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Al Rawahi Y, Wong M, Stormon M. Hereditary Angioedema Post-liver Transplant. JPGN REPORTS 2021; 2:e091. [PMID: 37205969 PMCID: PMC10191482 DOI: 10.1097/pg9.0000000000000091] [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: 07/16/2020] [Accepted: 03/08/2021] [Indexed: 05/21/2023]
Abstract
Liver transplantation is the standard of care in managing different types of liver disorders as well as a variety of inborn errors of metabolism. In the latter scenario, the liver-based enzyme abnormality is corrected by transplantation. Although rare, liver transplantation may result in the transmission of an inborn error of metabolism to the recipient. The present report describes the development of acquired hereditary angioedema likely following liver transplantation, with notable improvement with the initiation of C1 esterase inhibitor replacement therapy. This case report describes another example of a hepatic synthesis defect that, although rare, but can be acquired from donor's livers.
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Affiliation(s)
- Yusriya Al Rawahi
- From the Department of Gastroenterology, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Westmead, NSW
- Department of Child Health, Sultan Qaboos University Hospital, Al-Khoud, Muscat, Oman
| | - Melanie Wong
- Department of Immunology, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Westmead, NSW, Australia
| | - Michael Stormon
- From the Department of Gastroenterology, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Westmead, NSW
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Abstract
Abdominal pain is one of the most common conditions leading people to the emergency department. An uncommon but well described cause of abdominal pain is angioedema of the gastrointestinal tract due to recurrent angioedema without wheals. Abdominal involvement is very common in hereditary angioedema (HAE), but it is also described in acquired angioedema and allergic forms. In patients with HAE, the involvement of gastrointestinal tract with resultant abdominal pain occurs in 43-93% of cases. Attacks can involve the entire gastrointestinal tract, such as the oropharynx, small intestine, colon, liver, or pancreas. Pain is the most common gastrointestinal symptom, and it may occur for many years even without cutaneous or respiratory symptoms. The case report we included in this article emphasizes the importance of accurate evaluation of personal and family history in patients with a long history of acute, severe, and unexplained abdominal pain, and it gives an example of how diagnostic delay may be longer if gastroenterological symptoms are the predominant clinical presentation. Furthermore, sometimes the simultaneous presence of concomitant gastrointestinal disorders and HAE may cause difficulties in differential diagnosis. Gastroenterologists and other physicians should add HAE to their list of potential causes of unexplained abdominal pain. The initiation of appropriate prophylaxis and treatment will prevent needless suffering and useless surgical and medical procedures.
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Ferrara AL, Cristinziano L, Petraroli A, Bova M, Gigliotti MC, Marcella S, Modestino L, Varricchi G, Braile M, Galdiero MR, Spadaro G, Loffredo S. Roles of Immune Cells in Hereditary Angioedema. Clin Rev Allergy Immunol 2021; 60:369-382. [PMID: 34050913 PMCID: PMC8272703 DOI: 10.1007/s12016-021-08842-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 01/19/2023]
Abstract
Hereditary angioedema (HAE) is a rare genetic disease, characterized by recurrent and unexpected potentially life-threatening mucosal swelling. HAE may be further classified into HAE with C1‐inhibitor deficiency (C1‐INH‐HAE) and HAE with normal C1‐INH activity (nlC1‐INH‐HAE), mostly due to mutations leading to increased vascular permeability. Recent evidence implicates also the innate and adaptive immune responses in several aspects of angioedema pathophysiology. Monocytes/macrophages, granulocytes, lymphocytes, and mast cells contribute directly or indirectly to the pathophysiology of angioedema. Immune cells are a source of vasoactive mediators, including bradykinin, histamine, complement components, or vasoactive mediators, whose concentrations or activities are altered in both attacks and remissions of HAE. In turn, through the expression of various receptors, these cells are also activated by a plethora of molecules. Thereby, activated immune cells are the source of molecules in the context of HAE, and on the other hand, increased levels of certain mediators can, in turn, activate immune cells through the engagement of specific surface receptors and contribute to vascular endothelial processes that lead to hyperpemeability and tissue edema. In this review, we summarize recent developments in the putative involvement of the innate and adaptive immune system of angioedema.
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Affiliation(s)
- Anne Lise Ferrara
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | - Leonardo Cristinziano
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
| | - Angelica Petraroli
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
| | - Maria Bova
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
| | - Maria Celeste Gigliotti
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
| | - Simone Marcella
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
| | - Luca Modestino
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
| | - Gilda Varricchi
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | - Mariantonia Braile
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
| | - Maria Rosaria Galdiero
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy
| | - Giuseppe Spadaro
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
- WAO Center of Excellence, Naples, Italy
| | - Stefania Loffredo
- Department of Translational Medical Sciences, University of Naples Federico II, 80131, Naples, Italy.
- Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.
- WAO Center of Excellence, Naples, Italy.
- Institute of Experimental Endocrinology and Oncology (IEOS), National Research Council, Naples, Italy.
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Kajdácsi E, Veszeli N, Mező B, Jandrasics Z, Kőhalmi KV, Ferrara AL, Cervenak L, Varga L, Farkas H. Pathways of Neutrophil Granulocyte Activation in Hereditary Angioedema with C1 Inhibitor Deficiency. Clin Rev Allergy Immunol 2021; 60:383-395. [PMID: 33606193 PMCID: PMC8272702 DOI: 10.1007/s12016-021-08847-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 12/04/2022]
Abstract
Hereditary angioedema (HAE) with C1-inhibitor deficiency belongs to bradykinin-mediated angioedemas. It is characterized by recurrent subcutaneous and/or submucosal swelling episodes (HAE attacks) and erythema marginatum skin rash as a pre-attack (prodromal) phase. HAE attacks were shown to be accompanied by peripheral blood neutrophilia. We aimed to find molecular mechanisms that may explain the distinct role of neutrophil granulocytes in HAE. Plasma levels of blood cells and factors related to neutrophil activation (cytokines, chemokines, chemotactic factors, enzymes, and neutrophil extracellular trap) were measured in plasma samples obtained from patients during symptom-free periods (n = 77), during prodromal phase (n = 8) and attacks (n = 14), during a spontaneously resolved attack (n = 1), and in healthy controls (n = 79). Higher counts of white blood cells, lymphocytes, and neutrophil granulocytes were found in symptom-free patients compared with controls; these cell counts were elevated further during HAE attacks. The level of chemokine (C–C motif) ligand 5, monocyte chemoattractant protein-1, and myeloperoxidase were also higher in the symptom-free patients than in the controls. Levels of monocyte chemoattractant protein-1, leukotriene B4, neutrophil elastase, and myeloperoxidase were elevated during attacks. During erythema marginatum, white blood cells and monocyte count and levels of interleukin 8 were elevated compared with symptom-free period. Similar changes were detected during the attack follow-up. We conclude that the activation of NGs in symptom-free periods and a further increase observed during attacks suggests that NGs may be involved in the pathomechanism of HAE with C1-INH deficiency.
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Affiliation(s)
- Erika Kajdácsi
- Research Laboratory, Department of Internal Medicine and Hematology, Semmelweis University, 46 Szentkirályi str, 1088, Budapest, Hungary
| | - Nóra Veszeli
- MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Blanka Mező
- MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Zsófia Jandrasics
- Research Laboratory, Department of Internal Medicine and Hematology, Semmelweis University, 46 Szentkirályi str, 1088, Budapest, Hungary
| | - Kinga Viktória Kőhalmi
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
- Department of Rheumatology, Hospital of Hospitaller Brothers of St. John of God, Budapest, Hungary
| | - Anne Lise Ferrara
- Center for Basic and Clinical Immunology Research (CISI), Department of Translational Medical Science, University of Naples "Federico II", Napoli, Italy
| | - László Cervenak
- Research Laboratory, Department of Internal Medicine and Hematology, Semmelweis University, 46 Szentkirályi str, 1088, Budapest, Hungary
| | - Lilian Varga
- Research Laboratory, Department of Internal Medicine and Hematology, Semmelweis University, 46 Szentkirályi str, 1088, Budapest, Hungary
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- Research Laboratory, Department of Internal Medicine and Hematology, Semmelweis University, 46 Szentkirályi str, 1088, Budapest, Hungary.
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.
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Abstract
Hereditary angioedema (HAE) is a rare genetic disease with numerous gastrointestinal manifestations. Intussusception, although rare, has been a reported complication with documentation of bowel wall edema on endoscopy during an acute flare. With the advent of synthetic C1 esterase inhibitors, this disease has become more effectively treatable. This case report shows a HAE flare complicated by colonic intussusception, treated with C1 esterase inhibitor, with complete endoscopic resolution seen on hospital day 5. This case provides evidence that with proper medical treatment, an HAE flare with intussusception has the potential to resolve without any further need for surgical or endoscopic intervention.
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Ozden G, Yanardag Acik D. Can the neutrophil-lymphocyte ratio predict type 1 hereditary angioedema attacks? Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:649-653. [PMID: 32985276 DOI: 10.1080/00365513.2020.1827288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The neutrophil-lymphocyte ratio is a simple and easily used parameter for the assessment of inflammation. We aimed to determine the predictive potential of the neutrophil-lymphocyte ratio regarding episode occurrence in patients with hereditary angioedema. Sixty-six patients with Type 1 hereditary angioedema and 60 healthy controls were included in the study. The laboratory results of the patients in their episode-free periods were similar to those of the healthy controls. The median of neutrophil-lymphocyte ratio was higher during episodes when compared to normal periods (3.5 versus 2.0, p < .001). A significant positive correlation was present between the episode count and the neutrophil-lymphocyte ratio calculated during the episodes (r = 0.557, p < .001). We can conclude that the neutrophil-lymphocyte ratio, which is cheap and easy to calculate, can be used by clinicians as a predictive parameter for prediction of the episode count in patients with hereditary angioedema.
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Affiliation(s)
- Guzin Ozden
- Department of Internal Medicine and Immunology, Adana City Education and Research Hospital, Yüreğir, Turkey
| | - Didar Yanardag Acik
- Department of Internal Medicine and Haematology, Adana City Education and Research Hospital, Yüreğir, Turkey
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Henao MP, Kraschnewski JL, Kelbel T, Craig TJ. Diagnosis and screening of patients with hereditary angioedema in primary care. Ther Clin Risk Manag 2016; 12:701-11. [PMID: 27194914 PMCID: PMC4859422 DOI: 10.2147/tcrm.s86293] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant disease that commonly manifests with episodes of cutaneous or submucosal angioedema and intense abdominal pain. The condition usually presents due to a deficiency of C1 esterase inhibitor (C1-INH) that leads to the overproduction of bradykinin, causing an abrupt increase in vascular permeability. A less-understood and less-common form of the disease presents with normal C1-INH levels. Symptoms of angioedema may be confused initially with mast cell-mediated angioedema, such as allergic reactions, and may perplex physicians when epinephrine, antihistamine, or glucocorticoid therapies do not provide relief. Similarly, abdominal attacks may lead to unnecessary surgeries or opiate dependence. All affected individuals are at risk for a life-threatening episode of laryngeal angioedema, which continues to be a source of fatalities due to asphyxiation. Unfortunately, the diagnosis is delayed on average by almost a decade due to a misunderstanding of symptoms and general lack of awareness of the disease. Once physicians suspect HAE, however, diagnostic methods are reliable and available at most laboratories, and include testing for C4, C1-INH protein, and C1-INH functional levels. In patients with HAE, management consists of acute treatment of an attack as well as possible short- or long-term prophylaxis. Plasma-derived C1-INH, ecallantide, icatibant, and recombinant human C1-INH are new treatments that have been shown to be safe and effective in the treatment of HAE attacks. The current understanding of HAE has greatly improved in recent decades, leading to growing awareness, new treatments, improved management strategies, and better outcomes for patients.
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Affiliation(s)
- Maria Paula Henao
- Department of Medicine, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Jennifer L Kraschnewski
- Department of Medicine, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Theodore Kelbel
- Division of Allergy and Immunology, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Timothy J Craig
- Department of Medicine and Pediatrics, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
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Veszeli N, Csuka D, Zotter Z, Imreh É, Józsi M, Benedek S, Varga L, Farkas H. Neutrophil activation during attacks in patients with hereditary angioedema due to C1-inhibitor deficiency. Orphanet J Rare Dis 2015; 10:156. [PMID: 26654922 PMCID: PMC4674948 DOI: 10.1186/s13023-015-0374-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/02/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Earlier studies have shown that the absolute number of neutrophil granulocytes (NGs) may increase during attack of hereditary angioedema due to C1-inhibitor deficiency (C1-INH-HAE). Whether NGs undergo activation during attack has not yet been investigated. However, as neutrophil elastase (NE) can cleave and inactivate C1-INH which may contribute to the dysregulation of the kallikrein-kinin system and hence, to edema formation. Our aim was to investigate the possible activation of NGs during attacks. METHODS We studied blood samples obtained from 26 patients with C1-INH-HAE during symptom-free periods and during attacks, along with samples from 26 healthy volunteers. NG count (NGC), NE, myeloperoxidase (MPO), pentraxin 3 (PTX3), CRP, C5a, factor H, IL-8, and TNF-α levels were measured. RESULTS NGC was higher during attacks than during symptom-free periods (p = 0.0132), and the same was observed for NE (p = 0.0026), MPO (p = 0.0008), and PTX3 levels (p = 0.0409). There was a strong positive correlation between NE and MPO levels during attacks (p < 0.0001, R = 0.709). Furthermore, IL-8 (p = 0.0061) and TNF-α (p = 0.0186) levels were also elevated during attacks, compared with symptom-free periods. By contrast, C5a and factor H levels were similar in samples obtained during attacks or in symptom-free periods. CONCLUSION Increased NGC was associated with elevated NE and MPO levels - this suggests neutrophil activation during attacks. The strong positive correlation between NE and MPO levels, together with the elevated PTX3 concentration, may indicate the expression of neutrophil extracellular traps. All these processes may contribute to the activation of kallikrein-kinin system, which leads to the onset of an edematous episode.
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Affiliation(s)
- Nóra Veszeli
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Dorottya Csuka
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Zsuzsanna Zotter
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary. .,Urology Department, Medical Center, Hungarian Defence Forces, Budapest, Hungary.
| | - Éva Imreh
- Central Laboratory, Kútvölgyi Clinical Block, Budapest, Hungary.
| | - Mihály Józsi
- MTA-ELTE "Lendület" Complement Research Group, Department of Immunology, Eötvös Loránd University, Budapest, Hungary.
| | - Szabolcs Benedek
- Haematology Unit, 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
| | - Lilian Varga
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary.
| | - Henriette Farkas
- Hungarian Angioedema Center, 3rd Department of Internal Medicine, Semmelweis University, Kútvölgyi út 4, H-1125, Budapest, Hungary.
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Hereditary Angioedema and Gastrointestinal Complications: An Extensive Review of the Literature. Case Reports Immunol 2015; 2015:925861. [PMID: 26339513 PMCID: PMC4538593 DOI: 10.1155/2015/925861] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 07/12/2015] [Indexed: 12/19/2022] Open
Abstract
Hereditary Angioedema (HAE) is a rare autosomal dominant (AD) disease characterized by deficient (type 1) or nonfunctional (type 2) C1 inhibitor protein. The disorder is associated with episodes of angioedema of the face, larynx, lips, abdomen, or extremities. The angioedema is caused by the activation of the kallikrein-kinin system that leads to the release of vasoactive peptides, followed by edema, which in severe cases can be life threatening. The disease is usually not diagnosed until late adolescence and patients tend to have frequent episodes that can be severely impairing and have a high incidence of morbidity. Gastrointestinal involvement represents up to 80% of clinical presentations that are commonly confused with other gastrointestinal disorders such as appendicitis, cholecystitis, pancreatitis, and ischemic bower. We present a case of an HAE attack presenting as colonic intussusception managed conservatively with a C1 esterase inhibitor. Very few cases have been reported in the literature of HAE presentation in this manner, and there are no reports of any nonsurgical management of these cases.
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Rubinstein E, Stolz LE, Sheffer AL, Stevens C, Bousvaros A. Abdominal attacks and treatment in hereditary angioedema with C1-inhibitor deficiency. BMC Gastroenterol 2014; 14:71. [PMID: 24712435 PMCID: PMC4101849 DOI: 10.1186/1471-230x-14-71] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 03/28/2014] [Indexed: 11/24/2022] Open
Abstract
Background Hereditary angioedema (HAE) is characterized by unpredictable attacks of debilitating subcutaneous and mucosal edema. Gastrointestinal attacks are painful, of sudden onset and often mistaken for acute abdomen leading to unnecessary surgery. The purpose of this study was to analyze symptom presentation of gastrointestinal angioedema in pediatric and adult HAE patients. Methods Information collected during the clinical development of ecallantide for treatment of acute HAE attacks included affected anatomic location, accompanying symptoms, medical history, and pain assessments. Efficacy endpoints included Treatment Outcome Score (TOS, maximum score = 100; minimally important difference = 30), a point-in-time measure of treatment response, and time to treatment response. Results Forty-nine percent of 521 HAE attacks only involved abdominal symptoms. The most commonly reported abdominal symptoms were distension (77%), cramping (73%) and nausea (67%). The most common pain descriptors were tender, tiring-exhausting, aching, cramping and sickening. White blood cell counts were elevated (>10 × 109/L) in 23% of attacks (mean ± SD: 15.1 ± 11.27 × 109/L). A high proportion of patients reported a history of abdominal surgery, including appendectomy (23%), cholecystectomy (16.4%), and hysterectomy (8.2%). Mean TOS at 4 hours post ecallantide was 77±33 versus 29±65 for placebo. Median time to significant symptom resolution was 165 minutes (95% CI 136, 167) for ecallantide versus >4 hours (95% CI 161, >4 hours) for placebo. Anaphylactic reactions occurred in 6 of the 149 treated patients. Conclusions HAE should be considered in the differential diagnosis of patients with recurrent discrete episodes of severe, unexplained crampy abdominal pain associated with nausea. Trials registration The data used in the analysis were gathered across multiple clinical trials conducted during the clinical development program for ecallantide. All of the studies were conducted using Good Clinical Practices (GCP) and in accordance with the ethical principles that have their origins in the Declaration of Helsinki. Each site that participated in the clinical trials obtained the appropriate IRB or Ethics Committee approval prior to enrolling any patients. All patients provided written informed consent prior to undergoing any study-related procedures. Pediatric patients provided written assent and their parents or guardians gave written informed consent. The following trials have been registered at http://www.clinicaltrials.gov: EDEMA2 (identifier NCT01826916); EDEMA3 (identifier NCT00262080); EDEMA4 (identifier NCT00457015); and DX-88/19 (identifier NCT00456508).
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Affiliation(s)
- Eitan Rubinstein
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, 300 Longwood Ave, Fegan 5th Floor, Boston, MA 02115, USA.
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11
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Jalaj S, Scolapio JS. Gastrointestinal manifestations, diagnosis, and management of hereditary angioedema. J Clin Gastroenterol 2013; 47:817-23. [PMID: 24141983 DOI: 10.1097/mcg.0b013e31829e7edf] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Abdominal pain is one of the most common conditions in clinical practice and yet a challenging complaint to accurately diagnose due to the vast number of possible etiologies. When other health care providers cannot identify the cause of abdominal pain, gastroenterologists are often looked upon to help solve the diagnostic dilemma. Consequently, it is incumbent upon gastroenterologists to be well versed in the diagnosis and management of not only common but also rare causes of abdominal pain. One such uncommon but well-described cause of abdominal pain is angioedema of the intestinal tract due to hereditary angioedema. Acute onset, recurrent abdominal pain of varying severity is its most common presenting symptom, and misdiagnosis can not only lead to unnecessary surgical procedures but also death. The purpose of this review is to raise awareness among gastroenterologists about hereditary angioedema as a potential cause of recurrent, unexplained abdominal pain.
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Affiliation(s)
- Sujai Jalaj
- Department of Medicine, Division of Gastroenterology, University of Florida, Jacksonville, FL
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12
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Abstract
INTRODUCTION Isolated angioedema of the small intestine is a rare entity. The cases described have been related with angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, or C1 esterase inhibitor deficiency. We present a case of small intestine angioedema caused by calcium channel blockers (CCBs) and a review of the literature. CASE REPORT Over the course of approximately 2 years, a 56-year-old African American woman presented to our hospital with 8 similar episodes of diffuse, intermittent abdominal pain, nausea, vomiting, and diarrhea. The diagnostic workup was extensive and included normal stool studies, anticardiolipin antibodies, antinuclear antibodies, antineutrophil cytoplasmic antibodies, cryoglobulin studies, complement levels, urinary 5-hydroxyindoleacetic acid, and serum markers for inflammatory bowel diseases. A computed tomographic angiogram was normal. Abdominal computed tomographic scans showed prominent mural thickening of different intestinal segments, always involving the ileum. An esophagogastroduodenoscopy showed patchy edematous, violaceous folds in the second portion of the duodenum. Colonoscopy revealed a markedly edematous and erythematous distal ileum. The recurrences subsided after CCBs were discontinued in this patient and reoccurred when they were incidentally restarted. CONCLUSIONS Our case demonstrates that CCBs can cause isolated intestinal angioedema with distinctive endoscopic findings. The discontinuation of the involved medication is the key for both diagnosis and treatment.
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13
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Dollin M, Srinivasan S, Leith E, Slomovic A. Unilateral lacrimal gland atrophy in a patient with hereditary angioedema. Cornea 2007; 26:505-6. [PMID: 17457207 DOI: 10.1097/ico.0b013e318033b4cb] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE To report a case of unilateral lacrimal gland atrophy in a patient with hereditary angioedema (HAE). METHODS Observational case report with literature review. RESULTS A 32-year-old woman with HAE presented with dryness and irritation of the left eye (OS). Investigations revealed features of unilateral severe dry OS with atrophy of the ipsilateral lacrimal gland confirmed by magnetic resonance imaging (MRI). CONCLUSIONS Dry eye should be included in the ocular manifestations of HAE. Recurrent mucosal and soft-tissue inflammation secondary to HAE may lead to lacrimal gland atrophy. MRI is a useful, noninvasive tool in diagnosing lacrimal gland atrophy.
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Affiliation(s)
- Michael Dollin
- Faculty of Medicine, University of Toronto, Toronto, Canada
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14
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Affiliation(s)
- Roberto Persiani
- General Surgery Unit-Department of Surgery, Catholic University, Rome, Largo A Gemelli 8, 00168 Rome, Italy
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Bork K, Staubach P, Eckardt AJ, Hardt J. Symptoms, course, and complications of abdominal attacks in hereditary angioedema due to C1 inhibitor deficiency. Am J Gastroenterol 2006; 101:619-27. [PMID: 16464219 DOI: 10.1111/j.1572-0241.2006.00492.x] [Citation(s) in RCA: 186] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Recurrent abdominal attacks belong to the cardinal and most distressing symptoms of hereditary angioedema (HAE) due to C1 inhibitor deficiency. They are characterized by crampy pain, but may include vomiting, diarrhea, and other features. Detailed clinical data about the symptoms and course of abdominal attacks have not been reported. METHODS We retrospectively observed a total of 33,671 abdominal attacks in 153 patients with HAE including a prospectively examined subgroup of 23 patients. Symptoms, course, frequency of attacks, and complications were analyzed. RESULTS The relation of mild, moderate, and severe attacks was 1:1.4:5.6 in the prospective part of the study. Extra-abdominal symptoms preceded the abdominal symptoms. The mean maximal pain score was 8.4 (range 1-10). Vomiting occurred in 73% (24,696) and diarrhea in 41% (13,682) of the attacks. Circulatory collapse accompanied 4.4% (1,468) of the attacks, with loss of consciousness (LOC) occurring in 2.2% (739). Nine patients could clearly distinguish two types of abdominal attacks: vomiting and diarrhea. Rare complications included tetany, hemorrhagic stools, and intussusception of the colon. In 28% (43) of the patients, recurrent abdominal attacks had started before the characteristic swelling of the skin had ever occurred. A model is proposed to classify the severity of the attacks and to describe the clinical course. CONCLUSIONS Abdominal attacks in HAE constitute a more disabling and complex syndrome than previously assumed. Our results add to the understanding of symptoms and course of HAE and may aid in the early recognition of an impending attack and improve clinical management.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
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