Angioedema as a systemic disease

Nickel-induced labial angioedema in a pediatric patient with orthodontic braces: a case report

BACKGROUND

Angioedema is a condition marked by sudden, intense swelling of the subcutaneous and submucosal tissues, typically associated with hypersensitivity reactions, genetic mutations, or reactions to medications. It can also result from contact with allergens such as nickel, leading to dermatitis.

CASE PRESENTATION

A 12-year-old girl presented at our Pediatric Immunology and Allergology service with recurrent labial angioedema for over a year, linked to the consumption of legumes and tomatoes, and following the use of a metal flute. Despite a nickel-positive patch test and subsequent avoidance of nickel, her symptoms persisted. Further investigations to rule out other causes of angioedema were unproductive. It was later discovered that she had been wearing a nickel-containing orthodontic device applied a year earlier. The removal of this orthodontic device led to a cessation of the angioedema episodes, highlighting nickel as the likely trigger.

CONCLUSIONS

This case underscores the importance of considering prolonged nickel exposure from dental devices as a potential cause of angioedema. For patients predisposed to nickel hypersensitivity, using nickel-free alternatives such as ceramic for orthodontic appliances is crucial. Additionally, comprehensive allergen screening, including latex testing, should be conducted before the placement of such devices to prevent similar adverse reactions.

Risperidone-induced angioedema

Risperidone is a second-generation antipsychotic with common adverse effects, such as extrapyramidal symptoms, weight gain, hyperprolactinemia, and sedation. Angioedema, although generally considered to be uncommon, has previously been documented to occur following administration of some antipsychotics, including risperidone. This report describes a case of risperidone-induced angioedema in an older male patient.

Current and Emerging Therapeutics in Hereditary Angioedema

Angioedema is characterized by transient movement of fluid from the vasculature into the interstitial space leading to subcutaneous or submucosal non-pitting edema. Current evidence suggests that most angioedema conditions can be grouped into 2 categories: mast cell-mediated (previously termed histaminergic) or bradykinin-mediated angioedema. Although effective therapies for mast cell-mediated angioedema have existed for decades, specific therapies for bradykinin-mediated angioedema have more recently been developed. In recent years, rigorous studies of these therapies in treating hereditary angioedema (HAE) have led to regulatory approvals of medication for HAE management thereby greatly expanding HAE treatment options.

Risk of drug-induced angioedema: a pharmacovigilance study of FDA adverse event reporting system database

Objective

The purpose of this study is to explore and analyze the FDA Adverse Event Reporting System (FAERS) database to identify drug adverse reaction signals associated with angioedema. The findings aim to provide valuable insights for clinical drug safety considerations.

Methods

The Open Vigil 2.1 data platform was utilized to collect adverse event reports related to angioedema from the first quarter of 2004 to the fourth quarter of 2023. The reporting odds ratio (ROR) and proportional reporting ratio (PRR) were employed as disproportionality measures to detect adverse reaction signals Sof drugs associated with angioedema.

Results

A total of 38,921 reports were retrieved, with the majority being reported by healthcare professionals. The analysis included predominantly adult patients (≥18 years of age), with slightly higher representation of females compared to males. Among the top 30 drugs associated with the occurrence of angioedema, 24 drugs showed positive signals in the risk analysis. Based on the individual drug reporting odds ratio (95% confidence interval) as a measure of risk signal strength, the top five drugs are as follows: lisinopril [ROR (95% CI): 46.43 (42.59-50.62)], enalapril [ROR (95% CI): 43.51 (39.88-47.46)], perindopril [ROR (95% CI): 31.17 (27.5-35.32)], alteplase [ROR (95% CI): 29.3 (26.95-31.85)], ramipril [ROR (95% CI): 20.93 (19.66-22.28)]. After categorizing the drugs, the strongest positive signal was observed in the antithrombotic agents [ROR (95% CI): 22.53 (21.16-23.99)], following that, cardiovascular drugs [ROR (95% CI): 9.17 (8.87-9.48)], antibiotics [ROR (95% CI): 6.42 (5.91-6.96)], immunosuppressors [ROR (95% CI): 5.95 (5.55-6.39)], anti-inflammatory analgesics [ROR (95% CI): 4.65 (4.45-4.86)], antiallergic drugs [ROR (95% CI): 4.47 (3.99-5)], antiasthmatics [ROR (95% CI): 2.49 (2.14-2.89)], blood sugar control drugs [ROR (95% CI): 1.65 (1.38-1.97)], and digestive system drugs [ROR (95% CI): 1.59 (1.45-1.74)] exhibited progressively decreasing ROR values.

Conclusion

Many medications are associated with a high risk of angioedema. These medications play a crucial and potentially preventable role in controlling the occurrence of angioedema. It is essential to consider the risk level of drug-induced angioedema in clinical practice to optimize medication therapy.

New exploration of signal detection of Regional Risks from the perspective of data mining: a pharmacovigilance analysis based on spontaneous reporting data in Zhenjiang, China

BACKGROUND

This study aimed to adopt the conventional signal detection methods to explore a new way of risk identification and to mine important drug risks from the perspective of big data based on Zhenjiang Adverse Event Reporting System (ZAERS).

RESEARCH DESIGN AND METHODS

Data were extracted from ZAERS database between 2012 and 2022. The risks of all the reported drug event combinations were identified at the preferred term level and the standardized MedDRA query level using disproportionality analysis. Then, we conducted signal assessment according to the descriptions of drug labels.

RESULTS

In total 41,473 ADE were reported and there were 12 risky signals. Signal assessment indicates the suspected causal associations in clindamycin-taste and smell disorders, valsartan-hepatic enzyme increased and valsartan-edema peripheral; the specific manifestations of allergic reactions triggered by clindamycin, cefotaxime, cefazodime, ShexiangZhuanggu plaster, ShexiangZhuifeng plaster, and Yanhuning need to be refined in drug labels. In addition, the drug labels of NiuHuangShangQing tablet/capsule, Fuyanxiao capsule, and BiYanLing tablet should be improved.

CONCLUSIONS

In this study, we attempted a new way to find potential drug risks using small spontaneous reporting data. Our findings also suggested the need for more precise identification of allergic risks and the improvement of traditional Chinese medicine labels.

The role of the environment in allergic skin disease

PURPOSE OF REVIEW

This paper explores how environmental factors influence allergic skin diseases, including atopic dermatitis (AD), contact dermatitis (CD), urticaria, angioedema, and reactions to drugs and insect bites.

RECENT FINDINGS

Research indicates a significant impact of environmental elements on allergic skin diseases. High air pollution levels exacerbate symptoms, while climate change contributes to increased skin barrier dysfunction, particularly affecting AD. Allergen prevalence is influenced by climate and pollution. Irritants, like those in detergents and cosmetics, play a major role in CD. Plants also contribute, causing various skin reactions. Understanding the interplay between environmental factors and allergic skin diseases is crucial for effective management. Physicians must address these factors to support patient well-being and promote skin health amidst environmental changes.

Orbital compartment syndrome due to periorbital angioedema

A 68-year-old female presented with an episode of unilateral orbital compartment syndrome due to periorbital angioedema. The patient made a consultation at the general Emergency Room with sudden left periorbital edema and serious diminished ipsilateral visual acuity, with examination detecting orbital compartment syndrome secondary to a probable allergic angioedema after ingestion of ibuprofen. She received treatment with intravenous and oral corticosteroids, achieving a rapid improvement in the condition and clinical follow-up was carried out, with evaluation of the peripapillary retinal nerve fiber layer thickness and computed perimetry. Periorbital angioedema due to ibuprofen can be a cause of orbital compartment syndrome whose diagnosis and treatment must be carried out urgently to prevent permanent visual impairment.

Acupuncture as a therapeutic intervention for post-COVID-19 vaccination urticaria: a systematic review and meta-analysis protocol

INTRODUCTION

The COVID-19 pandemic persisted for over 3 years since its onset in December 2019, posing an ongoing global threat to human health. In the absence of specific antiviral medications for COVID-19, vaccination has emerged as a popular preventive measure adopted by the general public. However, an undesirable consequence of COVID-19 vaccination has been the frequent incidence of urticaria, a type of adverse skin manifestations. Despite the prevalence of this issue, there is currently a lack of clinical evidence exploring the potential utility of acupuncture as a therapeutic approach to managing urticaria arising after COVID-19 vaccination. To address this knowledge gap, this study aims to comprehensively evaluate the effectiveness and safety of acupuncture as a therapeutic intervention for treating urticaria in the general population following COVID-19 vaccination.

METHODS AND ANALYSIS

The retrieval strategies employed in this study involve obtaining all relevant articles published from December 2019 to October 2023. These articles will be obtained from databases including PubMed, EMBASE, Cochrane Library, Web of Science, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (SinoMed), VIP database and the WanFang database. Subsequently, the collected articles will undergo a thorough screening process based on predefined inclusion and exclusion criteria. Additionally, study quality will be evaluated using the Cochrane risk bias assessment tool. To conduct the meta-analysis, we will employ the Review Manager software (RevMan V.5.3). Finally, the study findings will be evaluated for their level of evidence.

ETHICS AND DISSEMINATION

As this is a secondary review of published clinical data, this study does not involve direct contact with human subjects, and therefore, ethical approval and consent are not required. The findings of the study will be disseminated through a peer-reviewed journal, ensuring that the results undergo rigorous evaluation by experts in the field.

PROSPERO REGISTRATION NUMBER

CRD42022377343.

Pseudo-Allergies in the Emergency Department: A Common Misdiagnosis of Hypersensitivity Type 1 Allergic Reaction

Type-1 hypersensitivity reaction represents an acute IgE-mediated reaction that can cause life-threatening conditions, such as anaphylactic shock, angioedema, and airway obstruction. Other reactions that can mimic type-1 hypersensitivity reactions include IgE-independent mast cell degranulation, bradykinin-mediated reactions, leukotrienes-mediated reactions, and pseudo-allergies. We use the term pseudo-allergy in this article for histamine-mediated reactions that are mast cell-independent. We did not discuss pseudo-allergic reactions that are not acute or life-threatening, such as celiac disease, Heiner's syndrome, eosinophilic esophagitis, and food protein-induced enterocolitis in our article because the emergency department is not the primary location to diagnose or treat these reactions. Herein, we present some allergic-like reactions that can be life-threatening, such as scombroid food poisoning (SFP), bradykinin-induced angioedema, IgE-independent angioedema, opioid-induced angioedema, and non-steroidal anti-inflammatory drug (NSAID)-induced hypersensitivity and angioedema. These reactions may have different treatments based on their mechanism of reaction. Histamine-mediated reactions, such as SFP, histamine-mediated angioedema, and mast cell degranulation induced by NSAIDs, and opioids can be treated with antihistamines, epinephrine, and corticosteroids. Bradykinin-induced angioedema, including hereditary angioedema and acquired angioedema, can be treated with fresh frozen plasma. Hereditary angioedema can be treated with many FDA-approved targeted medications, such as plasma-derived C1-INH, plasma kallikrein inhibitor (Ecallantide), and selective bradykinin-2 receptor antagonist (Icatibant). However, these targeted agents are not well-studied enough to be used for acquired angioedema. It is crucial for emergency medicine physicians to be familiar with and predict these reactions to prevent misdiagnosis, be prepared to treat these life-threatening conditions appropriately without delay and eliminate patients' exposure to any unnecessary investigations or treatments.

Dupilumab-Associated Angioedema in an Adult: A Case Report of an Adverse Event and Literature Review

Dupilumab is a monoclonal antibody that targets interleukin (IL)-4 and IL-13 for use in moderate to severe eczema, asthma, and nasal polyposis. Our case report presents a 47-year-old woman with a history of nasal polyposis who developed angioedema after being treated with dupilumab for recurrent polyposis. She tolerated her first dose of dupilumab without reaction, but 10 days after her second injection, she developed swelling of the lips and forehead. She was treated with steroids with partial resolution. She received two further doses, which followed similar courses before dupilumab was discontinued. To the best of the authors' knowledge, this is the first report of dupilumab-associated angioedema in an adult. This report may be instructional for prescribers providing patients with anticipatory guidance or evaluating otherwise unexplained angioedema.

Acquired Angioedema in Selected Neoplastic Diseases

Background and Objectives. Acquired angioedema is a relatively common revelation accompanying some diseases such as autoimmune or cancer. The study aimed to assess the incidence of one subtype of angioedema-C1-INH-AAE (acquired angioedema with C1 inhibitor deficiency). Material and methods. The study was retrospective and based on 1 312 patients with a final diagnosis of breast cancer, colorectal cancer, or lung cancer: 723 women and 589 men with a mean age of 58.2 ± 13.5 years. The cancer diagnosis according to the ICD (International Classification of Diseases)-10 code, medical history including TNM (Tumour, Node, Metastasis) staging, histopathology, and assessment of the occurrence of C1-INH-AAE angioedema were analysed. Results. C1-INH-AAE occurred more often in patients with cancer than in the control group, as follows: 327 (29%) vs. 53 (6%) for p < 0.05. C1-INH-AAEs were observed most often in the group of patients diagnosed with breast cancer compared to colorectal and lung groups: 197 (37%) vs. 108 (26%) vs. 22 (16%) (p < 0.05). A higher incidence of C1-INH-AAE was observed in the early stages of breast cancer. However, there was no relationship between the occurrence of C1-INH-AAE and the BRCA1 (Breast Cancer gene 1)/BRCA2 (Breast Cancer gene 2) mutation or histopathological types of breast cancer. Conclusion. Angioedema type C1-INH-AAE occurs more often in patients with selected neoplastic diseases, especially in the early stages of breast cancer.

Is Icatibant Safe for the Treatment of Hereditary Angioedema During Pregnancy?

PURPOSE OF REVIEW

Hereditary angioedema (HAE) is a disorder affecting bradykinin regulation presenting as recurrent cutaneous or mucosal swelling. Treatment options include plasma-derived or human-recombinant C1-inhibitor, icatibant, or ecallantide. Due to the lack of knowledge and experience on the topic, the treatment of choice in pregnancy is plasma-derived C1-inhibitor, and reporting any new experience is recommended. This review presents current guidelines for HAE treatment with a focus on pregnancy and reviews all experience with icatibant use during pregnancy.

RECENT FINDINGS

Our experience of treating a pregnant nC1-INH HAE patient with icatibant is presented, with no adverse effects or abnormalities, to add to the growing knowledge of icatibant use during pregnancy. Considering the limited number of attacks that our patient usually experiences, which continued at more or less the same frequency during pregnancy, we feel icatibant to be a safe choice for on-demand HAE treatment during pregnancy for such cases.

Clinical Perspectives and Management of Edema in Chronic Venous Disease—What about Ruscus?

Background: Edema is highly prevalent in patients with cardiovascular disease and is associated with various underlying pathologic conditions, making it challenging for physicians to diagnose and manage. Methods: We report on presentations from a virtual symposium at the Annual Meeting of the European Venous Forum (25 June 2021), which examined edema classification within clinical practice, provided guidance on making differential diagnoses and reviewed evidence for the use of the treatment combination of Ruscus extract, hesperidin methyl chalcone and vitamin C. Results: The understanding of the pathophysiologic mechanisms underlying fluid build-up in chronic venous disease (CVD) is limited. Despite amendments to the classic Starling Principle, discrepancies exist between the theories proposed and real-world evidence. Given the varied disease presentations seen in edema patients, thorough clinical examinations are recommended in order to make a differential diagnosis. The recent CEAP classification update states that edema should be considered a sign of CVD. The combination of Ruscus extract, hesperidin methyl chalcone and vitamin C improves venous tone and lymph contractility and reduces macromolecule permeability and inflammation. Conclusions: Data from randomized controlled trials support guideline recommendations for the use of Ruscus extract, hesperidin methyl chalcone and vitamin C to relieve major CVD-related symptoms and edema.

Angioedema-like presentation as the presenting finding of juvenile myositis and juvenile dermatomyositis in 2 patients

BACKGROUND

Juvenile dermatomyositis (JDM) is the most common subtype of idiopathic inflammatory myopathies in childhood. Gottron's papules, shawl sign, periorbital heliotrope rash, and periungual telengiectasis are characteristic skin findings of the disease. Besides characteristic skin involvement, some other skin findings, such as angioedema, may be seen prior or in the course of the disease. The presence of angioedema in JDM is emphasized in this report.

CASE PRESENTATIONS

We present 2 unrelated girls, aged 2 (case 1) and 12 years (case 2), who had developed symmetrical weakness in the proximal muscles, muscle pain, elevated muscle enzymes and angioedema. Both cases had abnormal muscle magnetic resonance imaging findings, suggestive of inflammatory myositis. Muscle biopsy was performed only in case 1, and major histocompatibility complex-1 expression on myofibers was shown consistent with JDM. Cases were diagnosed as probable and definite JDM, respectively. Angioedema was prominent, particularly in the lips and extremities of both cases, without laboratory evidence of C1 inhibitor deficiency or capillary leak syndrome, and absence of family history. Mast cell-mediated, acquired angioedema was the most likely diagnosis. In both cases, skin and muscle findings improved significantly with steroid treatment.

CONCLUSION

We suggest that angioedema may be among the characteristic skin findings in JDM, and may be included in subsequent definitions.

A validation study of the Japanese version of the Angioedema Activity Score (AAS) and the Angioedema Quality of Life Questionnaire (AE-QoL)

BACKGROUND

Recurrent angioedema (RecAE) has a substantial impact on patients' daily lives. However, there have been no disease-specific patient-reported outcomes (PROs) available in Japan to measure disease activity and health-related QoL impairment in such patients.

METHODS

Japanese versions of the Angioedema Activity Score (AAS) and the Angioedema Quality of Life Questionnaire (AE-QoL) were examined for their validity and reliability. By using these questionnaires, the relationship between disease activity and QoL impairment among the Japanese population of RecAE were analyzed in real-world setting.

RESULTS

The Japanese AAS and AE-QoL domains showed good internal consistency of 0.967 and > 0.835. For known group validity, AAS28 and AE-QoL total scores were higher in more severe patients than those with milder disease and QoL impairment, respectively. AAS28 showed strong correlation with indexes of disease activity, while the AE-QoL total score correlated with Dermatology Life Quality Index (DLQI). Sufficient reproductivity of the AAS and AE-QoL was shown by their intraclass correlation coefficients of 0.890 and 0.700. The Japanese population is characterized by the total score of AAS28, 34.3 ± 38.8 (mean ± SD); and AE-QoL, 38.7 ± 25.2. Each domain score of AE-QoL was 32.4 ± 29.7 in "Functioning", 35.0 ± 27.8 in "Fatigue/mood", 50.7 ± 30.6 in "Fears/shame", or 24.7 ± 29.8 in "Food". Changes in AAS28 and AE-QoL positively correlated to Patient global assessment of disease activity and DLQI, respectively.

CONCLUSIONS

The Japanese AAS and AE-QoL are valid and reliable instruments for Japanese patients with RecAE, and active disease affecting QoL. They help assess disease activity and QoL of RecAE in routine patient care and clinical trials.