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Marrawani M, Alatawneh M, Asafra F, Salloum OH, Abuayash AM, Samamra M. Hereditary angioedema presented as isolated ascending and transverse colon swelling mimicking acute abdomen. SAGE Open Med Case Rep 2024; 12:2050313X241272574. [PMID: 39224758 PMCID: PMC11367591 DOI: 10.1177/2050313x241272574] [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: 03/02/2024] [Accepted: 06/18/2024] [Indexed: 09/04/2024] Open
Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant condition characterized by C1-INH gene mutations, leading to recurrent angioedema episodes affecting various body parts, including the gastrointestinal tract. This case report describes a 24-year-old female presenting with symptoms mimicking an acute abdomen, characterized by severe abdominal cramps, anorexia, and diarrhea, with a significant past medical history of angioedema flares and emergency intubation for asphyxiation at age 11. Despite initial treatment with antihistamines showing no improvement, her symptoms spontaneously resolved. Further investigation revealed low complement C4 levels and reduced C1-INH function, confirming HAE with an unusual isolated involvement of the ascending and transverse colon. This case underscores the importance of considering HAE in patients presenting with acute abdominal symptoms, especially with a history suggestive of angioedema. It highlights the need for emergency physicians and gastroenterologists to be aware of HAE's clinical manifestations to avoid misdiagnosis and unnecessary interventions. Moreover, the case emphasizes the significance of patient education on recognizing symptoms and seeking timely medical attention to prevent severe complications. This report adds to the existing literature by detailing an uncommon presentation of HAE, aiming to enhance early diagnosis and management of this potentially life-threatening condition.
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Affiliation(s)
- Mohammad Marrawani
- Faculty of Medicine, Palestine Polytechnic University, Hebron, Palestine
| | - Mustafa Alatawneh
- Faculty of Medicine, Palestine Polytechnic University, Hebron, Palestine
| | - Fouad Asafra
- Faculty of Medicine, Palestine Polytechnic University, Hebron, Palestine
| | - Omar H Salloum
- Faculty of Medicine, Palestine Polytechnic University, Hebron, Palestine
| | | | - Mosab Samamra
- Faculty of Medicine, Palestine Polytechnic University, Hebron, Palestine
- Hebron Governmental Hospital (Alia), Hebron, Palestine
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Abstract
Health care providers are likely to encounter patients with recurrent unexplained abdominal pain. Because hereditary angioedema (HAE) is a rare disease, it may not be part of the differential diagnosis, especially for patients who do not have concurrent skin swelling in addition to abdominal symptoms. Abdominal pain is very common in patients with HAE, occurring in up to 93% of patients, with recurrent abdominal pain reported in up to 80% of patients. In 49% of HAE attacks with abdominal symptoms, isolated abdominal pain was the only symptom. Other abdominal symptoms that commonly present in patients with HAE include distension, cramping, nausea, vomiting, and diarrhea. The average time from onset of symptoms to diagnosis is 6 to 23 years. Under-recognition of HAE in patients presenting with predominant gastrointestinal symptoms is a key factor contributing to the delay in diagnosis, increasing the likelihood of unnecessary or exploratory surgeries or procedures and the potential risk of related complications. HAE should be considered in the differential diagnosis for patients with unexplained abdominal pain, nausea, vomiting, and/or diarrhea who have complete resolution of symptoms between episodes. As highly effective targeted therapies for HAE exist, recognition and diagnosis of HAE in patients presenting with isolated abdominal pain may significantly improve morbidity and mortality for these individuals.
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Gutierrez M, Veronez CL, Rodrigues Valle SO, Gonçalves RF, Ferriani MPL, Moreno AS, Arruda LK, Aun MV, Giavina-Bianchi P, Alonso MLO, Pesquero JB, Grumach AS. Unnecessary Abdominal Surgeries in Attacks of Hereditary Angioedema with Normal C1 Inhibitor. Clin Rev Allergy Immunol 2021; 61:60-65. [PMID: 33755867 DOI: 10.1007/s12016-021-08852-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 12/23/2022]
Abstract
Hereditary angioedema (HAE) is an autosomal dominant disease mostly due to the deficiency of C1 inhibitor (C1-INH). HAE with normal C1-INH was first described in 2000 and associated with mutations in the coagulation factor XII in 2006. Both diseases are associated with high bradykinin production, resulting in increased vascular permeability. Gastrointestinal edema due to HAE can be misdiagnosed as acute abdomen and unnecessary surgical procedures may be performed. The present study evaluates the prevalence of surgical procedures and/or acute abdomen in HAE patients with the coagulation factor XII mutation. It is a retrospective study where patients were diagnosed with recurrent angioedema without urticaria, normal C1-INH levels, and positive family history of angioedema. All patients were evaluated for the known mutations located at exon 9 of the F12 gene. Medical records were evaluated and questionnaires were applied to 52 patients with normal C1-INH levels (age range 13-76 years; 47/52, 90.38% women; 5/52, 9.61% men). F12 mutation was present in 32/52 patients (61.5%). Acute abdominal pain was diagnosed in 16/52 (30.76%) patients, appendicitis in 9/16 (56.2%), and undetermined diagnosis in 7/16 (43.7%). Among patients diagnosed with acute abdominal pain, 13/16 (81.2%) underwent surgery and 3/16 (18.7%) improved without surgical intervention. We conclude that many HAE patients with coagulation factor XII mutation were misdiagnosed with acute abdomen and subjected to unnecessary invasive procedures. It is critical to disseminate information about this rare mutation in patients with otherwise normal C1-INH activity, in order to speed up diagnosis and avoid misconduct.
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Affiliation(s)
- Marcel Gutierrez
- Faculdade de Medicina, Centro Universitario Saude ABC, Santo Andre, Sao Paulo, SP, Brazil
| | - Camila L Veronez
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, USA.,Research Service, San Diego Veterans Affairs Healthcare, San Diego, USA
| | - Solange O Rodrigues Valle
- Serviço de Imunologia. Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | | | - Adriana S Moreno
- Ribeirão Preto School of Medicine, University of São Paulo, Ribeirao Preto, SP, Brazil
| | - L Karla Arruda
- Ribeirão Preto School of Medicine, University of São Paulo, Ribeirao Preto, SP, Brazil
| | - Marcelo Vivolo Aun
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil.,Albert Einstein School of Medicine, Faculdade Israelita de Ciências da Saúde, Sao Paulo, SP, Brazil
| | - Pedro Giavina-Bianchi
- Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Maria Luiza Oliva Alonso
- Serviço de Imunologia. Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Joao B Pesquero
- Department of Biophysics, Federal University of São Paulo, Sao Paulo, Brazil
| | - Anete S Grumach
- Faculdade de Medicina, Centro Universitario Saude ABC, Santo Andre, Sao Paulo, SP, Brazil.
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4
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Mehmood A, Abdullah HMA, Inayat F, Ullah W. Wolf in the sheep's clothing: intestinal angioedema mimicking infectious colitis. BMJ Case Rep 2018; 11:11/1/e226682. [PMID: 30567241 DOI: 10.1136/bcr-2018-226682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hereditary angioedema (HAE) is a relatively rare clinical entity that can potentially cause life-threatening airway or intestinal oedema, patients with the latter usually presents with symptoms of gastroenteritis like vomiting, diarrhoea and abdominal pain. Here, we present a unique case of a less recognised type of HAE that is type III in a patient who presented with signs and symptoms consistent with infectious colitis. She previously had similar episodes and was managed multiple times with antibiotics, with no satisfactory response. There, she underwent extensive diagnostic evaluation. On the basis of findings of further investigations on the current visit, she was eventually diagnosed with intestinal angioedema. To the best of our knowledge, the present paper represents the third reported case of type III HAE-induced intestinal angioedema. Additionally, we undertake a literature review of HAE.
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Affiliation(s)
- Asif Mehmood
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
| | | | | | - Waqas Ullah
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, Pennsylvania, USA
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5
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Hahn J, Hoess A, Friedrich DT, Mayer B, Schauf L, Hoffmann TK, Greve J. Unnötige abdominelle Eingriffe bei Patienten mit hereditärem Angioödem. J Dtsch Dermatol Ges 2018; 16:1443-1450. [PMID: 30537315 DOI: 10.1111/ddg.13698_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/15/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Janina Hahn
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Germany (Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Deutschland)
| | - Alisa Hoess
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Germany (Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Deutschland)
| | - Daniel Thomas Friedrich
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Germany (Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Deutschland)
| | - Benjamin Mayer
- Institute for Epidemiology and Medical Biometry, Ulm University, Germany (Institut für Epidemiologie und Medizinische Biometrie, Universität Ulm)
| | - Lucia Schauf
- HAE Support Group Organization, Germany (HAE-Vereinigung e.V., Deutschland)
| | - Thomas K Hoffmann
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Germany (Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Deutschland)
| | - Jens Greve
- Department of Oto-Rhino-Laryngology Head and Neck Surgery, Ulm University Medical Center, Germany (Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Ulm, Deutschland)
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Hereditary Angioedema Type II: First Presentation in Adulthood with Recurrent Severe Abdominal Pain. Case Reports Immunol 2018; 2018:7435870. [PMID: 30510820 PMCID: PMC6231379 DOI: 10.1155/2018/7435870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/12/2018] [Accepted: 09/13/2018] [Indexed: 11/18/2022] Open
Abstract
A 27-year-old Emirate man presented to Cleveland Clinic Abu Dhabi emergency department with a 4 year history of recurrent episodes of severe swellings affecting different parts of his body. He used to get 2 swelling episodes every week affecting either his face, hands, feet or scrotum and severe abdominal pain twice a week. Abdominal CT scan and a colonoscopy showed bowel wall oedema. There was no family history of similar complaint or of hereditary angioedema (HAE). Complement studies confirmed the diagnosis of HAE type II. He was commenced on danazol 100 mg twice daily and his symptoms resolved. This case report highlights the importance of considering HAE in patients with recurrent unexplained abdominal pain even in the absence of positive family history of HAE.
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