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Valayer S, Defendi F, El Sissy C, Roos-Weil D, Ackermann F, Bouillet L, Boccon-Gibod I, Coppo P, Chafai N, Kalmi G, McAvoy C, Fain O, Gobert D. Splenectomy allows remission of angioedema with acquired C1-inhibitor deficiency associated with splenic marginal zone lymphoma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2543-2546. [PMID: 38851485 DOI: 10.1016/j.jaip.2024.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/17/2024] [Accepted: 05/29/2024] [Indexed: 06/10/2024]
Affiliation(s)
- Simon Valayer
- Sorbonne Université, service de médecine interne, AP-HP, Hôpital universitaire Saint Antoine, Paris, France.
| | - Federica Defendi
- Service d'immunologie, Hôpital universitaire Grenoble Alpes, Grenoble, France
| | - Carine El Sissy
- Service d'immunologie, Hôpital européen Georges Pompidou, Paris, France
| | - Damien Roos-Weil
- Sorbonne Université, service d'hématologie, AP-HP, Hôpital universitaire Pitié Salpétrière, Paris, France
| | | | - Laurence Bouillet
- Service de médecine interne et Centre National de Référence des angioedèmes (CREAK), Grenoble, France
| | - Isabelle Boccon-Gibod
- Service de médecine interne et Centre National de Référence des angioedèmes (CREAK), Grenoble, France
| | - Paul Coppo
- Sorbonne Université, service d'hématologie et Centre National de Référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Hôpital Saint Antoine, Paris, France
| | - Najim Chafai
- Sorbonne Université, service de chirurgie digestive, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Galith Kalmi
- Sorbonne Université, service de médecine interne, AP-HP, Hôpital universitaire Saint Antoine, Paris, France
| | - Chloe McAvoy
- Sorbonne Université, service de médecine interne, AP-HP, Hôpital universitaire Saint Antoine, Paris, France
| | - Olivier Fain
- Sorbonne Université, service de médecine interne, AP-HP, Hôpital universitaire Saint Antoine, Paris, France
| | - Delphine Gobert
- Sorbonne Université, service de médecine interne, AP-HP, Hôpital universitaire Saint Antoine, Paris, France
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2
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Harada N, Moriguchi M, Hakui S, Takayanagi S, Izuta Y, Kizawa Y, Shiragami H, Nakamae H, Hino M, Mugitani A. Acquired angioedema as a late-onset complication after cord blood transplantation: a subtype of chronic graft-versus-host disease. QJM 2024; 117:608-609. [PMID: 38598434 DOI: 10.1093/qjmed/hcae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Indexed: 04/12/2024] Open
Affiliation(s)
- N Harada
- Department of Hematology, Fuchu Hospital, Osaka, Japan
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - M Moriguchi
- Department of Hematology, Fuchu Hospital, Osaka, Japan
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - S Hakui
- Department of Gastroenterology, Fuchu Hospital, Osaka, Japan
| | - S Takayanagi
- Department of Gastroenterology, Fuchu Hospital, Osaka, Japan
| | - Y Izuta
- Department of Hematology, Fuchu Hospital, Osaka, Japan
| | - Y Kizawa
- Department of Hematology, Fuchu Hospital, Osaka, Japan
| | - H Shiragami
- Department of Hematology, Fuchu Hospital, Osaka, Japan
| | - H Nakamae
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - M Hino
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - A Mugitani
- Department of Hematology, Fuchu Hospital, Osaka, Japan
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3
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Lasica M, Anderson MA, Boussioutas A, Gregory GP, Hamad N, Manos K, McKelvie P, Ng M, Campbell B, Palfreyman E, Salvaris R, Weinkove R, Wight J, Opat S, Tam C. Marginal zone lymphomas: a consensus practice statement from the Australasian Lymphoma Alliance. Intern Med J 2024; 54:1017-1030. [PMID: 38881453 DOI: 10.1111/imj.16390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 03/17/2024] [Indexed: 06/18/2024]
Abstract
Marginal zone lymphomas (MZLs) are a rare, indolent group of non-Hodgkin lymphomas with different diagnostic, genetic and clinical features and therapeutic implications. The most common is extranodal MZL of mucosa-associated lymphoid tissue, followed by splenic MZL and nodal MZL. Patients with MZL generally have good outcomes with long survival rates but frequently have a relapsing/remitting course requiring several lines of therapy. The heterogeneous presentation and relapsing course present the clinician with several diagnostic and therapeutic challenges. This position statement presents evidence-based recommendations in the setting of Australia and New Zealand.
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Affiliation(s)
- Masa Lasica
- Department of Clinical Haematology, St Vincent's Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Mary A Anderson
- Department of Clinical Haematology, Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Blood Cells and Blood Cancer, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
| | - Alex Boussioutas
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
- The Alfred, Melbourne, Victoria, Australia
- Familial Cancer Clinic, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Gareth P Gregory
- Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Monash Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Kate Manos
- Department of Haematology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Penny McKelvie
- Department of Anatomical Pathology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Michael Ng
- GenesisCare St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Belinda Campbell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Pathology, University of Melbourne, Melbourne, Victoria, Australia
| | - Emma Palfreyman
- Department of Haematology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Ross Salvaris
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Robert Weinkove
- Te Rerenga Ora Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital, Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology and Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Joel Wight
- Department of Haematology and Bone Marrow Transplantation, Townsville University Hospital, Townsville, Queensland, Australia
- School of Medicine, James Cook University, Townsville, Queensland, Australia
| | - Stephen Opat
- Monash Haematology, Monash Health, Melbourne, Victoria, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Constantine Tam
- Haematology Department, Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
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4
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Tome J, Reichard KK, Wang XJ. Now You See Me: Acute and Recurrent Severe Abdominal Pain Associated With Bowel Edema. Gastroenterology 2024; 166:e10-e12. [PMID: 37926127 DOI: 10.1053/j.gastro.2023.10.030] [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: 10/11/2023] [Revised: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 11/07/2023]
Affiliation(s)
- June Tome
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Xiao Jing Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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5
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Kalmi G, Nguyen Y, Amarger S, Aubineau M, Bibes B, Blanchard-Delaunay C, Boccon-Gibod I, Bouillet L, Coppo P, Dalmas MC, Debord-Peguet S, Defendi F, Demoreuil C, Du-Thanh A, Gayet S, Hadjadj J, Jeandel PY, Launay D, Ly KH, Avoy CM, Niault M, Ollivier Y, Pelletier F, Porneuf M, Roos-Weil D, Fain O, Gobert D. Efficacy and Safety of Rituximab-Based Treatments in Angioedema With Acquired C1-Inhibitor Deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:212-222. [PMID: 37844846 DOI: 10.1016/j.jaip.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/28/2023] [Accepted: 10/10/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Angioedema (AE) due to acquired C1-inhibitor (C1-INH) deficiency (AAE-C1-INH) is related to excessive consumption of C1-INH or to anti-C1-INH antibodies, and is frequently associated with lymphoproliferative syndromes or monoclonal gammopathies. Standard of care for prophylactic treatment in this condition is not established. Rituximab may be effective to prevent attacks, especially if the lymphoid hemopathy is controlled, but data are scarce. OBJECTIVE To evaluate efficacy of rituximab in AAE-C1-INH. METHODS A retrospective multicenter study was carried out in France, including patients with AAE-C1-INH treated with rituximab between April 2005 and July 2019. RESULTS Fifty-five patients with AAE-C1-INH were included in the study, and 23 of them had an anti-C1-INH antibody. A lymphoid malignancy was identified in 39 patients, and a monoclonal gammopathy in 9. There was no associated condition in 7 cases. Thirty patients received rituximab alone or in association with chemotherapy (n = 25). Among 51 patients with available follow-up, 34 patients were in clinical remission and 17 patients had active AE after a median follow-up of 3.9 years (interquartile range, 1.5-7.7). Three patients died. The presence of anti-C1-INH antibodies was associated with a lower probability of AE remission (hazard ratio, 0.29 [95% CI, 0.12-0.67]; P = .004). Relapse was less frequent in patients with lymphoma (risk ratio, 0.27 [95% CI, 0.09-0.80]; P = .019) and in patients treated with rituximab and chemotherapy (risk ratio, 0.31 [95% CI, 0.12-0.79]; P = .014). CONCLUSIONS Rituximab is an efficient and well-tolerated therapeutic option in AE, especially in lymphoid malignancies and in the absence of detectable anti-C1-INH antibodies.
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Affiliation(s)
- Galith Kalmi
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France.
| | - Yann Nguyen
- Internal Medicine Department, Nord-Université Paris Cité, AP-HP, Hôpital Beaujon, Clichy-sous-Bois, France
| | - Stephanie Amarger
- Dermatology Department, University Hospital, Clermont-Ferrand, France
| | - Magali Aubineau
- Internal Medicine Department, Hospices Civils de Lyon, Lyon, France
| | - Beatrice Bibes
- Internal Medicine Department, Saint Grégoire Hospital, Rennes, France
| | | | - Isabelle Boccon-Gibod
- Internal Medicine Department, French National Reference Center for Angioedema (CREAK), Grenoble University Hospital, Grenoble, France
| | - Laurence Bouillet
- Internal Medicine Department, French National Reference Center for Angioedema (CREAK), Grenoble University Hospital, Grenoble, France; University Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, CHU Grenoble Alpes, TIMC, Grenoble, France; Internal Medicine Department, University Hospital La Tronche, Grenoble, France
| | - Paul Coppo
- Hematology Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | | | | | - Federica Defendi
- Immunology Department, Grenoble University Hospital, Grenoble, France
| | - Claire Demoreuil
- Internal Medicine Department, La Cavale Blanche University Hospital, Brest, France
| | - Aurélie Du-Thanh
- Dermatology Department, Montpellier University Hospital, Montpellier, France
| | - Stephane Gayet
- Internal Medicine Department, La Timone University Hospital, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Jerôme Hadjadj
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | | | - David Launay
- Internal and Immunological Medicine Department, Lille Hospital, U1286-INFINITE-Institute for Translational Research in Inflammation, Lille University, INSERM F-59000, Lille, France
| | - Kim Heang Ly
- Internal Medicine Department, Dupuytren University Hospital, Limoges, France
| | - Chloé Mc Avoy
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Mathilde Niault
- Hematology Department, Hôpital du Scorff-Lorient, Groupe Hospitalier Bretagne Sud, Lorient, France
| | - Yann Ollivier
- Medicine Department, Cote de Nacre University Hospital, Caen, France
| | - Fabien Pelletier
- Dermatology Department, Allergology Center, Besançon University Hospital, Besançon, France
| | - Marc Porneuf
- Hematology Department, Centre Hospitalier Yves le Foll, Saint-Brieuc, France (x)Hematology Department, Sorbonne Université, AP-HP, Pitié Salpêtrière Hospital, Paris, France
| | - Damien Roos-Weil
- Hematology Department, Centre Hospitalier Yves le Foll, Saint-Brieuc, France (x)Hematology Department, Sorbonne Université, AP-HP, Pitié Salpêtrière Hospital, Paris, France
| | - Olivier Fain
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Delphine Gobert
- Internal Medicine Department, Sorbonne Université, AP-HP, Hôpital Saint Antoine, Paris, France
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6
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Ng JY, Ooi M, Bennett SK, Rady K, Choi P, Lee WI, Cook MC, Randall KL, Pati NK. Acquired Angioedema Associated with Lymphoproliferative Disorders. Case Rep Oncol 2024; 17:329-336. [PMID: 38404406 PMCID: PMC10890797 DOI: 10.1159/000536458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/16/2024] [Indexed: 02/27/2024] Open
Abstract
Introduction Acquired angioedema due to C1 esterase inhibitor deficiency (C1INH-AAE) is most associated with lymphoproliferative disorders (LPDs), particularly low-grade B-cell subtypes. The condition remains under-recognized with long diagnostic delays due to various challenges including a lack of awareness of the condition. Case Presentation We discuss 4 cases of C1INH-AAE associated with low-grade B-cell LPDs, including various diagnostic and management challenges. As our cases illustrate, constitutional symptoms or overt manifestations of LPD at diagnosis are often absent. Hence, a comprehensive multimodal approach to screening for an underlying B-LPD is important when a diagnosis of acquired angioedema is made. Levels of complement C4, C1q, and C1INH are useful for diagnosing C1INH-AAE and for monitoring disease activity. Changes in these parameters may also indicate relapse of the underlying hematological malignancy. Treating the underlying disorder is important as this commonly leads to clinical improvement with decreased episodes of angioedema and normalization of complement studies. Conclusion Awareness of C1INH-AAE can lead to an early diagnosis of hematological malignancies. The absence of constitutional symptoms emphasizes the need for a comprehensive multimodal approach to screening for LPD in C1INH-AAE. C4, C1INH level, and function are useful for monitoring disease activity.
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Affiliation(s)
- Jun Yen Ng
- Department of Hematology, Canberra Hospital, Canberra, ACT, Australia
| | - Meidelynn Ooi
- Department of Hematology, Canberra Hospital, Canberra, ACT, Australia
| | - Samuel K. Bennett
- Department of Hematology, Canberra Hospital, Canberra, ACT, Australia
| | - Kirsty Rady
- Department of Hematology, Canberra Hospital, Canberra, ACT, Australia
| | - Philip Choi
- Department of Hematology, Canberra Hospital, Canberra, ACT, Australia
| | - Wei-I. Lee
- Department of Immunology, Canberra Hospital, Canberra, ACT, Australia
| | - Matthew C. Cook
- Department of Immunology, Canberra Hospital, Canberra, ACT, Australia
- Centre for Personalised Immunology, John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia
- Department of Medicine and Cambridge Institute for Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, UK
| | - Katrina L. Randall
- Department of Immunology, Canberra Hospital, Canberra, ACT, Australia
- School of Medicine and Psychology, Australian National University, Canberra, ACT, Australia
| | - Nalini K. Pati
- Department of Hematology, Canberra Hospital, Canberra, ACT, Australia
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7
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Wu K, Vadakara J. Rituximab in the Treatment of Acquired Angioedema Secondary to Marginal Zone Lymphoma of the Spleen. Cureus 2023; 15:e36790. [PMID: 37123708 PMCID: PMC10134409 DOI: 10.7759/cureus.36790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
Angioedema occurs in less than 1-2% of the population and amongst these cases, those with acquired angioedema are less prevalent than hereditary angioedema. Amongst cases of acquired angioedema, studies have shown that they were highly linked with an associated lymphoproliferative disorder, suspected secondary to the production of neutralizing autoantibodies from pathological B cell proliferation. We present a case of a patient who presented with recurrent episodes of angioedema and was found to have low C4 and C1 esterase function, initially concerning for a hereditary angioedema variant, who was subsequently found to have marginal B cell lymphoma mimicking hereditary angioedema.
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8
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Badini M, Georgitsogiannakos N, Angelella J, Wu MA. [Angioedema without Urticaria: Medical History and Findings]. PRAXIS 2023; 112:223-225. [PMID: 36919321 DOI: 10.1024/1661-8157/a003995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Angioedema without Urticaria: Medical History and Findings Abstract. Abstracts: We present the case of a woman with repeated attacks of angioedema without wheals. Given that there was no benefit from systemic steroid and antihistamines therapy, we interpretated the clinical picture as bradykinin- (and not histamine-) induced. Owing to the late onset and a negative family history, we suspected a case of angioedema due to acquired C1-INH deficiency. This hypothesis was later confirmed by specific hematological tests. We therefore started a specific prophylaxis and therapy in case of acute attacks.
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9
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Farrugia D, Caruana Dingli M, Grech M. Acquired angioedema: an unusual presentation of haematological malignancy. BMJ Case Rep 2022; 15:e249093. [PMID: 36123007 PMCID: PMC9486227 DOI: 10.1136/bcr-2022-249093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A previously healthy man in his 60s being worked up for splenomegaly presented to the emergency department with recurrent episodes of angioedema. Each episode was attributed to a precipitating cause, and consequently, the predisposing C1 esterase inhibitor (C1-INH) deficiency remained undiagnosed until the third presentation. The aetiology of acquired C1-INH deficiency would be primarily obscure and require further investigations to identify. A clonal B cell population was finally isolated by flow cytometry after multiple repeat marrow samples, and a diagnosis of splenic marginal zone lymphoma was subsequently reached. Response to single-agent rituximab was observed with resolution of splenomegaly, disappearance of the antibody and restoration of C1-INH levels.
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Affiliation(s)
| | | | - Mark Grech
- Haematology, Mater Dei Hospital, Msida, Malta
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10
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Kesh S, Singh U, Bernstein JA. Longitudinal experience with treatment of acquired angioedema using tranexamic acid. Allergy Asthma Proc 2022; 43:413-418. [PMID: 36065111 DOI: 10.2500/aap.2022.43.220043] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Acquired angioedema (AAE) is a rare form of angioedema (AE) and is often associated with lymphoproliferative conditions and/or anti-C1 esterase inhibitor (C1-INH) antibodies without clear treatment consensus. Current treatments have been reported to have variable effectiveness with different safety concerns. A large Italian cohort of patients with AAE was previously found to respond well to tranexamic acid (TXA). Herein, we report our experience treating AAE with TXA used as prophylaxis. Objective: The objective was to describe clinical characteristics of patients with AAE and to report our experience with treating AAE with TXA. Methods: A retrospective chart review of patients with AAE (N = 13) from a large practice was conducted to assess characteristics and treatment responses. Patient demographics in addition to C1-INH quantitative, C1-INH functional, C4, and C1q levels; the presence of C1-INH antibodies; and a history of lymphoproliferative disease were extracted. The patients were also characterized by their treatment response to TXA. Results: All the patients were white, with a mean age at diagnosis of 67 years, an average body mass index of 31.3 kg/m², and a male-to-female ratio of 7:6. Nine patients had positive C1-INH antibodies. The patients were on various prophylaxis treatments before TXA, including chemotherapy that targeted malignancy, cyclophosphamide, rituximab, and plasmapheresis. Ultimately, 11 of the 13 patients were on TXA for prophylaxis. At 1, 12, and 24 months after TXA treatment, attacks decreased by 97, 86, and 99%, respectively. One patient developed a deep vein thrombosis and TXA was stopped. Conclusion: These findings demonstrated that treatment of AAE with TXA was effective as prophylaxis for AE attacks. However, potential adverse effects remain a concern, which emphasizes the need for additional options.
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Affiliation(s)
- Susamita Kesh
- From the Division of Immunology and Allergy, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Umesh Singh
- Division of Immunology/Allergy Section, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
| | - Jonathan A Bernstein
- Division of Immunology/Allergy Section, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; and
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11
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Riller Q, Cohen-Aubart F, Roos-Weil D. [Splenic lymphoma, diagnosis and treatment]. Rev Med Interne 2022; 43:608-616. [PMID: 35691756 DOI: 10.1016/j.revmed.2022.05.009] [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: 03/24/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022]
Abstract
Some common clinical situations, such as splenomegaly or lymphocytosis, or less common, such as autoimmune hemolytic anemia, cold agglutinin disease, or cryoglobulinemia can lead to the diagnosis of splenic lymphoma. Splenic lymphoma is rare, mainly of non-hodgkinian origin, encompassing very different hematological entities in their clinical and biological presentation from an aggressive form such as hepato-splenic lymphoma to indolent B-cell lymphoma not requiring treatment such as marginal zone lymphoma, the most frequent form of splenic lymphoma. These entities can be challenging to diagnose and differentiate. This review presents different clinical and biological manifestations suspicious of splenic lymphoma and proposes a diagnosis work-up. We extended the strict definition of splenic lymphoma (lymphoma exclusively involving the spleen) to lymphoma thant can be revealed by a splenomegaly and we discuss the differential diagnosis of splenomegaly.
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Affiliation(s)
- Q Riller
- Service de médecine interne 2, Centre national de référence maladies systémiques rares, hôpital Pitié-Salpêtrière, Sorbonne université, Assistance publique-Hôpitaux de Paris, 75013 Paris, France.
| | - F Cohen-Aubart
- Service de médecine interne 2, Centre national de référence maladies systémiques rares, hôpital Pitié-Salpêtrière, Sorbonne université, Assistance publique-Hôpitaux de Paris, 75013 Paris, France
| | - D Roos-Weil
- Service d'hématologie clinique, hôpital Pitié-Salpêtrière, Sorbonne université, Assistance publique-Hôpitaux de Paris, 75013 Paris, France
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12
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Castelli R, Balzarotti M, Salvi E, Simona Rossi R, Lambertenghi Deliliers G, Bergamaschini L, Gidaro A. Risk-tailored treatment of splenic marginal zone lymphoma. Anticancer Drugs 2022; 33:e36-e42. [PMID: 34407041 DOI: 10.1097/cad.0000000000001165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Splenic marginal zone lymphoma (SMZL) is a rare lymphoproliferative disease involving B-cells and affecting elderly patients. SMZL plague peripheral blood and bone marrow, spleen. Lymph nodes are generally spared. SMZL is due to a protracted antigen stimulation of B lymphocytes and of microenvironment leading B-cell to polyclonal and then oligoclonal/monoclonal growth, promoting lymphoproliferation. Integration of the NOTCH2 and NFk-B signaling has been recently identified as the primary mechanism of neoplastic proliferation in SMZL. In total 20% of cases carry mutations in NOTCH2. Although SMZL has an indolent course, progression to diffuse large B-cell lymphoma occurs in about 10-15% of patients. Establishing the prognosis is a key step in disease management, depending on both individual risk and patients' health status. This review discusses tailored treatment of SMZL patients. Progression risk factors include nodal and extra-nodal involvement, peripheral lymphocytosis, anemia and thrombocytopenia. Patients with two or more score points have a median survival of <5 years. Watch and wait strategy is appropriate in low-risk and asymptomatic patients, whereas treatment of symptomatic patients ranges from splenectomy to rituximab monotherapy or associated with chemotherapy.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents, Immunological/therapeutic use
- Disease Progression
- Hepatitis B/pathology
- Hepatitis C/epidemiology
- Hepatitis C/pathology
- Humans
- Lymphoma, B-Cell, Marginal Zone/drug therapy
- Lymphoma, B-Cell, Marginal Zone/epidemiology
- Lymphoma, B-Cell, Marginal Zone/pathology
- Lymphoma, B-Cell, Marginal Zone/surgery
- Lymphoma, Large B-Cell, Diffuse/physiopathology
- NF-kappa B/metabolism
- Neoplasm Staging
- Precision Medicine/methods
- Receptor, Notch2/genetics
- Receptor, Notch2/metabolism
- Receptors, Antigen, B-Cell/genetics
- Receptors, Antigen, B-Cell/immunology
- Risk Assessment
- Risk Factors
- Signal Transduction
- Splenectomy
- Splenic Neoplasms/drug therapy
- Splenic Neoplasms/epidemiology
- Splenic Neoplasms/pathology
- Splenic Neoplasms/surgery
- Tumor Microenvironment/physiology
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Affiliation(s)
- Roberto Castelli
- Università degli studi di Sassari, scienze mediche chirurgiche e sperimentali
| | - Monica Balzarotti
- Medical Oncology and Hematology Unit, Humanitas Clinical and Research Center - IRCCS, Humanitas Cancer Center, Rozzano
| | - Emanuele Salvi
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan
| | - Roberta Simona Rossi
- Service of Pathology, ASST Fatebenefratelli-Sacco, Luigi Sacco, University Hospital Milano
| | | | - Luigi Bergamaschini
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan
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13
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Wonnaparhown A, Stefanovic A, Lugar P, Hostetler HP. Acquired angioedema in B cell lymphoproliferative disease: A retrospective case series. Clin Exp Immunol 2021; 206:378-383. [PMID: 34586637 DOI: 10.1111/cei.13667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/02/2021] [Accepted: 09/22/2021] [Indexed: 01/08/2023] Open
Abstract
Acquired angioedema due to C1-inhibitor (C1-INH) deficiency (AAE-C1-INH) is rare and is associated with underlying lymphoproliferative diseases. C1-INH deficiency may be due to neoplastic over-consumption of C1-INH and the generation of anti-C1-INH autoantibodies. Uncovering an occult malignancy can lead to earlier oncology referral and improvement of angioedema after treatment of the underlying lymphoproliferative disorder. We characterized seven patients with C1-INH-AAE that highlights the importance of recognizing the association between C1-INH-AAE and underlying malignancy. In acute attacks, patients may be resistant to C1-INH therapy due to the presence of anti-C1-INH autoantibodies or rapid complement consumption, and may respond better to icatibant or ecallantide, which directly affect bradykinin. Treatment of the underlying malignancy also improves AAE-C1-INH symptoms and supports the role of lymphoproliferative B cells in AAE-C1-INH pathophysiology. Monitoring levels of C4, C1-INH function and level, and C1q may be predictive of AAE-C1-INH control and be used as surrogates for treatment efficacy. With close monitoring, low-dose danazol can be effective for long-term prophylaxis. Annual evaluation in AAE-C1-INH is recommended if an underlying malignancy is not found, as angioedema may precede the development of malignancy by several years. Our single-center study has aided in standardization of comprehensive AAE-C1-INH diagnosis, treatment, and monitoring strategies towards future therapeutic clinical trials.
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Affiliation(s)
- Alex Wonnaparhown
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Alexandra Stefanovic
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Patricia Lugar
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Haley P Hostetler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Shi Y, Wang C. Where we are with acquired angioedema due to C1 inhibitor deficiency: A systematic literature review. Clin Immunol 2021; 230:108819. [PMID: 34358691 DOI: 10.1016/j.clim.2021.108819] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 11/29/2022]
Abstract
Acquired angioedema due to C1 inhibitor deficiency (C1-INH-AAE) is a rare disease characterized by adult-onset recurrent non-urticarial angioedema with low levels of C1-INH. It is associated with lymphoproliferative disorders, and treatments are off-label with variable success. We conducted a systematic literature review to include patients with C1-INH-AAE identified in PubMed and Embase databases between January 2006 and February 2021. Clinical features of these patients were summarized, and factors associated with disease remission were explored. A total of 121 patients were included in the current study with a median age at diagnosis of 64 years and 45.5% being male. An associated disease was recorded in 94 patients (77.7%), and lymphoproliferative disorder was the most reported (59/94, 62.8%). Anti-C1-INH autoantibodies were present in 45 of 71 patients (63.4%). Factors impacting disease remissions included age (odds ratio [OR] 0.951, 95% confidence interval [CI] 0.909-0.994, p = 0.027), male (OR 0.327, 95% CI 0.124-0.866, p = 0.025), presence of monoclonal gammopathy (OR 0.133, 95% CI 0.041-0.429, p = 0.001), requirement of specific on-demand treatment (OR 0.216, 95% CI 0.066-0.709, p = 0.012) and rituximab use (OR 2.865, 95% CI 1.038-7.911, p = 0.042). A total of nine patients (7.4%) died at last follow up and most were unrelated to C1-INH-AAE. Our results imply that C1-INH-AAE is primarily associated with underlying B or plasma cell abnormalities, and clone-directed therapies could be promising options for its long-term management.
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Affiliation(s)
- Yiyun Shi
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Chen Wang
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
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15
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Managing Chronic Urticaria and Recurrent Angioedema Differently with Advancing Age. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2186-2194. [PMID: 33819638 DOI: 10.1016/j.jaip.2021.03.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/08/2021] [Accepted: 03/22/2021] [Indexed: 12/12/2022]
Abstract
Angioedema and urticaria affect people of all ages. Accurate diagnosis and optimum management is essential for healthy aging. Older people continue to experience mast cell-mediated urticaria and angioedema, with a higher prevalence of autoimmune and a lower prevalence of autoallergic disease. Bradykinin-mediated angioedemas are more common in the elderly because of their association with angiotensin-converting enzyme inhibitor (ACEI) treatment. Acquired C1-inhibitor deficiency, another bradykinin-mediated angioedema, occurs predominantly in older people, whereas hereditary angioedema due to C1-inhibitor deficiency continues to cause symptoms, even in old age. Drug-induced angioedemas disproportionately affect older people, the most frequent users of ACEIs, aspirin, and nonsteroidal anti-inflammatory drugs. Accurate diagnosis and targeted treatment prevent unnecessary morbidity and mortality. Second-generation antihistamines with omalizumab if required are effective and well tolerated in older people with mast cell-mediated urticaria. For bradykinin-mediated angioedemas, these drugs are ineffective. C1-inhibitor replacement or blockade of kallikrein or the bradykinin B2 receptor of the contact pathway is required to treat hereditary angioedema and may be considered in other bradykinin-mediated angioedemas, if supportive treatment is insufficient. For aspirin-related angioedema and urticaria, alternative medications or, exceptionally, desensitization may be required.
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16
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Pólai Z, Balla Z, Andrási N, Kőhalmi KV, Temesszentandrási G, Benedek S, Varga L, Farkas H. A follow-up survey of patients with acquired angioedema due to C1-inhibitor deficiency. J Intern Med 2021; 289:547-558. [PMID: 33215769 DOI: 10.1111/joim.13182] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE) is a rare form of bradykinin-mediated angioedema. It is diagnosed by complement testing; its treatment consists of the management of angioedema (AE) attacks and of underlying disease. OBJECTIVE Evaluate the results of the clinical follow-up of patients with C1-INH-AAE. METHODS Between 1999 and 2020, 3938 patients with angioedema were evaluated, and 17 diagnosed with acquired C1-INH deficiency were followed-up. RESULTS Mean age of the 17 patients was 61 years at diagnosis. In 33%, ACE inhibitors provoked AE attacks. Autoantibodies against C1-INH were detected in 10 patients at diagnosis and in a further patient during follow-up. The AE attacks involved the skin in 70.6%, the upper airways in 41.2% and the tongue/lip in 52.9% of patients. Twelve of the 17 patients had an underlying condition, mainly (n = 11) lymphoproliferative disease. In 10 patients diagnosed with a haematological disorder, AAE symptoms preceded the onset of the latter. One patient has not experienced an AE attack since diagnosis. Twelve patients were treated for angioedema attacks, and 32% of the attacks required acute treatment. PdC1-INH was used to relieve AE attacks, and rituximab for the treatment of underlying disease (in six patients). Six patients had multiple AE attacks before any treatment. The symptom-free period increased in five patients after the on-demand administration of pdC1-INH concentrate and following treatment of the underlying disease in two patients. CONCLUSION Early diagnosis of C1-INH-AAE and underlying disease is indispensable to reduce disease burden by introducing appropriate, individualized treatment and regular follow-up.
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Affiliation(s)
- Zs Pólai
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Zs Balla
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - N Andrási
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - K V Kőhalmi
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,Buda Hospital of the Hospitaller Order of Saint John of God, Rheumatology Center, Budapest, Hungary
| | - Gy Temesszentandrási
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Sz Benedek
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - L Varga
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - H Farkas
- From the, Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
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17
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Thongtan T, Deb A, Bedanie G, Elmassry M, Soape M, Nugent K. Intestinal angioedema caused by an acquired C1 esterase inhibitor deficiency associated with underlying splenic marginal zone lymphoma. Proc (Bayl Univ Med Cent) 2021; 34:519-520. [PMID: 34219945 DOI: 10.1080/08998280.2021.1885277] [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: 10/22/2022] Open
Abstract
A 75-year-old woman presented with recurrent abdominal pain and vomiting for 1 year and was later found to have splenomegaly and pancytopenia. This case report depicts a clinical picture of intestinal angioedema, a challenging diagnosis, and an underlying rare syndrome of acquired C1 esterase inhibitor deficiency associated with splenic marginal zone lymphoma.
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Affiliation(s)
- Thanita Thongtan
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Anasua Deb
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Genanew Bedanie
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Mohamed Elmassry
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Matthew Soape
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
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18
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Belbézier A, Boccon-Gibod I, Bouillet L. Efficacy of lanadelumab in acquired angioedema with C1-inhibitor deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2490-2491. [PMID: 33556593 DOI: 10.1016/j.jaip.2021.01.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Aude Belbézier
- Department of Internal Medicine, Grenoble University Hospital, Grenoble, France.
| | - Isabelle Boccon-Gibod
- Department of Internal Medicine, Grenoble University Hospital, Grenoble, France; National Reference Centre for Angioedema, CREAK, Grenoble, France
| | - Laurence Bouillet
- Department of Internal Medicine, Grenoble University Hospital, Grenoble, France; National Reference Centre for Angioedema, CREAK, Grenoble, France
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19
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Gobert D, Bouillet L, Armengol G, Coppo P, Defendi F, Du-Thanh A, Hardy G, Javaud N, Jeandel PY, Launay D, Panayotopoulos V, Pelletier F, Boccon-Gibod I, Fain O. Angiœdèmes par déficit acquis en C1-inhibiteur : recommandations du CREAK pour le diagnostic et la prise en charge. Rev Med Interne 2020; 41:838-842. [DOI: 10.1016/j.revmed.2020.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/04/2020] [Accepted: 06/20/2020] [Indexed: 11/29/2022]
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20
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Boggs NA, Rao VK. The Role of Bone Marrow Evaluation in Clinical Allergy and Immunology Practice: When and Why. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:3356-3362. [PMID: 32531483 PMCID: PMC10996386 DOI: 10.1016/j.jaip.2020.05.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/24/2020] [Accepted: 05/27/2020] [Indexed: 11/21/2022]
Abstract
Allergists and immunologists rely on other specialists for higher risk procedures such as biopsies of the lung or gastrointestinal tract. However, we perform and interpret a handful of procedures ourselves. Training programs have historically required competency for prescribing immunoglobulin infusions, patch testing, rhino laryngoscopy, lung function testing, and provocation testing for airway hyperreactivity even though other specialists often perform them. Bone marrow aspirations and biopsies are not included in fellowship training assessments despite a significant number of marrow evaluations being requested by allergists and immunologists. For example, nearly 1 marrow assessment per month has been requested over 2 years for patients in the Allergy Immunology Clinic at Walter Reed National Military Medical Center. Marrow assessments are often required for diagnosis, monitoring, and treatment-related toxicities. Interpretive and procedural competency would benefit the field given the range of diseases in clinical immunology practice that require marrow assessment. We have generated a comprehensive list of the major conditions that might require bone marrow assessments in any Allergy and Immunology practice. We then summarize the specific tests that must be ordered and show how to determine sample quality. Finally, some providers may desire procedural competency and for those individuals we discuss tips for the procedure.
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Affiliation(s)
- Nathan A Boggs
- Uniformed Services University of the Health Sciences, Bethesda, Md.
| | - V Koneti Rao
- National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, Md
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21
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Ferriani MPL, Trevisan-Neto O, Costa JS, Melo JML, Moreno AS, Dias MM, Garibaldi PMM, Pereira GC, Chahud F, Traina F, Arruda LK. Acquired Angioedema due to C1 Inhibitor Deficiency Preceding Splenic Marginal Zone Lymphoma: Further Insights from Clinical Practice. Int Arch Allergy Immunol 2020; 181:941-946. [PMID: 32894844 DOI: 10.1159/000509805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/30/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acquired angioedema due to C1 inhibitor deficiency (AAE-C1-INH) is a very rare disease. In clinical practice, it may be difficult to differentiate AAE-C1-INH from hereditary angioedema due to C1-INH deficiency (HAE-C1-INH). In both conditions, patients are at an increased risk of death from asphyxiation due to upper airway obstruction. The association of AAE-C1-INH with lymphoproliferative and autoimmune diseases, and with presence of anti-C1-INH antibodies has been well documented, and treatment of the underlying condition may result in complete remission of angioedema. OBJECTIVES To discuss the clinical evaluation, diagnosis, and treatment outcomes of AAE-C1-INH in the context of the care of 2 patients with recurrent isolated angioedema. METHODS Two patients were followed up prospectively at our clinic. Measurements of C3, C4, C1-INH, and C1q levels were carried out by nephelometry, and the functional activity of C1-INH was determined by a chromogenic assay. Hematological investigation included morphological and immunophenotyping analysis of peripheral blood, bone marrow, and spleen histopathology. Sequencing of the 8 exons and adjacent intronic regions of the SERPING1 gene was performed using the Sanger method. RESULTS Two patients were diagnosed with AAE-C1-INH associated with splenic marginal zone lymphoma during follow-up. CONCLUSIONS Close follow-up, including detailed clinical history, physical examination, and laboratory tests, of our patients with AAE-C1-INH was essential for the early diagnosis and successful treatment of the lymphoproliferative disease, leading to the resolution of the angioedema attacks.
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Affiliation(s)
| | - Orlando Trevisan-Neto
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Julia S Costa
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Janaina M L Melo
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Adriana S Moreno
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Marina M Dias
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Pedro M M Garibaldi
- Department of Medical Images, Hematology and Clinical Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Gabriel C Pereira
- Department of Medical Images, Hematology and Clinical Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Fernando Chahud
- Department of Pathology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Fabiola Traina
- Department of Medical Images, Hematology and Clinical Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - L Karla Arruda
- Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil,
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Castelli R, Schiavon R, Preti C, Ferraris L. HIV-Related Lymphoproliferative Diseases in the Era of Combination Antiretroviral Therapy. Cardiovasc Hematol Disord Drug Targets 2020; 20:175-180. [PMID: 32294049 PMCID: PMC8226149 DOI: 10.2174/1871529x20666200415121009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 01/18/2020] [Accepted: 01/18/2020] [Indexed: 11/22/2022]
Abstract
HIV-positive patients have a 60- to 200-fold increased incidence of Non-Hodgkin Lymphomas (NHL) because of their impaired cellular immunity. Some NHL are considered Acquired Immunodeficiency Syndrome (AIDS) defining conditions. Diffuse large B-cell Lymphoma (DLBC) and Burkitt Lymphoma (BL) are the most commonly observed, whereas Primary Effusion Lymphoma (PEL), Central Nervous System Lymphomas (PCNSL), Plasmablastic Lymphoma (PBL) and classic Hodgkin Lymphoma (HL) are far less frequent. Multicentric Castleman disease (MCD) is an aggressive lymphoproliferative disorder highly prevalent in HIV-positive patients and strongly associated with HHV-8 virus infection. In the pre-Combination Antiretroviral Therapy (CART) era, patients with HIV-associated lymphoma had poor outcomes with median survival of 5 to 6 months. By improving the immunological status, CART extended the therapeutic options for HIV positive patients with lymphomas, allowing them to tolerate standard chemotherapies regimen with similar outcomes to those of the general population. The combination of CART and chemotherapy/ immuno-chemotherapy treatment has resulted in a remarkable prolongation of survival among HIVinfected patients with lymphomas. In this short communication, we briefly review the problems linked with the treatment of lymphoproliferative diseases in HIV patients. Combination Antiretroviral Therapy (CART) not only reduces HIV replication and restores the immunological status improving immune function of the HIV-related lymphomas patients but allows patients to deal with standard doses of chemotherapies. The association of CART and chemotherapy allowed to obtain better results in terms of overall survival and complete responses. In the setting of HIVassociated lymphomas, many issues remain open and their treatment is complicated by the patient's immunocompromised status and the need to treat HIV concurrently.
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Affiliation(s)
- Roberto Castelli
- Address correspondence to this author at the Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Luigi Sacco Hospital Milan, Milan, Italy; Tel: +39/02/50319830; Fax: +39/02/50319828;, E-mail:
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23
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Abdel-Samad NN, Kokai JS. A Case of Acquired Angioedema with Low C1 Inhibitor (C1-INH) Associated with Splenic Marginal Zone Lymphoma. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1476-1481. [PMID: 31588119 PMCID: PMC6792468 DOI: 10.12659/ajcr.915558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Patient: Male, 68 Final Diagnosis: AAE Symptoms: Angioedema Medication: — Clinical Procedure: — Specialty: Hematology
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Affiliation(s)
- Nizar N Abdel-Samad
- Department of Internal Medicine, Division of Hematology and Medical Oncology, The Moncton Hospital, Moncton, New Brunswick, Canada
| | - Judit S Kokai
- Dr. Sheldon H. Rubin Oncology Clinic, Clinical Trials, The Moncton Hospital - Horizon Health Network, Moncton, New Brunswick, Canada
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24
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Abstract
Angioedema is a clinical entity defined as self-limiting edema localized in the deeper layers of the skin and mucosa and lasting for several days. Angioedema can be provoked by bradykinin and/or mast cell mediators, including histamine. Four types of acquired and three types of hereditary angioedema have been identified. The most obvious form of angioedema associated with other systemic disease is acquired angioedema due to C1-inhibitor deficiency. It is characterized by acquired consumption of C1 inhibitor and various underlying disorders, such as multiple myeloma, chronic lymphocytic leukemia, rectal carcinoma, and non-Hodgkin lymphoma. Suspected cases need an accurate differential diagnosis to exclude all other types of acquired and hereditary angioedema.
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25
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Bork K, Staubach-Renz P, Hardt J. Angioedema due to acquired C1-inhibitor deficiency: spectrum and treatment with C1-inhibitor concentrate. Orphanet J Rare Dis 2019; 14:65. [PMID: 30866985 PMCID: PMC6417199 DOI: 10.1186/s13023-019-1043-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 03/05/2019] [Indexed: 11/23/2022] Open
Abstract
Background Acquired angioedema due to C1-inhibitor (C1-INH) deficiency (AAE-C1-INH) is a serious condition that may result in life-threatening asphyxiation due to laryngeal edema. It is associated with malignant B-cell lymphoma and other disorders. The purpose of this study was to describe the characteristics and associated disorders of patients with AAE-C1-INH and assess the efficacy of plasma-derived C1-INH concentrate (pdC1-INH) in the treatment of AAE-C1-INH. Forty-four patients with AAE-C1-INH from the Angioedema Outpatient Service of Mainz were assessed for associated disorders. In 32 of these patients, the duration of swelling attacks was measured before and after treatment with pdC1-INH (Berinert® (CSL Behring, Marburg, Germany)). The time between injection and complete resolution of symptoms and treatment effectiveness was provided by the patients. Results The following underlying disorders were present: monoclonal gammopathy of undetermined significance (47.7%), non-Hodgkin lymphoma (27.3%), anti-C1-INH autoantibodies alone (11.4%), and other conditions (4.5%). In 9.1% patients, no associated disorder could be found. AAE-C1-INH led to the detection of lymphoma in 75% of patients with the malignancy. Treatment with pdC1-INH shortened attacks by an average (SD) 54.4 (± 32.8) hours (P < 0.0001). The earlier the attack was treated, the shorter the time between injection and resolution of symptoms (P = 0.0149). A total of 3553 (97.7%) of the 3636 attacks were effectively treated with pdC1-INH as assessed by the patient. The mean (SD) dose per-attack was 787 (± 442) U. pdC1-INH was effective in 1246 (93.8%) of 1329 attacks in 8 patients with anti-C1-INH autoantibodies and in 344 (99.4%) of 346 attacks in 6 patients without autoantibodies. The average (SD) dose per effectively treated attack was 1238.4 (± 578.2) U in patients with anti-C1-INH autoantibodies and 510.2 (± 69.1) U in patients without autoantibodies. Conclusions pdC1-INH is highly effective in treating AAE-C1-INH patients and is also effective in the vast majority of attacks in patients with anti-C1-INH autoantibodies. It is fast-acting and reduces attack duration.
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Affiliation(s)
- Konrad Bork
- Department of Dermatology, Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Petra Staubach-Renz
- Department of Dermatology, Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Jochen Hardt
- Department of Medical Psychology and Medical Sociology, Johannes Gutenberg University, Mainz, Germany
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27
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Nedelea I, Deleanu D. Isolated angioedema: An overview of clinical features and etiology. Exp Ther Med 2018; 17:1068-1072. [PMID: 30679975 DOI: 10.3892/etm.2018.6982] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/03/2018] [Indexed: 01/22/2023] Open
Abstract
Angioedema can occur in isolation, accompanied by urticaria, or as a feature of anaphylaxis in mast cell-mediated disorders, bradykinin-mediated disorders, as well as in others with unknown mechanisms, such as infections, rare disorders, or idiopathic angioedema. In mast cell-mediated angioedema, other signs and symptoms of mast cell-mediator release are frequently seen. However, clear evidence of mast cell degranulation may be absent in histaminergic angioedema. Bradykinin-induced angioedema is not associated with urticaria or other symptoms of type I hypersensitivity reactions. For many of the known triggers of angioedema, the mechanism is unclear. While mast cell and bradykinin-mediated angioedema are relatively well defined in terms of diagnostic and therapeutic approach, angioedema with unknown mechanisms represents a challenge for patients and clinicians alike. Elucidating the clinical pattern and the possible causes of isolated angioedema is the key to a correct diagnosis. This review summarizes the causes, and clinical features of angioedema, with a focus on isolated angioedema.
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Affiliation(s)
- Irena Nedelea
- Allergology and Immunology Discipline, 'Iuliu Hațieganu' University of Medicine and Pharmacy, Cluj-Napoca 400012, Romania.,Department of Allergy, 'Professor Doctor Octavian Fodor' Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
| | - Diana Deleanu
- Allergology and Immunology Discipline, 'Iuliu Hațieganu' University of Medicine and Pharmacy, Cluj-Napoca 400012, Romania.,Department of Allergy, 'Professor Doctor Octavian Fodor' Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania.,Department of Internal Medicine, 'Professor Doctor Octavian Fodor' Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca 400162, Romania
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Splenic marginal zone lymphomas in acquired C1-inhibitor deficiency: clinical and molecular characterization. Med Oncol 2018; 35:118. [PMID: 30073422 DOI: 10.1007/s12032-018-1183-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/31/2018] [Indexed: 01/19/2023]
Abstract
Angioedema due to acquired deficiency of the inhibitor of the first component of complement (C1-INH) is a rare disease known as acquired angioedema (AAE). About 70% of patients with AEE display autoantibodies to C1-INH, the remaining patients have no antibodies to C1-INH. The clinical features of C1-INH deficiency include recurrent, self-limiting local swellings involving the skin, the gastrointestinal tract, and the upper respiratory tract. Swelling is due to accumulation of bradykinin released from high molecular weight kininogen. Patients with angioedema due to acquired C1 inhibitor deficiency (AEE) often have an associated lymphoproliferative disease including Non-Hodgkin Lymphomas (NHL). Among AAE patients with NHL, splenic marginal zone lymphoma (SMZL) has a higher prevalence (66%) compared to general population (2%) In the present study, we focused on patients with SMZL in AAE. We found 24 AAE patients with NHL and, among them 15 SMZL (62.5% of all NHL). We found NOTCH 2 activation in 4 /15 patients (26.6%) with SMZL, while no patients carried MYD 88 or BIRC3 mutations. Restricted immunoglobulin gene repertoire analysis showed that the IGHV1-2*04 allele was found to be over-represented in the group of patients with or without lymphoproliferative disease presenting with autoantibodies to C1-INH (41 of 55 (75%) of patients; p value 0.011) when compared to the control group of patients with AEE without antibodies to C1-INH, (7 of 27 (26%) of patients). Immunophenotyping failed to demonstrate the presence of autoreactive clones against C1-inhibitor. Taken together, these findings suggest a role for antigenic stimulation in the pathogenesis of lymphomas associated with AEE.
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Bonnin AJ, DeBrosse C, Moncrief T, Richmond GW. Case report presenting the diagnostic challenges in a patient with recurrent acquired angioedema, antiphospholipid antibodies and undetectable C2 levels. Allergy Asthma Clin Immunol 2018; 14:24. [PMID: 29881401 PMCID: PMC5985567 DOI: 10.1186/s13223-018-0246-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 03/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background Angioedema secondary to acquired C1 inhibitor deficiency (AAE) is a rare disease. It usually is associated with lymphoproliferative disorders. We present a case of AAE in a patient with antiphospholipid syndrome (APS), a non-Hodgkin lymphoproliferative disorder (NHL) with undetectable levels of C2, C4, and an undetectable CH50. The co-existence of AAE, APS, and NHL, with an undetectable C2 level, to the best of our knowledge, has never before reported together in the same patient. Case presentation A patient with a recent history of thrombosis presented with recurrent episodes of angioedema. The workup revealed undetectable levels of C2, C4 and undetectable CH50. Quantitative levels of C1 inhibitor and C1q were low. C1 inhibitor function was less than 40%. Anti-cardiolipin antibodies were found. The patient was initially treated on demand with intravenous plasma-derived human C1-INH concentrates, (Cinryze® Shire). Later the patient received prophylactic therapy with danazol. She was diagnosed with lymphoma 3 years after her first episode of angioedema. Single agent therapy with rituximab was not only effective in treating her lymphoma but also preventing further episodes of angioedema. Anti-cardiolipin antibody titers also declined. Additionally, marked early primary pathway complement component abnormalities and CH50 also corrected, although incomplete normalization of C4 proved to be due to a heterozygous C4 deficiency. Conclusion This case shows the unique association of AAE, APS and NHL in a patient with undetectable levels of early complement components. Additionally, this case also shows for the first time the effectiveness of rituximab therapy in all three disease states while co-existing simultaneously in the same patient.
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Affiliation(s)
- Arturo J Bonnin
- 1Department of Internal Medicine, Wright State University Boonshoft School of Medicine, Allergy and Asthma Centre of Dayton, 8039 Washington Village Drive, Suite #100, Centerville, Dayton, OH 45458 USA
| | | | - Terri Moncrief
- 1Department of Internal Medicine, Wright State University Boonshoft School of Medicine, Allergy and Asthma Centre of Dayton, 8039 Washington Village Drive, Suite #100, Centerville, Dayton, OH 45458 USA
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Refractory Abdominal Pain in a Patient with Chronic Lymphocytic Leukemia: Be Wary of Acquired Angioedema due to C1 Esterase Inhibitor Deficiency. Case Rep Hematol 2018; 2018:7809535. [PMID: 29545957 PMCID: PMC5818943 DOI: 10.1155/2018/7809535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/01/2017] [Accepted: 11/19/2017] [Indexed: 01/09/2023] Open
Abstract
Acquired angioedema due to C1 inhibitor deficiency (C1INH-AAE) is a rare and potentially fatal syndrome of bradykinin-mediated angioedema characterized by episodes of angioedema without urticaria. It typically manifests with nonpitting edema of the skin and edema in the gastrointestinal (GI) tract mucosa or upper airway. Edema of the upper airway and tongue may lead to life-threatening asphyxiation. C1INH-AAE is typically under-diagnosed because of its rarity and its propensity to mimic more common abdominal conditions and allergic reactions. In this article, we present the case of a 62-year-old male with a history of recently diagnosed chronic lymphocytic leukemia (CLL) who presented to our hospital with recurrent abdominal pain, initially suspected to have Clostridium difficile colitis and diverticulitis. He received a final diagnosis of acquired angioedema due to C1 esterase inhibitor deficiency due to concomitant symptoms of lip swelling, cutaneous nonpitting edema of his lower extremities, and complement level deficiencies. He received acute treatment with C1 esterase replacement and icatibant and was maintained on C1 esterase infusions. He also underwent chemotherapy for his underlying CLL and did not experience further recurrence of his angioedema.
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First-line treatment with bendamustine and rituximab, in patients with intermediate-/high-risk splenic marginal zone lymphomas. Med Oncol 2017; 35:15. [PMID: 29288421 DOI: 10.1007/s12032-017-1076-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/27/2017] [Indexed: 01/18/2023]
Abstract
Splenic marginal zone lymphomas (SMZLs) are rare indolent B cell neoplasms that affect the spleen, bone marrow, and blood. Although they have an indolent course in the majority of patients, who have a median survival of 8-10 years, ∼ 30% may experience a worse outcome. The prognostic criteria of progression are lymph node and extra-nodal involvement, high lymphocyte counts, anaemia, and thrombocytopenia. The treatment of SMZLs include a "wait and watch strategy", splenectomy, and alkylating agents ± rituximab. We here describe data relating to 70 patients with intermediate-/high-risk SMZLs, who received rituximab/bendamustine as first-line treatment for a median of 60 days (range 1-75) after diagnosis. Sixty patients (86%) achieved a complete response (CR), and seven (10%) a partial response (PR). Three patients (4.3%) experienced disease progression (PD). The median duration of remission was 18 months. Side effects were generally mild. Our findings suggest that rituximab/bendamustine is a feasible treatment option in patients with intermediate-/high-risk SMZLs.
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Busse PJ, Gernez Y. Clinical and biological response to rituximab treatment in 3 patients with acquired C1-inhibitor deficiency. Ann Allergy Asthma Immunol 2017; 119:380-382. [PMID: 28866304 DOI: 10.1016/j.anai.2017.07.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/13/2017] [Accepted: 07/28/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Paula J Busse
- Division of Allergy and Clinical Immunology, Icahn School of Medicine, Mount Sinai, New York, New York.
| | - Yael Gernez
- Division of Allergy and Clinical Immunology, Icahn School of Medicine, Mount Sinai, New York, New York
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Zanichelli A, Azin GM, Wu MA, Suffritti C, Maggioni L, Caccia S, Perego F, Vacchini R, Cicardi M. Diagnosis, Course, and Management of Angioedema in Patients With Acquired C1-Inhibitor Deficiency. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1307-1313. [PMID: 28284781 DOI: 10.1016/j.jaip.2016.12.032] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/13/2016] [Accepted: 12/21/2016] [Indexed: 02/09/2023]
Abstract
BACKGROUND Acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE) is a rare disease with no prevalence data or approved therapies. OBJECTIVE To report data on patients with C1-INH-AAE followed at Angioedema Center, Milan (from 1976 to 2015). METHODS Diagnostic criteria included history of recurrent angioedema without wheals; decreased C1-INH antigen levels and/or functional activity of C1-INH and C4 antigen less than 50% of normal; late symptom onset (>40 years); no family history of angioedema and C1-INH deficiency. RESULTS In total, 77 patients (58% females; median age, 70 years) were diagnosed with C1-INH-AAE and 675 patients with hereditary angioedema due to C1-INH deficiency (C1-INH-HAE) (1 patient with C1-INH-AAE/8.8 patients with C1-INH-HAE). Median age at diagnosis was 64 years. Median time between symptom onset and diagnosis was 2 years. Sixteen patients (21%) died since diagnosis, including 1 because of laryngeal edema. Angioedema of the face was most common (N = 63 [82%]), followed by abdomen (N = 51 [66%]), peripheries (N = 50 [65%]), and oral mucosa and/or glottis (N = 42 [55%]). Forty-eight of 71 patients (68%) had autoantibodies to C1-INH. In total, 56 patients (70%) used on-demand treatment for angioedema including intravenous pdC1-INH 2000 U (Berinert, CSL Behring, Marburg, Germany) (N = 49) and/or subcutaneous icatibant 30 mg (Firazyr, Shire; Milano, Italy) (N = 27). Eventually, 8 of 49 patients receiving pdC1-INH became nonresponsive; all had autoantibodies. Thirty-four patients received long-term prophylaxis with tranexamic acid (effective in 29) and 20 with androgens (effective in 8). CONCLUSIONS The incidence of C1-INH-AAE was 1 for every 8.8 patients with C1-INH-HAE. Thirty percent of the deaths were related to the disease. Treatments approved for C1-INH-HAE are effective in C1-INH-AAE, although with minimal differences.
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Affiliation(s)
- Andrea Zanichelli
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy.
| | - Giulia Maria Azin
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Maddalena Alessandra Wu
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Chiara Suffritti
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Lorena Maggioni
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Sonia Caccia
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Francesca Perego
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Romualdo Vacchini
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy; ASST Fatebenefratelli Sacco, Milan, Italy
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Wu MA, Perego F, Zanichelli A, Cicardi M. Angioedema Phenotypes: Disease Expression and Classification. Clin Rev Allergy Immunol 2017; 51:162-9. [PMID: 27113957 DOI: 10.1007/s12016-016-8541-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Due to marked heterogeneity of clinical presentations, comprehensive knowledge of angioedema phenotypes is crucial for correct diagnosis and choosing the appropriate therapeutic approach. One of the ways to a meaningful clinical distinction can be made between forms of angioedema occurring "with or without wheals." Angioedema with wheals (rash) is a hallmark of urticaria, either acute or chronic, spontaneous or inducible. Angioedema without wheals may still be manifested in about 10 % of patients with urticaria, but it may also occur as a separate entity. Several classifications of angioedema as part of urticaria were published over time, while a latest one, released in 2014 (HAWK group consensus, see below), provided a classification of all forms of "angioedema without wheals" distinct from urticaria, which will be the focus of the present review. At this time, the HAWK consensus classification is the best in terms of covering the pathophysiology, mediators involved, angioedema triggers, and clinical expression. According to this classification, three types of hereditary angioedema (genetic C1-INH deficiency, normal C1-INH with factor XII mutations, and unknown origin) and four types of acquired angioedema (C1-INH deficiency, related to ACE inhibitors intake, idiopathic histaminergic, and idiopathic non-histaminergic) are presented. We will review the distinctive clinical features of each phenotype in details.
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Affiliation(s)
- Maddalena Alessandra Wu
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Francesca Perego
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Andrea Zanichelli
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Luigi Sacco Hospital, Milan, Italy.
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Erratum. Br J Haematol 2016; 175:351. [DOI: 10.1111/bjh.14334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gobert D, Paule R, Ponard D, Levy P, Frémeaux-Bacchi V, Bouillet L, Boccon-Gibod I, Drouet C, Gayet S, Launay D, Martin L, Mekinian A, Leblond V, Fain O. A nationwide study of acquired C1-inhibitor deficiency in France: Characteristics and treatment responses in 92 patients. Medicine (Baltimore) 2016; 95:e4363. [PMID: 27537564 PMCID: PMC5370791 DOI: 10.1097/md.0000000000004363] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Acquired angioedema (AAE) due to C1-inhibitor (C1INH) deficiency is rare. Treatment options for acute attacks are variable and used off-label. Successful treatment of the associated lymphoma with rituximab seems to prevent acute attacks in subjects with AAE. The aim of this study was to describe AAE manifestations, its associated diseases, and patients' responses to treatments in a representative cohort.A retrospective nationwide study was conducted in France. The inclusion criteria were recurrent angioedema attacks and an acquired decrease in functional C1INH <50% of the reference value.A total of 92 cases were included, with a median age at onset of 62 years. Facial edema and abdominal pain were the most frequent symptoms. Fifteen patients were hospitalized in the intensive care unit because of laryngeal edema, and 1 patient died. Anti-C1INH antibodies were present in 43 patients. The associated diseases were primarily non-Hodgkin lymphoma (n = 44, with 24 splenic marginal zone lymphomas) and monoclonal gammopathy of undetermined significance (n = 24). Three patients had myeloma, 1 had amyloid light-chain (of immunoglobulin) (AL) amyloidosis, 1 patient had a bronchial adenocarcinoma, and 19 patients had no associated disease. Icatibant relieved the symptoms in all treated patients (n = 26), and plasma-derived C1INH concentrate in 19 of 21 treated patients. Six patients experienced thromboembolic events under tranexamic acid prophylaxis. Rituximab prevented angioedema in 27 of 34 patients as a monotherapy or in association with chemotherapy. Splenectomy controlled AAE in 7 patients treated for splenic marginal zone lymphoma. After a median follow-up of 4.2 years, angioedema was on remission in 52 patients.AAE cases are primarily associated with indolent lymphoma-especially splenic marginal zone lymphoma-and monoclonal gammopathy of undetermined significance but not with autoimmune diseases or other conditions. Icatibant and plasma-derived C1INH concentrate control attacks; splenectomy and immunochemotherapy prevent angioedema in lymphoma setting.
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Affiliation(s)
- Delphine Gobert
- Internal Medicine Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, DHU i2B, Paris 6 University, Paris
- Correspondence: Delphine Gobert, Internal Medicine Department, Hôpital Saint Antoine, 184 Rue Du Faubourg Saint Antoine, 75571 Paris Cedex 12, France (e-mail: )
| | - Romain Paule
- Hematology Department, Pitié Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 6 University, Paris
| | - Denise Ponard
- Immunology Laboratory, University Hospital, Grenoble
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
| | - Pierre Levy
- Public Health Department, Tenon Hospital, Assistance Publique-Hôpitaux de Paris, Paris 6 University
| | - Véronique Frémeaux-Bacchi
- Immunology Laboratory, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris 5 University, Paris
| | - Laurence Bouillet
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Joint Unit 1036 CNRS-CEA-INSERM, University Grenoble Alpes
- Internal Medicine Department, University Hospital, Grenoble
| | - Isabelle Boccon-Gibod
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Joint Unit 1036 CNRS-CEA-INSERM, University Grenoble Alpes
- Internal Medicine Department, University Hospital, Grenoble
| | - Christian Drouet
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Université Joseph Fourier Grenoble, GREPI/AGIM CNRS FRE 3405, Grenoble
| | - Stéphane Gayet
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Internal Medicine Department, La Conception Hospital, AP-HM, Marseille
| | - David Launay
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Internal Medicine and Clinical Immunology Department, Lille University Hospital
- LIRIC, INSERM UMR 995, EA2686, Lille
| | - Ludovic Martin
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
- Dermatology Department, L’UNAM Université, University Hospital, Angers, France
| | - Arsène Mekinian
- Internal Medicine Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, DHU i2B, Paris 6 University, Paris
| | - Véronique Leblond
- Hematology Department, Pitié Salpétrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 6 University, Paris
| | - Olivier Fain
- Internal Medicine Department, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, DHU i2B, Paris 6 University, Paris
- Centre de Référence et d’Etude des Angioedèmes à Kinine (CREAK) , Grenoble
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van Krieken JH. New developments in the pathology of malignant lymphoma. A review of the literature published from January-April 2016. J Hematop 2016; 9:73-83. [PMID: 27398102 PMCID: PMC4912577 DOI: 10.1007/s12308-016-0277-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- J Han van Krieken
- Department of Pathology, Radboud University Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Perrone S, D’Elia GM, Annechini G, Ferretti A, Tosti ME, Foà R, Pulsoni A. Splenic marginal zone lymphoma: Prognostic factors, role of watch and wait policy, and other therapeutic approaches in the rituximab era. Leuk Res 2016; 44:53-60. [DOI: 10.1016/j.leukres.2016.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/09/2016] [Accepted: 03/21/2016] [Indexed: 02/07/2023]
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Splenic marginal zone lymphoma: from genetics to management. Blood 2016; 127:2072-81. [DOI: 10.1182/blood-2015-11-624312] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 03/07/2016] [Indexed: 12/16/2022] Open
Abstract
AbstractSplenic marginal zone lymphoma (SMZL) is a rare B-cell malignancy involving the spleen, bone marrow, and frequently the blood. SMZL lymphomagenesis involves antigen and/or superantigen stimulation and molecular deregulation of genes (NOTCH2 and KLF2) involved in the physiological differentiation of spleen marginal zone B cells. Diagnosis requires either spleen histology or, alternatively, the documentation of a typical cell morphology and immunophenotype on blood cells coupled with the detection of intrasinusoidal infiltration by CD20+ cells in the bone marrow. Among B-cell tumors, deletion of 7q and NOTCH2 mutations are almost specific lesions of SMZL, thus representing promising diagnostic biomarkers of this lymphoma. Although the majority of SMZLs show an indolent course with a median survival of approximately 10 years, nearly 30% of patients experience a poor outcome. No randomized trials are reported for SMZL, and few prospective trials are available. A watch-and-wait approach is advisable for asymptomatic patients. Treatment options for symptomatic patients ranges from splenectomy to rituximab alone or combined with chemotherapy. In some geographic areas, a subset of patients with SMZL associates with hepatitis C virus infection, prompting virus eradication as an effective lymphoma treatment. It would be worthwhile to explore deregulated cellular programs of SMZL as therapeutic targets in the future; improved clinical and biological prognostication will be essential for identifying patients who may benefit from novel approaches.
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