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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.
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2
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Singh S, Bhandari A, Handa S, Mahajan R. Recurrent Epistaxis and Purple Vascular Stains in an Elderly Patient. Indian Dermatol Online J 2024; 15:123-125. [PMID: 38283013 PMCID: PMC10810400 DOI: 10.4103/idoj.idoj_28_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 01/30/2024] Open
Affiliation(s)
- Sukhdeep Singh
- Department of Dermatology, Venereology and Leprosy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Adhyatm Bhandari
- Department of Dermatology, Venereology and Leprosy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjeev Handa
- Department of Dermatology, Venereology and Leprosy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rahul Mahajan
- Department of Dermatology, Venereology and Leprosy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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3
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Gutiérrez-Macías A, Barroso-Benayos I, Burzako-Sánchez A. Utility of bevacizumab in chronic gastrointestinal bleeding in hereditary hemorrhagic telangiectasia. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2023; 88:433-434. [PMID: 37833139 DOI: 10.1016/j.rgmxen.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 04/25/2023] [Indexed: 10/15/2023]
Affiliation(s)
- A Gutiérrez-Macías
- Departamento de Medicina Interna, Hospital Universitario Basurto, Bilbao, Spain.
| | - I Barroso-Benayos
- Departamento de Medicina Interna, Hospital Universitario Basurto, Bilbao, Spain
| | - A Burzako-Sánchez
- Departamento de Medicina Interna, Hospital Universitario Basurto, Bilbao, Spain
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4
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Ravilla J, He P, Patel A. Hereditary Hemorrhagic Telangiectasia in a Young Adult: Gastrointestinal Arteriovenous Malformations as a Presenting Feature. Cureus 2023; 15:e43915. [PMID: 37746506 PMCID: PMC10512769 DOI: 10.7759/cureus.43915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is characterized by the presence of multiple arteriovenous malformations (AVM) in which arteries and venules are connected directly without intervening capillaries. The primary clinical presentation is spontaneous and recurrent nosebleeds (epistaxis), typically starting around 12. Telangiectases, which are small arteriovenous malformations, are commonly found in mucocutaneous areas and gastrointestinal (GI) mucosa. The presentation of epistaxis precedes the occurrence of telangiectases. Larger AVMs most commonly affect the lungs, liver, or brain, and complications from bleeding or shunting can be potentially life-threatening. Here, we discuss the case of a 44-year-old man who presented to the emergency department with a chief complaint of fatigue for three weeks associated with shortness of breath. His eventual labs revealed severe anemia with a hemoglobin of 4.4 g/dL. He denied any history of symptoms of GI bleeding. Computed tomography of the abdomen was done which did not reveal any intra-abdominal bleeding, hematoma, or abnormality. Further history revealed a recent diagnosis of HHT in his mother through genetic testing. During the stay, he also developed spontaneous epistaxis which was treated with topical vasoconstrictors by the ear, nose, and throat (ENT) physician. Given the high likelihood of HHT, he underwent luminal evaluation. Upper and lower endoscopies of the gut revealed multiple AVMs. A diagnosis of HHT was established as he fulfilled the criteria required for the diagnosis of HHT. It is rare for individuals with HHT to experience GI bleeding before the age of 50, making this case unique.
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Affiliation(s)
| | - Ping He
- Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - Anish Patel
- Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
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5
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Solela G, Adamseged M, Mohammed A. Hereditary hemorrhagic telangiectasia in a 42-year-old Ethiopian man presenting with severe anemia and high-output heart failure: A case report with literature review. Clin Case Rep 2023; 11:e7694. [PMID: 37448947 PMCID: PMC10337522 DOI: 10.1002/ccr3.7694] [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: 06/08/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
Key Clinical Messages Hereditary hemorrhagic telangiectasia (HHT), a rare hereditary disorder, can cause recurrent massive epistaxis and gastrointestinal bleeding leading to severe anemia. Early diagnosis of HHT is essential to provide timely interventional therapies. Abstract HHT is a rare autosomal dominant hereditary disease that results in abnormal vasculogenesis in the skin, mucous membranes, and visceral organs such as the liver, lungs, and brain. Clinical diagnosis of HHT is made using the Curacao criteria, which include recurrent spontaneous nosebleeds, mucocutaneous telangiectasias, visceral organ involvement, and first-degree family history of HHT. Here, we report a patient with HHT from Ethiopia, who presented with recurrent epistaxis and gastrointestinal bleeding, and severe anemia requiring frequent blood transfusions as well as cauterization. The presented case is a 42-year-old Black Ethiopian man with frequent hospitalization for severe anemia and high-output heart failure requiring frequent blood transfusions. His mother had bilateral epistaxis since her early adulthood. Physical examination was significant for tachycardia, pale conjunctivae, and tiny erythematous lesions over his tongue, ejection systolic murmur and peripheral edema. Laboratory investigations revealed severe anemia with iron deficiency picture. Upper gastrointestinal endoscopy showed multiple telangiectasia spots and abdominal Doppler ultrasound showed hepatic arterio-venous malformations. He received supportive management and electrocauterization of nasal, gastric, and duodenal telangiectasias. To the best of our knowledge, this is the first case of HHT to be reported from Ethiopia. High degree of suspicion and early diagnosis of HHT is essential to start preventive screening and surveillance and provide timely interventional therapies. HHT can cause recurrent massive epistaxis and gastrointestinal bleeding leading to severe anemia and high-output heart failure. In resource limited settings, selective cauterization of telangiectasia will help to control bleeding, although it does not avoid recurrent bleeding.
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Affiliation(s)
- Gashaw Solela
- Department of Internal MedicineYekatit 12 Hospital Medical CollegeAddis AbabaEthiopia
| | - Michael Adamseged
- Department of Internal MedicineYekatit 12 Hospital Medical CollegeAddis AbabaEthiopia
| | - Abdulsemed Mohammed
- Division of Gastroenterology and Hepatology, Department of Internal MedicineCollege of Health Sciences, Addis Ababa UniversityAddis AbabaEthiopia
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6
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Khan QA, Farkouh C, Khan A, Uddin Z, Abdi P, R Anthony M, Hadi FA, Khan E, Parvez S. Blue Rubber Bleb Nevus Syndrome Presenting as Anemia, Hemorrhage, and Hemangiomas: A Rare Case Report. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231173503. [PMID: 37205005 PMCID: PMC10186580 DOI: 10.1177/11795476231173503] [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: 02/23/2023] [Accepted: 04/12/2023] [Indexed: 05/21/2023]
Abstract
Background Blue Rubber Bleb Nevus syndrome (BRBNS) is a rare disorder, that results in congenital cutaneous hemangiomas of the skin and gastrointestinal tract. Although asymptomatic, the nevi present as soft, non-mobile, dark blue, compressible papules. Clinically it presents as iron deficiency anemia due to occult gastrointestinal bleeding. Case presentation A 22-year-old female patient presented with complaints of shortness of breath, fatigue, and palpitation for 2 months. On examination, she had a pale effect and widespread hemangiomas on her lips, hands, and feet. Laboratory results revealed iron deficiency anemia with hemoglobin (Hb) of 2.1 gm/dl and histopathology results of the hemangioma specimen showed angiokeratomas. Based on clinical manifestations and laboratory results, the patient was diagnosed with a case of BRBNS. The patient was transfused with red cell concentrate her symptoms improved but on the first follow-up visit her Hb again dropped to 8.6 mg/dl. Conclusion A high suspicion of BRBNS diagnosis should be considered if a patient presents with iron deficiency anemia and multiple cutaneous hemangiomas. Further screening should be done to explore internal bleeding and hemangiomas.
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Affiliation(s)
| | | | - Arooba Khan
- Khyber Teaching Hospital MTI KTH,
Peshawar, Pakistan
| | - Zahir Uddin
- Khyber Teaching Hospital MTI KTH,
Peshawar, Pakistan
| | - Parsa Abdi
- Memorial University, St. Johns, NL,
Canada
| | | | | | - Eyan Khan
- Khyber Medical College, Peshawar,
Pakistan
| | - Sara Parvez
- Khyber Teaching Hospital MTI KTH,
Peshawar, Pakistan
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Torres-Iglesias R, Mora-Luján JM, Iriarte A, Cerdà P, Alba E, Sánchez-Corral MÁ, Berrozpe A, Cruellas F, Gamundí E, Ribas J, Castellote J, Riera-Mestre A. Long-term use of somatostatin analogs for chronic gastrointestinal bleeding in hereditary hemorrhagic telangiectasia. Front Med (Lausanne) 2023; 10:1146080. [PMID: 37250655 PMCID: PMC10213420 DOI: 10.3389/fmed.2023.1146080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
Background Chronic bleeding due to gastrointestinal (GI) involvement in patients with hemorrhagic hereditary telangiectasia (HHT) can provoke severe anemia with high red blood cells (RBC) transfusion requirements. However, the evidence about how to deal with these patients is scarce. We aimed to assess the long-term efficacy and safety of somatostatin analogs (SA) for anemia management in HHT patients with GI involvement. Methods This is a prospective observational study including patients with HHT and GI involvement attended at a referral center. SA were considered for those patients with chronic anemia. Anemia-related variables were compared in patients receiving SA before and during treatment. Patients receiving SA were divided into responders (patients with minimal hemoglobin levels improvement >10 g/L and maintaining hemoglobin levels ≥80 g/L during treatment), and non-responders. Adverse effects during follow-up were collected. Results Among 119 HHT patients with GI involvement, 67 (56.3%) received SA. These patients showed lower minimal hemoglobin levels (73 [60-87] vs. 99 [70.2-122.5], p < 0.001), and more RBC transfusion requirements (61.2% vs. 38.5%, p = 0.014) than patients without SA therapy. Median treatment period was 20.9 ± 15.2 months. During treatment, there was a statistically significant improvement in minimum hemoglobin levels (94.7 ± 29.8 g/L vs. 74.7 ± 19.7, p < 0.001) and a reduction of patients with minimal hemoglobin levels <80 g/L (39 vs. 61%, p = 0.007) and RBC transfusions requirement (33.9% vs. 59.3%, p < 0.001). Sixteen (23.9%) patients showed mild adverse effects, mostly diarrhea or abdominal pain, leading to treatment discontinuation in 12 (17.9%) patients. Fifty-nine patients were eligible for efficacy assessment and 32 (54.2%) of them were considered responders. Age was associated with non-responder patients, OR 95% CI; 1.070 (1.014-1.130), p = 0.015. Conclusion SA can be considered a long-term effective and safe option for anemia management in HHT patients with GI bleeding. Older age is associated with poorer response.
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Affiliation(s)
- Raquel Torres-Iglesias
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - José María Mora-Luján
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Adriana Iriarte
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Pau Cerdà
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Esther Alba
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Radiology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Miguel Ángel Sánchez-Corral
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Cardiology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Ana Berrozpe
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Francesc Cruellas
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Otorhinolaryngology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Enric Gamundí
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Cytology and Hematology Laboratory, Antamomic Pathology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Jesús Ribas
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Pneumology Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Biomedical Research Networking Center on Respiratory Diseases (CIBERES), Madrid, Spain
| | - Jose Castellote
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Department of Digestive Diseases, Hospital Universitari de Bellvitge, Barcelona, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Antoni Riera-Mestre
- HHT Unit, Hospital Universitari de Bellvitge, Barcelona, Spain
- Internal Medicine Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
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Szmygin M, Szmygin P, Drelich K, Pustelniak O, Pech M, Jargiełło T. The role of interventional radiology in treatment of patients with hereditary hemorrhagic telangiectasia. Eur J Radiol 2023; 162:110769. [PMID: 36933496 DOI: 10.1016/j.ejrad.2023.110769] [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: 10/19/2022] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) also known as Osler-Weber-Rendu disease is a rare autosomal dominant, multi-organ disorder that leads to formation of abnormal vascular connections resulting in devastating and life-threatening complications. Due to its multisystem character, wide range of clinical manifestations and variable expressivity, HHT remains a diagnostic challenge and requires close cooperation of specialists from various medical fields. Interventional radiology plays a key role in the management of this disease, helping maintain the health of HHT patients and minimize the risk of fatal complications. The aim of this article is to review clinical manifestations, diagnostic guidelines and criteria of HHT as well as to present the means of endovascular therapy in the management of HHT patients.
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Affiliation(s)
- Maciej Szmygin
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Poland.
| | - Paweł Szmygin
- Medical University of Lublin, Department of Neurosurgery, Lublin, Poland
| | - Katarzyna Drelich
- Medical University of Lublin, Students' Scientific Society at the Department of Interventional Radiology and Neuroradiology, Lublin, Poland
| | - Olga Pustelniak
- Medical University of Lublin, Students' Scientific Society at the Department of Interventional Radiology and Neuroradiology, Lublin, Poland
| | - Maciej Pech
- Medical University of Magdeburg, Department of Radiology and Nuclear Medicine, Magdeburg, Germany
| | - Tomasz Jargiełło
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Poland
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9
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Bronchoscopy-guided removal of intrabronchial coil migration after coil embolization of pulmonary arteriovenous malformation. Radiol Case Rep 2022; 17:3410-3414. [PMID: 35899085 PMCID: PMC9309579 DOI: 10.1016/j.radcr.2022.06.078] [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: 03/30/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 11/21/2022] Open
Abstract
Pulmonary arteriovenous malformations develop in approximately 50% of hereditary hemorrhagic telangiectasia patients. Pulmonary arteriovenous malformations are often treated with coil embolization therapy. We report a case of a 45-year-old female with multiple pulmonary arteriovenous malformations due to underlying hereditary hemorrhagic telangiectasia who had undergone 14 coil embolization procedures over 16 years. She presented with sudden onset severe, unremitting, nonproductive cough from a foreign body sensation in the airway. Computed tomography of the chest demonstrated a metallic foreign body extending from the left lower lobe of the lung into the left mainstem bronchus and trachea. Bronchoscopy-guided removal of the foreign body revealed an intact embolization coil placed 8 years prior to presentation had partially migrated through the vessel and airway walls into the airway lumen, extending from the left lower lobe bronchus to the left mainstem bronchus. Coil migration is a rare, but potentially dangerous, complication of coil embolization therapy.
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10
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Sârbu F, Oprea VD, Tatu AL, Polea Drima E, Bojincă VC, Romila A. Hereditary Hemorrhagic Telangiectasia Associating Neuropsychiatric Manifestations with a Significant Impact on Disease Management-Case Report and Literature Review. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071059. [PMID: 35888148 PMCID: PMC9320563 DOI: 10.3390/life12071059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 11/28/2022]
Abstract
(1) Background: Genetic hereditary hemorrhagic telangiectasia (HHT) is clinically diagnosed. The clinical manifestations and lack of curative therapeutic interventions may lead to mental illnesses, mainly from the depression–anxiety spectrum. (2) Methods: We report the case of a 69-year-old patient diagnosed with HHT and associated psychiatric disorders; a comprehensive literature review was performed based on relevant keywords. (3) Results: Curaçao diagnostic criteria based the HHT diagnosis in our patient case at 63 years old around the surgical interventions for a basal cell carcinoma, after multiple episodes of epistaxis beginning in childhood, but with a long symptom-free period between 20 and 45 years of age. The anxiety–depressive disorder associated with nosocomephobia resulted in a delayed diagnosis and low adherence to medical monitoring. A comprehensive literature review revealed the scarcity of publications analyzing the impact of psychiatric disorders linked to this rare condition, frequently associating behavioral disengagement as a coping strategy, psychological distress, anxiety, depression, and hopelessness. (4) Conclusions: As patients with HHT face traumatic experiences from disease-related causes as well as recurring emergency hospital visits, active monitoring for mental illnesses and psychological support should be considered as part of the initial medical approach and throughout the continuum of care.
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Affiliation(s)
- Fabiola Sârbu
- Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galati, 800216 Galati, Romania; (F.S.); (E.P.D.); (A.R.)
- “Elisabeta Doamna” Psychiatric Hospital, 800179 Galati, Romania
| | - Violeta Diana Oprea
- Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galati, 800216 Galati, Romania; (F.S.); (E.P.D.); (A.R.)
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania
- Correspondence: (V.D.O.); (A.L.T.)
| | - Alin Laurențiu Tatu
- Clinical, Medical Department, Dermatology, ReForm UDJ, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galati, 800216 Galati, Romania
- Dermatology Department, Clinical Hospital of Infectious Diseases Saint Parascheva, 800179 Galati, Romania
- Correspondence: (V.D.O.); (A.L.T.)
| | - Eduard Polea Drima
- Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galati, 800216 Galati, Romania; (F.S.); (E.P.D.); (A.R.)
- “Elisabeta Doamna” Psychiatric Hospital, 800179 Galati, Romania
| | - Violeta Claudia Bojincă
- Internal Medicine Department, Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy in Bucharest, 020021 Bucharest, Romania;
- Department of Internal Medicine and Rheumatology, “Sf. Maria” Hospital, 011172 Bucharest, Romania
| | - Aurelia Romila
- Medical Department, Faculty of Medicine and Pharmacy, “Dunărea de Jos” University of Galati, 800216 Galati, Romania; (F.S.); (E.P.D.); (A.R.)
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania
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11
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Egido-Turrión C, Rossi E, Ollauri-Ibáñez C, Pérez-García ML, Sevilla MA, Bastida JM, González-Porras JR, Rodríguez-Barbero A, Bernabeu C, Lopez-Novoa JM, Pericacho M. Functional Alterations Involved in Increased Bleeding in Hereditary Hemorrhagic Telangiectasia Mouse Models. Front Med (Lausanne) 2022; 9:871903. [PMID: 35665360 PMCID: PMC9160577 DOI: 10.3389/fmed.2022.871903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/06/2022] [Indexed: 12/11/2022] Open
Abstract
Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal-dominant genetic disorder involving defects in two predominant genes known as endoglin (ENG; HHT-1) and activin receptor-like kinase 1 (ACVRL1/ALK1; HHT-2). It is characterized by mucocutaneous telangiectases that, due to their fragility, frequently break causing recurrent epistaxis and gastrointestinal bleeding. Because of the severity of hemorrhages, the study of the hemostasis involved in these vascular ruptures is critical to find therapies for this disease. Our results demonstrate that HHT patients with high bleeding, as determined by a high Epistaxis Severity Score (ESS), do not have prolonged clotting times or alterations in clotting factors. Considering that coagulation is only one of the processes involved in hemostasis, the main objective of this study was to investigate the overall mechanisms of hemostasis in HHT-1 (Eng+/−) and HHT-2 (Alk1+/−) mouse models, which do not show HHT vascular phenotypes in the meaning of spontaneous bleeding. In Eng+/− mice, the results of in vivo and in vitro assays suggest deficient platelet-endothelium interactions that impair a robust and stable thrombus formation. Consequently, the thrombus could be torn off and dragged by the mechanical force exerted by the bloodstream, leading to the reappearance of hemorrhages. In Alk1+/− mice, an overactivation of the fibrinolysis system was observed. These results support the idea that endoglin and Alk1 haploinsufficiency leads to a common phenotype of impaired hemostasis, but through different mechanisms. This contribution opens new therapeutic approaches to HHT patients' epistaxis.
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Affiliation(s)
- Cristina Egido-Turrión
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Elisa Rossi
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France
| | - Claudia Ollauri-Ibáñez
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - María L. Pérez-García
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Internal Medicine, Complejo Asistencial Universitario de Salamanca (CAUSA)-SACYL, Salamanca, Spain
| | - María A. Sevilla
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - José María Bastida
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Hematology, Complejo Asistencial Universitario de Salamanca (CAUSA)-SACYL, Salamanca, Spain
| | - José Ramón González-Porras
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Hematology, Complejo Asistencial Universitario de Salamanca (CAUSA)-SACYL, Salamanca, Spain
| | - Alicia Rodríguez-Barbero
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Carmelo Bernabeu
- Centro de Investigaciones Biológicas Margarita Salas, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - José M. Lopez-Novoa
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Miguel Pericacho
- Department of Physiology and Pharmacology, Universidad de Salamanca, Salamanca, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- *Correspondence: Miguel Pericacho
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12
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A Rare Case of Upper Gastrointestinal Bleeding: Osler-Weber-Rendu Syndrome. Medicina (B Aires) 2022; 58:medicina58030333. [PMID: 35334510 PMCID: PMC8951266 DOI: 10.3390/medicina58030333] [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: 11/29/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Abstract
Osler-Weber-Rendu disease, also known as hereditary hemorrhagic telangiectasia (HHT), is a rare, autosomal dominant condition that affects approximately 1 in 5000 patients causing abnormal blood vessel formation. HHT patients have mucocutaneous telangiectasias and arteriovenous malformations in various organs. The most prominent symptom of HHT is epistaxis, which, together with gastrointestinal bleeding, may cause iron deficiency anemia. This study is a case report of a 62-year-old patient who was admitted to the Department of Gastroenterology due to acute upper gastrointestinal bleeding and a history of recurrent epistaxis and melena for 4 days, which was confirmed in digital rectal examination. Urgent upper gastrointestinal endoscopy revealed active bleeding from multiple angioectatic spots with bright-looking salmon-colored patches in the antrum and the body suggestive of HHT. The bleeding from two angioectatic spots was stopped by argon plasma coagulation, and four clips were placed to provide good hemostasis. The patient was treated with a proton pomp inhibitor infusion and iron infusion. She was discharged with no signs of GI bleeding, normalized iron levels and a diagnosis of HHT. She was referred to further genetic testing, including evaluation of first-degree relatives. She also had performed unenhanced thin-cut computed tomography (CT) with angiography to exclude the presence of pulmonary arteriovenous malformations (PAVMs). Due to the fact that the patient did not manifest any other HHT-related symptoms and that the instrumental screening discloses no silent AVMs in other organs, the “watch-and-wait strategy” was applied. Although, Osler-Weber-Rendu syndrome is widely described in the medical literature, effective treatment of gastrointestinal telangiectasias is not always available and still lacks standardization to date, which makes the management of gastroenterological involvement still a challenging issue.
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Emmet E, Jagadish A, Malik R, Mehta R. Selected Disorders of the Blood and Hematopoietic System. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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14
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Rey M, Salazar JM, Leal DD, Sierra F, Pérez E, De la Hoz J, Reyes GA, Vásquez Roldán M. Hereditary hemorrhagic telangiectasia diagnosed by enteroscopy: a case report. J Int Med Res 2021; 49:3000605211067391. [PMID: 34939867 PMCID: PMC8721887 DOI: 10.1177/03000605211067391] [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] [Indexed: 11/15/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a very rare autosomal dominant multisystemic disease. Patients with this disease usually present with punctate mucocutaneous telangiectasias and arteriovenous malformations. The diagnostic criteria currently in use are the Curaçao criteria. HHT is considered a clinical diagnosis; thus, no imaging or preclinical laboratory is mandatory, and diagnosis and management are performed according to the experience of the treating team. We herein describe a 58-year-old man with no significant medical history who presented with a 15-day history of intermittent hematochezia. He was admitted to the hospital and underwent a series of laboratory tests, including colonoscopy, which showed normal results. Therefore, the patient was discharged with a diagnosis of gastrointestinal bleeding. During his second visit to the emergency room, the doctors requested video capsule endoscopy because of the patient's history, and a diagnosis of HHT was made. The entire approach and treatment were completed with antegrade double-balloon enteroscopy. This case highlights the importance of endoscopic methods for timely diagnosis and proper management.
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Affiliation(s)
| | | | | | | | - Erika Pérez
- Fundación Santa Fe de Bogotá, Bogotá, D.C. Colombia
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15
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Sobrepera S, Monroe E, Gemmete JJ, Hallam D, Pinchot JW, Kaufman C. Imaging to intervention: a review of what the Interventionalist needs to Know about Hereditary Hemorrhagic Telangiectasia. CVIR Endovasc 2021; 4:84. [PMID: 34882285 PMCID: PMC8660943 DOI: 10.1186/s42155-021-00270-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/19/2021] [Indexed: 12/17/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a disorder that affects 1 in 5000-10,000 people worldwide and can result in devastating complications such as cerebral abscess, stroke, massive hemorrhage, and even death. HHT is an autosomal dominant disorder that leads to the formation of abnormal communication between the arteries and veins with a resultant spectrum of vascular anomalies. The disorder affects many organ systems and thus requires a dedicated multidisciplinary approach. Interventional radiologists are vital members of this team providing expertise not only in disease management, but in complex embolotherapy, helping to maintain the health of these patients. This article reviews clinical manifestations, screening guidelines, diagnostic criteria, and endovascular management of HHT.
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Affiliation(s)
- Stephanie Sobrepera
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Eric Monroe
- Department of Radiology, University of Wisconsin, 1675 Highland Avenue, Madison, WI, 53792, USA
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Danial Hallam
- Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Jason W Pinchot
- Department of Radiology, University of Wisconsin, 1675 Highland Avenue, Madison, WI, 53792, USA
| | - Claire Kaufman
- Department of Radiology & Imaging Sciences, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132-2140, USA.
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Kitayama K, Ishiguro T, Komiyama M, Morisaki T, Morisaki H, Minase G, Hamanaka K, Miyatake S, Matsumoto N, Kato M, Takahashi T, Yorifuji T. Mutational and clinical spectrum of Japanese patients with hereditary hemorrhagic telangiectasia. BMC Med Genomics 2021; 14:288. [PMID: 34872578 PMCID: PMC8647423 DOI: 10.1186/s12920-021-01139-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/29/2021] [Indexed: 12/28/2022] Open
Abstract
Background Hereditary hemorrhagic telangiectasia (HHT) is a dominantly inherited vascular disorder characterized by recurrent epistaxis, skin/mucocutaneous telangiectasia, and organ/visceral arteriovenous malformations (AVM). HHT is mostly caused by mutations either in the ENG or ACVRL1 genes, and there are regional differences in the breakdown of causative genes. The clinical presentation is also variable between populations suggesting the influence of environmental or genetic backgrounds. In this study, we report the largest series of mutational and clinical analyses for East Asians. Methods Using DNAs derived from peripheral blood leukocytes of 281 Japanese HHT patients from 150 families, all exons and exon–intron boundaries of the ENG, ACVRL1, and SMAD4 genes were sequenced either by Sanger sequencing or by the next-generation sequencing. Deletions/amplifications were analyzed by the multiplex ligation-dependent probe amplification analyses. Clinical information was obtained by chart review. Results In total, 80 and 59 pathogenic/likely pathogenic variants were identified in the ENG and ACVRL1 genes, respectively. No pathogenic variants were identified in the SMAD4 gene. In the ENG gene, the majority (60/80) of the pathogenic variants were private mutations unique to a single family, and the variants were widely distributed without any distinct hot spots. In the ACVRL1 gene, the variants were more commonly found in exons 5–10 which encompasses the serine/threonine kinase domain. Of these, 25/59 variants were unique to a single family while those in exons 8–10 tended to be shared by multiple (2–7) families. Pulmonary and cerebral AVMs were more commonly found in ENG-HHT (69.1 vs. 14.4%, 34.0 vs. 5.2%) while hepatic AVM was more common in ACVRL1-HHT (31.5 vs. 73.2%). Notable differences include an increased incidence of cerebral (34.0% in ENG-HHT and 5.2% in ACVRL1-HHT), spinal (2.5% in ENG-HHT and 1.0% in ACVL1-HHT), and gastric AVM (13.0% in ENG-HHT, 26.8% in ACVRL1-HHT) in our cohort. Intrafamilial phenotypic heterogeneity not related to the age of examination was observed in 71.4% and 24.1% of ENG- and ACVRL1-HHT, respectively. Conclusions In a large Japanese cohort, ENG-HHT was 1.35 times more common than ACVRL1-HHT. The phenotypic presentations were similar to the previous reports although the cerebral, spinal, and gastric AVMs were more common. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-021-01139-y.
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Affiliation(s)
- Kana Kitayama
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima, Osaka, 534-0021, Japan
| | - Tomoya Ishiguro
- Department of Neuro-Intervention, Osaka City General Hospital, Osaka, Japan
| | - Masaki Komiyama
- Department of Neuro-Intervention, Osaka City General Hospital, Osaka, Japan
| | - Takayuki Morisaki
- Division of Molecular Pathology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan.,Department of Bioscience and Genetics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroko Morisaki
- Department of Medical Genetics, Sakakibara Heart Institute, Tokyo, Japan
| | - Gaku Minase
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Kohei Hamanaka
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Satoko Miyatake
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Naomichi Matsumoto
- Department of Human Genetics, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Masaru Kato
- Department of Genetic Medicine, Osaka City General Hospital, Osaka, Japan
| | - Toru Takahashi
- Department of Genetic Medicine, Osaka City General Hospital, Osaka, Japan
| | - Tohru Yorifuji
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima, Osaka, 534-0021, Japan. .,Department of Genetic Medicine, Osaka City General Hospital, Osaka, Japan.
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17
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The pediatric stomach - congenital abnormalities. Pediatr Radiol 2021; 51:2461-2469. [PMID: 34351495 DOI: 10.1007/s00247-021-05155-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 06/07/2021] [Accepted: 07/12/2021] [Indexed: 01/19/2023]
Abstract
Diagnostic imaging of the pediatric stomach often provides a challenge for practicing radiologists. Radiologists should be aware of relatively unusual congenital pathology, especially when imaging very young children with gastrointestinal symptoms. We review congenital pathology of the pediatric stomach.
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Tessier S, Lipton BA, Ido F, Longo S, Nanda S. Pathogenesis and therapy of arteriovenous malformations: A case report and narrative review. Int J Crit Illn Inj Sci 2021; 11:167-176. [PMID: 34760664 PMCID: PMC8547675 DOI: 10.4103/ijciis.ijciis_127_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/24/2020] [Accepted: 01/05/2021] [Indexed: 12/03/2022] Open
Abstract
Arteriovenous malformations (AVMs) are abnormal communications between arteries and veins that lack intervening capillary beds. They have been described in almost every organ in the body, emerging sporadically or as part of well-described syndromes. Hereditary hemorrhagic telangiectasia (HHT) is a rare, progressive, and lifelong disease characterized by AVMs and recurrent hemorrhaging. In the last 2 decades, significant advances have been made in understanding the pathogenesis of this condition. The accumulation of knowledge has led to a natural evolution of therapy, from open surgery to endovascular procedures, and now to a role for medications in certain AVMs. Here, we review a case of HHT and describe the most up-to-date clinical practice, including diagnosis of HHT, subtypes of HHT, and medical therapy.
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Affiliation(s)
- Steven Tessier
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Brooke A Lipton
- Lewis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Firas Ido
- Department of Pulmonary and Critical Care, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Santo Longo
- Department of Pathology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Sudip Nanda
- Department of Cardiology, St. Luke's University Health Network, Bethlehem, PA, USA
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19
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Green RJ, Swift AC. Hereditary haemorrhagic telangiectasia: an overview from an ear, nose and throat perspective. Br J Hosp Med (Lond) 2021; 82:1-9. [PMID: 34817255 DOI: 10.12968/hmed.2020.0560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Patients with hereditary haemorrhagic telangiectasia can present with a multitude of symptoms caused by telangiectasia and arteriovenous malformations in the nose, brain, gastrointestinal tract, liver and spinal cord. Clinicians should be aware of the potential diagnosis of hereditary haemorrhagic telangiectasia and how to manage these patients both in the acute and chronic setting. Identifying these patients and optimising their management can help reverse the reduced life expectancy back to that of the normal population. The management of these patients is complex and often requires a multidisciplinary approach, with difficult discussions to be had around screening for arteriovenous malformations and genetic testing. The stepwise management ladder can be used in both the medical and surgical strategies; there are multiple pharmacological and surgical options available, all with their own side effects and risks. Patient education is key to help informed decision making. This article outlines the clinical characteristics of the disease and management options available.
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Affiliation(s)
- Richard J Green
- Department of Otolaryngology, Ninewells Hospital, Dundee, UK
| | - Andrew C Swift
- Liverpool Head and Neck Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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20
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Incidence of Spontaneous Pulmonary AVM Rupture in HHT Patients. J Clin Med 2021; 10:jcm10204714. [PMID: 34682838 PMCID: PMC8540859 DOI: 10.3390/jcm10204714] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/18/2022] Open
Abstract
The spontaneous rupture of pulmonary AVMs, resulting in pulmonary hemorrhage and hydrothorax, is a life-threatening complication. While this phenomenon has been previously reported, the true incidence is not yet known. This study retrospectively reviewed records of 801 HHT patients with pulmonary AVMs to identify a single lifetime episode of hemothorax or pulmonary hemorrhage secondary to pulmonary AVM rupture. The lifetime prevalence and incidence of pulmonary AVM rupture in HHT patients was 2.7% and 0.16% respectively. In these patients, AVM rupture represented the initial presentation of HHT in nine (40.9%) cases and was life-threatening in nine (40.9%) cases. All cases occurred in virgin lesions, and subsequent embolization was curative. While a feared complication, pulmonary AVM rupture is rare and is likely effectively prevented by existing embolization techniques and indications.
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21
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Farhan A, Yuan F, Partan E, Weiss CR. Clinical manifestations of patients with GDF2 mutations associated with hereditary hemorrhagic telangiectasia type 5. Am J Med Genet A 2021; 188:199-209. [PMID: 34611981 DOI: 10.1002/ajmg.a.62522] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 09/05/2021] [Accepted: 09/11/2021] [Indexed: 12/29/2022]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant fibrovascular dysplasia caused by mutations in ENG, ACVRL1, and SMAD4. Increasingly, there has been an appreciation for vascular conditions with phenotypic overlap to HHT but which have distinct clinical manifestations and arise from novel or uncharacterized gene variants. This study reported on a cohort of four unrelated probands who were diagnosed with a rare form of GDF2-related HHT5, for which only five prior cases have been described. Two patients harbored heterozygous missense variants not previously annotated as pathogenic (p.Val403Ile; p.Glu355Gln). Clinically, these patients had features resembling HHT1, including cerebrovascular involvement of their disease (first report documenting cerebral involvement of HHT5), but with earlier onset of epistaxis and a unique anatomic distribution of dermal capillary lesions that involved the upper forelimbs, trunk, and head. The other two patients harbored interstitial deletions larger than five megabases between 10q11.22 and 10q11.23 that included GDF2. To our knowledge, this is the first report detailing large genomic deletions leading to HHT5. These patients also demonstrated mucocutaneous capillary dysplasias, including intranasal vascular lesions complicated by childhood-onset epistasis, with a number of extravascular findings related to their 10q11.21q11.23 deletion. In conclusion, patients with GDF2-related HHT may present with a number of unique characteristics that differ from classically reported features of HHT.
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Affiliation(s)
- Ahmed Farhan
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frank Yuan
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Partan
- McKusick-Nathans Institute of Genetic Medicine, Department of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Clifford R Weiss
- Division of Interventional Radiology, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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22
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Lam S, Guthrie KS, Latif MA, Weiss CR. Genetic counseling and testing for hereditary hemorrhagic telangiectasia. Clin Genet 2021; 101:275-284. [PMID: 34415050 DOI: 10.1111/cge.14050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/04/2021] [Accepted: 08/15/2021] [Indexed: 12/13/2022]
Abstract
Genetic counseling is an important means of identifying a patient's genetic risk of hereditary hemorrhagic telangiectasia (HHT) and assisting patients in making informed decisions about their health. With an increase in understanding of the genetic mechanisms underlying HHT over the last decade, genetic counseling is increasingly being incorporated into the care of patients affected by HHT. In addition to refining the diagnosis of symptomatic patients, genetic testing can help to distinguish asymptomatic, at-risk patients from those who are unaffected by HHT. The purpose of this review article is to summarize the current knowledge regarding the role of genetic counseling and genetic testing in identifying and managing HHT in at-risk populations. This article also reviews the guidelines, outcomes, risks, and challenges of genetic counseling and testing for HHT in various patient populations, and provides an algorithm for the use of genetic counseling in symptomatic and asymptomatic patients.
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Affiliation(s)
- Shravika Lam
- Russel H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Kelsey S Guthrie
- Institute of Genetic Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Muhammad A Latif
- Russel H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Clifford R Weiss
- Russel H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Mufti A, Sachdeva M, Maliyar K, Joseph M. Hereditary haemorrhagic telangiectasia: A case report. SAGE Open Med Case Rep 2021; 9:2050313X211003076. [PMID: 34394937 PMCID: PMC8358483 DOI: 10.1177/2050313x211003076] [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: 11/03/2020] [Accepted: 01/25/2021] [Indexed: 11/16/2022] Open
Abstract
Background Hereditary haemorrhagic telangiectasia is an autosomal dominant genetic disorder characterized by abnormalities in blood vessel formation. The clinical manifestations of patients affected with hereditary haemorrhagic telangiectasia include mucocutaneous telangiectasias and visceral arteriovenous malformations. Case Summary We report the case of a 30-year-old female diagnosed with hereditary haemorrhagic telangiectasia presenting with the classic triad of recurrent epistaxis, mucocutaneous telangiectasias and family history of hereditary haemorrhagic telangiectasia with activin receptor-like kinase 1 mutation. Upon skin examination, she was noted to have telangiectasias under left naris, inner lower lip and surface of the tongue, and a vascular malformation on the right forearm. Conclusion Although the skin involvement and epistaxis may be mild symptoms and signs of hereditary haemorrhagic telangiectasia, timely recognition of these can ensure vigilant monitoring of potential severe complications from cerebral and pulmonary visceral arteriovenous malformations.
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Affiliation(s)
- Asfandyar Mufti
- Division of Dermatology, University of Toronto, Toronto, ON, Canada
| | | | - Khalad Maliyar
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marissa Joseph
- Women's College Hospital, University of Toronto, Toronto, ON, Canada.,Section of Dermatology, Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Management of Refractory Gastrointestinal Bleeding in Hereditary Hemorrhagic Telangiectasia with Bevacizumab. Case Rep Gastrointest Med 2021; 2021:2242178. [PMID: 34306771 PMCID: PMC8263270 DOI: 10.1155/2021/2242178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/17/2021] [Accepted: 06/23/2021] [Indexed: 11/18/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder resulting in vascular malformations of several organs including the pulmonary, cerebral, and gastrointestinal systems. One sequela is recurrent gastrointestinal (GI) bleeding. Bevacizumab (Bev) is emerging as an effective treatment of recurrent gastrointestinal bleeding in HHT. Bev is a recombinant monoclonal antibody that inhibits vascular endothelial growth factor (VEGF), an integral part of angiogenesis.
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Sakurai Y, Kikuchi S, Shigeyasu K, Kakiuchi Y, Tanaka T, Umeda H, Sakamoto M, Takeda S, Yano S, Futagawa M, Kato F, Sogawa R, Yamamoto H, Kuroda S, Kondo Y, Teraishi F, Kishimoto H, Nishizaki M, Kagawa S, Hirasawa A, Fujiwara T. SMAD4 Germline Pathogenic Variant-Related Gastric Juvenile Polyposis with Adenocarcinoma Treated with Laparoscopic Total Gastrectomy: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932241. [PMID: 34143765 PMCID: PMC8218883 DOI: 10.12659/ajcr.932241] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND Juvenile polyposis syndrome is an uncommon, autosomal-dominant hereditary disease that is distinguished by multiple polyps in the stomach or intestinal tract. It is associated with a high risk of malignancy. Pathogenic variants in SMAD4 or BMPR1A account for 40% of all cases. CASE REPORT A 49-year-old woman underwent esophagogastroduodenoscopy because of exacerbation of anemia. She had numerous erythematous polyps in most parts of her stomach. Based on biopsy findings, juvenile polyposis syndrome (JPS) was suspected morphologically, but there was no evidence of malignancy. Colonoscopy showed stemmed hyperplastic polyps and an adenoma; video capsule endoscopy revealed no lesions in the small intestine. After preoperative surveillance, laparoscopic total gastrectomy with D1 lymph node dissection was performed to prevent malignant transformation. The pathological diagnosis was juvenile polyp-like polyposis with adenocarcinoma. In addition, a germline pathogenic variant in the SMAD4 gene was detected with genetic testing. CONCLUSIONS JPS can be diagnosed with endoscopy and genetic testing. Further, appropriate surgical management may prevent cancer-related death in patients with this condition.
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Affiliation(s)
- Yuya Sakurai
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.,Department of Surgery, Fukuyama Medical Center, Hiroshima, Japan
| | - Satoru Kikuchi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Kunitoshi Shigeyasu
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshihiko Kakiuchi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Takehiro Tanaka
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hibiki Umeda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Masaki Sakamoto
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Sho Takeda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Shuya Yano
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Mashu Futagawa
- Department of Clinical Genetics and Genomic Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Fumino Kato
- Department of Clinical Genetics and Genomic Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Reimi Sogawa
- Department of Clinical Genetics and Genomic Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hideki Yamamoto
- Department of Clinical Genetics and Genomic Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Shinji Kuroda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshitaka Kondo
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Fuminori Teraishi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroyuki Kishimoto
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Masahiko Nishizaki
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Shunsuke Kagawa
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Akira Hirasawa
- Department of Clinical Genetics and Genomic Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Notsu T, Adachi K, Mishiro T, Kishi K, Ishimura N, Ishihara S. Prevalence of Angiodysplasia Detected in Upper Gastrointestinal Endoscopic Examinations. Cureus 2021; 13:e14353. [PMID: 33972910 PMCID: PMC8105191 DOI: 10.7759/cureus.14353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background This study was performed to examine the prevalence of asymptomatic angiodysplasia detected in upper gastrointestinal endoscopic examinations and of hereditary hemorrhagic telangiectasia (HHT) suspected cases. Methodology The study participants were 5,034 individuals (3,206 males, 1,828 females; mean age 53.5 ± 9.8 years) who underwent an upper gastrointestinal endoscopic examination as part of a medical check-up. The presence of angiodysplasia was examined endoscopically from the pharynx to duodenal second portion. HHT suspected cases were diagnosed based on the presence of both upper gastrointestinal angiodysplasia and recurrent nasal bleeding episodes occurring in the subject as well as a first-degree relative. Results Angiodysplasia was endoscopically detected in 494 (9.8%) of the 5,061 subjects. Those with angiodysplasia lesions in the pharynx, larynx, esophagus, stomach, and duodenum numbered 44, 4, 155, 322, and 12, respectively. None had symptoms of upper gastrointestinal bleeding or severe anemia. Subjects with angiodysplasia showed significant male predominance and were significantly older than those without. A total of 11 (0.2%) were diagnosed as HHT suspected cases by the presence of upper gastrointestinal angiodysplasia and recurrent epistaxis episodes from childhood in the subject as well as a first-degree relative. Conclusions Asymptomatic angiodysplasia was detected in 9.8% of the subjects who underwent screening upper gastrointestinal endoscopic examinations.
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Affiliation(s)
- Takumi Notsu
- Health Center, Shimane Environment and Health Public Corporation, Matsue, JPN
| | - Kyoichi Adachi
- Health Center, Shimane Environment and Health Public Corporation, Matsue, JPN
| | - Tomoko Mishiro
- Health Center, Shimane Environment and Health Public Corporation, Matsue, JPN
| | - Kanako Kishi
- Health Center, Shimane Environment and Health Public Corporation, Matsue, JPN
| | - Norihisa Ishimura
- Second Department of Internal Medicine, Shimane University Faculty of Medicine, Izumo, JPN
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Lantz KE, Armstrong SQ, Butt F, Wang ML, Hardman R, Czum JM. Arteriovenous Malformations in the Setting of Osler-Weber-Rendu: What the Radiologist Needs to Know. Curr Probl Diagn Radiol 2021; 51:375-391. [PMID: 33827770 DOI: 10.1067/j.cpradiol.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 02/15/2021] [Accepted: 03/04/2021] [Indexed: 11/22/2022]
Abstract
Osler-Weber-Rendu, also known as Hereditary Hemorrhagic Telangiectasia, is an autosomal dominant disease with phenotypic manifestations that include pulmonary, cerebrospinal, hepatic, and other visceral arteriovenous malformations (AVMs). Pulmonary AVMs can result in hypoxemia, hemoptysis, or stroke due to paradoxical embolism. The mainstay of treatment is transcatheter embolization. Central nervous system and abdominal visceral AVMs contribute to morbidity of the disease. Radiologists should be familiar with the imaging manifestations and treatment algorithm of AVMs in Osler-Weber-Rendu to effectively guide patient care.
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Affiliation(s)
- Katherine E Lantz
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - Samuel Q Armstrong
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Frederick Butt
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Michelle L Wang
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Julianna M Czum
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Thompson KP, Nelson J, Kim H, Pawlikowska L, Marchuk DA, Lawton MT, Faughnan ME. Predictors of mortality in patients with hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2021; 16:12. [PMID: 33407668 PMCID: PMC7789194 DOI: 10.1186/s13023-020-01579-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 10/13/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Retrospective questionnaire and healthcare administrative data suggest reduced life expectancy in untreated hereditary hemorrhagic telangiectasia (HHT). Prospective data suggests similar mortality, to the general population, in Denmark's centre-treated HHT patients. However, clinical phenotypes vary widely in HHT, likely affecting mortality. We aimed to measure predictors of mortality among centre-treated HHT patients. HHT patients were recruited at 14 HHT centres of the Brain Vascular Malformation Consortium (BVMC) since 2010 and followed annually. Vital status, organ vascular malformations (VMs) and clinical symptoms data were collected at baseline and during follow-up (N = 1286). We tested whether organ VMs, HHT symptoms and HHT genes were associated with increased mortality using Cox regression analysis, adjusting for patient age, sex, and smoking status. RESULTS 59 deaths occurred over average follow-up time of 3.4 years (max 8.6 years). A history of anemia was associated with increased mortality (HR = 2.93, 95% CI 1.37-6.26, p = 0.006), as were gastro-intestinal (GI) bleeding (HR = 2.63, 95% CI 1.46-4.74, p = 0.001), and symptomatic liver VMs (HR = 2.10, 95% CI 1.15-3.84, p = 0.015). Brain VMs and pulmonary arteriovenous malformations (AVMs) were not associated with mortality (p > 0.05). Patients with SMAD4 mutation had significantly higher mortality (HR = 18.36, 95% CI 5.60-60.20, p < 0.001) compared to patients with ACVRL1 or ENG mutation, but this estimate is imprecise given the rarity of SMAD4 patients (n = 33, 4 deaths). CONCLUSIONS Chronic GI bleeding, anemia and symptomatic liver VMs are associated with increased mortality in HHT patients, independent of age, and in keeping with the limited treatment options for these aspects of HHT. Conversely, mortality does not appear to be associated with pulmonary AVMs or brain VMs, for which patients are routinely screened and treated preventatively at HHT Centres. This demonstrates the need for development of new therapies to treat chronic anemia, GI bleeding, and symptomatic liver VMs in order to reduce mortality among HHT patients.
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Affiliation(s)
- K P Thompson
- Toronto HHT Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B-1W8, USA
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - J Nelson
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA, USA
| | - H Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA, USA
- Institute for Human Genetics, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - L Pawlikowska
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, CA, USA
- Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - D A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA
| | - M T Lawton
- Barrow Neurological Institute, Phoenix, AZ, USA
| | - Marie E Faughnan
- Toronto HHT Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B-1W8, USA.
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada.
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Selected Disorders of the Blood and Hematopoietic System. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_158-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gastrointestinal Bleeding in Patients with Hereditary Hemorrhagic Telangiectasia: Risk Factors and Endoscopic Findings. J Clin Med 2019; 9:jcm9010082. [PMID: 31905627 PMCID: PMC7019907 DOI: 10.3390/jcm9010082] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/20/2019] [Accepted: 12/25/2019] [Indexed: 12/11/2022] Open
Abstract
Background: We aimed to describe risk factors for gastrointestinal (GI) bleeding and endoscopic findings in patients with hereditary hemorrhagic telangiectasia (HHT). Methods: This is a prospective study from a referral HHT unit. Endoscopic tests were performed when there was suspicion of GI bleeding, and patients were divided as follows: with, without, and with unsuspected GI involvement. Results: 67 (27.9%) patients with, 28 (11.7%) patients without, and 145 (60.4%) with unsuspected GI involvement were included. Age, tobacco use, endoglin (ENG) mutation, and hemoglobin were associated with GI involvement. Telangiectases were mostly in the stomach and duodenum, but 18.5% of patients with normal esophagogastroduodenoscopy (EGD) had GI involvement in video capsule endoscopy (VCE). Telangiectases ≤ 3 mm and ≤10 per location were most common. Among patients with GI disease, those with hemoglobin < 8 g/dL or transfusion requirements (65.7%) were older and had higher epistaxis severity score (ESS) and larger telangiectases (>3 mm). After a mean follow-up of 34.2 months, patients with GI involvement required more transfusions and more emergency department and hospital admissions, with no differences in mortality. Conclusions: Risk factors for GI involvement have been identified. Patients with GI involvement and severe anemia had larger telangiectases and higher ESS. VCE should be considered in patients with suspicion of GI bleeding, even if EGD is normal.
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Kroon S, Snijder RJ, Mager JJ, Post MC, Tenthof van Noorden J, van Geenen EJM, Drenth JPH, Grooteman KV. Octreotide for gastrointestinal bleeding in hereditary hemorrhagic telangiectasia: A prospective case series. Am J Hematol 2019; 94:E247-E249. [PMID: 31251413 DOI: 10.1002/ajh.25563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Steven Kroon
- Department of PulmonologySt Antonius Hospital Nieuwegein The Netherlands
| | - Repke J. Snijder
- Department of PulmonologySt Antonius Hospital Nieuwegein The Netherlands
| | - Johannes J. Mager
- Department of PulmonologySt Antonius Hospital Nieuwegein The Netherlands
| | - Martijn C. Post
- Department of CardiologySt Antonius Hospital Nieuwegein The Netherlands
| | | | | | - Joost P. H. Drenth
- Department of Gastroenterology and HepatologyRadboud UMC Nijmegen The Netherlands
| | - Karina V. Grooteman
- Department of Gastroenterology and HepatologyRadboud UMC Nijmegen The Netherlands
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Kim D, Seo EJ, Song YS, Suh CH, Kim JW, Kim DJ, Suh DC. Current Status of Clinical Diagnosis and Genetic Analysis of Hereditary Hemorrhagic Telangiectasia in South Korea: Multicenter Case Series and a Systematic Review. Neurointervention 2019; 14:91-98. [PMID: 31455059 PMCID: PMC6736501 DOI: 10.5469/neuroint.2019.00150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 08/18/2019] [Indexed: 01/28/2023] Open
Abstract
Purpose Hereditary hemorrhagic telangiectasia (HHT), a rare genetic vascular disorder, has been rarely reported in South Korea. We investigated the current prevalence and presenting patterns of genetically confirmed HHT in South Korea. Materials and Methods We defined HHT patients as those with proven mutations on known HHT-related genes (ENG, ACVRL1, SMAD4, and GDF2) or those fulfilling 3 or 4 of the Curaçao criteria. A computerized systematic search was performed in PubMed and KoreaMed using the following search term: (“hereditary hemorrhagic telangiectasia” AND “Korea”) OR (“Osler-Weber-Rendu” AND “Korea”). We also collected government health insurance data. HHT genetic testing results were collected from three tertiary hospitals in which the genetic tests were performed. We integrated patient data by analyzing each case to obtain the prevalence and presenting pattern of HHT in South Korea. Results We extracted 90 cases from 52 relevant articles from PubMed and KoreaMed. An additional 22 cases were identified from the three Korean tertiary hospitals after excluding seven cases that overlapped with those in the published articles. Finally, 112 HHT patients were identified (41 males and 71 females, aged 4–82 years [mean±standard deviation, 45.3±20.6 years]). The prevalence of HHT in South Korea is about 1 in 500,000, with an almost equal prevalence among men and women. Forty-nine patients underwent genetic testing, of whom 28 had HHT1 (ENG mutation) and 19 had HHT2 (ACVRL1 mutation); the other two patients were negative for ENG, ACVRL1, and SMAD4 mutations. Conclusion The prevalence of HHT is underestimated in Korea. The rate of phenotypic presentation seems to be similar to that found worldwide. Korean health insurance coverage is limited to representative genetic analysis to detect ENG and ACVRL1 mutations. Further genetic analyses to detect HHT3, HHT4, and other forms of HHT should be implemented.
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Affiliation(s)
- Donghyun Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eul-Ju Seo
- Department of Laboraory Medicines, Asan Medical Center, University of Ulsan, Seoul, Korea
| | - Yun Sun Song
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chong Hyun Suh
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Won Kim
- Department of Laboraory Medicines, Samsung Medical Center, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Chul Suh
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Successful Treatment of Hereditary Hemorrhagic Telangiectasia With Octreotide. ACG Case Rep J 2019; 6:e00088. [PMID: 31616764 PMCID: PMC6722341 DOI: 10.14309/crj.0000000000000088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/28/2019] [Indexed: 01/24/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a disorder characterized by telangiectasias and arteriovenous malformations. We present a case report of a 74-year-old man diagnosed with HHT having a favorable response to a somatostatin analogue for treatment. This patient had been suffering from chronic anemia from recurrent gastrointestinal bleeding, requiring oral/intravenous iron replacement, frequent endoscopic ablations, and blood transfusions. Due to insufficient treatment, he was started on subcutaneous octreotide, with significant improvement as evidenced by a steady increase in the hemoglobin level, decreased endoscopic interventions, and decreased blood transfusions, making this the first case of HHT successfully treated with octreotide.
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Merves M, Parsons K, Alazraki A, Meisel J, Sauer C, Li H. Significant Hematochezia and Intracranial Bleeding in Neonatal Hereditary Hemorrhagic Telangiectasia. AJP Rep 2019; 9:e10-e14. [PMID: 30701124 PMCID: PMC6351274 DOI: 10.1055/s-0039-1677735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 10/21/2018] [Indexed: 11/02/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an underreported autosomal dominant vascular dysplasia. Neonatal presentations of HHT are rare, as this disorder typically presents in adolescence or beyond with epistaxis. We report a female neonate with hematochezia on the 1st day of life secondary to multiple gastrointestinal arteriovenous malformations (AVMs) along with intracranial hemorrhage. We describe her clinical course and management, as well as her novel family mutation in ENG . This is the first reported HHT case with significant gastrointestinal bleeding in the newborn. We review neonatal HHT and raise the consideration for more directed prenatal imaging and delivery options for fetuses at high risk of HHT.
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Affiliation(s)
- Matthew Merves
- Department of Pediatrics, Division of Neonatology, Emory University, Atlanta, Georgia
| | - Kimberly Parsons
- Department of Pediatrics, Division of Neonatology, Emory University, Atlanta, Georgia
| | - Adina Alazraki
- Department of Radiology, Emory University, Atlanta, Georgia
| | | | - Cary Sauer
- Gastroenterology Section, Emory University, Atlanta, Georgia
| | - Hong Li
- Department of Human Genetics, Emory University, Atlanta, Georgia
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Riera-Mestre A, Mora Luján J, Sanchez Martínez R, Torralba Cabeza M, Patier de la Peña J, Juyol Rodrigo M, Lopez Wolf D, Ojeda Sosa A, Monserrat L, López Rodríguez M, Alonso Cotoner C, Beneyto Florido M, Fernández A, Gil Sánchez R, García Morillo J, Gómez Cerezo J, Gómez del Olmo V, Iglesias P, Juyol Rodrigo M, Lopez Osle N, López Rodríguez M, López Wolf D, Moreno de la Santa García M, Ojeda Sosa A, Patier de la Peña J, Perez Garcia M, Riera-Mestre A, Sánchez Martínez R, Torralba Cabeza M, Zarrabeitia Puente R. Computerized registry of patients with hemorrhagic hereditary telangiectasia (RiHHTa registry) in Spain: Objectives, methods, and preliminary results. Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Medical management of haemorrhagic hereditary telangiectasia in adult patients. Med Clin (Barc) 2018; 152:274-280. [PMID: 30502301 DOI: 10.1016/j.medcli.2018.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 12/26/2022]
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant inherited Rare Disease that causes a systemic anomalous vascular overgrowth. The approach and follow-up of these patients should be from multidisciplinary units. Its diagnosis is carried out according to Curaçao clinical Criteria. Telangiectasia in the nasal mucosa cause recurrent epistaxis, the main symptom of HHT and difficult to control. The three types of hepatic shunting, hepatic artery to hepatic vein, hepatic artery to portal vein or to portal vein to hepatic vein, can cause high-output heart failure, portal hypertension or porto-systemic encephalopathy, respectively. These types of vascular involvement can be established using computerised tomography. Pulmonary arteriovenous fistula should be screened for all HHT patients by contrast echocardiography. The main objective is to review the management of epistaxis, liver and lung involvement of the adult patient with HHT.
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Jackowska J, Klimza H, Zagozda N, Remacle M, Wojnowski W, Piersiala K, Wierzbicka M. Thyroplasty in unilateral vocal fold paresis with coexisting hereditary hemorrhagic telenagiectasia: A case report. Medicine (Baltimore) 2018; 97:e12727. [PMID: 30313073 PMCID: PMC6203463 DOI: 10.1097/md.0000000000012727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE The coincidence of an idiopathic unilateral vocal fold paresis and hereditary hemorrhagic telenagiectasia (HHT) is extremely rare and has not been described in the available literature yet. PATIENTS CONCERNS A 55-year-old female was admitted to hospital due to acute onset of hoarseness, voice fatigue, and effort dyspnea. In the past, the patient was diagnosed with HHT and on admission presented characteristic vascular lesions in the oral cavity. She reported also experiencing a moderate epistaxis at least once per month. DIAGNOSES The otolaryngological examination (fiberolaryngoscopy, phoniatric examination) revealed unchanged mobility and morphology of the right vocal fold and paresis of the left vocal fold in intermediate position. Computed tomography and magnetic resonance imaging of head, neck, and chest were inconclusive and showed no pathologic findings. INTERVENTIONS The unilateral paresis was treated for 12 months as idiopathic, with extensive rehabilitation. However, no improvement was observed. As a patient suffering from HHT is a challenge for anesthesiologists in terms of general anesthesia, the decision to perform type I thyroplasty (medialization) in local anesthesia was made. OUTCOMES There were no complications intraoperatively or in postoperative period. The implemented treatment was successful, as the voice quality improved both in perceptual evaluation (GRBAS scale) and acoustic analysis (F0, jitter, shimmer, NHR). LESSONS A routine surgical treatment in patients with HHT is a challenge. However, in this case, it was uneventful and successful, thus it can be recommended in other patients with similar background.
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Affiliation(s)
- Joanna Jackowska
- Department of Otolaryngology, Head and Neck Surgery, Poznań University of Medical Sciences, Poland
| | - Hanna Klimza
- Department of Otolaryngology, Head and Neck Surgery, Poznań University of Medical Sciences, Poland
| | - Natalia Zagozda
- Department of Otolaryngology, Head and Neck Surgery, Poznań University of Medical Sciences, Poland
| | - Marc Remacle
- Departments of Otorhinolaryngology, Head and Neck Surgery, CHL-Eich, Luxembourg, Luxembourg
| | - Waldemar Wojnowski
- Department of Otolaryngology, Head and Neck Surgery, Poznań University of Medical Sciences, Poland
| | - Krzysztof Piersiala
- Student Research Group at the Department of Otolaryngology, Head and Neck Surgery, Poznań University of Medical Sciences, Poznań, Poland
| | - Małgorzata Wierzbicka
- Department of Otolaryngology, Head and Neck Surgery, Poznań University of Medical Sciences, Poland
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Riera-Mestre A, Mora Luján JM, Sanchez Martínez R, Torralba Cabeza MA, Patier de la Peña JL, Juyol Rodrigo MC, Lopez Wolf D, Ojeda Sosa A, Monserrat L, López Rodríguez M. Computerized registry of patients with hemorrhagic hereditary telangiectasia (RiHHTa Registry) in Spain: Objectives, methods, and preliminary results. Rev Clin Esp 2018; 218:468-476. [PMID: 30177223 DOI: 10.1016/j.rce.2018.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/08/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Hereditary hemorrhagic telangiectasia (HHT) is a rare disease with autosomal dominant inheritance that causes systemic vascular affectation. MATERIAL AND METHOD After development a multicentric Spanish national registry, called RiHHTa, main clinical manifestations and diagnostic procedures of the first patients introduced are described. RESULTS 141 patients were included, of which 91 (64.5%) were women. The mean age at diagnosis was 42 years. Mutations in the ACVRL1 gene predominated over the ENG gene. The initial symptom was recurrent epistaxis in 130 (92.2%) patients and in three (2.1%), brain abscess. Pulmonary arteriovenous (AV) fistula were detected in 36 (45%) of the 79 patients who underwent thoracic CT angiography. The contrast echocardiography detected very few bubbles (grade I) or none, in 36 (45%) of these 79 affected patients. In 43 (67.2%) of the 64 patients with an abdominal CT angiography, hepatic vascular malformations were detected, mostly telangiectasias, AV and arterio-portal fistula, and extrahepatic in 14 (10%) subjects. More than half of the patients were screened for the presence of brain arteriovenous malformations which was found in 3.9% of them. The upper part of the intestinal tube was the most (95%) affected region. CONCLUSION The RiHHTa Registry allows improving the management of patients with HHT. An inadequate use of thoracic CT angiography and the usefulness of abdominal CT angiography has been detected in order to define subtypes of hepatic vascular involvement and detect extrahepatic vascular involvement.
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Affiliation(s)
- A Riera-Mestre
- Unidad de Telangiectasia Hemorrágica Hereditaria, Servicio de Medicina Interna, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, España; Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, España; Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna.
| | - J M Mora Luján
- Unidad de Telangiectasia Hemorrágica Hereditaria, Servicio de Medicina Interna, Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, España; Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna
| | - R Sanchez Martínez
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital General Universitario de Alicante, Alicante, España
| | - M A Torralba Cabeza
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J L Patier de la Peña
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, España
| | - M C Juyol Rodrigo
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Universitario Miguel Servet, Zaragoza, España
| | - D Lopez Wolf
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - A Ojeda Sosa
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Insular Universitario de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, España
| | - L Monserrat
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Health in Code, A Coruña, España
| | - M López Rodríguez
- Grupo de Trabajo en Enfermedades Minoritarias, Sociedad Española de Medicina Interna; Servicio de Medicina Interna, Hospital Central de la Cruz Roja, Madrid, España
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Bruceta M, De Souza L, Carr Z, Bonavia A, Karamchandani K. Novel Association of Juvenile Polyposis Syndrome With Atrial Septal Aneurysm and Patent Foramen Ovale: A Case Report. A A Pract 2018; 10:331-334. [PMID: 29634562 DOI: 10.1213/xaa.0000000000000714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Juvenile polyposis syndrome is an autosomal-dominant disorder characterized by the presence of hundreds of gastrointestinal polyps. The genes most commonly found are BMPR1A and SMAD4. The latter has been linked to vascular malformations and hereditary hemorrhagic telangiectasias. We present the case of a young woman diagnosed with juvenile polyposis syndrome and SMAD-4 mutation, who developed embolic strokes from an atrial septal aneurysm and patent foramen ovale. This case highlights the propensity of patients with juvenile polyposis syndrome and SMAD-4 mutations to develop atrial septal aneurysm and patent foramen ovale, and warrants appropriate cardiac workup in at-risk individuals.
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Affiliation(s)
- Melanio Bruceta
- From the Department of Anesthesiology & Perioperative Medicine, Penn State University College of Medicine, Hershey, Pennsylvania
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Mahon S. Hereditary Polyposis Syndromes: Opportunities for Early Detection in Individuals and Families. Clin J Oncol Nurs 2018; 22:151-156. [DOI: 10.1188/18.cjon.151-156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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