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Maurer M, Magerl M, Betschel S, Aberer W, Ansotegui IJ, Aygören-Pürsün E, Banerji A, Bara NA, Boccon-Gibod I, Bork K, Bouillet L, Boysen HB, Brodszki N, Busse PJ, Bygum A, Caballero T, Cancian M, Castaldo AJ, Cohn DM, Csuka D, Farkas H, Gompels M, Gower R, Grumach AS, Guidos-Fogelbach G, Hide M, Kang HR, Kaplan AP, Katelaris CH, Kiani-Alikhan S, Lei WT, Lockey RF, Longhurst H, Lumry W, MacGinnitie A, Malbran A, Martinez Saguer I, Matta Campos JJ, Nast A, Nguyen D, Nieto-Martinez SA, Pawankar R, Peter J, Porebski G, Prior N, Reshef A, Riedl M, Ritchie B, Sheikh FR, Smith WB, Spaeth PJ, Stobiecki M, Toubi E, Varga LA, Weller K, Zanichelli A, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema – The 2021 revision and update. World Allergy Organ J 2022; 15:100627. [PMID: 35497649 PMCID: PMC9023902 DOI: 10.1016/j.waojou.2022.100627] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 11/05/2021] [Accepted: 12/21/2021] [Indexed: 12/21/2022] Open
Abstract
Hereditary Angioedema (HAE) is a rare and disabling disease for which early diagnosis and effective therapy are critical. This revision and update of the global WAO/EAACI guideline on the diagnosis and management of HAE provides up-to-date guidance for the management of HAE. For this update and revision of the guideline, an international panel of experts reviewed the existing evidence, developed 28 recommendations, and established consensus by an online DELPHI process. The goal of these recommendations and guideline is to help physicians and their patients in making rational decisions in the management of HAE with deficient C1-inhibitor (type 1) and HAE with dysfunctional C1-inhibitor (type 2), by providing guidance on common and important clinical issues, such as: 1) How should HAE be diagnosed? 2) When should HAE patients receive prophylactic on top of on-demand treatment and what treatments should be used? 3) What are the goals of treatment? 4) Should HAE management be different for special HAE patient groups such as children or pregnant/breast feeding women? 5) How should HAE patients monitor their disease activity, impact, and control? It is also the intention of this guideline to help establish global standards for the management of HAE and to encourage and facilitate the use of recommended diagnostics and therapies for all patients.
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Maurer M, Magerl M, Betschel S, Aberer W, Ansotegui IJ, Aygören‐Pürsün E, Banerji A, Bara N, Boccon‐Gibod I, Bork K, Bouillet L, Boysen HB, Brodszki N, Busse PJ, Bygum A, Caballero T, Cancian M, Castaldo A, Cohn DM, Csuka D, Farkas H, Gompels M, Gower R, Grumach AS, Guidos‐Fogelbach G, Hide M, Kang H, Kaplan AP, Katelaris C, Kiani‐Alikhan S, Lei W, Lockey R, Longhurst H, Lumry WB, MacGinnitie A, Malbran A, Martinez Saguer I, Matta JJ, Nast A, Nguyen D, Nieto‐Martinez SA, Pawankar R, Peter J, Porebski G, Prior N, Reshef A, Riedl M, Ritchie B, Rafique Sheikh F, Smith WR, Spaeth PJ, Stobiecki M, Toubi E, Varga LA, Weller K, Zanichelli A, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema-The 2021 revision and update. Allergy 2022; 77:1961-1990. [PMID: 35006617 DOI: 10.1111/all.15214] [Citation(s) in RCA: 137] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/22/2021] [Accepted: 12/08/2021] [Indexed: 12/11/2022]
Abstract
Hereditary angioedema (HAE) is a rare and disabling disease for which early diagnosis and effective therapy are critical. This revision and update of the global WAO/EAACI guideline on the diagnosis and management of HAE provides up-to-date guidance for the management of HAE. For this update and revision of the guideline, an international panel of experts reviewed the existing evidence, developed 28 recommendations, and established consensus by an online DELPHI process. The goal of these recommendations and guideline is to help physicians and their patients in making rational decisions in the management of HAE with deficient C1 inhibitor (type 1) and HAE with dysfunctional C1 inhibitor (type 2), by providing guidance on common and important clinical issues, such as: (1) How should HAE be diagnosed? (2) When should HAE patients receive prophylactic on top of on-demand treatment and what treatments should be used? (3) What are the goals of treatment? (4) Should HAE management be different for special HAE patient groups such as children or pregnant/breast-feeding women? and (5) How should HAE patients monitor their disease activity, impact, and control? It is also the intention of this guideline to help establish global standards for the management of HAE and to encourage and facilitate the use of recommended diagnostics and therapies for all patients.
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Affiliation(s)
- Marcus Maurer
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | - Markus Magerl
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | | | - Werner Aberer
- Department of Dermatology Medical University of Graz Graz Austria
| | | | - Emel Aygören‐Pürsün
- Center for Children and Adolescents University Hospital Frankfurt Frankfurt Germany
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology Massachusetts General Hospital Boston Massachusetts USA
| | - Noémi‐Anna Bara
- Romanian Hereditary Angioedema Expertise CentreMediquest Clinical Research Center Sangeorgiu de Mures Romania
| | - Isabelle Boccon‐Gibod
- National Reference Center for Angioedema (CREAK) Angioedema Center of Reference and Excellence (ACARE) Grenoble Alpes University Hospital Grenoble France
| | - Konrad Bork
- Department of Dermatology University Medical CenterJohannes Gutenberg University Mainz Germany
| | - Laurence Bouillet
- National Reference Center for Angioedema (CREAK) Angioedema Center of Reference and Excellence (ACARE) Grenoble Alpes University Hospital Grenoble France
| | | | - Nicholas Brodszki
- Department of Pediatric Immunology Childrens HospitalSkåne University Hospital Lund Sweden
| | | | - Anette Bygum
- Clinical Institute University of Southern Denmark Odense Denmark
- Department of Clinical Genetics Odense University Hospital Odense Denmark
| | - Teresa Caballero
- Allergy Department Hospital Universitario La PazIdiPaz, CIBERER U754 Madrid Spain
| | - Mauro Cancian
- Department of Systems Medicine University Hospital of Padua Padua Italy
| | | | - Danny M. Cohn
- Department of Vascular Medicine Amsterdam UMC/University of Amsterdam Amsterdam The Netherlands
| | - Dorottya Csuka
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Henriette Farkas
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Mark Gompels
- Clinical Immunology North Bristol NHS Trust Bristol UK
| | - Richard Gower
- Marycliff Clinical ResearchPrinciple Research Solutions Spokane Washington USA
| | | | | | - Michihiro Hide
- Department of Dermatology Hiroshima Citizens Hospital Hiroshima Japan
- Department of Dermatology Hiroshima University Hiroshima Japan
| | - Hye‐Ryun Kang
- Department of Internal Medicine Seoul National University College of Medicine Seoul Korea
| | - Allen Phillip Kaplan
- Division of Pulmonary, Critical Care, Allergy and Immunology Medical university of South Carolina Charleston South Carolina USA
| | - Constance Katelaris
- Department of Medicine Campbelltown Hospital and Western Sydney University Sydney NSW Australia
| | | | - Wei‐Te Lei
- Division of Allergy, Immunology, and Rheumatology Department of Pediatrics Mackay Memorial Hospital Hsinchu Taiwan
| | - Richard Lockey
- Division of Allergy and Immunology Department of Internal Medicine Morsani College of MedicineUniversity of South Florida Tampa Florida USA
| | - Hilary Longhurst
- Department of Immunology Auckland District Health Board and Department of MedicineUniversity of Auckland Auckland New Zealand
| | - William B. Lumry
- Internal Medicine Allergy Division University of Texas Health Science Center Dallas Texas USA
| | - Andrew MacGinnitie
- Division of Immunology Department of Pediatrics Boston Children's HospitalHarvard Medical School Boston Massachusetts USA
| | - Alejandro Malbran
- Unidad de Alergia, Asma e Inmunología Clínica Buenos Aires Argentina
| | | | | | - Alexander Nast
- Department of Dermatology, Venereology and Allergology Division of Evidence‐Based Medicine Charité ‐ Universitätsmedizin Berlincorporate member of Free University of BerlinHumboldt University of Berlin, and Berlin Institute of Health Berlin Germany
| | - Dinh Nguyen
- Respiratory, Allergy and Clinical Immunology Unit Internal Medicine Department Vinmec Healthcare System College of Health SciencesVinUniversity Hanoi Vietnam
| | | | - Ruby Pawankar
- Department of Pediatrics Nippon Medical School Tokyo Japan
| | - Jonathan Peter
- Division of Allergy and Clinical Immunology University of Cape Town Cape Town South Africa
- Allergy and Immunology Unit University of Cape Town Lung Institute Cape Town South Africa
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology Jagiellonian University Medical College Krakow Poland
| | - Nieves Prior
- Allergy Hospital Universitario Severo Ochoa Madrid Spain
| | - Avner Reshef
- Angioderma CenterBarzilai University Medical Center Ashkelon Israel
| | - Marc Riedl
- Division of Rheumatology, Allergy and Immunology University of California San Diego La Jolla California USA
| | - Bruce Ritchie
- Departments of Medicine and Medical Oncology University of Alberta Edmonton AB Canada
| | - Farrukh Rafique Sheikh
- Section of Adult Allergy & Immunology Department of Medicine King Faisal Specialist Hospital & Research Centre Riyadh Saudi Arabia
| | - William R. Smith
- Clinical Immunology and Allergy Royal Adelaide Hospital Adelaide SA Australia
| | - Peter J. Spaeth
- Institute of PharmacologyUniversity of Bern Bern Switzerland
| | - Marcin Stobiecki
- Department of Clinical and Environmental Allergology Jagiellonian University Medical College Krakow Poland
| | - Elias Toubi
- Division of Allergy and Clinical Immunology Bnai Zion Medical CenterAffiliated with Rappaport Faculty of MedicineTechnion‐Israel Institute of Technology Haifa Israel
| | - Lilian Agnes Varga
- Department of Internal Medicine and Haematology Hungarian Angioedema Center of Reference and Excellence Semmelweis University Budapest Hungary
| | - Karsten Weller
- Institute of Allergology Charité—Universitätsmedizin Berlincorporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin Berlin Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Immunology and Allergology Berlin Germany
| | - Andrea Zanichelli
- Department of Internal Medicine ASST Fatebenefratelli Sacco Ospedale Luigi Sacco‐University of Milan Milan Italy
| | - Yuxiang Zhi
- Department of Allergy and Clinical Immunology Bejing Union Medical College Hospital & Chinese Academy of Medical Sciences Bejing China
| | - Bruce Zuraw
- University of California, San Diego San Diego California USA
| | - Timothy Craig
- Departments of Medicine and Pediatrics Penn State University Hershey Pennsylvania USA
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Jindal AK, Bishnoi A, Dogra S. Hereditary Angioedema: Diagnostic Algorithm and Current Treatment Concepts. Indian Dermatol Online J 2021; 12:796-804. [PMID: 34934714 PMCID: PMC8653746 DOI: 10.4103/idoj.idoj_398_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 11/23/2022] Open
Abstract
Hereditary angioedema (HAE) is an uncommon disorder with a global prevalence of approximately 1 in 10,000 to 1 in 50,000 population. This disease is grossly underrecognized in India because of lack of awareness and/or lack of diagnostic facilities. Clinical manifestations include swelling over face, eyes, lips, hands, feet, and genitals, abdominal pain, and life-threatening laryngeal edema. HAE should be suspected in all patients who present with angioedema without wheals and who do not respond to antihistamines and/or steroids. C1 levels, C1-INH levels, and C1-INH function should be checked in all patients suspected to have HAE. C1q levels should be assessed in patients with suspected autoimmune-mediated acquired angioedema. Management of HAE constitutes the treatment of acute attack and short-term and long-term prophylaxis. Because of lack of all first-line recommended medications, the management of HAE in India is a challenging task. Patients are managed using fresh frozen plasma (acute treatment), tranexamic acid, and attenuated androgens (prophylaxis). Even though attenuated androgens have been shown to be effective in the prevention of attacks of HAE, the side effect profile especially in children and in females is a serious concern. Hence, the treatment needs to be individualized considering the risk-benefit ratio of long-term prophylaxis. In this review, we provide an overview of diagnostic strategy for patients with HAE and the current treatment concepts with emphasis on currently available treatment options in resource-constrained settings.
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Affiliation(s)
| | - Anuradha Bishnoi
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Grumach AS, Staubach-Renz P, Villa RC, Diez-Zuluaga S, Reese I, Lumry WR. Triggers of Exacerbation in Chronic Urticaria and Recurrent Angioedema-Prevalence and Relevance. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2160-2168. [PMID: 34112472 DOI: 10.1016/j.jaip.2021.04.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/09/2021] [Accepted: 04/15/2021] [Indexed: 02/06/2023]
Abstract
Patients with urticaria and angioedema often have triggers that cause an outbreak or a swelling episode or worsen their chronic condition. Exploring these factors with each patient may result in better understanding and control of their disease. Patients should be advised to avoid known triggers, if feasible, or prepare to prevent or control an exacerbation with appropriate pretreatment if avoidance is not possible. In this review, we describe and discuss a variety of factors for which there is evidence that they cause or exacerbate chronic spontaneous urticaria and angioedema. These potentially exacerbating factors include drugs, food additives, and naturally occurring pseudoallergens, mental stress, and trauma.
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Affiliation(s)
| | | | - Ricardo Cardona Villa
- Facultad de Medicina-Universidad de Antioquia, Grupo de Alergología Clínica y Experimental, Medellín, Colombia
| | - Susana Diez-Zuluaga
- Facultad de Medicina-Universidad de Antioquia, Grupo de Alergología Clínica y Experimental, Medellín, Colombia
| | - Imke Reese
- Dietary Counseling and Nutrition Therapy Centre, Munich, Germany
| | - William R Lumry
- Clinical Faculty, University of Texas Southwestern Medical School, Allergy and Asthma Specialists, Dallas, Texas.
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Abstract
Abdominal pain is one of the most common conditions leading people to the emergency department. An uncommon but well described cause of abdominal pain is angioedema of the gastrointestinal tract due to recurrent angioedema without wheals. Abdominal involvement is very common in hereditary angioedema (HAE), but it is also described in acquired angioedema and allergic forms. In patients with HAE, the involvement of gastrointestinal tract with resultant abdominal pain occurs in 43-93% of cases. Attacks can involve the entire gastrointestinal tract, such as the oropharynx, small intestine, colon, liver, or pancreas. Pain is the most common gastrointestinal symptom, and it may occur for many years even without cutaneous or respiratory symptoms. The case report we included in this article emphasizes the importance of accurate evaluation of personal and family history in patients with a long history of acute, severe, and unexplained abdominal pain, and it gives an example of how diagnostic delay may be longer if gastroenterological symptoms are the predominant clinical presentation. Furthermore, sometimes the simultaneous presence of concomitant gastrointestinal disorders and HAE may cause difficulties in differential diagnosis. Gastroenterologists and other physicians should add HAE to their list of potential causes of unexplained abdominal pain. The initiation of appropriate prophylaxis and treatment will prevent needless suffering and useless surgical and medical procedures.
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Mitigating Disparity in Health-care Resources Between Countries for Management of Hereditary Angioedema. Clin Rev Allergy Immunol 2021; 61:84-97. [PMID: 34003432 PMCID: PMC8282575 DOI: 10.1007/s12016-021-08854-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 12/28/2022]
Abstract
Hereditary angioedema (HAE) is a rare genetic disorder characterized by recurrent episodes of skin and mucosal edema. The main treatment goal is to enable a “normal life” for all patients. However, due to high costs, there are limited options for the management of HAE in most developing and low-income countries. As a result, most of the recommended first-line treatments are not available. In this review, we attempt to highlight the disparities in health-care resources for the management of patients with HAE amongst different countries. Data was collected from HAE experts in countries who provide tabulated information regarding management and availability of HAE treatments in their countries. We reviewed the two most recent international HAE guidelines. Using India, the world’s second most populous country, as a paradigm for HAE management in lower-income countries, we reviewed the evidence for second-line and non-recommended practices reported by HAE experts. Results suggest significant inequities in provision of HAE services and treatments. HAE patients in low-income countries do not have access to life-saving acute drugs or recently developed highly effective prophylactic medications. Most low-income countries do not have specialized HAE services or diagnostic facilities, resulting in consequent long delays in diagnosis. Suggestions for optimizing the use of limited resources as a basis for future discussion and reaching a global consensus are provided. There is an urgent need to improve HAE services, diagnostics and treatments currently available to lower-income countries. We recommend that all HAE stakeholders support the need for global equity and access to these essential measures.
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Molecular Dambusters: What Is Behind Hyperpermeability in Bradykinin-Mediated Angioedema? Clin Rev Allergy Immunol 2021; 60:318-347. [PMID: 33725263 PMCID: PMC7962090 DOI: 10.1007/s12016-021-08851-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 02/08/2023]
Abstract
In the last few decades, a substantial body of evidence underlined the pivotal role of bradykinin in certain types of angioedema. The formation and breakdown of bradykinin has been studied thoroughly; however, numerous questions remained open regarding the triggering, course, and termination of angioedema attacks. Recently, it became clear that vascular endothelial cells have an integrative role in the regulation of vessel permeability. Apart from bradykinin, a great number of factors of different origin, structure, and mechanism of action are capable of modifying the integrity of vascular endothelium, and thus, may participate in the regulation of angioedema formation. Our aim in this review is to describe the most important permeability factors and the molecular mechanisms how they act on endothelial cells. Based on endothelial cell function, we also attempt to explain some of the challenging findings regarding bradykinin-mediated angioedema, where the function of bradykinin itself cannot account for the pathophysiology. By deciphering the complex scenario of vascular permeability regulation and edema formation, we may gain better scientific tools to be able to predict and treat not only bradykinin-mediated but other types of angioedema as well.
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Short-term prophylaxis in patients with angioedema due to C1-inhibitor deficiency undergoing dental procedures: An observational study. PLoS One 2020; 15:e0230128. [PMID: 32163480 PMCID: PMC7067439 DOI: 10.1371/journal.pone.0230128] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/23/2020] [Indexed: 12/02/2022] Open
Abstract
Background Patients affected by angioedema due to hereditary and acquired C1-inhibitor (C1-INH) deficiency (HAE and AAE, respectively) report trouble accessing dental care, due to the risk of a life-threatening oropharyngeal and laryngeal attack triggered by dental procedures. The aim of this study was to assess the identification of hurdles in receiving dental care, and the effectiveness of short-term prophylaxis (STP) in preventing angioedema attacks. In addition, the study evaluated the impact of dental care in angioedema disease. All patients affected by angioedema due to C1-INH deficiency who were treated in the dentistry outpatient department of ASST Fatebenefratelli Sacco hospital (Milan, Italy) between 2009 and 2017 were considered for the analysis. Data were collected from patients’ records. Results Twenty-nine patients were analyzed (27 with HAE and 2 with AAE). Of these, 63.0% reported that they had previously experienced hurdles in accessing dental care. Among patients with pathological oral status, at the first visit, 59.26% patients had moderate-to-severe oral disease. Seventy-five dental procedures were performed in 20 patients. Sixty procedures were preceded by STP (58 with plasma-derived C1-INH and 2 with danazol) in patients with/without long-term prophylaxis (LTP). Post-procedural attacks occurred in two patients. One HAE patient undergoing a tooth extraction without STP/LTP experienced a laryngeal attack. The other post-procedural attack occurred in an AAE patient with anti-C1-INH antibodies with STP with pdC1-INH. The angioedema disease did not worsen in any patient after dental care, but improved in four of them. Conclusions Most C1-INH-HAE patients reported hurdles in receiving dental care. STP protects against attacks after dental procedures. Treating oral diseases results in improvement in the frequency of attacks.
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Andrási N, Veszeli N, Holdonner Á, Temesszentandrási G, Kőhalmi KV, Varga L, Farkas H. Evaluation of the efficacy and safety of home treatment with the recombinant human C1-inhibitor in hereditary angioedema resulting from C1-inhibitor deficiency. Int Immunopharmacol 2020; 80:106216. [DOI: 10.1016/j.intimp.2020.106216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 01/14/2020] [Indexed: 11/25/2022]
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Abstract
Angioedema is a localized swelling of the skin and submucosal tissues and is generally benign and self-limiting. However, it can be life threatening if angioedema involves the upper airway, resulting in airway obstruction. Airway protection would be critical and lifesaving in patients with angioedema irrespective of the underlying etiology. Detailed history and physical examination can help identify the underlying mechanism of angioedema in an individual patient (ie, mast-cell versus bradykinin-mediated angioedema). Treatment of angioedema depends on the underlying etiology. Mast cell-mediated angioedema is generally responsive to steroids, antihistamines, and epinephrine (when indicated), unlike bradykinin-mediated disease. [Pediatr Ann. 2019;48(12):e473-e478.].
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Jamil B, Naeem MS, Anachebe T, Majeed MH. Hereditary angio-oedema as a rare cause of small-bowel obstruction. BMJ Case Rep 2019; 12:e231186. [PMID: 31653632 PMCID: PMC6827814 DOI: 10.1136/bcr-2019-231186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2019] [Indexed: 11/04/2022] Open
Abstract
A 52-year-old man with known hereditary angio-oedema (HAE) presented with a 2-day history of progressive severe abdominal pain, distension, nausea, vomiting and constipation. CT of his abdomen and pelvis showed small-bowel obstruction and ascites. HAE is a rare autosomal dominant disorder caused by a C1 esterase deficiency and involves episodic oedema of subcutaneous and mucosal tissues. It commonly affects the face and limbs, causing deformity; the respiratory tract, causing life-threatening laryngeal swelling; and the gastrointestinal tract, causing small-bowel obstruction. An infusion of a C1 esterase inhibitor was given to the patient. His symptoms resolved within 6 hours, and a repeat CT showed complete resolution 24 hours later. Small-bowel obstruction in HAE is often misdiagnosed, leading to ineffective treatment and unnecessary surgery. Therefore, this should be suspected in patients with HAE presenting with an acute abdomen, and clinicians should understand the unique treatment required.
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Affiliation(s)
- Bilal Jamil
- Surgery, Our Lady of Lourdes Hospital, Drogheda, Ireland
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12
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Bygum A. Hereditary Angio-Oedema for Dermatologists. Dermatology 2019; 235:263-275. [PMID: 31167185 DOI: 10.1159/000500196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/08/2019] [Indexed: 11/19/2022] Open
Abstract
Among angio-oedema patients, hereditary angio-oedema (HAE) should not be overlooked. Besides skin swellings, these patients might have very painful abdominal attacks and potentially life-threatening angio-oedema of the upper airway. They will not respond to traditional anti-allergic therapy with antihistamines, corticosteroids, and adrenaline, and instead need specific drugs targeting the kallikrein-kinin pathway. Classically, patients with HAE have a quantitative or qualitative deficiency of the C1 inhibitor (C1INH) due to different mutations in SERPING1, although a new subtype with normal C1INH has been recognised more recently. This latter variant is diagnosed based on clinical features, family history, or molecular genetic testing for mutations in F12, ANGPT1,or PLG.The diagnosis of HAE is often delayed due to a general unfamiliarity with this orphan disease. However, undiagnosed patients are at an increased risk of unnecessary surgical interventions or life-threatening laryngeal swellings. Within the last decade, new and effective therapies have been developed and launched for acute and prophylactic therapy. Even more drugs are under evaluation in clinical trials. It is therefore of utmost importance that patients with HAE are diagnosed as soon as possible and offered relevant therapy with orphan drugs to reduce morbidity, prevent mortality, and improve quality of life.
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Affiliation(s)
- Anette Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark,
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Neutrophils Are Dysregulated in Patients with Hereditary Angioedema Types I and II in a Symptom-Free Period. Mediators Inflamm 2019; 2019:9515628. [PMID: 31236065 PMCID: PMC6545807 DOI: 10.1155/2019/9515628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/06/2019] [Accepted: 03/18/2019] [Indexed: 12/23/2022] Open
Abstract
Neutrophils impact on processes preceding the formation of bradykinin, a major swelling mediator in hereditary angioedema (HAE), yet their potential role in HAE pathogenesis has not been sufficiently studied. We assessed the relative mRNA expression of 10 genes related to neutrophil activation using RNA extracted from the peripheral blood neutrophils of 23 HAE patients in a symptom-free period and 39 healthy donors. Increased relative mRNA expression levels of CD274, IL1B, IL1RN, IL8, MMP9, and TLR4, together with a lack in their mutual correlations detected in HAE patients compared to healthy controls, suggested a preactivated state and dysregulation of patients' neutrophils. Patients' neutrophil-alerted state was further supported by increased CD11b, decreased CD16 plasma membrane deposition, and increased relative CD274+ and CD87+ neutrophil counts, but not by increased neutrophil elastase or myeloperoxidase plasma levels. As CD274 mediates inhibitory signals to different immune cells, neutrophils were cocultured with T-cells/PBMC. The decrease in CD25+ and IFN-γ + T-cell/PBMC ratio in patients indicated the patients' neutrophil suppressive functions. In summary, the results showed neutrophils' alerted state and dysregulation at the transcript level in patients with HAE types I and II even in a symptom-free period, which might make them more susceptible to edema formation. Neutrophils' T-cell suppressive capacity in HAE patients needs to be further investigated.
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Maurer M, Magerl M, Ansotegui I, Aygören-Pürsün E, Betschel S, Bork K, Bowen T, Balle Boysen H, Farkas H, Grumach AS, Hide M, Katelaris C, Lockey R, Longhurst H, Lumry WR, Martinez-Saguer I, Moldovan D, Nast A, Pawankar R, Potter P, Riedl M, Ritchie B, Rosenwasser L, Sánchez-Borges M, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema-The 2017 revision and update. Allergy 2018; 73:1575-1596. [PMID: 29318628 DOI: 10.1111/all.13384] [Citation(s) in RCA: 298] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 12/25/2022]
Abstract
Hereditary Angioedema (HAE) is a rare and disabling disease. Early diagnosis and appropriate therapy are essential. This update and revision of the global guideline for HAE provides up-to-date consensus recommendations for the management of HAE. In the development of this update and revision of the guideline, an international expert panel reviewed the existing evidence and developed 20 recommendations that were discussed, finalized and consented during the guideline consensus conference in June 2016 in Vienna. The final version of this update and revision of the guideline incorporates the contributions of a board of expert reviewers and the endorsing societies. The goal of this guideline update and revision is to provide clinicians and their patients with guidance that will assist them in making rational decisions in the management of HAE with deficient C1-inhibitor (type 1) and HAE with dysfunctional C1-inhibitor (type 2). The key clinical questions covered by these recommendations are: (1) How should HAE-1/2 be defined and classified?, (2) How should HAE-1/2 be diagnosed?, (3) Should HAE-1/2 patients receive prophylactic and/or on-demand treatment and what treatment options should be used?, (4) Should HAE-1/2 management be different for special HAE-1/2 patient groups such as pregnant/lactating women or children?, and (5) Should HAE-1/2 management incorporate self-administration of therapies and patient support measures?
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Affiliation(s)
- M. Maurer
- Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - M. Magerl
- Department of Dermatology and Allergy; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - I. Ansotegui
- Department of Allergy and Immunology; Hospital Quironsalud Bizkaia; Bilbao Spain
| | - E. Aygören-Pürsün
- Center for Children and Adolescents; University Hospital Frankfurt; Frankfurt Germany
| | - S. Betschel
- Division of Clinical Immunology and Allergy; St. Michael's Hospital; University of Toronto; Toronto ON Canada
| | - K. Bork
- Department of Dermatology; Johannes Gutenberg University Mainz; Mainz Germany
| | - T. Bowen
- Department of Medicine and Pediatrics; University of Calgary; Calgary AB Canada
| | | | - H. Farkas
- Hungarian Angioedema Center; 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - A. S. Grumach
- Clinical Immunology; Faculdade de Medicina ABC; São Paulo Brazil
| | - M. Hide
- Department of Dermatology; Hiroshima University; Hiroshima Japan
| | - C. Katelaris
- Department of Medicine; Campbelltown Hospital and Western Sydney University; Sydney NSW Australia
| | - R. Lockey
- Department of Internal Medicine; University of South Florida Morsani College of Medicine; Tampa FL USA
| | - H. Longhurst
- Department of Clinical Biochemistry and Immunology; Addenbrooke's Hospital; Cambridge University Hospitals NHS Foundation Trust; UK
| | - W. R. Lumry
- Department of Internal Medicine; Allergy/Immunology Division; Southwestern Medical School; University of Texas; Dallas TX USA
| | | | - D. Moldovan
- University of Medicine and Pharmacy; Tîrgu Mures Romania
| | - A. Nast
- Berlin Institute of Health; Department of Dermatology, Venereology und Allergy; Division of Evidence based Medicine (dEBM); Corporate Member of Freie Universität Berlin; Humboldt-Universität zu Berlin; Charité-Universitätsmedizin Berlin; Berlin Germany
| | - R. Pawankar
- Department of Pediatrics; Nippon Medical School; Tokyo Japan
| | - P. Potter
- Department of Medicine; University of Cape Town; Cape Town South Africa
| | - M. Riedl
- Department of Medicine; University of California-San Diego; La Jolla CA USA
| | - B. Ritchie
- Division of Hematology; University of Alberta; Edmonton AB Canada
| | - L. Rosenwasser
- Allergy and Immunology Department; University of Missouri at Kansas City School of Medicine; Kansas City MO USA
| | - M. Sánchez-Borges
- Allergy and Clinical Immunology Department; Centro Medico Docente La Trinidad; Caracas Venezuela
| | - Y. Zhi
- Department of Allergy; Peking Union Medical College Hospital and Chinese Academy of Medical Sciences; Beijing China
| | - B. Zuraw
- Department of Medicine; University of California-San Diego; La Jolla CA USA
- San Diego VA Healthcare; San Diego CA USA
| | - T. Craig
- Department of Medicine and Pediatrics; Penn State University; Hershey PA USA
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Maurer M, Magerl M, Ansotegui I, Aygören-Pürsün E, Betschel S, Bork K, Bowen T, Boysen HB, Farkas H, Grumach AS, Hide M, Katelaris C, Lockey R, Longhurst H, Lumry WR, Martinez-Saguer I, Moldovan D, Nast A, Pawankar R, Potter P, Riedl M, Ritchie B, Rosenwasser L, Sánchez-Borges M, Zhi Y, Zuraw B, Craig T. The international WAO/EAACI guideline for the management of hereditary angioedema – the 2017 revision and update. World Allergy Organ J 2018. [DOI: 10.1186/s40413-017-0180-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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16
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Greve J, Strassen U, Gorczyza M, Dominas N, Frahm UM, Mühlberg H, Wiednig M, Zampeli V, Magerl M. Prophylaxis in hereditary angioedema (HAE) with C1 inhibitor deficiency. J Dtsch Dermatol Ges 2016; 14:266-75. [PMID: 26972189 DOI: 10.1111/ddg.12856] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hereditary angioedema (HAE) is a rare congenital disorder characterized by recurrent episodes of subcutaneous or submucosal edema. Laryngeal manifestations can be life-threatening. In the majority of cases, the disease can be adequately treated with an on-demand approach--in some cases, however, short- or long-term prophylaxis is indicated. Attenuated androgens used to be the drugs of choice, but they are associated with considerable side effects and no longer commercially available in the German-speaking countries of the EU. They are currently being replaced by more effective and more tolerable agents such C1-inhibitors, the kallikrein inhibitor ecallantide, and the B2 receptor antagonist icatibant, which have recently obtained market authorization. These new drugs have had a major impact, especially on the indications and procedures for long-term prophylaxis. According to the most recent international consensus papers and our own experience, self-administered C1-inhibitors are now the first option for long-term prophylactic therapy. The decision for prophylaxis should no longer be based on single parameters such as the frequency of attacks but on adequate overall disease control including quality of life. More drugs are currently being developed, which may lead to further changes in the treatment algorithms of HAE.
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Affiliation(s)
- Jens Greve
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Ulrich Strassen
- Department of Otorhinolaryngology, Head and Neck Surgery, Technical University of Munich, Germany
| | - Marina Gorczyza
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité - Universitätsmedizin, Berlin, Germany
| | - Nina Dominas
- Department of Otorhinolaryngology, Head and Neck Surgery, University hospital, Essen, Germany
| | - Uta-Marie Frahm
- Department of Otorhinolaryngology, Head and Neck Surgery, University hospital, Essen, Germany
| | | | - Michaela Wiednig
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Vasiliki Zampeli
- Departments of Dermatology, Venereology, Allergology, and Immunology, Dessau Medical Center, Dessau, Weinheim, Germany
| | - Markus Magerl
- Department of Dermatology and Allergy, Allergie-Centrum-Charité, Charité - Universitätsmedizin, Berlin, Germany
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Zotter Z, Veszeli N, Kőhalmi KV, Varga L, Imreh É, Kovács G, Nallbani M, Farkas H. Bacteriuria increases the risk of edematous attacks in hereditary angioedema with C1-inhibitor deficiency. Allergy 2016; 71:1791-1793. [PMID: 27548887 DOI: 10.1111/all.13034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2016] [Indexed: 11/30/2022]
Abstract
Urinary tract infections are considered among the most common infectious disorders in humans. Various infections may have a role in inducing HAE attacks. Our study intended to evaluate bacteriuria in the urinalysis of patients with C1-INH-HAE. Urine specimens contributed by 139 patients with C1-INH-HAE at the annual control visits were studied retrospectively for microorganisms. We analyzed the presence of bacteriuria in relation to the clinical symptoms. Taking into account three randomly selected urine specimens, we found that the cumulative number of edematous attacks was higher in patients with bacteriuria than in those without (P = 0.019, P = 0.022, P = 0.014). Considering the same patients, attack number was significantly higher (14.51 vs 8.63) in patients with bacteriuria than in those without (P < 0.0001). In patients with bacteriuria, we found a higher incidence of edema formation during the year before evaluation, which may suggest the triggering role of bacteriuria in the occurrence of edematous episodes.
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Affiliation(s)
- Z. Zotter
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
- Urology Department; Medical Center; Hungarian Defence Forces; Budapest Hungary
| | - N. Veszeli
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - K. V. Kőhalmi
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - L. Varga
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
| | - É. Imreh
- Department of Laboratory Medicine; Semmelweis University; Budapest Hungary
| | - G. Kovács
- Urology Department; Medical Center; Hungarian Defence Forces; Budapest Hungary
| | - M. Nallbani
- Urology Department; Medical Center; Hungarian Defence Forces; Budapest Hungary
| | - H. Farkas
- 3rd Department of Internal Medicine; Semmelweis University; Budapest Hungary
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Greve J, Strassen U, Gorczyza M, Dominas N, Frahm UM, Mühlberg H, Wiednig M, Zampeli V, Magerl M. Prophylaxe beim hereditären Angioödem (HAE) mit C1-Inhibitormangel. J Dtsch Dermatol Ges 2016. [DOI: 10.1111/ddg.12856_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jens Greve
- Abteilung für Hals-Nasen- Ohrenheilkunde; Kopf- und Halschirurgie, Universitätsklinikum Ulm; Ulm Deutschland
| | - Ulrich Strassen
- Abteilung für Hals-Nasen-Ohrenheilkunde; Kopf- und Halschirurgie, Technische Universität München; München Deutschland
| | - Marina Gorczyza
- Abteilung für Dermatologie und Allergologie; Allergiezentrum Charité, Charité-Universitätsmedizin Berlin; Deutschland
| | - Nina Dominas
- Abteilung für Hals-Nasen-Ohrenheilkunde; Kopf- und Halschirurgie, Universität klinikum; Essen Deutschland
| | - Uta-Marie Frahm
- Abteilung für Hals-Nasen-Ohrenheilkunde; Kopf- und Halschirurgie, Universität klinikum; Essen Deutschland
| | - Heike Mühlberg
- Healthcare at Home Deutschland GmbH; Weinheim Deutschland
| | - Michaela Wiednig
- Abteilung für Dermatologie; Medizinische Universität Graz; Graz Österreich
| | - Vasiliki Zampeli
- Abteilungen für Dermatologie, Venerologie, Allergologie und Immunologie; Städtisches Klinikum Dessau; Dessau Deutschland
| | - Markus Magerl
- Abteilung für Dermatologie und Allergologie; Allergiezentrum Charité, Charité-Universitätsmedizin Berlin; Deutschland
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Idiopathic Thrombocytopenic Purpura Misdiagnosed as Hereditary Angioedema. Case Rep Dermatol Med 2016; 2015:934247. [PMID: 26819784 PMCID: PMC4706890 DOI: 10.1155/2015/934247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/05/2015] [Accepted: 12/15/2015] [Indexed: 12/03/2022] Open
Abstract
Hereditary angioedema is a rare, but potentially life-threatening genetic disorder that results from an autosomal dominant trait. It is characterized by acute, recurrent attacks of severe local edema, most commonly affecting the skin and mucosa. Swelling in hereditary angioedema patients does however not always have to be caused by angioedema but can relate to other concomitant disorders. In this report we are focusing on misdiagnosis in a patient with known hereditary angioedema, whose bleeding episode caused by idiopathic thrombocytopenic purpura was mistaken for an acute attack of hereditary angioedema. The case illustrates how clinicians can have difficulties in handling patients with rare diseases, especially in the emergency care setting.
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20
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Frazer-Abel A, Sepiashvili L, Mbughuni MM, Willrich MAV. Overview of Laboratory Testing and Clinical Presentations of Complement Deficiencies and Dysregulation. Adv Clin Chem 2016; 77:1-75. [PMID: 27717414 DOI: 10.1016/bs.acc.2016.06.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Historically, complement disorders have been attributed to immunodeficiency associated with severe or frequent infection. More recently, however, complement has been recognized for its role in inflammation, autoimmune disorders, and vision loss. This paradigm shift requires a fundamental change in how complement testing is performed and interpreted. Here, we provide an overview of the complement pathways and summarize recent literature related to hereditary and acquired angioedema, infectious diseases, autoimmunity, and age-related macular degeneration. The impact of complement dysregulation in atypical hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria, and C3 glomerulopathies is also described. The advent of therapeutics such as eculizumab and other complement inhibitors has driven the need to more fully understand complement to facilitate diagnosis and monitoring. In this report, we review analytical methods and discuss challenges for the clinical laboratory in measuring this complex biochemical system.
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Leiding JW, Beakes D, Dreskin SC, Grumach A, Hide M, Reshef A, Triggiani M, Kaliner MA. Case Title: 45 year-old male with recurrent angioedema: WAO international case-based discussions. World Allergy Organ J 2014; 7:2. [PMID: 24450312 PMCID: PMC3929145 DOI: 10.1186/1939-4551-7-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 10/31/2013] [Indexed: 12/05/2022] Open
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22
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Aygören‐Pürsün E, Martinez Saguer I, Kreuz W, Klingebiel T, Schwabe D. Risk of angioedema following invasive or surgical procedures in HAE type I and II--the natural history. Allergy 2013; 68:1034-9. [PMID: 23968383 PMCID: PMC4223932 DOI: 10.1111/all.12186] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2013] [Indexed: 01/28/2023]
Abstract
Background Hereditary angioedema (HAE), caused by deficiency in C1-inhibitor (C1-INH), leads to unpredictable edema of subcutaneous tissues with potentially fatal complications. As surgery can be a trigger for edema episodes, current guidelines recommend preoperative prophylaxis with C1-INH or attenuated androgens in patients with HAE undergoing surgery. However, the risk of an HAE attack in patients without prophylaxis has not been quantified. Objectives This analysis examined rates of perioperative edema in patients with HAE not receiving prophylaxis. Methods This was a retrospective analysis of records of randomly selected patients with HAE type I or II treated at the Frankfurt Comprehensive Care Centre. These were examined for information about surgical procedures and the presence of perioperative angioedema. Results A total of 331 patients were included; 247 underwent 700 invasive procedures. Of these procedures, 335 were conducted in 144 patients who had not received prophylaxis at the time of surgery. Categories representing significant numbers of procedures were abdominal (n = 113), ENT (n = 71), and gynecological (n = 58) procedures. The rate of documented angioedema without prophylaxis across all procedures was 5.7%; in 24.8% of procedures, the presence of perioperative angioedema could not be excluded, leading to a maximum potential risk of 30.5%. Predictors of perioperative angioedema could not be identified. Conclusion The risk of perioperative angioedema in patients with HAE type I or II without prophylaxis undergoing surgical procedures ranged from 5.7% to 30.5% (CI 3.5–35.7%). The unpredictability of HAE episodes supports current international treatment recommendations to consider short-term prophylaxis for all HAE patients undergoing surgery.
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Affiliation(s)
- E. Aygören‐Pürsün
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
| | - I. Martinez Saguer
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
| | - W. Kreuz
- Internationales Forschungsinstitut für Gerinnungsstörungen und Immundefekte Mörfelden‐Walldorf Germany
| | - T. Klingebiel
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
| | - D. Schwabe
- Hospital of the Goethe‐University Frankfurt Pediatric Clinic Angioedema Centre Frankfurt Germany
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23
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Zuraw BL, Bernstein JA, Lang DM, Craig T, Dreyfus D, Hsieh F, Khan D, Sheikh J, Weldon D, Bernstein DI, Blessing-Moore J, Cox L, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CR, Schuller DE, Spector SL, Tilles SA, Wallace D. A focused parameter update: Hereditary angioedema, acquired C1 inhibitor deficiency, and angiotensin-converting enzyme inhibitor–associated angioedema. J Allergy Clin Immunol 2013; 131:1491-3. [DOI: 10.1016/j.jaci.2013.03.034] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 03/11/2013] [Accepted: 03/14/2013] [Indexed: 11/26/2022]
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Abstract
Hereditary Angioedema (HAE) is a rare disease and for this reason proper diagnosis and appropriate therapy are often unknown or not available for physicians and other health care providers. For this reason we convened a group of specialists that focus upon HAE from around the world to develop not only a consensus on diagnosis and management of HAE, but to also provide evidence based grades, strength of evidence and classification for the consensus. Since both consensus and evidence grading were adhered to the document meets criteria as a guideline. The outcome of the guideline is to improve diagnosis and management of patients with HAE throughout the world and to help initiate uniform care and availability of therapies to all with the diagnosis no matter where the residence of the individual with HAE exists.
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Caballero T. Angio-oedema due to hereditary C1 inhibitor deficiency in children. Allergol Immunopathol (Madr) 2013; 41:45-53. [PMID: 22417938 DOI: 10.1016/j.aller.2012.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 12/29/2011] [Accepted: 01/02/2012] [Indexed: 11/28/2022]
Abstract
Hereditary angio-oedema due to C1 inhibitor deficiency (HAE-C1-INH) is a rare inherited disorder characterised by recurring and debilitating episodes of cutaneous swelling and abdominal pain and less frequent episodes of laryngeal oedema. Symptom onset is usually in childhood and early adolescence, with earlier disease onset associated with greater disease severity. Although HAE-C1-INH attacks are generally less frequent and less severe in children than in adults, they can cause significant physical and psychological impairment and affect advancement in school. There are often significant delays in the diagnosis of HAE-C1-INH due to its variable clinical presentation and because abdominal symptoms can often mimic other common paediatric gastrointestinal disorders. In recent years, several disease-specific agents have become available for the acute and prophylactic treatment of HAE-C1-INH. Although these treatments have not been evaluated rigorously in controlled clinical trials in children with HAE-C1-INH, paediatric data on efficacy and safety are available for some agents. Early diagnosis and initiation of appropriate therapy in children with HAE-C1-INH can help reduce the burden of this illness in the paediatric population.
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Affiliation(s)
- T Caballero
- Servicio de Alergia, Hospital La Paz Health Research Institute (IdiPaz), Biomedical Research Network on Rare diseases-U754 (CIBERER), Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain.
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Farkas H, Zotter Z, Csuka D, Szabó E, Nébenfűhrer Z, Temesszentandrási G, Jakab L, Varga L, Harmat G, Karádi I. Short-term prophylaxis in hereditary angioedema due to deficiency of the C1-inhibitor--a long-term survey. Allergy 2012; 67:1586-93. [PMID: 23025435 DOI: 10.1111/all.12032] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hereditary angioedema is a potentially life-threatening disorder, because edema occurring in the mucosa of the upper airways can lead to suffocation. The management of HAE consists of avoiding the triggering factors, prophylaxis, and the acute treatment of edematous episodes. Medical procedures can also provoke edematous attacks, and therefore, short-term prophylaxis (STP) is recommended before such interventions. Our aim was to evaluate the efficacy and safety of STP administered before medical procedures. METHODS We conducted a retrospective analysis before and a prospective survey after establishing the diagnosis in a group of 137 (60 males, 77 females; 20 pediatric and 117 adult) patients with HAE. Both were implemented using questionnaires, patient diaries and hospital charts focusing on medical interventions provoking edematous attack, and the medicinal products (C1-INH concentrate, tranexamic acid, and danazol) administered for STP. RESULTS Comparing surgical interventions performed without pre-event STP (in 39/89 patients before HAE was diagnosed), or after STP (in 3/55 cases after diagnosis), we found a significant (P < 0.0001, Fisher's exact test) reduction in the number of edematous episodes. Evaluating the efficacy of the drugs administered for STP revealed that C1-INH concentrate (Berinert(®) , CSL Behring, Marburg, Germany) was significantly (P = 0.0096, Fisher's exact test) superior to orally administered drugs in reducing the instances of postprocedural edema. None of the medicinal products caused adverse events potentially related to STP. CONCLUSIONS STP reduces the number of postprocedural edematous episodes. C1-INH concentrate is safe and effective for prophylaxis. When this agent is not available, danazol is a potential alternative for prophylaxis before elective medical interventions.
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Affiliation(s)
- H. Farkas
- 3rd Department of Internal Medicine; Semmelweis University; Budapest; Hungary
| | - Z. Zotter
- 3rd Department of Internal Medicine; Semmelweis University; Budapest; Hungary
| | - D. Csuka
- 3rd Department of Internal Medicine; Semmelweis University; Budapest; Hungary
| | - E. Szabó
- 3rd Department of Internal Medicine; Semmelweis University; Budapest; Hungary
| | - Z. Nébenfűhrer
- 3rd Department of Internal Medicine; Semmelweis University; Budapest; Hungary
| | | | - L. Jakab
- 3rd Department of Internal Medicine; Semmelweis University; Budapest; Hungary
| | - L. Varga
- 3rd Department of Internal Medicine; Semmelweis University; Budapest; Hungary
| | - G. Harmat
- “Heim Pál” Children's Hospital; Budapest; Hungary
| | - I. Karádi
- 3rd Department of Internal Medicine; Semmelweis University; Budapest; Hungary
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27
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Guilarte M. Actualización en angioedema hereditario por déficit del inhibidor de C1. Med Clin (Barc) 2012; 139:452-7. [DOI: 10.1016/j.medcli.2012.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 03/14/2012] [Accepted: 03/22/2012] [Indexed: 11/26/2022]
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Abstract
Hereditary angio-oedema is caused by a heterozygous deficiency of C1 inhibitor. This inhibitor regulates several inflammatory pathways, and patients with hereditary angio-oedema have intermittent cutaneous or mucosal swellings because of a failure to control local production of bradykinin. Swellings typically evolve in several hours and persist for a few days. In addition to orofacial angio-oedema, painless swellings affect peripheries, which causes disfigurement or interference with work and other activities of daily living. Angio-oedema affecting the gastrointestinal tract or abdominal viscera causes severe pain often with vomiting due to oedematous bowel obstruction. About 2% of swellings involve the larynx and can be fatal if untreated. About 50% of patients have laryngeal swellings that are potentially fatal despite prophylaxis. In this Seminar we review the clinical features, diagnosis, and management of hereditary angio-oedema, with specific emphasis on the new treatments available for acute swellings.
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Affiliation(s)
- Hilary Longhurst
- Department of Immunology, Barts and The London National Health Service Trust, Whitechapel, London, UK.
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Lee SY. Future candidates for indications of Helicobacter pylori eradication: do the indications need to be revised? J Gastroenterol Hepatol 2012; 27:200-11. [PMID: 22098099 DOI: 10.1111/j.1440-1746.2011.06961.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Since the discovery of Helicobacter pylori in 1982, the development of several treatment guidelines has allowed a consensus on the indications for H. pylori eradication. Beyond these currently accepted indications, including various upper gastrointestinal disorders and extragastric diseases, a significant amount of new information regarding H. pylori eradication is emerging. Certain types of acute gastritis, such as nodular gastritis, hypertrophic gastritis, Ménétrier's disease, hemorrhagic gastritis, and granulomatous gastritis are reversible after H. pylori eradication. Further, for chronic gastritis, closed-type atrophic gastritis and complete-type intestinal metaplasia appear to be more reversible after H. pylori eradication than open-type atrophic gastritis and incomplete-type intestinal metaplasia. Eradication can also be considered in subjects younger than 40 years who have a family history of gastric cancer and in subjects with long-term medications that might lead to bleeding (antiplatelet agents) or atrophy (proton pump inhibitors). Emerging evidence indicates that H. pylori eradication could be an effective treatment for some extragastric diseases that are unresponsive to conventional therapy. In such conditions, routine screening for eradication of H. pylori has not previously been recommended; a "test-and-treat" approach is suggested in the aforementioned situations. Given that H. pylori eradication is effective when the gastritis is reversible, future indications should be expanded to include acute gastric lesions that show marked improvement upon H. pylori eradication rather than just focusing on chronic gastric lesions. Future indications for H. pylori eradication should focus more on reversible lesions before preneoplastic conditions develop.
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Affiliation(s)
- Sun-Young Lee
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea.
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Prematta MJ, Prematta T, Craig TJ. Treatment of hereditary angioedema with plasma-derived C1 inhibitor. Ther Clin Risk Manag 2011; 4:975-82. [PMID: 19209279 PMCID: PMC2621399 DOI: 10.2147/tcrm.s3172] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Plasma-derived C1 inhibitor (C1-INH) concentrate is a treatment option for acute hereditary angioedema (HAE) attacks and is considered the standard-of-care in many countries, although it is not yet available in the United States. Studies are still being conducted to establish its safety and efficacy as required by the FDA. OBJECTIVE To review the medical literature to determine if C1-INH concentrate is a safe and effective treatment for acute HAE attacks. METHODS THE FOLLOWING KEYWORDS WERE SEARCHED IN PUBMED AND OVID: C1 esterase inhibitor, C1-inhibitor, C1 inhibitor, and hereditary angioedema treatment. English-language articles were searched from 1966 to the present to look for studies demonstrating the efficacy and the safety of C1-INH concentrate. RESULTS The English-language literature search revealed several studies showing significantly improved relief of HAE symptoms with the administration of C1-INH concentrate - many studies demonstrated some improvement of symptoms within 30 minutes. Side effects have been similar to placebo, and no proven cases of viral transmission have occurred in over 20 years. CONCLUSION C1-INH concentrate appears to be a very safe and effective treatment option for HAE.
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Affiliation(s)
- Michael J Prematta
- Section of Allergy and Immunology, Penn State University, Milton S. Hershey Medical Center, PA, USA
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Floccard B, Crozon J, Rimmelé T, Vulliez A, Coppere B, Chamouard V, Boccon-Gibod I, Bouillet L, Allaouchiche B. Prise en charge en urgence de l’angiœdème à bradykinine. ACTA ACUST UNITED AC 2011; 30:578-88. [DOI: 10.1016/j.annfar.2011.01.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 01/25/2011] [Indexed: 11/30/2022]
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No Evidence for Linkage between the Hereditary Angiooedema Clinical Phenotype and the BDKR1, BDKR2, ACE or MBL2 gene. Scand J Immunol 2011; 74:100-6. [DOI: 10.1111/j.1365-3083.2011.02547.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Tüzün Y, Keskin S, Kote E. The role of Helicobacter pylori infection in skin diseases: facts and controversies. Clin Dermatol 2010; 28:478-82. [PMID: 20797505 DOI: 10.1016/j.clindermatol.2010.03.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Helicobacter pylori is a Gram-negative bacterium that is considered a causative agent of peptic ulcer disease, gastric lymphoma, and gastric carcinoma. H pylori triggers an intense leucocyte infiltration of the gastric submucosa, an action that is mediated by proinflammatory cytokines. Because this pathogenetic mechanism is common to many other diseases, H pylori seroprevalence has also been investigated in other diseases. H pylori seropositivity is associated with various dermatologic disorders. Although the precise role of H pylori is unknown in these diseases, the organism can be eradicated, using simple and reliable drug regimens. This contribution highlights the dermatologic diseases associated with H pylori seropositivity.
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Affiliation(s)
- Yalçin Tüzün
- Department of Dermatology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey.
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Longhurst HJ. Management of acute attacks of hereditary angioedema: potential role of icatibant. Vasc Health Risk Manag 2010; 6:795-802. [PMID: 20859548 PMCID: PMC2941790 DOI: 10.2147/vhrm.s4332] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Indexed: 11/23/2022] Open
Abstract
Icatibant (Firazyr(®)) is a novel subcutaneous treatment recently licensed in the European Union for acute hereditary angioedema. Hereditary angioedema, resulting from inherited partial C1 inhibitor deficiency, is a disabling condition characterized by intermittent episodes of bradykinin-mediated angioedema. Icatibant blocks bradykinin B2 receptors, attenutating the episode. Randomized double-blind, placebo-controlled trials of icatibant, showed significant superiority over oral tranexamic acid in 74 European patients and a trend to improvement in a similar US trial comparing icatibant with placebo in 55 patients. Outcomes for several endpoints did not reach significance in the US trial, perhaps because of low participant numbers and confounding factors: a further trial is planned. Open label studies have shown benefit in multiple treatments for attacks at all sites. Approximately 10% of patients require a second dose for re-emergent symptoms, usually 10 to 27 hours after the initial treatment. Its subcutaneous route of administration, good tolerability and novel mode of action make icatibant a promising addition to the limited repertoire of treatments for hereditary angioedema.
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Wedi B, Raap U, Wieczorek D, Kapp A. Urticaria and infections. Allergy Asthma Clin Immunol 2009; 5:10. [PMID: 20066173 PMCID: PMC2804274 DOI: 10.1186/1710-1492-5-10] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Accepted: 12/01/2009] [Indexed: 12/28/2022] Open
Abstract
Urticaria is a group of diseases that share a distinct skin reaction pattern. Triggering of urticaria by infections has been discussed for many years but the exact role and pathogenesis of mast cell activation by infectious processes is unclear. In spontaneous acute urticaria there is no doubt for a causal relationship to infections and all chronic urticaria must have started as acute. Whereas in physical or distinct urticaria subtypes the evidence for infections is sparse, remission of annoying spontaneous chronic urticaria has been reported after successful treatment of persistent infections. Current summarizing available studies that evaluated the course of the chronic urticaria after proven Helicobacter eradication demonstrate a statistically significant benefit compared to untreated patients or Helicobacter-negative controls without urticaria (p < 0.001). Since infections can be easily treated some diagnostic procedures should be included in the routine work-up, especially the search for Helicobacter pylori. This review will update the reader regarding the role of infections in different urticaria subtypes.
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Affiliation(s)
- Bettina Wedi
- Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany.
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Spyridonidou A, Iatrou C, Alexoudis A, Vogiatzaki T, Polychronidis A, Simopoulos C. Peri-operative management of a patient with hereditary angioedema undergoing laparoscopic cholecystectomy. Anaesthesia 2009; 65:74-7. [PMID: 19849675 DOI: 10.1111/j.1365-2044.2009.06130.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Hereditary angioedema is a rare genetic disorder resulting from an inherited deficiency or dysfunction of the C1-esterase inhibitor of the classic complement pathway. It is characterised by recurrent episodes of angioedema, without urticaria or pruritus, most often affecting the skin or the mucosal tissues of the upper respiratory and gastrointestinal tracts. We describe the peri-operative care of a woman with hereditary angioedema undergoing laparoscopic cholecystectomy with emphasis on the role of anaesthetists as peri-operative physicians.
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Affiliation(s)
- A Spyridonidou
- Department of Anaesthesiology, Democritus University of Thrace, Alexandroupolis, Greece.
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Grigoriadou S, Longhurst HJ. Clinical Immunology Review Series: An approach to the patient with angio-oedema. Clin Exp Immunol 2009; 155:367-77. [PMID: 19220828 DOI: 10.1111/j.1365-2249.2008.03845.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Angio-oedema is a common reason for attendance at the accident and emergency department and for referral to immunology/allergy clinics. Causative factors should always be sought, but a large proportion of patients have the idiopathic form of the disease. A minority of patients represent a diagnostic and treatment challenge. Failure to identify the more unusual causes of angio-oedema may result in life-threatening situations. Common and rare causes of angio-oedema will be discussed in this article, as well as the diagnostic and treatment pathways for the management of these patients. A comprehensive history and close monitoring of response to treatment are the most cost-effective diagnostic and treatment tools.
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Affiliation(s)
- S Grigoriadou
- Barts and The London NHS Trust, Royal London Hospital, London, UK
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Mukeba D, Chandrikakumari K, Giot JB, Leonard P, Meuris C, Frippiat F, Moutschen M. Autoimmune angioneurotic edema in a patient with Helicobacter pylori infection. Helicobacter 2009; 14:9-11. [PMID: 19191890 DOI: 10.1111/j.1523-5378.2009.00651.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Association of acquired autoimmune angioneurotic edema with other diseases is increasing. However, the precise mechanism by which antibodies to C1-esterase inhibitor (C1-INH) are produced, is not elucidated. We describe a patient with IgA antibodies against C1-INH without other autoimmune markers. Our patient had gastritis and Helicobacter pylori infection, proven by biopsy. This case suggests that H. pylori infection can act as triggering factor for acquired autoimmune angioneurotic edema.
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Affiliation(s)
- Didier Mukeba
- Department of Internal Medicine and Infectious Diseases, Centre Hospitalier Universitaire, Liege, Belgium
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Moyaert H, Franceschi F, Roccarina D, Ducatelle R, Haesebrouck F, Gasbarrini A. Extragastric manifestations of Helicobacter pylori infection: other Helicobacters. Helicobacter 2008; 13 Suppl 1:47-57. [PMID: 18783522 DOI: 10.1111/j.1523-5378.2008.00634.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The finding that Helicobacter pylori is the main cause of gastritis and peptic ulcer disease has opened a new era in the gastrointestinal world. Today there is evidence that H. pylori may also play a role in different nongastric diseases, opening the new "extragastric manifestations of H. pylori infection" field. Concerning this, several studies have been published in the last year. The most convincing data arise from those investigating idiopathic thrombocytopenic purpura and sideropenic anemia, while there is also an increasing evidence for a possible association with atherosclerotic disease. Furthermore, the discovery of a number of other novel Helicobacter species has stimulated the research in different extragastric diseases, in which an infectious hypothesis is plausible. In particular, several species have been studied for a potential role in different liver and intestinal diseases with interesting findings.
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Affiliation(s)
- Hilde Moyaert
- Department of Pathology, Bacteriology, and Avian Diseases, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
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