulmonary and hepatic nodules. First, she visited her primary physician for general fatigue due to anemia. She had recurrent epistaxis, and her mother had suffered from hereditary hemorrhagic telangiectasia (HHT). Telangiectasias were present in the stomach. This patient was diagnosed with HHT. Computed tomography (CT) revealed multiple pulmonary and hepatic nodules. The pulmonary nodules were due to bleeding from arteriovenous malformations of the lung. Abdominal CT and angiography showed a dilated and meandering hepatic artery, arteriovenous shunts and multiple hepatic nodules. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) showed enhancement in the early dynamic phase and in the liver-specific phase. A liver tumor biopsy of a hepatic nodule showed nodular regenerative hyperplasia (NRH). This report presents a case of HHT with multiple pulmonary and hepatic nodular lesions. Gd-EOB-DTPA-enhanced MRI was useful for making a diagnosis of NRH.
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