Guillain-Barré syndrome following danazol and corticosteroid therapy for hereditary angioedema

Lack of increased prevalence of immunoregulatory disorders in hereditary angioedema due to C1-inhibitor deficiency

Hereditary angioedema due to deficiency of C1-INH (HAE-C1-INH) is associated with enhanced consumption of the early complement components, which may predispose for autoimmune disease. We assessed the prevalence of such disorders among HAE- C1-INH patients and their impact on the natural course of HAE-C1-INH. Clinical data and immunoserological parameters of 130 HAE-C1-INH and 174 non-C1-INH-deficient patients with angioedema were analyzed. In our study, the incidence of immunoregulatory disorders was 11.5% in the population of HAE-C1-INH patients and 5.2% among non-C1-INH-deficient controls with angioedema. Immunoserology screening revealed a greater prevalence of anticardiolipin IgM (p=0.0118) among HAE-C1-INH patients, than in those with non-C1-INH-deficient angioedema. We did not find higher prevalence of immunoregulatory disorders among our HAE-C1-INH patients. However, in patients with confirmed immunoregulatory disorders, the latter influenced both the severity of HAE-C1-INH and the effectiveness of its long-term management. Appropriate management of the immunoregulatory disease thus identified improves the symptoms of HAE-C1-INH.

Guillain-Barré syndrome

The leading cause of acute neuromuscular weakness in the developed world is Guillain-Barré syndrome (GBS). Mortality rates vary widely. This article discusses the care and management of patients with GBS, with an emphasis on those patients who require admission to an intensive care unit.

Drug-associated Guillain-Barré syndrome: a literature review

OBJECTIVE

To present an overview of reported drug-associated Guillain-Barré syndrome (GBS) and current management of the disease.

DATA SOURCES

Case reports and reviews of drug-associated GBS published in the English-language literature from 1982 through 1994 were retrieved from MEDLINE. An additional search was done through the Iowa Drug Information System for the same period. This search yielded incidents that occurred as early as 1976. The key search terms were GBS, polyneuropathy, chemically induced polyradiculoneuropathy, and etiology of GBS. The searches were limited to human subjects.

DATA SYNTHESIS

Drugs that have been associated with GBS are presented, and although no definite relationships have been established, selected reports attempt to show an increased incidence of GBS after drug therapy. Outcome of medical management of GBS has been variable; however, death occurs in less than 10% of those affected.

CONCLUSIONS

GBS and clinically similar states have been reported to occur with a variety of drugs and biologics; however, because of the paucity of available data a well-defined cause and effect relationship has not been established between GBS and any drug. There appears to be no treatment of choice for this disorder. Further comparative studies should be done to determine the therapy with the most consistent outcome.

A case-control study of drugs and other determinants as potential causes of Guillain-Barré syndrome

The Guillain-Barré syndrome is an inflammatory demyelinating polyneuropathy with an acute or subacute onset. The current case-control study was performed to investigate the possible role of drugs and other determinants in the causation of the Guillain-Barré syndrome. Patients were included as cases if they fulfilled the criteria for acute Guillain-Barré syndrome and were unable to walk 10 m independently and had been admitted to the hospital within 2 weeks of onset of the neuropathy. For every case, two controls without the disease were obtained from the general practitioner (GP) of the patient with Guillain-Barré syndrome. Controls had the same type of health care insurance, were of the same gender and age (within 5 years), and resident in the same area. By telephone, the GPs of the patients with Guillain-Barré syndrome were interviewed. There were 71 female and 75 male cases and 142 female and 149 male controls. Significantly more cases than controls had been prescribed drugs in the 3 months prior to the index date and also diagnoses or symptoms in cases were more common. Case patients used significantly more frequently antipropulsives (loperamide), penicillins (amoxicillin with or without clavulanic acid) and vaccines. Female controls used significantly more often oral contraceptives. More cases than controls suffered from infections of the respiratory, gastrointestinal or urinary tract prior to the onset of neurological symptoms. In a logistic regression analysis, symptoms concerning the gastrointestinal and respiratory system were strongly associated with the Guillain-Barré syndrome. The use of oral contraceptives was significantly lower in female cases which could be compatible with the hypothesis that these drugs are protective.

[Angioneurotic edema and anesthesia: preparation and perioperative monitoring]

Hereditary angioneurotic oedema is an autosomal dominant disease associated with serum deficiency of functional C1-inhibitor. It is characterized by periodic swelling of subcutaneous tissues, abdominal viscera and upper airways. Lethal acute episodes of oedema can occur during anaesthesia and surgery. It is essential to prepare such patients before surgery. This article describes three cases (kidney transplantation, caesarean section, normal delivery) and the various preventive measures used to avoid acute episodes during anaesthesia and surgery. Antibrinolytic agents, androgens, fresh frozen plasma, C1-inhibitor concentrate can be administered. Their various indications are discussed.

Pseudotumor cerebri induced by danazol

Intracranial hypertension with papilledema occurred in two patients receiving danazol therapy for either cyclic neutropenia or immune hemolytic anemia. Results of clinical, laboratory, and neuroradiologic studies showed no apparent cause for the condition in Case 1 and the papilledema resolved one month after discontinuing danazol. Carotid angiography in Case 2 demonstrated cerebral venous sinus thrombosis; the papilledema showed gradual improvement after cessation of danazol. An additional seven cases of pseudotumor cerebri presumed secondary to danazol therapy have been reported to the Food and Drug Administration. The papilledema resolved in all seven cases soon after discontinuing danazol. A drug-induced complication should be suspected, and alternative therapy sought, in patients who develop intracranial hypertension associated with administration of danazol.

Immune complex assays: diagnostic and clinical application

The presence of circulating immune complexes have been described in many different human disease states but the significance of their presence has always been a subject for debate. Improvements in the methods of detecting immune complexes have demonstrated a wide degree of heterogeneity, which accounts for the difficulty in obtaining accurate and reproducible measurements, even in the same individual. Techniques for isolating individual complexes, characterizing their pathophysiological properties, and biochemically analyzing the nature of the complexed antigen are now being used to provide data that is helping to clarify the role of immune complexes in the pathogenesis of disease. In addition, such studies are also providing data which is proving that immune complexes have a potential role in immune regulation.