1
|
Yagi T, Takano K, Umehara T, Arita H, Maeda N, Nakanishi K. Catheter embolization for pulmonary arteriovenous malformations during chemotherapy for appendiceal adenocarcinoma: A case report of associated brain abscess. Radiol Case Rep 2024; 19:5507-5512. [PMID: 39285968 PMCID: PMC11403889 DOI: 10.1016/j.radcr.2024.08.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 08/11/2024] [Accepted: 08/12/2024] [Indexed: 09/19/2024] Open
Abstract
Pulmonary arteriovenous malformations are rare, abnormal, low-resistance vascular structures that connect a pulmonary artery to a vein. They are common in patients with hereditary hemorrhagic telangiectasia; however, acquired malformations can occur in patients with underlying diseases such as chest trauma, hepatic cirrhosis, and mitral stenosis. Pulmonary arteriovenous malformations bypass the normal pulmonary capillary bed and result in intrapulmonary right-to-left shunts, which may cause central nervous system complications such as brain abscesses or ischemic stroke. Brain abscesses related to pulmonary arteriovenous malformations are not uncommon; however, reports of their occurrence during chemotherapy are limited. Here, we report the case of a 68-year-old woman with bilateral pulmonary arteriovenous malformations and appendiceal adenocarcinoma who developed a bacterial brain abscess during chemotherapy. The infection was treated using abscess drainage and antibiotic therapy. After the brain abscess healed, catheter embolization was performed on the pulmonary arteriovenous malformations and chemotherapy was resumed. The present case suggests that if a patient with a malignancy has a pulmonary arteriovenous malformation, clinicians should pay special attention to complications such as brain abscesses during chemotherapy. For patients who do not urgently need chemotherapy, embolization of the pulmonary arteriovenous malformation before chemotherapy may be a better treatment option.
Collapse
Affiliation(s)
- Toshinari Yagi
- Department of Outpatient Chemotherapy, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka 541-8567, Japan
| | - Koji Takano
- Department of Neurosurgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka 541-8567, Japan
| | - Toru Umehara
- Department of Neurosurgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka 541-8567, Japan
| | - Hideyuki Arita
- Department of Neurosurgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka 541-8567, Japan
| | - Noboru Maeda
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka 541-8567, Japan
| | - Katsuyuki Nakanishi
- Department of Diagnostic and Interventional Radiology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka 541-8567, Japan
| |
Collapse
|
2
|
Al-Samkari H, Kasthuri RS, Iyer VN, Pishko AM, Decker JE, Weiss CR, Whitehead KJ, Conrad MB, Zumberg MS, Zhou JY, Parambil J, Marsh D, Clancy M, Bradley L, Wisniewski L, Carper BA, Thomas SM, McCrae KR. Pomalidomide for Epistaxis in Hereditary Hemorrhagic Telangiectasia. N Engl J Med 2024; 391:1015-1027. [PMID: 39292928 PMCID: PMC11412318 DOI: 10.1056/nejmoa2312749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/20/2024]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is characterized by extensive telangiectasias and arteriovenous malformations. The primary clinical manifestation is epistaxis that results in iron-deficiency anemia and reduced health-related quality of life. METHODS We conducted a randomized, placebo-controlled trial to evaluate the safety and efficacy of pomalidomide for the treatment of HHT. We randomly assigned patients, in a 2:1 ratio, to receive pomalidomide at a dose of 4 mg daily or matching placebo for 24 weeks. The primary outcome was the change from baseline through week 24 in the Epistaxis Severity Score (a validated bleeding score in HHT; range, 0 to 10, with higher scores indicating worse bleeding). A reduction of 0.71 points or more is considered clinically significant. A key secondary outcome was the HHT-specific quality-of-life score (range, 0 to 16, with higher scores indicating more limitations). RESULTS The trial was closed to enrollment in June 2023 after a planned interim analysis met a prespecified threshold for efficacy. A total of 144 patients underwent randomization; 95 patients were assigned to receive pomalidomide and 49 to receive placebo. The baseline mean (±SD) Epistaxis Severity Score was 5.0±1.5, a finding consistent with moderate-to-severe epistaxis. At 24 weeks, the mean difference between the pomalidomide group and the placebo group in the change from baseline in the Epistaxis Severity Score was -0.94 points (95% confidence interval [CI], -1.57 to -0.31; P = 0.004). The mean difference in the changes in the HHT-specific quality-of-life score between the groups was -1.4 points (95% CI, -2.6 to -0.3). Adverse events that were more common in the pomalidomide group than in the placebo group included neutropenia, constipation, and rash. CONCLUSIONS Among patients with HHT, pomalidomide treatment resulted in a significant, clinically relevant reduction in epistaxis severity. No unexpected safety signals were identified. (Funded by the National Heart, Lung, and Blood Institute; PATH-HHT Clinicaltrials.gov number, NCT03910244).
Collapse
Affiliation(s)
- Hanny Al-Samkari
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Raj S Kasthuri
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Vivek N Iyer
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Allyson M Pishko
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Jake E Decker
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Clifford R Weiss
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Kevin J Whitehead
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Miles B Conrad
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Marc S Zumberg
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Jenny Y Zhou
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Joseph Parambil
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Derek Marsh
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Marianne Clancy
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Lauren Bradley
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Lisa Wisniewski
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Benjamin A Carper
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Sonia M Thomas
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| | - Keith R McCrae
- From Massachusetts General Hospital, Boston (H.A.-S.); University of North Carolina, Chapel Hill (R.S.K.), and RTI International, Research Triangle Park (D.M., L.B., B.A.C., S.M.T.) - both in North Carolina; Mayo Clinic, Rochester, MN (V.N.I.); University of Pennsylvania, Philadelphia (A.M.P.); Medical College of Wisconsin, Milwaukee (J.E.D.); Johns Hopkins University, Baltimore (C.R.W.), and CureHHT, Monkton (M.C.) - both in Maryland; University of Utah, Salt Lake City (K.J.W.); University of California, San Francisco, San Francisco (M.B.C.); University of Florida, Gainesville (M.S.Z.); University of California, San Diego, La Jolla (J.Y.Z.); and Taussig Cancer Center and Lerner Research Institute (K.R.M.), Cleveland Clinic (J.P., L.W., K.R.M.), Cleveland
| |
Collapse
|
3
|
Iacobas I, Hammill AM. Hereditary hemorrhagic telangiectasia - pediatric review. Curr Opin Pediatr 2024:00008480-990000000-00214. [PMID: 39254659 DOI: 10.1097/mop.0000000000001398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
PURPOSE OF REVIEW Hereditary hemorrhagic telangiectasia (HHT) diagnostic and management approach for pediatrics underwent significant advances over the last couple of years. RECENT FINDINGS In 2020, new guidelines for HHT were published that included a pediatric section thus attracting special focus into the childhood presentation. SUMMARY Curacao criteria are specific, but not sensitive enough in children. Genetic testing is encouraged for all family members even if asymptomatic. Standardized scoring for epistaxis is strongly encouraged, as it allows monitoring and can stratify therapeutic approaches. Early screening for pulmonary and brain visceral arteriovenous malformations (AVMs) in pediatric patients with confirmed genetic alterations of HHT should be instituted. Graded trans-esophageal echocardiogram with agitated saline contrast can be used as screening method for pulmonary AVMs. As pulmonary AVMs can develop throughout lifetime, guidelines recommend repeated screening even in asymptomatic patients at least every 5 years. Signs of stroke in childhood are more subtle than in adults. Cerebral imaging in early childhood can identify brain AVMs that may benefit from early intervention. Embolization of high-risk pulmonary and cerebral AVMs should be performed at specialized centers even at pediatric age. One or two classic HHT telangiectasia can be considered diagnostic in children. Antibiotic prophylaxis with dental procedures continues to be recommended.
Collapse
Affiliation(s)
- Ionela Iacobas
- Pediatric Hematology-Oncology, TCH Vascular Anomalies Center, TCH HHT Center of Excellence, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Adrienne M Hammill
- Pediatrics Cancer and Blood Diseases Institute, Division of Hematology, HHT Center of Excellence, Sturge-Weber Center of Excellence Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
4
|
Elmqaddem O, Koulali H, Zazour A, Nasiri M, Ismaili MZ, Kharrasse G. Ischemic cholangitis: Lethal complication of Osler-Weber-Rendu disease. Radiol Case Rep 2024; 19:3810-3813. [PMID: 39006092 PMCID: PMC11245895 DOI: 10.1016/j.radcr.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 07/16/2024] Open
Abstract
Osler-Weber-Rendu disease (OWRD), also known as hereditary haemorrhagic telangiectasia (HHT), is an autosomal dominant genetic disorder characterised by arteriovenous malformations in several organs. Ischemic cholangitis is a rare life-threatening complication of OWRD, with only a few documented cases in the literature. A liver transplant is the main curative treatment. In this paper, we report a case of a 33-year-old woman with a history of recurrent epistaxis, admitted with abdominal pain and fever, physical examination found multiple cutaneous and mucosal telangiectasias and the biological workup showed cholestasis, abdominal imaging identified arterio-venous shunts and multiple cystic hepatic lesions, one of them seemed to communicate with an intrahepatic biliary duct, finally the diagnosis of ischemic cholangitis due to OWRD was retained and antibiotic treatment has been initiated. We review the various therapeutic options available to improve the management of this fatal complication.
Collapse
Affiliation(s)
- Ouiam Elmqaddem
- Digestive Disease Research Laboratory, Medical School, Mohammed First University, Faculty of Medicine and Pharmacy Oujda, Morocco
- Department of Hepato-gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
| | - Hajar Koulali
- Digestive Disease Research Laboratory, Medical School, Mohammed First University, Faculty of Medicine and Pharmacy Oujda, Morocco
- Department of Hepato-gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
| | - Abdelkrim Zazour
- Digestive Disease Research Laboratory, Medical School, Mohammed First University, Faculty of Medicine and Pharmacy Oujda, Morocco
- Department of Hepato-gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
| | - Meryem Nasiri
- Digestive Disease Research Laboratory, Medical School, Mohammed First University, Faculty of Medicine and Pharmacy Oujda, Morocco
- Department of Hepato-gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
| | - Moulay Zahi Ismaili
- Digestive Disease Research Laboratory, Medical School, Mohammed First University, Faculty of Medicine and Pharmacy Oujda, Morocco
- Department of Hepato-gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
| | - Ghizlane Kharrasse
- Digestive Disease Research Laboratory, Medical School, Mohammed First University, Faculty of Medicine and Pharmacy Oujda, Morocco
- Department of Hepato-gastroenterology, Mohammed VI University Hospital, Oujda, Morocco
| |
Collapse
|
5
|
Kelly C, Buscarini E, Manfredi G, Gregory S, Heneghan MA. Hepatic manifestations of hereditary haemorrhagic telangiectasia. Liver Int 2024; 44:2220-2234. [PMID: 38847503 DOI: 10.1111/liv.16008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 05/01/2024] [Accepted: 05/25/2024] [Indexed: 08/30/2024]
Abstract
Hereditary haemorrhagic telangiectasia is a genetic condition of abnormal blood vessel formation resulting from an imbalance of pro- and anti-angiogenic products of the transforming growth factor β/bone morphogenetic protein signalling pathway which contributes to vascular remodelling and maintenance. Hepatic vascular malformations are common although less frequently symptomatic, but may result in high-output cardiac failure, portal hypertension and biliary ischaemia. Whilst the understanding of the genetic and cell signalling pathways that are the hallmark of hereditary haemorrhagic telangiectasia have been clarified, there remain challenges in therapy for these patients. Only patients with symptomatic hepatic vascular malformations require treatment, with most (63%) responding to first-line medical therapy. For non-responders, bevacizumab is effective in reducing cardiac output in those with heart failure secondary to hepatic vascular malformations as well as other manifestations of the disease. Although liver transplantation is the only curative option, optimal timing is critical. Novel anti-angiogenetic drugs and those that target aberrant cell signalling pathway are being explored.
Collapse
Affiliation(s)
- Claire Kelly
- Institute of Liver Studies, Kings College Hospital, London, UK
| | | | - Guido Manfredi
- VASCERN HHT Reference Centre, ASST Maggiore Hospital, Crema, Italy
| | | | | |
Collapse
|
6
|
Alyafaie A, Han W, Li Y, Vydro SA, Vella M, Truong TL, Park L, Langston D, Kim H, Conrad MB, Hetts SW. Arterial Spin-Labeling MR Imaging in the Detection of Intracranial Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia. AJNR Am J Neuroradiol 2024; 45:1019-1024. [PMID: 38991769 PMCID: PMC11383423 DOI: 10.3174/ajnr.a8281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/07/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND AND PURPOSE Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease that causes vascular malformations in a variety of organs and tissues, including brain AVMs. Because brain AVMs have the potential to cause disabling or fatal intracranial hemorrhage, detection of these lesions before rupture is the goal of screening MR imaging/MRA examinations in patients with HHT. Prior studies have demonstrated superior sensitivity for HHT-related brain AVMs by using postcontrast MR imaging sequences as compared with MRA alone. We now present data regarding the incremental benefit of including arterial spin-labeling (ASL) perfusion sequences as part of MR imaging/MRA screening in patients with this condition. MATERIALS AND METHODS We retrospectively analyzed 831 patients at the UCSF Hereditary Hemorrhagic Telangiectasia Center of Excellence. Of these, 42 patients had complete MR imaging/MRA, ASL perfusion scans, and criterion-standard DSA data. Two neuroradiologists reviewed imaging studies and a third provided adjudication when needed. RESULTS Eight patients had no brain AVMs detected on DSA. The remaining 34 patients had 57 brain AVMs on DSA. Of the 57 identified AVMs, 51 (89.5%) were detected on ASL and 43 (75.4%) were detected on conventional MR imaging/MRA sequences (P = .049), with 8 lesions detected on ASL perfusion but not on conventional MR imaging. CONCLUSIONS ASL provides increased sensitivity for brain AVMs in patients with HHT. Inclusion of ASL should be considered as part of comprehensive MR imaging/MRA screening protocols for institutions taking care of patients with HHT.
Collapse
Affiliation(s)
- Adam Alyafaie
- From the School of Medicine (A.A., S.A.V.), University of California, San Francisco, San Francisco, California
| | - Woody Han
- Department of Radiology and Biomedical Imaging (W.H., Y.L., M.V.), University of California, San Francisco, San Francisco, California
| | - Yi Li
- Department of Radiology and Biomedical Imaging (W.H., Y.L., M.V.), University of California, San Francisco, San Francisco, California
| | - Samuel A Vydro
- From the School of Medicine (A.A., S.A.V.), University of California, San Francisco, San Francisco, California
| | - Maya Vella
- Department of Radiology and Biomedical Imaging (W.H., Y.L., M.V.), University of California, San Francisco, San Francisco, California
| | - Torianna L Truong
- HHT Center of Excellence, Department of Radiology and Biomedical Imaging (T.L.T., L.P., D.L., M.B.C.), University of California, San Francisco, San Francisco, California
| | - Lindsay Park
- HHT Center of Excellence, Department of Radiology and Biomedical Imaging (T.L.T., L.P., D.L., M.B.C.), University of California, San Francisco, San Francisco, California
| | - Daniel Langston
- HHT Center of Excellence, Department of Radiology and Biomedical Imaging (T.L.T., L.P., D.L., M.B.C.), University of California, San Francisco, San Francisco, California
| | - Helen Kim
- Department of Anesthesia, and Perioperative Care (H.K.), University of California, San Francisco, San Francisco, California
| | - Miles B Conrad
- HHT Center of Excellence, Department of Radiology and Biomedical Imaging (T.L.T., L.P., D.L., M.B.C.), University of California, San Francisco, San Francisco, California
| | - Steven W Hetts
- HHT Center of Excellence, Departments of Radiology, Biomedical Imaging, and Neurological Surgery (S.W.H.), University of California, San Francisco, San Francisco, California
| |
Collapse
|
7
|
Chiang CM, Chiang HC, Chiu HC. An Uncommon Cause of Hemobilia. Gastroenterology 2024; 167:e5-e8. [PMID: 38253186 DOI: 10.1053/j.gastro.2024.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024]
Affiliation(s)
- Chien-Ming Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsueh-Chien Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hung-Chih Chiu
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| |
Collapse
|
8
|
Goto H, Tanimura I, Nakano Y, Takeshita Y, Takamura T. Thyroid Arteriovenous Malformation in Hereditary Hemorrhagic Telangiectasia: Insights on Successful Noninvasive Imaging. JCEM CASE REPORTS 2024; 2:luae138. [PMID: 39135960 PMCID: PMC11317758 DOI: 10.1210/jcemcr/luae138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Indexed: 08/15/2024]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) causes arteriovenous malformations (AVMs) in several organs. This report is the first to document and image a thyroid AVM complication in HHT. A 72-year-old woman with HHT was referred for thyroid nodule evaluation. Ultrasonography showed a hypervascularized nodule in the right thyroid lobe which was initially suspected to be malignant. However, 3-dimensional computed tomography angiography demonstrated a thyroid AVM with abnormal anastomosis of the superior thyroid artery and the inferior thyroid vein. In the formation of thyroid AVM, here, chronic thyroiditis and hypothyroidism complications may have been a second hit, due to the predisposing first-hit germline mutation. This report sheds light on overlooked thyroid lesions in HHT and advocates a noninvasive imaging approach in diagnosing thyroid AVMs. Furthermore, this case suggests a potential mechanism of AVM formation in human HHT, possibly supporting the second-hit hypothesis.
Collapse
Affiliation(s)
- Hisanori Goto
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa, 920-8640, Japan
| | - Iyo Tanimura
- Department of Radiology, Kanazawa University Hospital, Kanazawa, 920-8641, Japan
| | - Yujiro Nakano
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa, 920-8640, Japan
| | - Yumie Takeshita
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa, 920-8640, Japan
| | - Toshinari Takamura
- Department of Endocrinology and Metabolism, Kanazawa University Graduate School of Medical Sciences, Kanazawa, 920-8640, Japan
| |
Collapse
|
9
|
Caillot C, Saurin JC, Hervieu V, Faoucher M, Reversat J, Decullier E, Poncet G, Bailly S, Giraud S, Dupuis-Girod S. Phenotypic characterisation of SMAD4 variant carriers. J Med Genet 2024; 61:734-740. [PMID: 38575304 PMCID: PMC11287639 DOI: 10.1136/jmg-2023-109632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 03/15/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Both hereditary haemorrhagic telangiectasia (HHT) and juvenile polyposis syndrome (JPS) are known to be caused by SMAD4 pathogenic variants, with overlapping symptoms for both disorders in some patients. Additional connective tissue disorders have also been reported. Here, we describe carriers of SMAD4 variants followed in an HHT reference centre to further delineate the phenotype. METHODS Observational study based on data collected from the Clinical Investigation for the Rendu-Osler Cohort database. RESULTS Thirty-three participants from 15 families, out of 1114 patients with HHT, had an SMAD4 variant (3%).Regarding HHT, 26 out of 33 participants (88%) had a definite clinical diagnosis based on Curaçao criteria. Complication frequencies were as follows: epistaxis (n=27/33, 82%), cutaneous telangiectases (n=19/33, 58%), pulmonary arteriovenous malformations (n=17/32, 53%), hepatic arteriovenous malformations (AVMs) (n=7/18, 39%), digestive angiodysplasia (n=13/22, 59%). No cerebral AVMs were diagnosed.Regarding juvenile polyposis, 25 out of 31 participants (81%) met the criteria defined by Jass et al for juvenile polyposis syndrome. Seven patients (21%) had a prophylactic gastrectomy due to an extensive gastric polyposis incompatible with endoscopic follow-up, and four patients (13%) developed a digestive cancer.Regarding connective tissue disorders, 20 (61%) had at least one symptom, and 4 (15%) participants who underwent echocardiography had an aortic dilation. CONCLUSION We describe a large cohort of SMAD4 variant carriers in the context of HHT. Digestive complications are frequent, early and diffuse, justifying endoscopy every 2 years. The HHT phenotype, associating pulmonary and hepatic AVMs, warrants systematic screening. Connective tissue disorders broaden the phenotype associated with SMAD4 gene variants and justify systematic cardiac ultrasound and skeletal complications screening.
Collapse
Affiliation(s)
- Claire Caillot
- Service de Génétique et Centre de référence pour la maladie de Rendu-Osler, Femme-Mère-Enfants Hospital, Hospices Civils de Lyon, Bron, France
| | - Jean-Christophe Saurin
- Service de Gastroenterologie, Hôpital E. Herriot, Hospices Civils de Lyon, Lyon, France
- Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Valérie Hervieu
- Institut de Pathologie Est, Hospices Civils de Lyon, Lyon, France
| | - Marie Faoucher
- Service de génétique, Centre de Biologie et Pathologie Est, Hospices Civils de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Julie Reversat
- Service de génétique, Centre de Biologie et Pathologie Est, Hospices Civils de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Evelyne Decullier
- Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Gilles Poncet
- Université Claude Bernard Lyon 1, Villeurbanne, France
- Service de Chirurgie Digestive, Hôpital E. Herriot Lyon, Hospices Civils de Lyon, Lyon, France
| | - Sabine Bailly
- Biosanté Lab, Unit U1292, Health Department of IRIG, CEA de Grenoble, Grenoble, France
| | - Sophie Giraud
- Service de génétique, Centre de Biologie et Pathologie Est, Hospices Civils de Lyon, Lyon, France
| | - Sophie Dupuis-Girod
- Service de Génétique et Centre de référence pour la maladie de Rendu-Osler, Femme-Mère-Enfants Hospital, Hospices Civils de Lyon, Bron, France
- Biosanté Lab, Unit U1292, Health Department of IRIG, CEA de Grenoble, Grenoble, France
| |
Collapse
|
10
|
Tyburec M, Braslavsky A, Serrano C, Vázquez C, Serra M. Management of hereditary hemorrhagic telangiectasia-like symptoms induced by trastuzumab emtansine in a breast cancer patient: case report. J Chemother 2024:1-5. [PMID: 39028266 DOI: 10.1080/1120009x.2024.2379169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 07/08/2024] [Indexed: 07/20/2024]
Abstract
Trastuzumab emtansine (T-DM1) is a targeted therapy combining trastuzumab and emtansine for human epidermal growth factor receptor 2(HER2)-positive breast cancer, with common side effects including fatigue, nausea, pain, headache, low platelet count, and elevated liver enzymes. Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant vascular dysplasia characterized by vascular malformations and telangiectasias in various organs. We present a case of a female patient with advanced breast cancer who developed HHT-like symptoms while on T-DM1 treatment. A 59-year-old woman treated with radiotherapy and T-DM1 every 21 days developed recurring nosebleeds and mucocutaneous and liver telangiectasias indistinguishable from HHT three months after receiving the first dose of T-DM1. Other organ vascular malformations were ruled out through screening protocols. The patient had no previous HHT symptoms or family history. Nasal care measures like lubrication and antifibrinolytics (tranexamic acid) were provided. In addition, propranolol was also prescribed due to its antiangiogenic and antitumoral properties, leading to significantly decreased epistaxis and telangiectasias. Microtubule disruptions caused by T-DM1, along with other angiogenic mechanisms may contribute to the development of telangiectasias resembling HHT. The use of propranolol, an initial approach for HHT, proved to be effective in this case. It is crucial for oncologists and HHT specialists to be aware of this rare adverse event associated with T-DM1 and to implement appropriate management strategies.
Collapse
Affiliation(s)
- Micaela Tyburec
- Instituto Universitario Hospital Italiano, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ana Braslavsky
- Argentine Rendu Study Group (ARG), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Candelaria Serrano
- Argentine Rendu Study Group (ARG), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- ENT Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carolina Vázquez
- Argentine Rendu Study Group (ARG), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marcelo Serra
- Argentine Rendu Study Group (ARG), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- HHT Unit and Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
11
|
Wu J, Liu B, Zhou Z. Genetic analysis of a family with hereditary hemorrhagic telangiectasia caused by a novel frameshift deletion mutation of the endoglin (ENG) gene. Med Clin (Barc) 2024:S0025-7753(24)00385-3. [PMID: 39025773 DOI: 10.1016/j.medcli.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Jiangtao Wu
- Department of Radiology, The First Affiliated Hospital of Dali University, Dali, China
| | - Bin Liu
- Department of General Surgery, Baoshan People's Hospital, Bao shan, China
| | - Zhou Zhou
- Department of Radiology, The First Affiliated Hospital of Dali University, Dali, China.
| |
Collapse
|
12
|
Whitehead KJ, Toydemir D, Wooderchak-Donahue W, Oakley GM, McRae B, Putnam A, McDonald J, Bayrak-Toydemir P. Investigation of the Genetic Determinants of Telangiectasia and Solid Organ Arteriovenous Malformation Formation in Hereditary Hemorrhagic Telangiectasia (HHT). Int J Mol Sci 2024; 25:7682. [PMID: 39062925 PMCID: PMC11276621 DOI: 10.3390/ijms25147682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 07/10/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Telangiectases and arteriovenous malformations (AVMs) are the characteristic lesions of Hereditary Hemorrhagic Telangiectasia (HHT). Somatic second-hit loss-of-function variations in the HHT causative genes, ENG and ACVRL1, have been described in dermal telangiectasias. It is unclear if somatic second-hit mutations also cause the formation of AVMs and nasal telangiectasias in HHT. To investigate the genetic mechanism of AVM formation in HHT, we evaluated multiple affected tissues from fourteen individuals. DNA was extracted from fresh/frozen tissue of 15 nasal telangiectasia, 4 dermal telangiectasia, and 9 normal control tissue biopsies, from nine unrelated individuals with HHT. DNA from six formalin-fixed paraffin-embedded (FFPE) AVM tissues (brain, lung, liver, and gallbladder) from five individuals was evaluated. A 736 vascular malformation and cancer gene next-generation sequencing (NGS) panel was used to evaluate these tissues down to 1% somatic mosaicism. Somatic second-hit mutations were identified in three in four AVM biopsies (75%) or half of the FFPE (50%) samples, including the loss of heterozygosity in ENG in one brain AVM sample, in which the germline mutation occurred in a different allele than a nearby somatic mutation (both are loss-of-function mutations). Eight of nine (88.9%) patients in whom telangiectasia tissues were evaluated had a somatic mutation ranging from 0.68 to 1.96% in the same gene with the germline mutation. Six of fifteen (40%) nasal and two of four (50%) dermal telangiectasia had a detectable somatic second hit. Additional low-level somatic mutations in other genes were identified in several telangiectasias. This is the first report that nasal telangiectasias and solid organ AVMs in HHT are caused by very-low-level somatic biallelic second-hit mutations.
Collapse
Affiliation(s)
- Kevin J. Whitehead
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah, Salt Lake City, UT 84112, USA;
- HHT Center, Department of Radiology, University of Utah, Salt Lake City, UT 84112, USA
| | - Doruk Toydemir
- School of Liberal Arts, Tulane University, New Orleans, LA 70118, USA;
| | | | - Gretchen M. Oakley
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, UT 84112, USA; (G.M.O.); (B.M.)
| | - Bryan McRae
- Department of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, UT 84112, USA; (G.M.O.); (B.M.)
| | - Angelica Putnam
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA (A.P.); (J.M.)
| | - Jamie McDonald
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA (A.P.); (J.M.)
| | - Pinar Bayrak-Toydemir
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA (A.P.); (J.M.)
- ARUP Laboratories|Institute for Clinical and Experimental Pathology, 500 Chipeta Way, Salt Lake City, UT 84103, USA
| |
Collapse
|
13
|
Sekarski L, White AJ, Amba KT. Hereditary hemorrhagic telangiectasia diagnosis: A case report. J Pediatr Nurs 2024; 77:106-110. [PMID: 38492257 DOI: 10.1016/j.pedn.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 03/18/2024]
Abstract
This case report presents a 13-year-old patient with a lung nodule identified on a chest radiograph in the emergency department during an evaluation of knee and side pain after a fall. The patient had nosebleeds, family history of hereditary hemorrhagic telangiectasia (HHT) and after chest computed tomography with angiography, the nodule was defined as a single pulmonary arteriovenous malformation (PAVM). Neither parent nor patient had been evaluated for HHT, an autosomal dominant disease, despite the family history. This patient satisfied the clinical criteria for the diagnosis and had a confirmatory genetic test, which led to diagnosis in mother also. The patient's PAVMs were treated, decreasing the risk of life threatening complications. Diagnosing HHT in children is often delayed or missed, even in families with HHT, as in this case report. Without any physical signs or clinical symptoms, families and healthcare providers often dismiss the possibility of the diagnosis. Children with HHT are at the same risk for complications of stroke, anemia, hypoxemia, heart failure and increased morbidity as adults. It is essential to recognize the importance of family history when evaluating children in primary care and urgent settings, as this patient's diagnosis was delayed 13 years. Awareness of HHT signs and symptoms are essential to early referral to an HHT specialist, for diagnosis and management.
Collapse
Affiliation(s)
- Lynne Sekarski
- SSM Health Cardinal Glennon Children's Hospital, 1465 S. Grand Blvd., St Louis, MO, USA.
| | - Andrew J White
- St. Louis University School of Medicine, 1402 S. Grand Blvd., St. Louis, MO, USA.
| | - Katheryne Tifuh Amba
- SSM Health Cardinal Glennon Children's Hospital, 1465 S. Grand Blvd., St Louis, MO, USA.
| |
Collapse
|
14
|
Droege F, König J, Lang KS, Jablonska J, Pylaeva E, Huckenbeck C, Wrobeln A, Duerig I, Thangavelu K, Lang S, Geisthoff U. Increased Risk for Infections and Allergic Disease in Hereditary Hemorrhagic Telangiectasia. J Clin Med 2024; 13:3752. [PMID: 38999318 PMCID: PMC11242906 DOI: 10.3390/jcm13133752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/19/2024] [Accepted: 06/22/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Hereditary hemorrhagic telangiectasia (HHT) is a rare disorder characterized by dilated blood vessels. Different immunological changes have been described in these patients. In this study, the predisposition of patients with HHT to infections and allergic diseases was assessed. Methods: Patients with HHT completed an online survey in English or German. Their data were compared to non-affected partners or friends. Results: A total of 430 out of 588 respondents with HHT answered our questions about infections and allergies. Patients with HHT suffered significantly more often from various types of allergies than their partners, especially type I allergies (n = 226/276, 82%), and had a higher risk for sinusitis, urinary tract infections, pulmonary infections, and abscesses. A total of 38% of the patients took antibiotics prior to dental or surgical procedures (n = 57/152), and, in 10% of these patients, pulmonary arteriovenous malformations (PAVMs) were not detected. On the other hand, 51% of patients with PAVM did not report a prophylactic antibiotic intake (n = 40/79). The patients who needed iron supplementations suffered more often from sepsis (OR: 9.00, 95%CI: 0.92-88.16). Conclusions: Compared to their non-affected controls, patients with HHT showed an increased risk for infections in different organs and allergic diseases. There is a need for campaigns raising greater awareness recommending prophylactic antibiotic intake in patients with PAVM.
Collapse
Affiliation(s)
- Freya Droege
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, 55101 Mainz, Germany;
| | - Karl S. Lang
- Institute of Immunology, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany;
| | - Jadwiga Jablonska
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Ekaterina Pylaeva
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Carolin Huckenbeck
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Anna Wrobeln
- Institute of Physiology, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany;
| | - Inga Duerig
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Kruthika Thangavelu
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, University Hospital of Marburg, Philipps-University of Marburg, Baldingerstrasse, 35042 Marburg, Germany; (K.T.); (U.G.)
| | - Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Urban Geisthoff
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, University Hospital of Marburg, Philipps-University of Marburg, Baldingerstrasse, 35042 Marburg, Germany; (K.T.); (U.G.)
| |
Collapse
|
15
|
Lorente-Herraiz L, Cuesta AM, Recio-Poveda L, Botella LM, Albiñana V. Endothelial-to-Mesenchymal Transition in an Hereditary Hemorrhagic Telangiectasia-like Pediatric Case of Multiple Pulmonary Arteriovenous Malformations. Int J Mol Sci 2024; 25:6163. [PMID: 38892351 PMCID: PMC11172626 DOI: 10.3390/ijms25116163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/30/2024] [Accepted: 06/01/2024] [Indexed: 06/21/2024] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs) are vascular anomalies resulting in abnormal connections between pulmonary arteries and veins. In 80% of cases, PAVMs are present from birth, but clinical manifestations are rarely seen in childhood. These congenital malformations are typically associated with Hereditary Hemorrhagic Telangiectasia (HHT), a rare disease that affects 1 in 5000/8000 individuals. HHT disease is frequently caused by mutations in genes involved in the TGF-β pathway. However, approximately 15% of patients do not have a genetic diagnosis and, among the genetically diagnosed, more than 33% do not meet the Curaçao criteria. This makes clinical diagnosis even more challenging in the pediatric age group. Here, we introduce an 8-year-old patient bearing a severe phenotype of multiple diffuse PAVMs caused by an unknown mutation which ended in lung transplantation. Phenotypically, the case under study follows a molecular pattern which is HHT-like. Therefore, molecular- biological and cellular-functional analyses have been performed in primary endothelial cells (ECs) isolated from the explanted lung. The findings revealed a loss of functionality in lung endothelial tissue and a stimulation of endothelial-to-mesenchymal transition. Understanding the molecular basis of this transition could potentially offer new therapeutic strategies to delay lung transplantation in severe cases.
Collapse
Affiliation(s)
- Laura Lorente-Herraiz
- Departamento de Biomedicina Molecular, Centro de Investigaciones Biológicas Margarita Salas, CIB-CSIC, 28040 Madrid, Spain; (L.L.-H.); (L.R.-P.); (L.M.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, 28029 Madrid, Spain;
| | - Angel M. Cuesta
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, 28029 Madrid, Spain;
- Departamento de Bioquímica, Facultad de Farmacia, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Lucía Recio-Poveda
- Departamento de Biomedicina Molecular, Centro de Investigaciones Biológicas Margarita Salas, CIB-CSIC, 28040 Madrid, Spain; (L.L.-H.); (L.R.-P.); (L.M.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, 28029 Madrid, Spain;
| | - Luisa M. Botella
- Departamento de Biomedicina Molecular, Centro de Investigaciones Biológicas Margarita Salas, CIB-CSIC, 28040 Madrid, Spain; (L.L.-H.); (L.R.-P.); (L.M.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, 28029 Madrid, Spain;
| | - Virginia Albiñana
- Departamento de Biomedicina Molecular, Centro de Investigaciones Biológicas Margarita Salas, CIB-CSIC, 28040 Madrid, Spain; (L.L.-H.); (L.R.-P.); (L.M.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), ISCIII, 28029 Madrid, Spain;
| |
Collapse
|
16
|
Hagiwara S, Takase T, Oda I, Komeda Y, Nishida N, Yoshida A, Yamamoto T, Matsubara T, Kudo M. Hereditary hemorrhagic telangiectasia with hepatic arteriovenous shunt diagnosed due to liver damage. Clin J Gastroenterol 2024; 17:477-483. [PMID: 38436842 PMCID: PMC11127884 DOI: 10.1007/s12328-024-01923-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/11/2024] [Indexed: 03/05/2024]
Abstract
A 53-year-old woman was diagnosed with liver dysfunction in August 20XX. Computed tomography (CT) revealed multiple hepatic AV shunts, and she was placed under observation. In March 20XX + 3, she developed back pain, and CT performed during an emergency hospital visit showed evidence of intrahepatic bile duct dilatation. She was referred to our gastroenterology department in May 20XX + 3. We conducted investigations on suspicion of hereditary hemorrhagic telangiectasia (HHT) with hepatic AV shunting based on contrast-enhanced CT performed at another hospital. HHT is generally discovered due to epistaxis, but there are also cases where it is diagnosed during examination of liver damage.
Collapse
Affiliation(s)
- Satoru Hagiwara
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan.
| | - Toru Takase
- Department of Cardiovascular Medicine, Kindai University Faculty of Medicine, Osaka, Japan
| | - Itsuki Oda
- Department of Clinical Genetics, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yoriaki Komeda
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Akihiro Yoshida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Tomoki Yamamoto
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Takuya Matsubara
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan
| |
Collapse
|
17
|
Beslow LA, Krings T, Kim H, Hetts SW, Lawton MT, Ratjen F, Whitehead KJ, Gossage JR, McCulloch CE, Clancy M, Bagheri N, Faughnan ME. De Novo Brain Vascular Malformations in Hereditary Hemorrhagic Telangiectasia. Pediatr Neurol 2024; 155:120-125. [PMID: 38631080 PMCID: PMC11102835 DOI: 10.1016/j.pediatrneurol.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/26/2024] [Accepted: 03/15/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Approximately 10% of people with hereditary hemorrhagic telangiectasia (HHT) have brain vascular malformations (VMs). Few reports describe de novo brain VM formation. International HHT Guidelines recommend initial brain VM screening upon HHT diagnosis in children but do not address rescreening. We aimed to confirm whether brain VMs can form de novo in patients with HHT. METHODS The Brain Vascular Malformation Consortium HHT project is a 17-center longitudinal study enrolling patients since 2010. We analyzed the database for de novo VMs defined as those detected (1) on follow-up neuroimaging in a patient without previous brain VMs or (2) in a location distinct from previously identified brain VMs and reported those in whom a de novo VM could be confirmed on central neuroimaging review. RESULTS Of 1909 patients enrolled, 409 (21%) had brain VMs. Seven patients were recorded as having de novo brain VMs, and imaging was available for central review in four. We confirmed that three (0.7% of individuals with brain VMs) had de novo brain VMs (two capillary malformations, one brain arteriovenous malformation) with intervals of six, nine, and 13 years from initial imaging. Two with de novo brain VMs were <18 years. The fourth patient, a child, did not have a de novo brain VM but had a radiologically confirmed increase in size of an existing brain arteriovenous malformation. CONCLUSIONS Brain VMs can, albeit rarely, form de novo in patients with HHT. Given the potential risk of hemorrhage from brain VMs, regular rescreening in patients with HHT may be warranted.
Collapse
Affiliation(s)
- Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Timo Krings
- Division of Neuroradiology, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Helen Kim
- Department of Anesthesia, University of California - San Francisco, San Francisco, California
| | - Steven W Hetts
- Division of Neurointerventional Radiology, University of California - San Francisco, San Francisco, California
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Felix Ratjen
- Department of Paediatrics, Division of Paediatric Respiratory Medicine, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Kevin J Whitehead
- Departments of Internal Medicine and Pediatrics, The University of Utah, Salt Lake City, Utah
| | - James R Gossage
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics, University of California - San Francisco, San Francisco, California
| | | | - Negar Bagheri
- Toronto HHT Centre, Department of Medicine, St. Michael's Hospital and Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Marie E Faughnan
- Toronto HHT Centre, Department of Medicine, St. Michael's Hospital and Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
18
|
Pearson M, McGowan R, Greene P, Lam W, Miedzybrodzka Z, Berg J. Outcomes of patients with Juvenile Polyposis-Hereditary Haemorrhagic Telangiectasia caused by pathogenic SMAD4 variants in a pan-Scotland cohort. Eur J Hum Genet 2024; 32:731-735. [PMID: 38627541 PMCID: PMC11153582 DOI: 10.1038/s41431-024-01607-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/20/2024] [Accepted: 03/28/2024] [Indexed: 06/07/2024] Open
Abstract
Constitutional loss of SMAD4 function results in Juvenile Polyposis-Hereditary Haemorrhagic Telangiectasia Overlap Syndrome (JP-HHT). A retrospective multi-centre case-note review identified 28 patients with a pathogenic SMAD4 variant from 13 families across all Scottish Clinical Genetics Centres. This provided a complete clinical picture of the Scottish JP-HHT cohort. Colonic polyps were identified in 87% (23/28) and gastric polyps in 67% (12/18) of screened patients. Complication rates were high: 43% (10/23) of patients with polyps required a colectomy and 42% (5/12) required a gastrectomy. Colorectal cancer occurred in 25% (7/28) of patients, at a median age of 33 years. Pulmonary arteriovenous malformations were identified in 42% (8/19) of screened patients. 88% (23/26) and 81% (17/21) of patients exhibited JP and HHT features respectively, with 70% (14/20) demonstrating features of both conditions. We have shown that individuals with a pathogenic SMAD4 variant are all at high risk of both gastrointestinal neoplasia and HHT-related vascular complications, requiring a comprehensive screening programme.
Collapse
Affiliation(s)
| | - Ruth McGowan
- West of Scotland Centre for Genomic Medicine, Glasgow, Scotland, UK
| | - Philip Greene
- South East of Scotland Clinical Genetics Service, Edinburgh, UK
| | - Wayne Lam
- South East of Scotland Clinical Genetics Service, Edinburgh, UK
| | - Zofia Miedzybrodzka
- School of Medicine, Medical Sciences, Nutrition and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Jonathan Berg
- School of Medicine, University of Dundee, Dundee, Scotland, UK.
| |
Collapse
|
19
|
Filbrich M, Brisbois D, Lebrun Y, Godin PA, Verscheure S. Spontaneous haemothorax caused by a ruptured pulmonary arterio-venous malformation: A manifestation of hereditary haemorrhagic telangiectasia in pregnancy. Obstet Med 2024; 17:112-115. [PMID: 38784192 PMCID: PMC11110747 DOI: 10.1177/1753495x221145809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 05/25/2024] Open
Abstract
We report our experience of managing a massive haemothorax caused by a ruptured, previously unknown, pulmonary arteriovenous malformation (pAVM) at 34 + 5 weeks of gestation, which proved to be a manifestation of hereditary haemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome. The patient underwent an emergency caesarean section under general anaesthesia after placement of a chest tube and gave birth to a healthy infant. A postoperative thoracic computed tomography angiography highlighted the presence of the large pAVM. Transcatheter embolization was performed right after the delivery. Subsequent patient's anamnesis, family history and genetic analysis finally revealed the presence of the syndrome. The aim of our report is to create awareness of this serious condition with potential life-threatening complications, especially in pregnancy. Simple criteria have been published and allow to easily consider HHT and the presence of potential AVM during anamnesis, ideally even before pregnancy.
Collapse
Affiliation(s)
- Maike Filbrich
- Cliniques Universitaires Saint Luc, Bruxelles, Belgium
- Clinique MontLégia CHC, Liege, Belgium
| | | | | | | | | |
Collapse
|
20
|
Pillai AK, Steigner ML, Aghayev A, Ahmad S, Ferencik M, Kandathil A, Kirsch DS, Lee YJ, Nagpal P, O'Neil K, Partovi S, Revels S, Ripley B, Russell RR, Saboo SS, Tannenbaum A, Thomas R, Wells BJ, Yu HS, Kalva SP. ACR Appropriateness Criteria® Pulmonary Arteriovenous Malformation (PAVM): 2023 Update. J Am Coll Radiol 2024; 21:S268-S285. [PMID: 38823949 DOI: 10.1016/j.jacr.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Pulmonary arteriovenous malformations (PAVMs) occur in 30% to 50% of patients with hereditary hemorrhagic telangiectasia. Clinical presentations vary from asymptomatic disease to complications resulting from the right to left shunting of blood through the PAVM such as paradoxical stroke, brain abscesses, hypoxemia, and cardiac failure. Radiology plays an important role both in the diagnosis and treatment of PAVM. Based on different clinical scenarios, the appropriate imaging study has been reviewed and is presented in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Collapse
Affiliation(s)
- Anil K Pillai
- University of Texas Southwestern Medical Center, Dallas, Texas.
| | | | - Ayaz Aghayev
- Panel Vice Chair, Brigham & Women's Hospital, Boston, Massachusetts
| | - Sarah Ahmad
- University of Toronto, Toronto, Ontario, Canada; American College of Physicians
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography
| | - Asha Kandathil
- University of Texas Southwestern Medical Center, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Yoo Jin Lee
- University of California San Francisco, San Francisco, California
| | - Prashant Nagpal
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin O'Neil
- Wilmington Health, Wilmington, North Carolina; American College of Chest Physicians
| | | | - Sha'Shonda Revels
- UCLA Medical Center, Los Angeles, California; The Society of Thoracic Surgeons
| | - Beth Ripley
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Raymond R Russell
- The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; Nuclear cardiology expert
| | | | | | - Richard Thomas
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Bryan J Wells
- Emory University, Atlanta, Georgia; American Society of Echocardiography
| | - Hei Shun Yu
- Brigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER
| | - Sanjeeva P Kalva
- Specialty Chair, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
21
|
Otsuka E, Kitamura M, Sawase K, Nakamura M, Inoue H, Yamaguchi K, Funakoshi S, Takazono T, Mukae H, Nishino T. Hereditary Hemorrhagic Telangiectasia in a Patient Undergoing Hemodialysis with Anticoagulants and Antiplatelets. Intern Med 2024; 63:1609-1614. [PMID: 37866921 PMCID: PMC11189710 DOI: 10.2169/internalmedicine.2180-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/07/2023] [Indexed: 10/24/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder that causes abnormal blood vessel formation and bleeding. We herein report a 61-year-old woman with aggravated HHT symptoms after hemodialysis initiation. She was diagnosed with HHT based on her recurrent bleeding, abnormal blood vessel formation, and family history. Despite bleeding complications, the patient required anticoagulants and antiplatelet agents to treat cardiovascular complications. Eventually, the patient died of extensive cerebral hemorrhaging. Our experience suggests that special attention should be paid to bleeding complications in high-risk patients.
Collapse
Affiliation(s)
- Emiko Otsuka
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Nagasaki Renal Center, Japan
| | - Mineaki Kitamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Nagasaki Renal Center, Japan
| | | | - Maiko Nakamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
- Nagasaki Renal Center, Japan
| | - Hiro Inoue
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Kosei Yamaguchi
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | | | - Takahiro Takazono
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, Japan
| |
Collapse
|
22
|
Sakaida H, Kobayashi M, Takeuchi K. Usefulness of endoscopic endonasal underwater surgery using a combination of coblation and a lens-cleaning system for hemostasis in hereditary hemorrhagic telangiectasia. Auris Nasus Larynx 2024; 51:512-516. [PMID: 38522355 DOI: 10.1016/j.anl.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/26/2024]
Abstract
Hemostatic procedures for controlling nasal bleeding in refractory diseases such as hereditary hemorrhagic telangiectasia (HHT) can be challenging. In this report, we present a novel technique for underwater endoscopic endonasal hemostatic surgery, which was performed on a 69-year-old man with HHT. The patient had been experiencing frequent episodes of nasal bleeding and had many telangiectasias in the nasal cavity, which were the cause of the bleeding. These telangiectasias were effectively treated using a coblation device in combination with an endoscope lens-cleaning system that supplied saline to create stable underwater conditions. There are several advantages to this technique, including provision of a stable and clear endoscopic field of view, allowing for better visualization of the surgical site. This makes it easier to identify bleeding points and ensure accurate hemostasis. Additionally, the hydrostatic pressure created by the underwater environment helps to reduce bleeding during the procedure. However, it is important to take careful precautions to prevent water from entering the lower airway. With this precautionary measure, this technique is particularly useful in managing bleeding in patients with HHT.
Collapse
Affiliation(s)
- Hiroshi Sakaida
- Department of Otorhinolaryngology-Head and Neck Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
| | - Masayoshi Kobayashi
- Department of Otorhinolaryngology-Head and Neck Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Kazuhiko Takeuchi
- Department of Otorhinolaryngology-Head and Neck Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| |
Collapse
|
23
|
Vázquez-Lavista LG, González-Ramos V, Janka-Zires M, Ramírez-Muciño JA, Arroyo-Ortiz F. Osler Weber Rendu Syndrome. Urology 2024; 187:94-95. [PMID: 38479558 DOI: 10.1016/j.urology.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 04/01/2024]
Affiliation(s)
| | | | | | | | - Fania Arroyo-Ortiz
- Fundación Clinica Médica Sur, Anesthesiology Department, México City, México
| |
Collapse
|
24
|
Al Tabosh T, Liu H, Koça D, Al Tarrass M, Tu L, Giraud S, Delagrange L, Beaudoin M, Rivière S, Grobost V, Rondeau-Lutz M, Dupuis O, Ricard N, Tillet E, Machillot P, Salomon A, Picart C, Battail C, Dupuis-Girod S, Guignabert C, Desroches-Castan A, Bailly S. Impact of heterozygous ALK1 mutations on the transcriptomic response to BMP9 and BMP10 in endothelial cells from hereditary hemorrhagic telangiectasia and pulmonary arterial hypertension donors. Angiogenesis 2024; 27:211-227. [PMID: 38294582 PMCID: PMC11021321 DOI: 10.1007/s10456-023-09902-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/03/2023] [Indexed: 02/01/2024]
Abstract
Heterozygous activin receptor-like kinase 1 (ALK1) mutations are associated with two vascular diseases: hereditary hemorrhagic telangiectasia (HHT) and more rarely pulmonary arterial hypertension (PAH). Here, we aimed to understand the impact of ALK1 mutations on BMP9 and BMP10 transcriptomic responses in endothelial cells. Endothelial colony-forming cells (ECFCs) and microvascular endothelial cells (HMVECs) carrying loss of function ALK1 mutations were isolated from newborn HHT and adult PAH donors, respectively. RNA-sequencing was performed on each type of cells compared to controls following an 18 h stimulation with BMP9 or BMP10. In control ECFCs, BMP9 and BMP10 stimulations induced similar transcriptomic responses with around 800 differentially expressed genes (DEGs). ALK1-mutated ECFCs unexpectedly revealed highly similar transcriptomic profiles to controls, both at the baseline and upon stimulation, and normal activation of Smad1/5 that could not be explained by a compensation in cell-surface ALK1 level. Conversely, PAH HMVECs revealed strong transcriptional dysregulations compared to controls with > 1200 DEGs at the baseline. Consequently, because our study involved two variables, ALK1 genotype and BMP stimulation, we performed two-factor differential expression analysis and identified 44 BMP9-dysregulated genes in mutated HMVECs, but none in ECFCs. Yet, the impaired regulation of at least one hit, namely lunatic fringe (LFNG), was validated by RT-qPCR in three different ALK1-mutated endothelial models. In conclusion, ALK1 heterozygosity only modified the BMP9/BMP10 regulation of few genes, including LFNG involved in NOTCH signaling. Future studies will uncover whether dysregulations in such hits are enough to promote HHT/PAH pathogenesis, making them potential therapeutic targets, or if second hits are necessary.
Collapse
Affiliation(s)
- T Al Tabosh
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - H Liu
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - D Koça
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - M Al Tarrass
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - L Tu
- Faculté de Médecine, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
| | - S Giraud
- Genetics Department, Femme-Mère-Enfants Hospital, Hospices Civils de Lyon, 69677, Bron, France
| | - L Delagrange
- Genetics Department, Femme-Mère-Enfants Hospital, Hospices Civils de Lyon, 69677, Bron, France
- National Reference Center for HHT, 69677, Bron, France
| | - M Beaudoin
- Genetics Department, Femme-Mère-Enfants Hospital, Hospices Civils de Lyon, 69677, Bron, France
- National Reference Center for HHT, 69677, Bron, France
| | - S Rivière
- Internal Medicine Department, CHU of Montpellier, St Eloi Hospital and Center of Clinical Investigation, INSERM, CIC 1411, 34295, Montpellier Cedex 7, France
| | - V Grobost
- Internal Medicine Department, CHU Estaing, 63100, Clermont-Ferrand, France
| | - M Rondeau-Lutz
- Internal Medicine Department, University Hospital of Strasbourg, 67091, Strasbourg Cedex, France
| | - O Dupuis
- Hôpital Lyon SUD, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, 69100, Villeurbanne, France
- Faculty of Medicine, Lyon University, 69921, Lyon, France
| | - N Ricard
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - E Tillet
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - P Machillot
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - A Salomon
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - C Picart
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - C Battail
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - S Dupuis-Girod
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
- Genetics Department, Femme-Mère-Enfants Hospital, Hospices Civils de Lyon, 69677, Bron, France
- National Reference Center for HHT, 69677, Bron, France
| | - C Guignabert
- Faculté de Médecine, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Université Paris-Saclay, 94276, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 «Pulmonary Hypertension: Pathophysiology and Novel Therapies», Hôpital Marie Lannelongue, 92350, Le Plessis-Robinson, France
| | - A Desroches-Castan
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France
| | - S Bailly
- Biosanté unit U1292, Grenoble Alpes University, INSERM, CEA, 38000, Grenoble, France.
| |
Collapse
|
25
|
Mattheis S, Wanke I. Interdisciplinary Management of Vascular Anomalies in the Head and Neck. Laryngorhinootologie 2024; 103:S125-S147. [PMID: 38697145 DOI: 10.1055/a-2225-9932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
Vascular anomalies in the head and neck area are usually rare diseases and pose a particular diagnostic and therapeutic challenge. They are divided into vascular tumours and vascular malformations. A distinction is made between benign tumours, such as infantile haemangioma, and rare malignant tumours, such as angiosarcoma. Vascular malformations are categorised as simple malformations, mixed malformations, large vessel anomalies and those associated with other anomalies. Treatment is interdisciplinary and various modalities are available. These include clinical observation, sclerotherapy, embolisation, ablative and coagulating procedures, surgical resection and systemic drug therapy. Treatment is challenging, as vascular anomalies in the head and neck region practically always affect function and aesthetics. A better understanding of the genetic and molecular biological basis of vascular anomalies has recently led to clinical research into targeted drug therapies. This article provides an up-to-date overview of the diagnosis, clinic and treatment of vascular anomalies in the head and neck region.
Collapse
Affiliation(s)
- Stefan Mattheis
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsmedizin Essen (Direktor: Prof. Dr. Stephan Lang)
| | - Isabel Wanke
- Zentrum für Neuroradiologie, Klinik Hirslanden, Zürich, Schweiz
| |
Collapse
|
26
|
Delpon JE, Greffier J, Lacombe H, Barbe A, Bouin M, De Oliveira F, Mansuy A, Delagrange L, Fargeton AE, Beregi JP, Cottin V, Dupuis-Girod S, Si-Mohamed SA. Ultra-low dose chest CT for the diagnosis of pulmonary arteriovenous malformation in patients with hereditary hemorrhagic telangiectasia. Diagn Interv Imaging 2024:S2211-5684(24)00082-2. [PMID: 38604894 DOI: 10.1016/j.diii.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE The purpose of this study was to compare ultra-low dose (ULD) and standard low-dose (SLD) chest computed tomography (CT) in terms of radiation exposure, image quality and diagnostic value for diagnosing pulmonary arteriovenous malformation (AVM) in patients with hereditary hemorrhagic telangiectasia (HHT). MATERIALS AND METHODS In this prospective board-approved study consecutive patients with HHT referred to a reference center for screening and/or follow-up chest CT examination were prospectively included from December 2020 to January 2022. Patients underwent two consecutive non-contrast chest CTs without dose modulation (i.e., one ULD protocol [80 kVp or 100 kVp, CTDIvol of 0.3 mGy or 0.6 mGy] and one SLD protocol [140 kVp, CTDIvol of 1.3 mGy]). Objective image noises measured at the level of tracheal carina were compared between the two protocols. Overall image quality and diagnostic confidence were scored on a 4-point Likert scale (1 = insufficient to 4 = excellent). Sensitivity, specificity, positive predictive value and negative predictive value of ULD CT for diagnosing pulmonary AVM with a feeding artery of over 2 mm in diameter were calculated along with their 95% confidence intervals (CI) using SLD images as the standard of reference. RESULTS A total of 44 consecutive patients with HHT (31 women; mean age, 42 ± 16 [standard deviation (SD)] years; body mass index, 23.2 ± 4.5 [SD] kg/m2) were included. Thirty-four pulmonary AVMs with a feeding artery of over 2 mm in diameter were found with SLD images versus 35 with ULD images. Sensitivity, specificity, predictive positive value, and predictive negative value of ULD CT for the diagnosis of PAVM were 100% (34/34; 95% CI: 90-100), 96% (18/19; 95% CI: 74-100), 97% (34/35; 95% CI: 85-100) and 100% (18/18; 95% CI: 81-100), respectively. A significant difference in diagnostic confidence scores was found between ULD (3.8 ± 0.4 [SD]) and SLD (3.9 ± 0.1 [SD]) CT images (P = 0.03). No differences in overall image quality scores were found between ULD CT examinations (3.9 ± 0.2 [SD]) and SLD (4 ± 0 [SD]) CT examinations (P = 0.77). Effective radiation dose decreased significantly by 78.8% with ULD protocol, with no significant differences in noise values between ULD CT images (16.7 ± 5.0 [SD] HU) and SLD images (17.7 ± 6.6 [SD] HU) (P = 0.07). CONCLUSION ULD chest CT provides 100% sensitivity and 96% specificity for the diagnosis of treatable pulmonary AVM with a feeding artery of over 2 mm in diameter, leading to a 78.8% dose-saving compared with a standard low-dose protocol.
Collapse
Affiliation(s)
- Jean-Etienne Delpon
- Department of Radiology, Hôpital Louis Pradel, Hospices Civils de Lyon, 69677, Bron, France
| | - Joel Greffier
- Department of Radiology, CHU Nîmes, University Montpellier, Medical Imaging Group Nîmes, 30029 Nîmes, France
| | - Hugo Lacombe
- Université de Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, INSERM, CREATIS UMR 5220, U1206, 69100 Villeurbanne, France; CT Clinical Science, Philips, 92150 Suresnes, France
| | - Apolline Barbe
- Imaging Department, Cellule Recherche en Imagerie, Hospices Civils de Lyon, 69677 Bron, France
| | - Morgane Bouin
- Imaging Department, Cellule Recherche en Imagerie, Hospices Civils de Lyon, 69677 Bron, France
| | - Fabien De Oliveira
- Department of Radiology, Hôpital Louis Pradel, Hospices Civils de Lyon, 69677, Bron, France; Department of Radiology, CHU Nîmes, University Montpellier, Medical Imaging Group Nîmes, 30029 Nîmes, France
| | - Adeline Mansuy
- Imaging Department, Cellule Recherche en Imagerie, Hospices Civils de Lyon, 69677 Bron, France
| | - Laura Delagrange
- Imaging Department, Cellule Recherche en Imagerie, Hospices Civils de Lyon, 69677 Bron, France
| | - Anne-Emmanuelle Fargeton
- Department of Genetics and Centre National de Référence pour la Maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, 69677 Bron, France
| | - Jean-Paul Beregi
- Department of Radiology, CHU Nîmes, University Montpellier, Medical Imaging Group Nîmes, 30029 Nîmes, France
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, Louis Pradel Hospital, Hospices Civils de Lyon, Claude Bernard University Lyon, INRAE, ERN-LUNG, Lyon, France
| | - Sophie Dupuis-Girod
- Department of Genetics and Centre National de Référence pour la Maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, 69677 Bron, France
| | - Salim Aymeric Si-Mohamed
- Department of Radiology, Hôpital Louis Pradel, Hospices Civils de Lyon, 69677, Bron, France; Université de Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, INSERM, CREATIS UMR 5220, U1206, 69100 Villeurbanne, France.
| |
Collapse
|
27
|
Park Z, Dunston R, Ranasinghe T. Personalised stroke evaluation and management: tailoring individualised patient care for hereditary haemorrhagic telangiectasia. BMJ Case Rep 2024; 17:e257682. [PMID: 38575333 PMCID: PMC11002385 DOI: 10.1136/bcr-2023-257682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 04/06/2024] Open
Abstract
SummaryHereditary haemorrhagic telangiectasia (HHT) has an estimated prevalence of 1 in 5000-8000 individuals globally with pulmonary arteriovenous malformations (PAVMs) affecting approximately 15%-50% of HHT patients. Ischaemic stroke is a known complication of PAVMs that affects ≤30% of patients with PAVMs. Studies have shown that patients with PAVMs have ischaemic stroke a decade earlier than routine stroke. The predominant mechanism of ischaemic stroke in HHT patients is paradoxical embolism due to PAVMs, but most HHT-related PAVMs are asymptomatic. Additionally, HHT is often underdiagnosed in patients and poses a challenge to physicians due to its rarity. We present a case of a patient with ischaemic stroke who was subsequently diagnosed with HHT and found to have a PAVM on further evaluation. This case highlights the importance of using an individualised patient-centred stroke evaluation and screening for PAVMs in patients who had a stroke with possible or suspected HHT and definite HHT.
Collapse
Affiliation(s)
- Zackary Park
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Randy Dunston
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Neurology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Tamra Ranasinghe
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Neurology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| |
Collapse
|
28
|
Fu X, Wang Z, Feng Y, Zhang G, Li X, Li T, Wang S. Ruptured pulmonary arteriovenous fistula causing hemothorax in a patient with hereditary hemorrhagic telangiectasia: A case report. Pulm Circ 2024; 14:e12408. [PMID: 38939305 PMCID: PMC11208164 DOI: 10.1002/pul2.12408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024] Open
Affiliation(s)
- Xiangkai Fu
- Department of Cardiovascular CenterThe First Hospital of Jilin UniversityChangchunJilinChina
| | - Zixiao Wang
- Department of Cardiovascular CenterThe First Hospital of Jilin UniversityChangchunJilinChina
| | - Yinghan Feng
- Department of Cardiovascular CenterThe First Hospital of Jilin UniversityChangchunJilinChina
| | - Guoying Zhang
- Department of Cardiovascular CenterThe First Hospital of Jilin UniversityChangchunJilinChina
| | - Xianzhi Li
- Department of Cardiovascular CenterThe First Hospital of Jilin UniversityChangchunJilinChina
| | - Te Li
- Department of GeriatricsThe First Hospital of Jilin UniversityChangchunJilinChina
| | - Shudong Wang
- Department of Cardiovascular CenterThe First Hospital of Jilin UniversityChangchunJilinChina
| |
Collapse
|
29
|
Tusseau M, Eyries M, Chatron N, Coulet F, Guichet A, Colin E, Demeer B, Maillard H, Thevenon J, Lavigne C, Saillour V, Paris C, De Sainte Agathe JM, Pujalte M, Guilhem A, Dupuis-Girod S, Lesca G. Genome sequencing identify chromosome 9 inversions disrupting ENG in 2 unrelated HHT families. Eur J Med Genet 2024; 68:104919. [PMID: 38355093 DOI: 10.1016/j.ejmg.2024.104919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 01/05/2024] [Accepted: 02/04/2024] [Indexed: 02/16/2024]
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber disease, is a dominant inherited vascular disorder. The clinical diagnosis is based on the Curaçao criteria and pathogenic variants in the ENG and ACVRL1 genes are responsible for most cases of HHT. Four families with a negative targeted gene panel and selected by a multidisciplinary team were selected and whole-genome sequencing was performed according to the recommendations of the French National Plan for Genomic Medicine. Structural variations were confirmed by standard molecular cytogenetic analysis (FISH). In two families with a definite diagnosis of HHT, we identified two different paracentric inversions of chromosome 9, both disrupting the ENG gene. These inversions are considered as pathogenic and causative for the HHT phenotype of the patients. This is the first time structural variations are reported to cause HHT. As such balanced events are often missed by exon-based sequencing (panel, exome), structural variations may be an under-recognized cause of HHT. Genome sequencing for the detection of these events could be suggested for patients with a definite diagnosis of HHT and in whom no causative pathogenic variant was identified.
Collapse
Affiliation(s)
- M Tusseau
- Hospices Civils de Lyon, Department of Medical Genetics and National HHT Reference Center, University Hospital of Lyon, Lyon, France; Laboratoire AURAGEN, Lyon, France
| | - M Eyries
- Department of Medical Genetics, AP-HP Sorbonne University, Paris, France; Laboratoire Multisites SeqOIA, Paris, France
| | - N Chatron
- Hospices Civils de Lyon, Department of Medical Genetics and National HHT Reference Center, University Hospital of Lyon, Lyon, France; Laboratoire AURAGEN, Lyon, France
| | - F Coulet
- Department of Medical Genetics, AP-HP Sorbonne University, Paris, France; Laboratoire Multisites SeqOIA, Paris, France
| | - A Guichet
- Service de Génétique Médicale, CHU D'Angers, Angers, France
| | - E Colin
- Service de Génétique Médicale, CHU D'Angers, Angers, France
| | - B Demeer
- Genetics Department, CLAD Nord de France, CHU Amiens, France; CHIMERE, UR UPJV 7516, Université Picardie Jules Verne, Amiens, France
| | - H Maillard
- Department of Internal Medicine and Clinical Immunology, Referral Centre for Rare Systemic Autoimmune Diseases for North and North-West France (CeRAINO), CHU Lille, 59000, Lille, France
| | | | - C Lavigne
- Department of Internal Medicine and Clinical Immunology, Angers University Hospital, Angers, France
| | - V Saillour
- Laboratoire Multisites SeqOIA, Paris, France
| | - C Paris
- Laboratoire AURAGEN, Lyon, France
| | - J M De Sainte Agathe
- Department of Medical Genetics, AP-HP Sorbonne University, Paris, France; Laboratoire Multisites SeqOIA, Paris, France
| | - M Pujalte
- Hospices Civils de Lyon, Department of Medical Genetics and National HHT Reference Center, University Hospital of Lyon, Lyon, France; Laboratoire AURAGEN, Lyon, France
| | - A Guilhem
- Hospices Civils de Lyon, Department of Medical Genetics and National HHT Reference Center, University Hospital of Lyon, Lyon, France
| | - S Dupuis-Girod
- Hospices Civils de Lyon, Department of Medical Genetics and National HHT Reference Center, University Hospital of Lyon, Lyon, France
| | - G Lesca
- Hospices Civils de Lyon, Department of Medical Genetics and National HHT Reference Center, University Hospital of Lyon, Lyon, France; Laboratoire AURAGEN, Lyon, France.
| |
Collapse
|
30
|
Hayama M, Maeda Y, Obata S, Tsuda T, Takeda K, Nishida T, Inohara H. Understanding hereditary hemorrhagic telangiectasia: From genetic anomalies to systemic manifestations, quality of life, and epistaxis management-Exploring the otolaryngologist's integral role. Auris Nasus Larynx 2024; 51:305-312. [PMID: 38008660 DOI: 10.1016/j.anl.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/19/2023] [Accepted: 11/07/2023] [Indexed: 11/28/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Rendu-Weber syndrome, is a rare autosomal dominant disorder characterized by vascular malformations. This comprehensive review aimed to provide an overview and summarize various aspects of HHT, including the genetic abnormalities, complications associated with visceral arteriovenous malformations (AVMs), prognosis of HHT, quality of life (QOL), and treatment of epistaxis. In addition, this review highlights the challenges in diagnosing HHT and emphasizes the critical role of otolaryngologists in the early detection of HHT. Otolaryngologists can refer patients with refractory epistaxis for AVM screening to expedite intervention. Mutation of the genes involved in the transforming growth factor-β signaling pathway leads to the incidence of HHT, resulting in the formation of abnormal blood vessel formation. These vascular malformations commonly manifest as telangiectasia on the skin and mucous membranes; however, epistaxis remains the hallmark symptom of HHT. The impact of HHT goes beyond the visible symptoms and often includes the formation of life-threatening visceral AVMs in the lungs, liver, and brain. The prognosis of patients with HHT is closely related to the development of these complications, necessitating timely diagnosis and intervention. Refractory epistaxis diminishes the QOL of patients with HHT. The management of epistaxis ranges from conservative measures to advanced interventions such as prevention, conservative treatments, ablation, surgical procedures, and the administration of anti-angiogenic agents. However, effective management requires a multidisciplinary approach. The diagnosis of HHT remains challenging due to its variable presentation and lack of awareness among physicians. This review highlights the importance of reducing the duration between symptom onset and diagnosis. Otolaryngologists who are experienced in the management of refractory epistaxis can aid in identifying potential cases of HHT. They can facilitate the initiation of screening for visceral AVMs via prompt recognition of the signs and symptoms of HHT, contributing to improved patient outcomes. Early detection and intervention through screening can extend the life expectancy of patients with HHT to levels comparable with that of the general population. In conclusion, this review provides insight into various aspects of HHT and emphasizes the importance of timely diagnosis and intervention in the mitigation of the potentially life-threatening complications associated with this disorder. Otolaryngologists play a critical role in this process, serving as gatekeepers to the identification of cases of HHT and implementation of appropriate screening and management pathways, thereby improving the life expectancy and QOL of patients.
Collapse
Affiliation(s)
- Masaki Hayama
- Department of Otorhinolaryngology, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya City, Hyogo, Japan; Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan.
| | - Yohei Maeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan; Department of Otorhinolaryngology, Japan Community Healthcare Organization Osaka Hospital, Osaka City, Osaka, Japan
| | - Sho Obata
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Takeshi Tsuda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Kazuya Takeda
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Takeo Nishida
- Department of Neurosurgery, Hyogo Prefectural Nishinomiya Hospital, Nishinomiya City, Hyogo, Japan; Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| | - Hidenori Inohara
- Department of Otorhinolaryngology-Head and Neck Surgery, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
| |
Collapse
|
31
|
L'Huillier R, Pagnoux G, Dupuis-Girod S, Stacoffe N. Conservative management by embolization of a ruptured renal arterio-venous malformation (AVM) in Hereditary Hemorrhagic Telangiectasia (HHT). CVIR Endovasc 2024; 7:30. [PMID: 38492037 PMCID: PMC10944426 DOI: 10.1186/s42155-024-00444-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/07/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Renal arteriovenous malformation (AVM) in Hereditary Hemorrhagic Telangiectasia (HHT) is uncommon and only few cases have been described, mainly with surgical management because of uncontrolled hematuria. CASE PRESENTATION We managed a 70-year-old patient with HHT who presented with hematuria and left flank pain. Computed Tomography and ultrasound showed left renal AVM of 18 mm with clotting in the urinary tract. An external ureteral catheter was placed during 3 days to allow rinsing and facilitate elimination of clots. Given the patient's hemodynamic stability, a non-surgical management was chosen. Treatment of the AVM was performed by trans-arterial embolization using micro-coils and ethylene-vinyl alcohol copolymer. CONCLUSIONS Our case study shows a conservative management by embolization of ruptured left renal AVM revealed by hematuria in a 70-year-old patient with HHT.
Collapse
Affiliation(s)
- Romain L'Huillier
- Department of Diagnostic and Interventional Radiology, Hospices Civils de Lyon, University of Lyon, Pavillon B, Hôpital Edouard Herriot, 5 Place D'Arsonval, Lyon, 69003, France.
- LabTAU - Inserm U1032, Lyon, 69003, France.
- The French Comprehensive Liver Center, Hospices Civils de Lyon, University of Lyon, Lyon, 69004, France.
| | - Gaële Pagnoux
- Department of Diagnostic and Interventional Radiology, Hospices Civils de Lyon, University of Lyon, Pavillon B, Hôpital Edouard Herriot, 5 Place D'Arsonval, Lyon, 69003, France
| | - Sophie Dupuis-Girod
- Genetics Department and National, Hospices Civils de Lyon, HHT Reference Center Hôpital Femme-Mère-Enfant, Bron, 69677, France
- Laboratory Biology of Cancer and Infection, Inserm, CEA, Université Grenoble Alpes, Grenoble, France
| | - Nicolas Stacoffe
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, 69495, France
| |
Collapse
|
32
|
Xie Y, Wang J, Zou Y. Pulmonary arteriovenous fistula. J Vasc Surg Venous Lymphat Disord 2024; 12:101717. [PMID: 37972756 DOI: 10.1016/j.jvsv.2023.101717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Yong Xie
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Jian Wang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China.
| | - Yinghua Zou
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| |
Collapse
|
33
|
Liu K, Fu J, Guo K, Maghsoudloo M, Cheng J, Fu J. The ENG/VEGFα Pathway Is Likely Affected by a Nonsense Variant of Endoglin (ENG)/CD105, Causing Hereditary Hemorrhagic Telangiectasia Type 1 (HHT1) in a Chinese Family. Genes (Basel) 2024; 15:304. [PMID: 38540362 PMCID: PMC10970080 DOI: 10.3390/genes15030304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 06/14/2024] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also called Rendu-Osler syndrome, is a group of rare genetic diseases characterized by autosomal dominance, multisystemic vascular dysplasia, and age-related penetrance. This includes arteriovenous malformations (AVMs) in the skin, brain, lung, liver, and mucous membranes. The correlations between the phenotype and genotype for HHT are not clear. An HHT Chinese pedigree was recruited. Whole exome sequencing (WES) analysis, Sanger verification, and co-segregation were conducted. Western blotting was performed for monitoring ENG/VEGFα signaling. As a result, a nonsense, heterozygous variant for ENG/CD105: c.G1169A:p. Trp390Ter of the proband with hereditary hemorrhagic telangiectasia type 1 (HHT1) was identified, which co-segregated with the disease in the M666 pedigree. Western blotting found that, compared with the normal levels associated with non-carrier family members, the ENG protein levels in the proband showed approximately a one-half decrease (47.4% decrease), while levels of the VEGFα protein, in the proband, showed approximately a one-quarter decrease (25.6% decrease), implying that ENG haploinsufficiency, displayed in the carrier of this variant, may affect VEGFα expression downregulation. Pearson and Spearman correlation analyses further supported TGFβ/ENG/VEGFα signaling, implying ENG regulation in the blood vessels. Thus, next-generation sequencing including WES should provide an accurate strategy for gene diagnosis, therapy, genetic counseling, and clinical management for rare genetic diseases including that in HHT1 patients.
Collapse
Affiliation(s)
- Kemeng Liu
- Key Laboratory of Epigenetics and Oncology, The Research Center for Preclinical Medicine, Southwest Medical University, Luzhou 646000, China; (K.L.); (J.F.); (K.G.); (M.M.); (J.C.)
| | - Jiewen Fu
- Key Laboratory of Epigenetics and Oncology, The Research Center for Preclinical Medicine, Southwest Medical University, Luzhou 646000, China; (K.L.); (J.F.); (K.G.); (M.M.); (J.C.)
- School of Basic Medical Sciences, Southwest Medical University, Luzhou 646000, China
| | - Kan Guo
- Key Laboratory of Epigenetics and Oncology, The Research Center for Preclinical Medicine, Southwest Medical University, Luzhou 646000, China; (K.L.); (J.F.); (K.G.); (M.M.); (J.C.)
| | - Mazaher Maghsoudloo
- Key Laboratory of Epigenetics and Oncology, The Research Center for Preclinical Medicine, Southwest Medical University, Luzhou 646000, China; (K.L.); (J.F.); (K.G.); (M.M.); (J.C.)
| | - Jingliang Cheng
- Key Laboratory of Epigenetics and Oncology, The Research Center for Preclinical Medicine, Southwest Medical University, Luzhou 646000, China; (K.L.); (J.F.); (K.G.); (M.M.); (J.C.)
| | - Junjiang Fu
- Key Laboratory of Epigenetics and Oncology, The Research Center for Preclinical Medicine, Southwest Medical University, Luzhou 646000, China; (K.L.); (J.F.); (K.G.); (M.M.); (J.C.)
| |
Collapse
|
34
|
Gatts J, Chandra SR, Ricci K. Medical Management and Therapeutic Updates on Vascular Anomalies of the Head and Neck: Part 2. Oral Maxillofac Surg Clin North Am 2024; 36:115-123. [PMID: 37981343 DOI: 10.1016/j.coms.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Discovery of inherited and somatic genetic mutations, along with advancements in clinical and scientific research, has improved understanding of vascular anomalies and changed the treatment paradigm. With aim of minimizing need for invasive procedures and improving disease outcomes, molecularly targeted medications and anti-angiogenesis agents have become important as both adjuncts to surgery, and increasingly, as the primary treatment of vascular anomalies. This article highlights the commonly used and emerging therapeutic medications for non-malignant vascular tumors and vascular malformations in addition to medical management of associated hematologic abnormalities.
Collapse
Affiliation(s)
- Jorie Gatts
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Srinivasa R Chandra
- Department of Oral and Maxillofacial Surgery, Oregon Health and Sciences University, Portland, OR, USA.
| | - Kiersten Ricci
- Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA
| |
Collapse
|
35
|
Kofoed MS, Tørring PM, Christensen AA, Lange B, Kjeldsen AD, Nielsen TH. High risk of ischaemic stroke amongst patients with hereditary haemorrhagic telangiectasia. Eur J Neurol 2024; 31:e16128. [PMID: 37955551 PMCID: PMC11235815 DOI: 10.1111/ene.16128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/19/2023] [Accepted: 10/19/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND AND PURPOSE Hereditary haemorrhagic telangiectasia (HHT) is a genetic disease with fragile blood vessels and vascular malformations, potentially causing neurological manifestations, including stroke and cerebral abscesses. The study aimed to investigate neurological manifestations in the Danish HHT database, focusing on pulmonary arteriovenous malformations (PAVMs) as a risk factor for cerebral events. METHODS Retrospective analysis of the Danish HHT database was conducted, cross-referencing neurological outcomes with the Danish Apoplexy Register for accuracy. Patients were stratified by HHT type. Primary outcomes included ischaemic stroke, transient ischaemic attack and cerebral haemorrhage. Secondary outcomes comprised age, age at HHT diagnosis, age at cerebral ischaemic event, and PAVM and cerebral arteriovenous malformation status. RESULTS Six hundred and sixty-four HHT patients were included. PAVM was diagnosed in 54% of patients, with higher prevalence in HHT type 1 (70%) compared to HHT type 2 (34%) and juvenile polyposis HHT (66%). Ischaemic stroke or transient ischaemic attack occurred in 12.5%, with a higher risk associated with macroscopic PAVM. Logistic regression showed a nearly 10 times increased risk of ischaemic stroke with macroscopic PAVM. Cerebral abscesses occurred in 3.2% of patients, all with macroscopic PAVM. Incomplete PAVM closure increased cerebral abscess risk. CONCLUSION This study provides valuable insights into the prevalence of neurological manifestations and vascular events in HHT patients. The presence of PAVM was associated with an increased risk of ischaemic stroke, highlighting the importance of early screening and intervention. The findings emphasize the need for comprehensive management strategies targeting both vascular and neurological complications in HHT patients, especially regarding secondary stroke prevention.
Collapse
Affiliation(s)
- Mikkel Seremet Kofoed
- Department of Neurosurgery, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
- BRIDGE (Brain Research—Inter Disciplinary Guided Excellence)University of Southern DenmarkOdenseDenmark
- Department of Ear, Nose and Throat Surgery, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
- University of Southern Denmark (SDU)OdenseDenmark
- OPENRegion of Southern DenmarkOdenseDenmark
| | - Pernille M. Tørring
- Department of Clinical GeneticsOdense University HospitalOdenseDenmark
- VASCERN HHT Reference CenterOdense Universitetshospital, Syddansk UniversitetOdenseDenmark
| | - Alex Alban Christensen
- Department of Neurology, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
| | - Bibi Lange
- Department of Ear, Nose and Throat Surgery, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
| | - Anette Drøhse Kjeldsen
- Department of Ear, Nose and Throat Surgery, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
- University of Southern Denmark (SDU)OdenseDenmark
- OPENRegion of Southern DenmarkOdenseDenmark
- VASCERN HHT Reference CenterOdense Universitetshospital, Syddansk UniversitetOdenseDenmark
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Clinical InstituteUniversity of Southern DenmarkOdenseDenmark
- BRIDGE (Brain Research—Inter Disciplinary Guided Excellence)University of Southern DenmarkOdenseDenmark
- University of Southern Denmark (SDU)OdenseDenmark
- OPENRegion of Southern DenmarkOdenseDenmark
| |
Collapse
|
36
|
Jørgensen OJ, Steineger JE, Hillarp A, Pareli Wåland E, Holme PA, Heimdal K, Dheyauldeen S. Elevated FVIII levels in hereditary hemorrhagic telangiectasia: Implications for clinical management. Laryngoscope Investig Otolaryngol 2024; 9:e1196. [PMID: 38362186 PMCID: PMC10866586 DOI: 10.1002/lio2.1196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/10/2023] [Accepted: 11/26/2023] [Indexed: 02/17/2024] Open
Abstract
Objectives The objective of this study was twofold: to determine the prevalence of arterial and venous thromboembolic events in the Norwegian Hereditary Hemorrhagic Telangiectasia (HHT) population, and to explore potential factors linked to such events, with particular emphasis on FVIII. Methods Patients with an HHT diagnosis attending the Otorhinolaryngology Department at Oslo University Hospital-Rikshospitalet were included consecutively between April 2021 and November 2022. We recorded the participants' medical history with an emphasis on thromboembolic events. Measurements of blood constituents, including FVIII, FIX, vWF, hemoglobin, iron, ferritin, and CRP were performed. Results One hundred and thirty-four patients were included in the study. The total prevalence of thromboembolic events among the participants was 23.1%. FVIII levels were high (>150 IU/dL) in the majority of HHT patients (n = 84) (68.3%) and were significantly associated with thromboembolic events (p < .001), as was age. Of the patients with high FVIII levels, 28 (33%) had experienced a thromboembolic event. Furthermore, FVIII levels were measured consecutively in 51 patients and were found to fluctuate above or below 150 IU/dL in 25% of these cases. Conclusion Thromboembolic events are highly prevalent in the Norwegian HHT population and are significantly associated with FVIII levels. FVIII levels can fluctuate, and measurements should be repeated in HHT patients to assess the risk of thromboembolic events. Level of Evidence 4.
Collapse
Affiliation(s)
- Ole Jakob Jørgensen
- Department of Otorhinolaryngology & Head and Neck SurgeryOslo University Hospital, Medical Faculty, University of OsloOsloNorway
| | - Johan Edvard Steineger
- Department of Otorhinolaryngology & Head and Neck SurgeryOslo University Hospital, Medical Faculty, University of OsloOsloNorway
| | - Andreas Hillarp
- Department of Translational MedicineLund UniversityLundSweden
- Department of Medical Biochemistry, Section for Haemostasis and ThrombosisOslo University HospitalOsloNorway
| | - Erik Pareli Wåland
- Department of Medical Biochemistry, Section for Haemostasis and ThrombosisOslo University HospitalOsloNorway
| | - Pål André Holme
- Department of HematologyOslo University Hospital, Institute of Clinical Medicine, Faculty of Medicine, University of OsloOsloNorway
| | - Ketil Heimdal
- Department of Medical GeneticsOslo University HospitalOsloNorway
| | - Sinan Dheyauldeen
- Department of Otorhinolaryngology & Head and Neck SurgeryOslo University Hospital, Medical Faculty, University of OsloOsloNorway
| |
Collapse
|
37
|
Shovlin CL, Almaghlouth FI, Alsafi A, Coote N, Rennie C, Wallace GM, Govani FS, Research Consortium GE. Updates on diagnostic criteria for hereditary haemorrhagic telangiectasia in the light of whole genome sequencing of 'gene-negative' individuals recruited to the 100 000 Genomes Project. J Med Genet 2024; 61:182-185. [PMID: 37586837 PMCID: PMC10850674 DOI: 10.1136/jmg-2023-109195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/23/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Claire L Shovlin
- National Heart and Lung Institute, Imperial College London, London, UK
- Specialist Medicine, Imperial College Healthcare NHS Trust, London, UK
| | | | - Ali Alsafi
- Imaging, Imperial College Healthcare NHS Trust, London, UK
| | - Nicola Coote
- Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Fatima S Govani
- National Heart and Lung Institute, Imperial College London, London, UK
| | | |
Collapse
|
38
|
Trembath HE, Yeh JJ, Lopez NE. Gastrointestinal Malignancy: Genetic Implications to Clinical Applications. Cancer Treat Res 2024; 192:305-418. [PMID: 39212927 DOI: 10.1007/978-3-031-61238-1_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Advances in molecular genetics have revolutionized our understanding of the pathogenesis, progression, and therapeutic options for treating gastrointestinal (GI) cancers. This chapter provides a comprehensive overview of the molecular landscape of GI cancers, focusing on key genetic alterations implicated in tumorigenesis across various anatomical sites including GIST, colon and rectum, and pancreas. Emphasis is placed on critical oncogenic pathways, such as mutations in tumor suppressor genes, oncogenes, chromosomal instability, microsatellite instability, and epigenetic modifications. The role of molecular biomarkers in predicting prognosis, guiding treatment decisions, and monitoring therapeutic response is discussed, highlighting the integration of genomic profiling into clinical practice. Finally, we address the evolving landscape of precision oncology in GI cancers, considering targeted therapies and immunotherapies.
Collapse
Affiliation(s)
- Hannah E Trembath
- Division of Colon and Rectal Surgery, Department of Surgery, University of California San Diego, 4303 La Jolla Village Drive Suite 2110, San Diego, CA, 92122, USA
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, 170 Manning Drive, CB#7213, 1150 Physician's Office Building, Chapel Hill, NC, 27599-7213, USA
| | - Jen Jen Yeh
- Division of Colon and Rectal Surgery, Department of Surgery, University of California San Diego, 4303 La Jolla Village Drive Suite 2110, San Diego, CA, 92122, USA
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, 170 Manning Drive, CB#7213, 1150 Physician's Office Building, Chapel Hill, NC, 27599-7213, USA
| | - Nicole E Lopez
- Division of Colon and Rectal Surgery, Department of Surgery, University of California San Diego, 4303 La Jolla Village Drive Suite 2110, San Diego, CA, 92122, USA.
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, 170 Manning Drive, CB#7213, 1150 Physician's Office Building, Chapel Hill, NC, 27599-7213, USA.
| |
Collapse
|
39
|
Cerdà P, Castillo SD, Aguilera C, Iriarte A, Rocamora JL, Larrinaga AM, Viñals F, Graupera M, Riera-Mestre A. New genetic drivers in hemorrhagic hereditary telangiectasia. Eur J Intern Med 2024; 119:99-108. [PMID: 37689549 DOI: 10.1016/j.ejim.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a rare vascular disease inherited in an autosomal dominant manner. Disease-causing variants in endoglin (ENG) and activin A receptor type II-like 1 (ACVRL1) genes are detected in around 90% of the patients; also 2% of patients harbor pathogenic variants at SMAD4 and GDF2. Importantly, the genetic cause of 8% of patients with clinical HHT remains unknown. Here, we present new putative genetic drivers of HHT. METHODS To identify new HHT genetic drivers, we performed exome sequencing of 19 HHT patients and relatives with unknown HHT genetic etiology. We applied a multistep filtration strategy to catalog deleterious variants and prioritize gene candidates based on their known relevance in endothelial cell biology. Additionally, we performed in vitro validation of one of the identified variants. RESULTS We identified variants in the INHA, HIF1A, JAK2, DNM2, POSTN, ANGPTL4, FOXO1 and SMAD6 genes as putative drivers in HHT. We have identified the SMAD6 p.(Glu407Lys) variant in one of the families; this is a loss-of-function variant leading to the activation of the BMP/TGFβ signaling in endothelial cells. CONCLUSIONS Variants in these genes should be considered for genetic testing in patients with HHT phenotype and negative for ACVRL1/ENG mutations.
Collapse
Affiliation(s)
- Pau Cerdà
- HHT Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain; Internal Medicine Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sandra D Castillo
- Endothelial Pathobiology and Microenvironment Group, Josep Carreras Leukaemia Research Institute, Badalona, Spain
| | - Cinthia Aguilera
- HHT Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Genetics Laboratory, Laboratori Clínic Territorial Metropolitana Sud, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Adriana Iriarte
- HHT Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain; Internal Medicine Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - José Luis Rocamora
- HHT Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain; Molecular Signaling Group, Molecular Mechanisms and Experimental Therapy in Oncology Program (Oncobell), Institut d'Investigacio Biomedica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ane M Larrinaga
- Endothelial Pathobiology and Microenvironment Group, Josep Carreras Leukaemia Research Institute, Badalona, Spain
| | - Francesc Viñals
- Molecular Signaling Group, Molecular Mechanisms and Experimental Therapy in Oncology Program (Oncobell), Institut d'Investigacio Biomedica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Department of Physiological Sciences, Faculty of Medicine and Health Sciences, Universitat de Barcelona (UB), L'Hospitalet de Llobregat, Spain; Program Against Cancer Therapeutic Resistance (ProCURE), Institut Catala d'Oncologia (ICO), L'Hospitalet de Llobregat, Spain
| | - Mariona Graupera
- Endothelial Pathobiology and Microenvironment Group, Josep Carreras Leukaemia Research Institute, Badalona, Spain; CIBERONC, Instituto de Salud Carlos III, Madrid, Spain; ICREA, Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Antoni Riera-Mestre
- HHT Unit, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain; Internal Medicine Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Department of Clinical Sciences, Faculty of Medicine and Health Sciences, Universitat de Barcelona (UB), L'Hospitalet de Llobregat, Spain.
| |
Collapse
|
40
|
Engel ER, Wusik K, Bright P, Vadivelu S, Taylor JM, Hammill A. Prevalence and Predictors of Hereditary Hemorrhagic Telangiectasia and Capillary-Malformation Arteriovenous Malformation Syndrome Among Children with Neurovascular Malformations. J Pediatr 2024; 264:113761. [PMID: 37797790 DOI: 10.1016/j.jpeds.2023.113761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/18/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To investigate the prevalence and predictors of hereditary hemorrhagic telangiectasia (HHT) and capillary-malformation arteriovenous malformation (CM-AVM) syndrome among children with no prior personal or family history of these diseases who presented with an arteriovenous shunt lesion. STUDY DESIGN A retrospective chart review was completed on patients aged 0 through 21 years with arteriovenous shunt lesions evaluated at our Cerebrovascular Center. Diagnosis of definite or suspected HHT or CM-AVM was based on clinical features and genetic testing. Associations between final diagnosis and type and number of lesions, epistaxis, telangiectasias, CM, and pulmonary AVMs were assessed. RESULTS Eighty-nine patients were included. Thirteen (14.6%) had definite HHT, 11 (12.4%) suspected HHT, and 4 (4.5%) definite CM-AVM. Having ≥2 episodes of epistaxis/year and ≥ 2 sites with telangiectasias were each associated with definite HHT (P < .001). Having ≥ 2 CM was associated with definite CM-AVM (P < .001). Pulmonary AVM was associated with increased odds of having definite HHT (OR = 6.3, 95% CI: 1.2-33.4). Multiple lesions (OR = 24.5, 95% CI: 4.5-134.8) and arteriovenous fistulas (OR = 6.2, 95% CI: 1.9-20.3) each increased the likelihood of having definite HHT or CM-AVM. Genetic testing was positive in 31% of patients tested. CONCLUSIONS We recommend that children with neurovascular shunt lesions be offered genetic testing and undergo further evaluation for HHT and CM-AVM. Awareness and early diagnosis of these conditions is a critical step toward improving long-term outcomes and preventing disease-associated complications.
Collapse
Affiliation(s)
- Elissa R Engel
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Katie Wusik
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Philip Bright
- University of Kentucky College of Medicine, Northern Kentucky Campus, Highland Heights, KY
| | - Sudhakar Vadivelu
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - J Michael Taylor
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adrienne Hammill
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
41
|
Müller MC, Weiler-Normann C, Meyer M, Schramm C, Buescher G. [Brain abscess as a complication of pulmonary manifestation of HHT]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:71-75. [PMID: 37418022 PMCID: PMC10776712 DOI: 10.1007/s00108-023-01557-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 07/08/2023]
Abstract
A 43-year-old female patient with a brain abscess and a complicated clinical course was diagnosed with hereditary haemorrhagic telangiectasia (HHT) at the Martin Zeitz Centre for Rare Diseases in Hamburg, Germany. The brain abscess was caused by pulmonary arteriovenous malformations (AVM), a typical finding in HHT. Patients with cryptogenic brain abscess should be screened for pulmonary AVM and HHT. This case report illustrates the importance of patient history and interdisciplinary exchange in patients with a broad clinical spectrum as well as interdisciplinary treatment in the case of complications of rare diseases.
Collapse
Affiliation(s)
- May Cathleen Müller
- Martin Zeitz Centrum für Seltene Erkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Christina Weiler-Normann
- Martin Zeitz Centrum für Seltene Erkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- I. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Mathias Meyer
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Christoph Schramm
- Martin Zeitz Centrum für Seltene Erkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- I. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Gustav Buescher
- Martin Zeitz Centrum für Seltene Erkrankungen, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.
- I. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| |
Collapse
|
42
|
Groen K, van der Vis JJ, van Batenburg AA, Kazemier KM, de Bruijn MJ, Stadhouders R, Arp P, Verkerk AJ, Schoemaker AE, de Bie CI, Massink MP, van Beek FT, Grutters JC, Vergouw LJ, van Moorsel CH. A new variant in the ZCCHC8 gene: diverse clinical phenotypes and expression in the lung. ERJ Open Res 2024; 10:00487-2023. [PMID: 38375433 PMCID: PMC10875464 DOI: 10.1183/23120541.00487-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/12/2023] [Indexed: 02/21/2024] Open
Abstract
Introduction Pulmonary fibrosis is a severe disease which can be familial. A genetic cause can only be found in ∼40% of families. Searching for shared novel genetic variants may aid the discovery of new genetic causes of disease. Methods Whole-exome sequencing was performed in 152 unrelated patients with a suspected genetic cause of pulmonary fibrosis from the St Antonius interstitial lung disease biobank. Variants of interest were selected by filtering for novel, potentially deleterious variants that were present in at least three unrelated pulmonary fibrosis patients. Results The novel c.586G>A p.(E196K) variant in the ZCCHC8 gene was observed in three unrelated patients: two familial patients and one sporadic patient, who was later genealogically linked to one of the families. The variant was identified in nine additional relatives with pulmonary fibrosis and other telomere-related phenotypes, such as pulmonary arterial venous malformations, emphysema, myelodysplastic syndrome, acute myeloid leukaemia and dyskeratosis congenita. One family showed incomplete segregation, with absence of the variant in one pulmonary fibrosis patient who carried a PARN variant. The majority of ZCCHC8 variant carriers showed short telomeres in blood. ZCCHC8 protein was located in different lung cell types, including alveolar type 2 (AT2) pneumocytes, the culprit cells in pulmonary fibrosis. AT2 cells showed telomere shortening and increased DNA damage, which was comparable to patients with sporadic pulmonary fibrosis and those with pulmonary fibrosis carrying a telomere-related gene variant, respectively. Discussion The ZCCHC8 c.586G>A variant confirms the involvement of ZCCHC8 in pulmonary fibrosis and short-telomere syndromes and underlines the importance of including the ZCCHC8 gene in diagnostic gene panels for these diseases.
Collapse
Affiliation(s)
- Karlijn Groen
- Department of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Joanne J. van der Vis
- Department of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
- Department of Clinical Chemistry, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Aernoud A. van Batenburg
- Department of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Karin M. Kazemier
- Department of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
- Center of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Ralph Stadhouders
- Department of Pulmonary Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Pascal Arp
- Department of Internal Medicine, Laboratory of Population Genomics, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Annemieke J.M.H. Verkerk
- Department of Internal Medicine, Laboratory of Population Genomics, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Angela E. Schoemaker
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte I. de Bie
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maarten P.G. Massink
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frouke T. van Beek
- Department of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Jan C. Grutters
- Department of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Leonie J.M. Vergouw
- Department of Internal Medicine, Laboratory of Population Genomics, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Coline H.M. van Moorsel
- Department of Pulmonology, St Antonius ILD Center of Excellence, St Antonius Hospital, Nieuwegein, the Netherlands
| |
Collapse
|
43
|
Jain K, McCarley SC, Mukhtar G, Ferlin A, Fleming A, Morris-Rosendahl DJ, Shovlin CL. Pathogenic Variant Frequencies in Hereditary Haemorrhagic Telangiectasia Support Clinical Evidence of Protection from Myocardial Infarction. J Clin Med 2023; 13:250. [PMID: 38202257 PMCID: PMC10779873 DOI: 10.3390/jcm13010250] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/20/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a vascular dysplasia inherited as an autosomal dominant trait, due to a single heterozygous loss-of-function variant, usually in ACVRL1 (encoding activin receptor-like kinase 1 [ALK1]), ENG (encoding endoglin [CD105]), or SMAD4. In a consecutive single-centre series of 37 positive clinical genetic tests performed in 2021-2023, a skewed distribution pattern was noted, with 30 of 32 variants reported only once, but ACVRL1 c.1231C>T (p.Arg411Trp) identified as the disease-causal gene in five different HHT families. In the same centre's non-overlapping 1992-2020 series where 110/134 (82.1%) HHT-causal variants were reported only once, ACVRL1 c.1231C>T (p.Arg411Trp) was identified in nine further families. In a 14-country, four-continent HHT Mutation Database where 181/250 (72.4%) HHT-causal variants were reported only once, ACVRL1 c.1231C>T (p.Arg411Trp) was reported by 12 different laboratories, the adjacent ACVRL1 c.1232G>A (p.Arg411Gln) by 14, and ACVRL1 c.1120C>T (p.Arg374Trp) by 18. Unlike the majority of HHT-causal ACVRL1 variants, these encode ALK1 protein that reaches the endothelial cell surface but fails to signal. Six variants of this type were present in the three series and were reported 6.8-25.5 (mean 8.9) times more frequently than the other ACVRL1 missense variants (all p-values < 0.0039). Noting lower rates of myocardial infarction reported in HHT, we explore potential mechanisms, including a selective paradigm relevant to ALK1's role in the initiating event of atherosclerosis, where a plausible dominant negative effect of these specific variants can be proposed. In conclusion, there is an ~9-fold excess of kinase-inactive, cell surface-expressed ACVRL1/ALK1 pathogenic missense variants in HHT. The findings support further examination of differential clinical and cellular phenotypes by HHT causal gene molecular subtypes.
Collapse
Affiliation(s)
- Kinshuk Jain
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
| | - Sarah C. McCarley
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
| | - Ghazel Mukhtar
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
| | - Anna Ferlin
- Clinical Genetics and Genomics Laboratory, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Trust, London SE1 7EH, UK; (A.F.); (A.F.)
| | - Andrew Fleming
- Clinical Genetics and Genomics Laboratory, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Trust, London SE1 7EH, UK; (A.F.); (A.F.)
| | - Deborah J. Morris-Rosendahl
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
- Clinical Genetics and Genomics Laboratory, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Trust, London SE1 7EH, UK; (A.F.); (A.F.)
| | - Claire L. Shovlin
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
- Specialist Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK
- Social, Genetic and Environmental Determinants of Health, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
| |
Collapse
|
44
|
Jamindar P, Pope M, Gossage J. Long Term Survival of Heritable Pulmonary Arterial Hypertension Associated with Hereditary Hemorrhagic Telangiectasia: A Case Series. J Clin Med 2023; 13:141. [PMID: 38202148 PMCID: PMC10780235 DOI: 10.3390/jcm13010141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/16/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a hereditary disease characterized by recurrent epistaxis, mucocutaneous telangiectasias, and visceral arteriovenous malformations. Multiple genetic mutations have been linked to this rare disease, including ENG, ALK1 (ACVRL1), and MADH4. Pulmonary hypertension is a potential complication of HHT, with the most common phenotypes being World Health Organization (WHO) group 1 heritable pulmonary arterial hypertension (PAH), which is typically associated with ALK1 mutation; WHO group 2 pulmonary hypertension due to high output heart failure from hepatic arteriovenous malformations and/or anemia; and WHO group 2 due to high pulmonary artery wedge pressure. There is scarce evidence to help guide treatment of heritable PAH in HHT, and observational literature suggests that patients with HHT and heritable PAH have a worse prognosis compared to patients with idiopathic PAH. We describe the diagnosis, pulmonary hemodynamics, and detailed treatment courses of three patients with ALK1-associated HHT and PAH, who all exhibited objective clinical improvement with parenteral prostacyclins and oral agents.
Collapse
Affiliation(s)
- Parth Jamindar
- Division of Pulmonary, Critical Care and Sleep Medicine, Augusta University Medical Center, Augusta, GA 30912, USA; (P.J.); (J.G.)
| | - Michael Pope
- Division of Internal Medicine, Augusta University Medical Center, Augusta, GA 30912, USA
| | - James Gossage
- Division of Pulmonary, Critical Care and Sleep Medicine, Augusta University Medical Center, Augusta, GA 30912, USA; (P.J.); (J.G.)
| |
Collapse
|
45
|
McCarley SC, Murphy DA, Thompson J, Shovlin CL. Pharmacogenomic Considerations for Anticoagulant Prescription in Patients with Hereditary Haemorrhagic Telangiectasia. J Clin Med 2023; 12:7710. [PMID: 38137783 PMCID: PMC10744266 DOI: 10.3390/jcm12247710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a vascular dysplasia that commonly results in bleeding but with frequent indications for therapeutic anticoagulation. Our aims were to advance the understanding of drug-specific intolerance and evaluate if there was an indication for pharmacogenomic testing. Genes encoding proteins involved in the absorption, distribution, metabolism, and excretion of warfarin, heparin, and direct oral anticoagulants (DOACs) apixaban, rivaroxaban, edoxaban, and dabigatran were identified and examined. Linkage disequilibrium with HHT genes was excluded, before variants within these genes were examined following whole genome sequencing of general and HHT populations. The 44 genes identified included 5/17 actionable pharmacogenes with guidelines. The 76,156 participants in the Genome Aggregation Database v3.1.2 had 28,446 variants, including 9668 missense substitutions and 1076 predicted loss-of-function (frameshift, nonsense, and consensus splice site) variants, i.e., approximately 1 in 7.9 individuals had a missense substitution, and 1 in 71 had a loss-of-function variant. Focusing on the 17 genes relevant to usually preferred DOACs, similar variant profiles were identified in HHT patients. With HHT patients at particular risk of haemorrhage when undergoing anticoagulant treatment, we explore how pre-emptive pharmacogenomic testing, alongside HHT gene testing, may prove beneficial in reducing the risk of bleeding and conclude that HHT patients are well placed to be at the vanguard of personalised prescribing.
Collapse
Affiliation(s)
- Sarah C. McCarley
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
| | - Daniel A. Murphy
- Pharmacy Department, Imperial College Healthcare NHS Trust, London W2 1NY, UK;
- Social, Genetic and Envionmental Determinants of Health Theme, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
| | - Jack Thompson
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
| | - Claire L. Shovlin
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (S.C.M.); (J.T.)
- Social, Genetic and Envionmental Determinants of Health Theme, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
- Specialist Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| |
Collapse
|
46
|
Cheng HC, Faughnan ME, terBrugge KG, Liu HM, Krings T. Prevalence and Characteristics of Intracranial Aneurysms in Hereditary Hemorrhagic Telangiectasia. AJNR Am J Neuroradiol 2023; 44:1367-1372. [PMID: 38050014 PMCID: PMC10714847 DOI: 10.3174/ajnr.a8058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/06/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND AND PURPOSE The association between hereditary hemorrhagic telangiectasia and intracranial aneurysms remains controversial. This study evaluated the prevalence and characteristics of intracranial aneurysms in patients with hereditary hemorrhagic telangiectasia with brain vascular malformations. MATERIALS AND METHODS Between 2007 and 2021, patients enrolled in the Brain Vascular Malformation Consortium with definite hereditary hemorrhagic telangiectasia, the presence of brain vascular malformations, and available angiographic studies of the brain were retrospectively reviewed. Angiographic features of intracranial aneurysms and their relationship to coexisting brain vascular malformations were analyzed. We also examined the association between baseline clinical features and the presence of intracranial aneurysms. RESULTS One hundred eighty patients were included. A total of 14 intracranial aneurysms were found in 9 (5%) patients, and 4 intracranial aneurysms were considered flow-related aneurysms. Patients with intracranial aneurysms were significantly older than patients without intracranial aneurysms (mean, 48.1 [SD, 18.2] years versus 33.5 [SD, 21.0] years; P = .042). If we excluded flow-related intracranial aneurysms, the prevalence of intracranial aneurysms was 3.3%. All intracranial aneurysms were in the anterior circulation, were unruptured, and had an average maximal diameter of 3.9 (SD, 1.5) mm. No intracranial aneurysms were found in pediatric patients with hereditary hemorrhagic telangiectasia. No statistically significant correlation was observed among other baseline demographics, hereditary hemorrhagic telangiectasia features, and the presence of intracranial aneurysms. CONCLUSIONS The prevalence of intracranial aneurysms in this large cohort study is comparable with that in the general population and might be increased slightly due to hemodynamic factors associated with shunting brain vascular malformations.
Collapse
Affiliation(s)
- How-Chung Cheng
- From the Division of Neuroradiology (H.-C.C., K.G.t., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurosurgery (H.-C.C.), Department of Surgery, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Marie E Faughnan
- Toronto HHT Centre (M.E.F.), St. Michael's Hospital and Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
- Division of Respirology (M.E.F.), Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karel G terBrugge
- From the Division of Neuroradiology (H.-C.C., K.G.t., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hon-Man Liu
- Department of Medical Imaging (H.-M.L.), Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Timo Krings
- From the Division of Neuroradiology (H.-C.C., K.G.t., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
47
|
Niklasson J, Rönnblom A, Lidian A, Thor A. Oral manifestations and dental considerations of patients with hereditary hemorrhagic telangiectasia: a scoping review. Oral Surg Oral Med Oral Pathol Oral Radiol 2023; 136:691-702. [PMID: 37752017 DOI: 10.1016/j.oooo.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/20/2023] [Accepted: 08/05/2023] [Indexed: 09/28/2023]
Abstract
OBJECTIVE We examined the range, nature, and extent of research conducted regarding the oral and dental implications of hereditary hemorrhagic telangiectasia (HHT) to identify gaps in the research and knowledge of the field. STUDY DESIGN We performed a scoping review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews and 2017 Guidance for the Conduct of Joanna Briggs Institute Scoping Reviews. We searched the MEDLINE and Web of Science databases for all full-text articles published in English from December 1946 to October 2022. RESULTS We identified 103 articles describing oral and dental considerations of patients with HHT, primarily case reports. Most reported oral telangiectasias of the tongue, lips, and palate. Many reported management of bleeding and the use or recommendation of prophylactic antibiotics before dental procedures. CONCLUSIONS Oral telangiectasias are commonly found in patients with hereditary hemorrhagic telangiectasia, and dental professionals may be the first to diagnose it in their patients. Early detection and diagnosis are important to prevent potentially fatal outcomes, and prophylactic antibiotics before procedures may be warranted.
Collapse
Affiliation(s)
- Julia Niklasson
- Department of Plastic and Oral and Maxillofacial Surgery, Uppsala University, Uppsala, Sweden.
| | - Anders Rönnblom
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Adnan Lidian
- Department of Otorhinolaryngology and Head and Neck Surgery, Uppsala University, Uppsala, Sweden
| | - Andreas Thor
- Department of Plastic and Oral and Maxillofacial Surgery, Uppsala University, Uppsala, Sweden
| |
Collapse
|
48
|
Pollak M, Gatt D, Shaw M, Hewko SL, Lamanna A, Santos S, Ratjen F. Longitudinal Assessment of Curaçao Criteria in Children with Hereditary Hemorrhagic Telangiectasia. J Pediatr 2023; 263:113665. [PMID: 37572862 DOI: 10.1016/j.jpeds.2023.113665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVE To assess the utility of the Curaçao criteria by age over time in children with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN This was a single-center, retrospective analysis of patients attending the HHT clinic at the Hospital for Sick Children (Toronto, Canada) between 2000 and 2019. The evaluation of the Curaçao criteria was completed during initial and follow-up visits. Screening for pulmonary and brain arteriovenous malformations was completed at 5 yearly intervals. RESULTS A total of 116 patients with genetic confirmation of HHT were included in the analysis. At initial screening at a median (IQR) age of 8.4 (2.8, 12.9) years, 41% met criteria for a definite clinical diagnosis (≥3 criteria). In children <6 years at presentation, only 23% fulfilled at least 3 criteria initially. In longitudinal follow-up, 63% reached a definite clinical diagnosis, with a median (IQR) follow-up duration of 5.2 (3.2, 7.9) years (P = .005). Specifically, more patients met the epistaxis and telangiectasia criteria at last visit compared with initial (79% vs 60%; P = .006; 47% vs 30%; P = .02) but not for the arteriovenous malformation criterion (59% vs 57%; P = .65). CONCLUSIONS In the pediatric population, most patients do not meet definite clinical criteria of HHT at initial presentation. Although the number of diagnostic criteria met increased over time, mainly due to new onset of epistaxis and telangiectasia, accuracy remained low during follow-up visits. Relying solely on clinical criteria may lead to underdiagnosis of HHT in children.
Collapse
Affiliation(s)
- Mordechai Pollak
- Pediatric Respiratory Division, The Hospital for Sick Children, Toronto, Ontario, Canada; Pediatric Pulmonology Institute, The Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel.
| | - Dvir Gatt
- Pediatric Respiratory Division, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle Shaw
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sheryl L Hewko
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Anthony Lamanna
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sara Santos
- Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| | - Felix Ratjen
- Pediatric Respiratory Division, The Hospital for Sick Children, Toronto, Ontario, Canada; Translational Medicine, SickKids Research Institute, Toronto, Ontario, Canada
| |
Collapse
|
49
|
Manfredi G, Crinò SF, Alicante S, Romeo S, Berté R, Gandolfi S, Spinazzola A, Fiini M, Forner P, Buscarini E. Gastrointestinal bleeding in patients with hereditary hemorrhagic telangiectasia: Long-term results of endoscopic treatment. Endosc Int Open 2023; 11:E1145-E1152. [PMID: 38108019 PMCID: PMC10723967 DOI: 10.1055/a-2190-9303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/04/2023] [Indexed: 12/19/2023] Open
Abstract
Background and study aims This longitudinal prospective study evaluated the long-term outcome of endoscopic treatment of gastrointestinal bleeding in hereditary hemorrhagic telangiectases (HHT), its safety and outcome predictors. Patients and methods Consecutive patients with HHT and either anemia disproportionate to epistaxis or overt gastrointestinal bleeding received endoscopic treatment of gastrointestinal telangiectases with argon plasma coagulation (APC). Hemoglobin levels and transfusion requirements were evaluated before and after treatment. Treatment effectiveness was classified as: 1) complete: hemoglobin level during the follow-up ≥9 g/dL; 2) complete with recurrence: hemoglobin ≥9 g/dL for at least 12 months with subsequent drop to <9 g/dL; or 3) absent: no improvement of hemoglobin level. Adverse events (AEs) were classified as mild, moderate, severe or fatal. Correlations were searched between treatment outcome and demographic/genetic characteristics, number, size and site of telangiectases, and hepatic arterio-venous malformations grade. Results Forty-seven patients with HHT were enrolled. At median follow-up of 134 months (range 20-243 months), 41 of 47 patients showed treatment response (complete or with recurrence) after one (14/47) or more (27/47) endoscopic treatments. Median hemoglobin levels were 7.0 g/dL and 11.9 g/dL at baseline and at the end of follow-up, respectively. Transfusion requirement decreased from 22.8 to 7.3 red cell unit/year. A higher baseline number of telangiectases was associated with a lower chance of response ( P =0.008). Only one severe AE (0.4%, jejunal perforation) was recorded. Conclusions Endoscopic treatment of gastrointestinal teleangiectases for gastrointestinal bleeding in patients with HHT is effective in the long term and safe.
Collapse
Affiliation(s)
- Guido Manfredi
- Gastroenterology and Endoscopy Department, Center of reference VASCERN HHT, Maggiore Hospital Crema, Crema, Italy
| | | | - Saverio Alicante
- Gastroenterology and Endoscopy Department, Center of reference VASCERN HHT, Maggiore Hospital Crema, Crema, Italy
| | - Samanta Romeo
- Gastroenterology and Endoscopy Department, Center of reference VASCERN HHT, Maggiore Hospital Crema, Crema, Italy
| | - Roberto Berté
- Gastroenterology and Endoscopy Department, Center of reference VASCERN HHT, Maggiore Hospital Crema, Crema, Italy
| | | | | | - Michela Fiini
- Cardiology Department, Maggiore Hospital Crema, Crema, Italy
| | | | - Elisabetta Buscarini
- Gastroenterology and Endoscopy Department, Center of reference VASCERN HHT, Maggiore Hospital Crema, Crema, Italy
| |
Collapse
|
50
|
Dupuis-Girod S, Rivière S, Lavigne C, Fargeton AE, Gilbert-Dussardier B, Grobost V, Leguy-Seguin V, Maillard H, Mohamed S, Decullier E, Roux A, Bernard L, Saurin JC, Saroul N, Faure F, Cartier C, Altwegg R, Laccourreye L, Oberti F, Beaudoin M, Dhelens C, Desvignes C, Azzopardi N, Paintaud G, Hermann R, Chinet T. Efficacy and safety of intravenous bevacizumab on severe bleeding associated with hemorrhagic hereditary telangiectasia: A national, randomized multicenter trial. J Intern Med 2023; 294:761-774. [PMID: 37592715 DOI: 10.1111/joim.13714] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
BACKGROUND Bevacizumab-a humanized monoclonal antibody-has been widely used to treat patients with hereditary hemorrhagic telangiectasia (HHT), but no randomized trial has yet been conducted. METHODS This study is a double-blind multicenter randomized phase 2 trial with a 1:1 active-treatment-to-placebo ratio. We included patients over the age of 18 with a confirmed diagnosis and the need for at least four red blood cell (RBC) units transfused in the 3 months before study enrollment. Bevacizumab was administered at a dose of 5 mg/kg every 14 days with a total of six injections. The primary efficacy criterion was a decrease of at least 50% in the cumulative number of RBC units transfused in a 3-month period before and after treatment. RESULTS A total of 24 patients (12 in each group) were included and randomized at 4 different centers. In intention-to-treat analysis, 63.6% of patients (7/11) in the bevacizumab group versus 33.3% of patients (4/12) in the placebo group decreased the number of blood transfusions by at least 50% (p = 0.22). Hemoglobin levels significantly improved at 6 months in the bevacizumab versus placebo group (p = 0.02). The pharmacokinetics study revealed that patients with high exposure to bevacizumab had a significant decrease in RBC transfusions (p = 0.03). Fifty-nine adverse events were observed, 34 in the placebo arm versus 25 in the bevacizumab arm. CONCLUSION Though the present trial was underpowered, patients with HHT receiving bevacizumab required numerically fewer red blood cell transfusions than those receiving placebo, particularly those with high exposure.
Collapse
Affiliation(s)
- Sophie Dupuis-Girod
- Service de Génétique et centre de référence de la maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, Bron, France
- Inserm, CEA, Laboratory Biology of Cancer and Infection, Université Grenoble Alpes, Grenoble, France
| | - Sophie Rivière
- Service de Médecine Interne A, Centre Hospitalier Universitaire, Montpellier, France
| | - Christian Lavigne
- Service de médecine interne-Immunologie clinique, CHU d'Angers, Angers cedex 09, France
| | - Anne-Emmanuelle Fargeton
- Service de Génétique et centre de référence de la maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, Bron, France
| | | | - Vincent Grobost
- Service de Médecine Interne CHU Estaing, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | | | - Hélène Maillard
- CHU Lille, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Shirine Mohamed
- Département de Médecine interne et Immunologie Clinique, CHRU BRABOIS, Vandoeuvre-lès-Nancy, France
| | - Evelyne Decullier
- Hospices Civils de Lyon, Pôle Santé Publique, Lyon, France
- Faculté de médecine, Université Lyon 1, Lyon, France
| | - Adeline Roux
- Hospices Civils de Lyon, Pôle Santé Publique, Lyon, France
- Faculté de médecine, Université Lyon 1, Lyon, France
| | | | - Jean-Christophe Saurin
- Faculté de médecine, Université Lyon 1, Lyon, France
- Hospices Civils de Lyon, Service d'Hépato-gastroentérologie, Hôpital E. Herriot, Lyon, France
| | - Nicolas Saroul
- CHU Clermont Ferrand, Hôpital Gabriel Montpied, Service d'ORL, Clermont-Ferrand, France
| | - Frédéric Faure
- Hospices Civils de Lyon, Hôpital E. Herriot, Service d'ORL, Lyon, France
| | - Cesar Cartier
- Service d'ORL Centre Hospitalier Universitaire, Montpellier, France
| | - Romain Altwegg
- Service Hépatogastroentérologie CHU St Eloi, Montpellier, France
| | | | - Frédéric Oberti
- Service Hépatogastroentérologie, UPRES EA 3859, Faculté de médecine, CHU Angers and Laboratoire HIFIH, Angers, France
| | - Marjolaine Beaudoin
- Service de Génétique et centre de référence de la maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, Bron, France
| | - Carole Dhelens
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Pharmacie à Usage Intérieur, Lyon, France
| | - Céline Desvignes
- CHRU de Tours, Plateforme Recherche, Centre Pilote de suivi Biologique des traitements par Anticorps (CePiBAc), Tours, France
- EA 4245 Transplantation, Immunologie, Inflammation (T2I), Université de Tours, Tours, France
| | | | - Gilles Paintaud
- EA 4245 Transplantation, Immunologie, Inflammation (T2I), Université de Tours, Tours, France
- Service de Pharmacologie Médicale, CHRU de Tours, Tours, France
| | - Ruben Hermann
- Hospices Civils de Lyon, Hôpital Femme-Mère-Enfants, Service d'ORL et centre de référence de la maladie de Rendu-Osler, Bron, France
| | - Thierry Chinet
- Centre Rendu-Osler, Hôpital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, Université de Versailles SQY, Boulogne, France
| |
Collapse
|