Refractory exacerbations of hereditary angioedema with associated Helicobacter pylori infection

Gastrointestinal manifestations of angioedema: a potential area of misdiagnosis

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.

Hereditary angio-oedema as a rare cause of small-bowel obstruction

A 52-year-old man with known hereditary angio-oedema (HAE) presented with a 2-day history of progressive severe abdominal pain, distension, nausea, vomiting and constipation. CT of his abdomen and pelvis showed small-bowel obstruction and ascites. HAE is a rare autosomal dominant disorder caused by a C1 esterase deficiency and involves episodic oedema of subcutaneous and mucosal tissues. It commonly affects the face and limbs, causing deformity; the respiratory tract, causing life-threatening laryngeal swelling; and the gastrointestinal tract, causing small-bowel obstruction. An infusion of a C1 esterase inhibitor was given to the patient. His symptoms resolved within 6 hours, and a repeat CT showed complete resolution 24 hours later. Small-bowel obstruction in HAE is often misdiagnosed, leading to ineffective treatment and unnecessary surgery. Therefore, this should be suspected in patients with HAE presenting with an acute abdomen, and clinicians should understand the unique treatment required.

Treatment of hereditary angioedema with plasma-derived C1 inhibitor

BACKGROUND

Plasma-derived C1 inhibitor (C1-INH) concentrate is a treatment option for acute hereditary angioedema (HAE) attacks and is considered the standard-of-care in many countries, although it is not yet available in the United States. Studies are still being conducted to establish its safety and efficacy as required by the FDA.

OBJECTIVE

To review the medical literature to determine if C1-INH concentrate is a safe and effective treatment for acute HAE attacks.

METHODS

THE FOLLOWING KEYWORDS WERE SEARCHED IN PUBMED AND OVID: C1 esterase inhibitor, C1-inhibitor, C1 inhibitor, and hereditary angioedema treatment. English-language articles were searched from 1966 to the present to look for studies demonstrating the efficacy and the safety of C1-INH concentrate.

RESULTS

The English-language literature search revealed several studies showing significantly improved relief of HAE symptoms with the administration of C1-INH concentrate - many studies demonstrated some improvement of symptoms within 30 minutes. Side effects have been similar to placebo, and no proven cases of viral transmission have occurred in over 20 years.

CONCLUSION

C1-INH concentrate appears to be a very safe and effective treatment option for HAE.

[Acute pancreatitis associated with hereditary angioedema]

Hereditary angioedema (HAE) is an infrequent, recurrent, and potentially lethal disorder caused by a deficiency of C(1) inhibitor or its activity. Abdominal pain secondary to bowel edema is common in these patients. However, a thorough literature search yielded only six previously reported cases of pancreatitis associated with this entity.

The role of Helicobacter pylori infection in skin diseases: facts and controversies

Helicobacter pylori is a Gram-negative bacterium that is considered a causative agent of peptic ulcer disease, gastric lymphoma, and gastric carcinoma. H pylori triggers an intense leucocyte infiltration of the gastric submucosa, an action that is mediated by proinflammatory cytokines. Because this pathogenetic mechanism is common to many other diseases, H pylori seroprevalence has also been investigated in other diseases. H pylori seropositivity is associated with various dermatologic disorders. Although the precise role of H pylori is unknown in these diseases, the organism can be eradicated, using simple and reliable drug regimens. This contribution highlights the dermatologic diseases associated with H pylori seropositivity.

Hereditary angioedema: current and emerging treatment options

Angioedema can result from allergic, hereditary, and acquired conditions. Hereditary angioedema (HAE) attacks are disabling at the time of occurrence and can be life threatening; they often result in hospitalization and intensive care unit admission. Although there are several variants of HAE, they share a final common pathway: unopposed activation of multiple kinins and mediators including kallikrein and bradykinin. This leads to increased vascular permeability, which in turn produces the edema after which the condition is named. Older treatment options licensed in the United States, anabolic steroids and antifibrinolytics, have troublesome side effect profiles and may not reverse a severe acute attack. In Europe, C1 esterase inhibitor (C1-INH) concentrates have been used since 1974 for both preventing and terminating attacks. Two of these have now been licensed in the United States for use in HAE patients, one for prophylaxis and the other for treating acute abdominal and facial HAE attacks. The first kinin pathway modulator, ecallantide, has also been licensed recently in the United States for treating HAE attacks. The objective of this article is to describe HAE and review the available options for managing patients, as well as different drugs currently under investigation. Specific attention is given to the perioperative management of patients with HAE.

Urticaria and infections

Urticaria is a group of diseases that share a distinct skin reaction pattern. Triggering of urticaria by infections has been discussed for many years but the exact role and pathogenesis of mast cell activation by infectious processes is unclear. In spontaneous acute urticaria there is no doubt for a causal relationship to infections and all chronic urticaria must have started as acute. Whereas in physical or distinct urticaria subtypes the evidence for infections is sparse, remission of annoying spontaneous chronic urticaria has been reported after successful treatment of persistent infections. Current summarizing available studies that evaluated the course of the chronic urticaria after proven Helicobacter eradication demonstrate a statistically significant benefit compared to untreated patients or Helicobacter-negative controls without urticaria (p < 0.001). Since infections can be easily treated some diagnostic procedures should be included in the routine work-up, especially the search for Helicobacter pylori. This review will update the reader regarding the role of infections in different urticaria subtypes.

Management of hereditary angioedema in pediatric patients

Hereditary angioneurotic edema is a rare disorder caused by the congenital deficiency of C1 inhibitor. Recurring angioedematous paroxysms that most commonly involve the subcutis (eg, extremities, face, trunk, and genitals) or the submucosa (eg, intestines and larynx) are the hallmarks of hereditary angioneurotic edema. Edema formation is related to reduction or dysfunction of C1 inhibitor, and conventional therapy with antihistamines and corticosteroids is ineffective. Manifestations occur during the initial 2 decades of life, but even today there is a long delay between the onset of initial symptoms and the diagnosis of hereditary angioneurotic edema. Although a variety of reviews have been published during the last 3 decades on the general management of hereditary angioneurotic edema, little has been published regarding management of pediatric hereditary angioneurotic edema. Thus, we review our experience and published data to provide an approach to hereditary angioneurotic edema in childhood.

Helicobacter pylori infection as a triggering factor of attacks in patients with hereditary angioedema

BACKGROUND

Helicobacter pylori infection is considered among the causative factors of urticaria and angioedema. Having conducted a study on 65 patients, Hungarian authors reported in 2001 that successful eradication of H. pylori is followed by a significant reduction in the number of attacks in patients with hereditary angioedema (HAE). The present study aimed to reinvestigate the relationship between H. pylori infection and the attack rate in the framework of an international collaborative study.

MATERIALS AND METHODS

Within the framework of the PREHAEAT project launched by the European Union, further 152 patients were studied in seven collaborating centers, and participants of the earlier study were followed up in order to detect any relationship between H. pylori infection and the occurrence of attacks in patients suffered from HAE.

RESULTS

The proportion of patients experiencing frequent (> or = 5 per year) abdominal attacks was higher (p = .002) among the H. pylori-infected participants of the international study who underwent eradication as compared to the rest of patients. Successful eradication of H. pylori significantly (p = .0006) reduced the number of attacks in these patients as well. Nine subjects of the previous Hungarian study who underwent eradication therapy for dyspepsia were followed up for an additional 4 years. In these patients, attack frequency remained consistently low.

CONCLUSIONS

As shown by experience from the Hungarian and the international trial, the number of frequent, edematous abdominal attacks may decrease substantially following the eradication of H. pylori from HAE patients infected with this pathogen. Therefore, screening of patients with HAE for H. pylori infection seems warranted. Eradication of H. pylori may lead to a marked reduction in disease severity.

Angioedema

Although first described more than 130 years ago, the pathophysiology, origin, and management of the several types of angioedema are poorly understood by most dermatologists. Although clinically similar, angioedema can be caused by either mast cell degranulation or activation of kinin formation. In the former category, allergic and nonsteroidal anti-inflammatory drug-induced angioedema are frequently accompanied by urticaria. Idiopathic chronic angioedema is also usually accompanied by urticaria, but can occur without hives. In either case, an autoimmune process leading to dermal mast cell degranulation occurs in some patients. In these patients, histamine-releasing IgG anti-FcepsilonR1 autoantibodies are believed to be the cause of the disease, removal or suppression by immunomodulation being followed by remission. Angiotensin-converting enzyme inhibitor-induced angioedema is unaccompanied by hives, and is caused by the inhibition of enzymatic degradation of tissue bradykinin. Hereditary angioedema, caused by unchecked tissue bradykinin formation, is recognized biochemically by a low plasma C'4 and low quantitative or functional C'1 inhibitor. Progress has now been made in understanding the molecular genetic basis of the two isoforms of this dominantly inherited disease. Recently, a third type of hereditary angioedema has been defined by several groups. Occurring exclusively in women, it is not associated with detectable abnormalities of the complement system. Angioedema caused by a C'1 esterase inhibitor deficiency can also be acquired in several clinical settings, including lymphoma and autoimmune connective tissue disease. It can also occur as a consequence of specific anti-C'1 esterase autoantibodies in some patients. We have reviewed the clinical features, diagnosis, and management of these different subtypes of angioedema.

LEARNING OBJECTIVE

After completing this learning activity, participants should be aware of the classification, causes, and differential diagnosis of angioedema, the molecular basis of hereditary and non-hereditary forms of angioedema, and be able to formulate a pathophysiology-based treatment strategy for each of the subtypes of angioedema.

C1 inhibitor deficiency: consensus document

We present a consensus document on the diagnosis and management of C1 inhibitor deficiency, a syndrome characterized clinically by recurrent episodes of angio-oedema. In hereditary angio-oedema, a rare autosomal dominant condition, C1 inhibitor function is reduced due to impaired transcription or production of non-functional protein. The diagnosis is confirmed by the presence of a low serum C4 and absent or greatly reduced C1 inhibitor level or function. The condition can cause fatal laryngeal oedema and features indistinguishable from gastrointestinal tract obstruction. Attacks can be precipitated by trauma, infection and other stimulants. Treatment is graded according to response and the clinical site of swelling. Acute treatment for severe attack is by infusion of C1 inhibitor concentrate and for minor attack attenuated androgens and/or tranexamic acid. Prophylactic treatment is by attenuated androgens and/or tranexamic acid. There are a number of new products in trial, including genetically engineered C1 esterase inhibitor, kallikrein inhibitor and bradykinin B2 receptor antagonist. Individual sections provide special advice with respect to diagnosis, management (prophylaxis and emergency care), special situations (childhood, pregnancy, contraception, travel and dental care) and service specification.

Angioedema. Pathogenesis, differential diagnosis, and treatment

Angioedema is a constellation of syndromes that present a great challenge to the clinician. The term "angioedema" describes the localized, transient, episodic edema of the deeper layers of the skin or of the mucosa of the gastrointestinal tract. Although angioedema may affect any part of the body, the skin and gastrointestinal tract are involved most commonly by far. Episodic abdominal pain arising from angioedema affecting any intra-abdominal organ may occur without skin angioedema; therefore, angioedema must be included in the differential diagnosis of intermittent, unexplained abdominal pain. Angioedema is caused by extravasation of plasma in the affected areas, which at times is accompanied by nonspecific, minimal cellular infiltrate. The most commonly identified causes of angioedema are medications, allergens, and physical agents, but most angioedema is idiopathic. Rare forms of angioedema associated with either hereditary or acquired faulty activation of the complement and kallikrein-kinin systems have been extensively described. Taking a comprehensive personal and family history, performing a physical examination, and compulsively monitoring the response to therapy are the most rewarding and cost-effective diagnostic and treatment tools. Diligent and knowledgeable follow-up by the attending physician spares patients costly and unnecessary tests as well as harmful treatment. The most effective treatment depends on the identification of the causative mechanism and--especially when the mechanism is not identified--on the clinician's knowledge and experience with innovative therapeutic regimens.

Helicobacter pylori infection in skin diseases: a critical appraisal

More than 50% of the human population have long-term Helicobacter pylori infection, causing, in some cases, severe diseases such as peptic ulcers and stomach cancer. In the last few years several extra-gastrointestinal disorders have been associated with H. pylori infection. This review summarized the current medical literature, identified through hand searching and MEDLINE research, including our own studies, with regard to H. pylori and skin diseases. From the literature it can be seen that the role of H. pylori in skin diseases is still a controversial subject. Randomized controlled trials with adequate masking and sample sizes are still lacking. The best evidence comes from studies investigating chronic urticaria in which chronic urticaria disappeared in many patients with H. pylori infection after careful eradication of the H. pylori. Moreover, there are promising recent reports of beneficial H. pylori eradication in Behçet's disease, pruritus cutaneus, prurigo chronica, prurigo nodularis and in some patients with lichen planus, but not in rosacea or psoriasis. Before any conclusions with respect to other skin diseases such as atopic dermatitis, Schoenlein-Henoch Purpura, Sweet's syndrome, Sjögren syndrome or systemic sclerosis may be drawn, additional randomized, double-blinded and placebo-controlled studies including adequate diagnostic schedules, sufficient eradication treatment protocols, confirmation of eradication and adequate control groups are needed. The cutaneous pathology of H. pylori is far from being clear, but it is speculated that the systemic effects may involve increased mucosal permeability to alimentary antigens, immunomodulation, an autoimmune mechanism or the impairment of vascular integrity.

Chronic pruritus associated with Helicobacter pylori

BACKGROUND

Helicobacter pylori is an established cause of gastritis and has been implicated in extradigestive diseases.

OBJECTIVE

To investigate the role of H. pylori in patients with unexplained refractory pruritus.

METHODS

Ten patients with severe pruritus unresponsive to conventional therapy were evaluated for active H. pylori infection by H. pylori serology followed by either esophagogastroduodenoscopy (EGD) or urea breath test. Of the 10 patients, 8 were found to have active infection. All 10 received anti-H. pylori antibiotic therapy and were reevaluated for relief of pruritus.

RESULTS

Of 8 patients with active H. pylori infection, 87.5% (7/8) had some type of pruritus relief after triple therapy. Of these, 62.5% (5/8) had complete relief and 25% (2/8) had temporary relief of pruritus. The remaining 12.5% (1/8) did not respond. Two control patients without active H. pylori infection had no relief of pruritus with therapy.

CONCLUSIONS

We have identified a population of patients with refractory pruritus and active H. pylori infection whose pruritus resolved after eradication of H. pylori.

Chronic Pruritus Associated with Helicobacter Pylori

Background:

Helicobacter pylori is an established cause of gastritis and has been implicated in extradigestive diseases.

Objective:

To investigate the role of H. pylori in patients with unexplained refractory pruritus.

Methods:

Ten patients with severe pruritus unresponsive to conventional therapy were evaluated for active H. pylori infection by H. pylori serology followed by either esophagogastroduodenoscopy (EGD) or urea breath test. Of the 10 patients, 8 were found to have active infection. All 10 received anti- H. pylori antibiotic therapy and were reevaluated for relief of pruritus.

Results:

Of 8 patients with active H. pylori infection, 87.5% (7/8) had some type of pruritus relief after triple therapy. Of these, 62.5% (5/8) had complete relief and 25% (2/8) had temporary relief of pruritus. The remaining 12.5% (1/8) did not respond. Two control patients without active H. pylori infection had no relief of pruritus with therapy.

Conclusions:

We have identified a population of patients with refractory pruritus and active H. pylori infection whose pruritus resolved after eradication of H. pylori.

Hereditary angioedema as a cause of transient abdominal pain

Isolated angioedema, without urticaria or itching, occurs as a result of an inherited or acquired defect in C1 esterase inhibitor activity. Most cases of isolated angioedema are caused by one of two types of hereditary angioedema (HAE). We present a case of the much rarer type II HAE with abdominal pain as the sole presenting symptom. Hereditary angioedema should be suspected in young adults with episodic abdominal pain for which common causes have been excluded. A history of HAE or episodic abdominal pain in family members is not necessary for diagnosis.

Eradication of Helicobacter pylori and improvement of hereditary angioneurotic oedema

Helicobacter pylori infection is thought to be a causal factor in various dermatological disorders. We assessed the frequency of H pylori infection in 65 patients with hereditary angioneurotic oedema. We measured the serum concentration of antibodies against H pylori and did the carbon-14-urease breath test in patients with positive H pylori serology. 19 of 65 patients had H pylori infection. All patients with infection, and 11 of 46 without infection, had a history of recurrent episodes of acute abdominal pain. We successfully eradicated H. pylori infection in 18 patients. The frequency of abdominal symptoms was significantly higher in the infected group (p=0.002 after adjustment for age). In nine of 19 patients with dyspepsia, the frequency of oedematous episodes decreased from 100 over 10 months before eradication to 19 during the 10-month follow-up period. Screening for, and eradication of, H pylori infection seems to be justified in patients with hereditary angioneurotic oedema.

Helicobacter pylori and idiopathic chronic urticaria

BACKGROUND

Different studies have shown a high prevalence of Helicobacter pylori (HP) infection in patients with chronic urticaria (CU), and occasional remission of the skin lesions after eradication therapy. Recent investigations, however, have failed to find a significant relationship between the two conditions. We designed a case-control study to assess the prevalence of HP infection and the effect of bacterium eradication on the outcome of the skin disease in patients affected by CU. The literature is reviewed.

METHODS

Twenty-five patients diagnosed with CU were included. Information about their medical history and a complete laboratory investigation ruled out other diseases or situations suspected to cause CU. Twenty-five healthy volunteers from a census-based, randomized sample were used as controls. HP infection was assessed by the (13)C-urea breath test (UBT). Eradication therapy included oral amoxicillin, omeprazole, and clarithromycin for 1 week.

RESULTS

The high prevalence of HP infection (68%) and mean titer of UBT (24.13) in our patients with idiopathic CU do not differ from the general population. Marked differences were observed in the mean age of the CU patients with positive UBT (45.52years) vs. those without HP infection (35.25 years). After eradication therapy, only one patient showed a complete remission of urticaria and two showed a partial remission.

CONCLUSIONS

Our results support a lack of relationship between HP infection and the course of idiopathic CU.