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Trainotti S, Johnson F, Hahn J, Hofauer B, Greve J, Wollenberg B, Hoffmann TK, Lochbaum R. Acquired Angioedema Due to C1-Inhibitor Deficiency (AAE-C1-INH)-A Bicenter Retrospective Study on Diagnosis, Course, and Therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3772-3779. [PMID: 37716525 DOI: 10.1016/j.jaip.2023.09.003] [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: 10/25/2022] [Revised: 08/06/2023] [Accepted: 09/01/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Acquired angioedema with C1-inhibitor deficiency (AAE-C1-INH) is a rare condition resembling hereditary angioedema (HAE), but with late onset and low C1-inhibitor (C1-INH) due to consumption potentially caused by autoimmune diseases and mainly lymphatic malignancies. Being about 10-fold rarer than HAE, there is limited knowledge and no licensed therapy. OBJECTIVE To report clinical and biological data from a newly described population of 20 patients with AAE-C1-INH assessing diagnostic delay, AAE-C1-INH:HAE-ratio, underlying conditions, and therapeutic management in Germany. METHODS Retrospective data analysis of 20 patients from 2 angioedema centers in southern Germany. RESULTS Median age at symptoms' onset was 64 years (60% females), with predominant swellings of the face (85%) and low levels for C1-INH in almost all patients. The ratio AAE-C1-INH:HAE was 1:9.7. From symptoms' onset to diagnosis of AAE-C1-INH, the median delay was 7.5 months, and between AAE-C1-INH symptoms' onset and diagnosis of the underlying hematological condition (n = 9) it was 4 months (median). Four patients had a history of solid neoplasm, 1 had a papillary thyroid carcinoma as the only potential cause for AAE-C1-INH, with treatment of the malignancy resulting in resolution of AAE-C1-INH. All the symptomatic patients were treated with off-label on-demand icatibant subcutaneously or C1-INH concentrate intravenously, and 6 severely affected patients needed off-label long-term prophylaxis with good symptom control. CONCLUSIONS AAE-C1-INH is characterized by late-onset swellings mainly involving the face and low C1-INH levels. Diagnostic delay for AAE-C1-INH is further decreasing despite being about 10-fold rarer than HAE. Patients severely affected without underlying condition or no indication for treatment could benefit from off-label therapy.
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Affiliation(s)
- Susanne Trainotti
- Department of Otorhinolaryngology, Technical University of Munich, Munich, Germany.
| | - Felix Johnson
- University Hospital for Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Janina Hahn
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Benedikt Hofauer
- University Hospital for Otorhinolaryngology, Head and Neck Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jens Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Barbara Wollenberg
- Department of Otorhinolaryngology, Technical University of Munich, Munich, Germany
| | - Thomas K Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Robin Lochbaum
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
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Polai Z, Kajdacsi E, Cervenak L, Balla Z, Benedek S, Varga L, Farkas H. C1-inhibitor/C1-inhibitor antibody complexes in acquired angioedema due to C1-inhibitor deficiency. Orphanet J Rare Dis 2023; 18:24. [PMID: 36726161 PMCID: PMC9890765 DOI: 10.1186/s13023-023-02625-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Autoantibodies against C1-inhibitor (C1-INH-Ab) have a diagnostic value in acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE), even though antibodies can circulate in complexes, which can be undetectable by proven methods. Our aim was to measure C1-INH/C1-INH-Ab complexes (CAC) and investigate their connection to C1-INH-Ab and the changes in their titer over time. RESULTS 19 patients were diagnosed with C1-INH-AAE in the Hungarian Angioedema Center of Reference and Excellence; 79% of them had an underlying disease. Samples were examined with a newly developed in-house complex ELISA method. Patients with high C1-INH-Ab titer had a CAC titer which did not exceed the normal level and the ones with high CAC titer had a C1-INH-Ab titer which did not exceed the normal level. In case of those patients who had C1-INH-Ab and CAC of the same type of immunoglobulin, the increasing titer of C1-INH-Ab went together with the decreasing level of CAC and vice versa. CAC titer was already increased before the diagnosis of the underlying disease. CONCLUSIONS Free circulating and complex antibodies are in a dynamically changing equilibrium. CAC measurements can help to predict the development of an underlying disease. The efficiency of the treatment for underlying disease can be monitored by the decreasing CAC titers. Our results show that the CAC can be of important additional information besides the complement panel examination in case of C1-INH-AAE. Measurement of CAC is recommended to be done parallelly with C1-INH-Ab, so as to detect both free and bound antibodies.
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Affiliation(s)
- Zsofia Polai
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Szentkiralyi u. 46, Budapest, 1088 Hungary
| | - Erika Kajdacsi
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Laszlo Cervenak
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Balla
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Szentkiralyi u. 46, Budapest, 1088 Hungary
| | - Szabolcs Benedek
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Lilian Varga
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Szentkiralyi u. 46, Budapest, 1088 Hungary
| | - Henriette Farkas
- Department of Internal Medicine and Haematology, Hungarian Angioedema Center of Reference and Excellence, Semmelweis University, Szentkiralyi u. 46, Budapest, 1088, Hungary.
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Polai Z, Balla Z, Benedek S, Kajdacsi E, Farkas H. Laryngeal angioedema caused by a rare disease – a case report. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2022. [DOI: 10.1016/j.cpccr.2022.100201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Baeza ML, González-Quevedo T, Caballero T, Guilarte M, Lleonart R, Varela S, Castro M, Díaz C, Escudero E, García MG, Laffond E, Muñoz-Bellido FJ, Núñez R, Prior N, Sala-Cunill A, Sáenz de San Pedro B, Prieto-García A. Angioedema Due to Acquired Deficiency of C1-Inhibitor: A Cohort Study in Spain and a Comparison With Other Series. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1020-1028. [PMID: 34844023 DOI: 10.1016/j.jaip.2021.11.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/25/2021] [Accepted: 11/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Data on acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE) from 4 European countries (France, Italy, Germany, and Hungary) were recently published. OBJECTIVE To report data from a group of 50 patients with acquired C1-INH deficiency from Spain, of whom 46 had angioedema, and compare them with other European series. METHODS We performed a retrospective observational study of 46 patients with C1-INH-AAE and 4 asymptomatic patients. Clinical and biological characteristics and associated diseases were assessed and compared with other European series. RESULTS Women accounted for 73.9% of cases. The prevalence of C1-INH-AAE related to hereditary forms was 1/10.1. Overall, 8.7% patients were aged <40 years. Diagnostic delay was 1.1 years. Angioedema mainly affected the face (91.3%), followed by the oropharynx (63%), extremities (50%), and abdomen (37%). Only 1 patient underwent orotracheal intubation. Erythema marginatum was present in 1 patient. A hematologic disorder was recorded in 50% of patients. Angioedema preceded all benign conditions, mostly monoclonal gammopathy of undetermined significance, but appeared very close to or after malignant hematologic diseases (median, 2.2 and 0.29 years). Autoimmune diseases were associated in 50% (autoimmune thyroiditis, 21.5%; systemic lupus erythematosus, 10.9%). Half of them coexisted with hematologic disorders. Anti-C1-INH antibodies were found in 67% of tested patients and were not related to the associated disease. Long-term prophylaxis was necessary in 52.2%, most of whom responded to tranexamic acid. CONCLUSIONS This study emphasizes the possibility of C1-INH-AAE in patients younger than 40 and in autoimmune diseases other than systemic lupus erythematosus such as autoimmune thyroiditis.
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Affiliation(s)
- Maria L Baeza
- Hospital General Universitario Gregorio Marañón, Allergy Section, Madrid, Spain; Biomedical Research Network on Rare Diseases (CIBERER, U761), Madrid, Spain; Institute for Health Research Gregorio Marañón, Madrid, Spain.
| | - Teresa González-Quevedo
- Hospital Universitario Virgen del Rocío, Allergy Section, Sevilla, Spain; Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - Teresa Caballero
- Hospital Universitario La Paz, Allergy Section, Madrid, Spain; Hospital La Paz Institute for Health Research (IdiPaz), Madrid, Spain; Biomedical Research Network on Rare Diseases (CIBERER, U754), Madrid, Spain
| | - Mar Guilarte
- Hospital Universitari Vall d'Hebron, Allergy Section, Barcelona, Spain; Vall d'Hebron Research Institute, Allergy Section, Barcelona, Spain
| | - Ramon Lleonart
- Hospital Universitario Bellvitge de L'Hospitalet de Llobregat, Allergy Section, Barcelona, Spain
| | - Susana Varela
- Complexo Hospitalario de Ourense, Allergy Section, Ourense, Spain
| | - Monica Castro
- Complejo Hospitalario Universitario de Ferrol, Allergy Section, Ferrol, Spain
| | - Carmen Díaz
- Hospital Universitario Central de Asturias, Allergy Section, Oviedo, Spain
| | - Elena Escudero
- Complejo Hospitalario de Pontevedra, Allergy Section, Pontevedra, Spain
| | - Marimar G García
- Complexo Hospitalario de Ourense, Allergy Section, Ourense, Spain
| | - Elena Laffond
- Complejo Asistencial Universitario de Salamanca, Allergy Section, Salamanca, Spain
| | | | - Ramon Núñez
- Hospital Universitario Lucus Augusti, Allergy Section, Lugo, Spain
| | - Nieves Prior
- Hospital Universitario Severo Ochoa de Leganés, Allergy Section, Madrid, Spain
| | - Anna Sala-Cunill
- Hospital Universitari Vall d'Hebron, Allergy Section, Barcelona, Spain; Vall d'Hebron Research Institute, Allergy Section, Barcelona, Spain
| | | | - Alicia Prieto-García
- Hospital General Universitario Gregorio Marañón, Allergy Section, Madrid, Spain; Institute for Health Research Gregorio Marañón, Madrid, Spain
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Grumach AS, Veronez CL, Csuka D, Farkas H. Angioedema Without Wheals: Challenges in Laboratorial Diagnosis. Front Immunol 2021; 12:785736. [PMID: 34956216 PMCID: PMC8694242 DOI: 10.3389/fimmu.2021.785736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Angioedema is a prevailing symptom in different diseases, frequently occurring in the presence of urticaria. Recurrent angioedema without urticaria (AE) can be hereditary (HAE) and acquired (AAE), and several subtypes can be distinguished, although clinical presentation is quite similar in some of them. They present with subcutaneous and mucosal swellings, affecting extremities, face, genitals, bowels, and upper airways. AE is commonly misdiagnosed due to restricted access and availability of appropriate laboratorial tests. HAE with C1 inhibitor defect is associated with quantitative and/or functional deficiency. Although bradykinin-mediated disease results mainly from disturbance in the kallikrein–kinin system, traditionally complement evaluation has been used for diagnosis. Diagnosis is established by nephelometry, turbidimetry, or radial immunodiffusion for quantitative measurement of C1 inhibitor, and chromogenic assay or ELISA has been used for functional C1-INH analysis. Wrong handling of the samples can lead to misdiagnosis and, consequently, mistaken inappropriate approaches. Dried blood spot (DBS) tests have been used for decades in newborn screening for certain metabolic diseases, and there has been growing interest in their use for other congenital conditions. Recently, DBS is now proposed as an efficient tool to diagnose HAE with C1 inhibitor deficiency, and its use would improve the access to outbound areas and family members. Regarding HAE with normal C1 inhibitor, complement assays’ results are normal and the genetic sequencing of target genes, such as exon 9 of F12 and PLG, is the only available method. New methods to measure cleaved high-molecular-weight kininogen and activated plasma kallikrein have emerged as potential biochemical tests to identify bradykinin-mediated angioedema. Validated biomarkers of kallikrein–kinin system activation could be helpful in differentiating mechanisms of angioedema. Our aim is to focus on the capability to differentiate histaminergic AE from bradykinin-mediated AE. In addition, we will describe the challenges developing specific tests like direct bradykinin measurements. The need for quality tests to improve the diagnosis is well represented by the variability of results in functional assays.
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Affiliation(s)
- Anete S Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitario Faculdade de Medicina ABC (FMABC), Santo Andre, Brazil
| | - Camila L Veronez
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, CA, United States.,Research Service, San Diego Veterans Affairs Healthcare, San Diego, CA, United States
| | - Dorottya Csuka
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
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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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Angioedema without urticaria: novel findings which must be measured in clinical setting. Curr Opin Allergy Clin Immunol 2020; 20:253-260. [DOI: 10.1097/aci.0000000000000633] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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