1
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Ugur MC, Baysal M, Umit EG. The Role of Thalidomide and Its Analogs in the Treatment of Hereditary Hemorrhagic Telangiectasia: A Systematic Review. J Clin Med 2024; 13:5404. [PMID: 39336893 PMCID: PMC11432169 DOI: 10.3390/jcm13185404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2024] [Revised: 09/08/2024] [Accepted: 09/11/2024] [Indexed: 09/30/2024] Open
Abstract
Background: Hereditary hemorrhagic telangiectasia (HHT) is a disease characterized by arteriovenous malformations and telangiectases, in which the endothelium and immune system play a role in the pathophysiology. Therefore, treatments with antiangiogenic properties which are also regarded as immunomodulators were demonstrated to play an important role in treatment. This systematic review aimed to gather the accumulated information of the use of thalidomide and its analogs in the treatment of HHT. Methods: In this systematic review, publications that were published up to March 2024 and met the inclusion criteria were compiled using the keywords 'thalidomide', 'lenalidomide', 'pomalidomide', 'immunomodulatory drugs' and 'HHT' in Medline and Scholars databases. Results: A total of 53 articles were evaluated and 15 were included in the study. Thalidomide was the predominant used agent and was observed to be used in patients with ages ranging from 37 to 77 years, with doses ranging from 50 to 200 mg daily, and the mean follow-up period was observed to be 6-60 months. Assessments regarding efficacy were based on the epistaxis severity score (ESS), hemoglobin level, and transfusion independence. While thalidomide showed significant efficacy, it also had an adverse event rate of any severity of up to 85% of patients. Use of lenalidomide to control bleeding in HHT was reported in a single case report, while the use of pomalidomide was observed to be investigated in Phase 1 and Phase 2 studies in patients aged 48 to 70 years, with doses ranging from 1 to 5 mg daily for 6-24 months. This treatment was reported to provide significant improvement in hemoglobin levels and ESS. Adverse events of any severity were observed at a frequency of 60-66%. Conclusions: Antiangiogenic agents such as thalidomide, lenalidomide, and pomalidomide may be effective in managing HHT. However, further studies are needed to optimize the timing, dose, and sequence.
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Affiliation(s)
- Mehmet Can Ugur
- Division of Hematology, Department of Internal Medicine, Çiğli Training and Research Hospital, İzmir Bakırçay University, 35665 İzmir, Turkey;
| | - Mehmet Baysal
- Division of Hematology, Ali Osman Sönmez Oncology Hospital, 16040 Bursa, Turkey
| | - Elif Gulsum Umit
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Trakya University, 22030 Edirne, Turkey;
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2
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Wen SY, Huang YY. A case of hereditary hemorrhagic telangiectasia treated with cryotherapy. J Cosmet Dermatol 2024; 23:1929-1930. [PMID: 38297409 DOI: 10.1111/jocd.16202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/12/2024] [Accepted: 01/18/2024] [Indexed: 02/02/2024]
Affiliation(s)
- Su-Ying Wen
- Section Head of Department of Dermatology, Renai Branch, Taipei City Hospital, Taipei, Taiwan
| | - Ya-Yun Huang
- Department of Dermatology, Taipei City Hospital, Renai Branch, Taipei, Taiwan
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3
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Solela G, Adamseged M, Mohammed A. Hereditary hemorrhagic telangiectasia in a 42-year-old Ethiopian man presenting with severe anemia and high-output heart failure: A case report with literature review. Clin Case Rep 2023; 11:e7694. [PMID: 37448947 PMCID: PMC10337522 DOI: 10.1002/ccr3.7694] [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: 06/08/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023] Open
Abstract
Key Clinical Messages Hereditary hemorrhagic telangiectasia (HHT), a rare hereditary disorder, can cause recurrent massive epistaxis and gastrointestinal bleeding leading to severe anemia. Early diagnosis of HHT is essential to provide timely interventional therapies. Abstract HHT is a rare autosomal dominant hereditary disease that results in abnormal vasculogenesis in the skin, mucous membranes, and visceral organs such as the liver, lungs, and brain. Clinical diagnosis of HHT is made using the Curacao criteria, which include recurrent spontaneous nosebleeds, mucocutaneous telangiectasias, visceral organ involvement, and first-degree family history of HHT. Here, we report a patient with HHT from Ethiopia, who presented with recurrent epistaxis and gastrointestinal bleeding, and severe anemia requiring frequent blood transfusions as well as cauterization. The presented case is a 42-year-old Black Ethiopian man with frequent hospitalization for severe anemia and high-output heart failure requiring frequent blood transfusions. His mother had bilateral epistaxis since her early adulthood. Physical examination was significant for tachycardia, pale conjunctivae, and tiny erythematous lesions over his tongue, ejection systolic murmur and peripheral edema. Laboratory investigations revealed severe anemia with iron deficiency picture. Upper gastrointestinal endoscopy showed multiple telangiectasia spots and abdominal Doppler ultrasound showed hepatic arterio-venous malformations. He received supportive management and electrocauterization of nasal, gastric, and duodenal telangiectasias. To the best of our knowledge, this is the first case of HHT to be reported from Ethiopia. High degree of suspicion and early diagnosis of HHT is essential to start preventive screening and surveillance and provide timely interventional therapies. HHT can cause recurrent massive epistaxis and gastrointestinal bleeding leading to severe anemia and high-output heart failure. In resource limited settings, selective cauterization of telangiectasia will help to control bleeding, although it does not avoid recurrent bleeding.
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Affiliation(s)
- Gashaw Solela
- Department of Internal MedicineYekatit 12 Hospital Medical CollegeAddis AbabaEthiopia
| | - Michael Adamseged
- Department of Internal MedicineYekatit 12 Hospital Medical CollegeAddis AbabaEthiopia
| | - Abdulsemed Mohammed
- Division of Gastroenterology and Hepatology, Department of Internal MedicineCollege of Health Sciences, Addis Ababa UniversityAddis AbabaEthiopia
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4
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Dupuis-Girod S, Shovlin CL, Kjeldsen AD, Mager HJ, Sabba C, Droege F, Fargeton AE, Fialla AD, Gandolfi S, Hermann R, Lenato GM, Manfredi G, Post MC, Rennie C, Suppressa P, Sure U, Crocione C, Blom R, Botella LM, Brocca F, Coxall C, Druckman KT, Erasme D, Federici P, Grabowski C, Lundgren M, Søderman T, Woods D, E B. European Reference Network for Rare Vascular Diseases (VASCERN): When and how to use intravenous bevacizumab in Hereditary Haemorrhagic Telangiectasia (HHT)? Eur J Med Genet 2022; 65:104575. [DOI: 10.1016/j.ejmg.2022.104575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 06/09/2022] [Accepted: 07/20/2022] [Indexed: 11/25/2022]
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5
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Wang M, Jiao Y, Zeng C, Zhang C, He Q, Yang Y, Tu W, Qiu H, Shi H, Zhang D, Kang D, Wang S, Liu AL, Jiang W, Cao Y, Zhao J. Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas. Front Neurol 2021; 12:651663. [PMID: 34177760 PMCID: PMC8219979 DOI: 10.3389/fneur.2021.651663] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas. Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association. Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III. Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.
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Affiliation(s)
- Mingze Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaofan Zeng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wenjun Tu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hancheng Qiu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - A-Li Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Gamma Knife Center, Beijing Neurosurgical Institute, Beijing, China
| | - Weijian Jiang
- Department of Vascular Neurosurgery, Chinese People's Liberation Army Rocket Army Characteristic Medical Center, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
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6
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Raper DMS, Winkler EA, Rutledge WC, Cooke DL, Abla AA. An Update on Medications for Brain Arteriovenous Malformations. Neurosurgery 2021; 87:871-878. [PMID: 32433738 DOI: 10.1093/neuros/nyaa192] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/17/2020] [Indexed: 02/07/2023] Open
Abstract
Despite a variety of treatment options for brain arteriovenous malformations (bAVMs), many lesions remain challenging to treat and present significant ongoing risk for hemorrhage. In Vitro investigations have recently led to a greater understanding of the formation, growth, and rupture of bAVMs. This has, in turn, led to the development of therapeutic targets for medications for bAVMs, some of which have begun testing in clinical trials in humans. These include bevacizumab, targeting the vascular endothelial growth factor driven angiogenic pathway; thalidomide or lenalidomide, targeting blood-brain barrier impairment; and doxycycline, targeting matrix metalloproteinase overexpression. A variety of other medications appear promising but either requires adaptation from other disease states or development from early bench studies into the clinical realm. This review aims to provide an overview of the current state of development of medications targeting bAVMs and to highlight their likely applications in the future.
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Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Daniel L Cooke
- Department of Radiology and Biomedical Engineering, University of California, San Francisco, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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7
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Jan W, Tameez Ud Din A, Chaudhary FMD, Tameez-Ud-Din A, Nawaz F. Hereditary Hemorrhagic Telangiectasia: A Rare Cause of Anemia. Cureus 2019; 11:e5349. [PMID: 31602353 PMCID: PMC6779147 DOI: 10.7759/cureus.5349] [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] [Indexed: 11/20/2022] Open
Abstract
Hereditary hemorrhagic telangiectasias (HHT), also known as Osler-Weber-Rendu syndrome, is an uncommon genetic disorder. It is inherited as an autosomal dominant disorder with varying penetrance and expression. The diagnosis of HHT requires the presence of at least three out of four clinical criteria. These so-called Curaçao criteria include epistaxis, telangiectasias, visceral involvement, and a family history of HHT in a first-degree relative. Visceral involvement can involve the gastrointestinal (GI) tract, resulting in the development of GI telangiectasias. One of the complications is anemia due to the chronic blood loss from these vascular malformations. Here, we present a case of a 26-year-old male who was diagnosed with HHT. He initially had episodes of epistaxis but now presented to us with features of anemia. According to the patient, he didn’t have epistaxis for the past many months and on his esophagogastroduodenoscopy (EGD) and colonoscopy, there was evidence of multiple small telangiectasias seen in his stomach, duodenum, and colon. He was managed with blood transfusion and was discharged on oral iron supplementation. This is a rare cause of anemia and should be evaluated if other features of HHT are present.
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Affiliation(s)
- Waseem Jan
- Gastroenterlogy, Nishtar Medical University & Hospital, Multan, PAK
| | | | | | | | - Faisal Nawaz
- Gastroenterology, Good Hope Hospital, University Hospitals Birmingham, Birmingham, GBR
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8
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Shaligram SS, Winkler E, Cooke D, Su H. Risk factors for hemorrhage of brain arteriovenous malformation. CNS Neurosci Ther 2019; 25:1085-1095. [PMID: 31359618 PMCID: PMC6776739 DOI: 10.1111/cns.13200] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/09/2019] [Accepted: 07/11/2019] [Indexed: 12/16/2022] Open
Abstract
Patients with brain arteriovenous malformation (bAVM) are at risk of intracranial hemorrhage (ICH). Overall, bAVM accounts for 25% of hemorrhagic strokes in adults <50 years of age. The treatment of unruptured bAVMs has become controversial, because the natural history of these patients may be less morbid than invasive therapies. Available treatments include observation, surgical resection, endovascular embolization, stereotactic radiosurgery, or combination thereof. Knowing the risk factors for bAVM hemorrhage is crucial for selecting appropriate therapeutic strategies. In this review, we discussed several biological risk factors, which may contribute to bAVM hemorrhage.
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Affiliation(s)
- Sonali S Shaligram
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative care, University of California, San Francisco, California
| | - Ethan Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Daniel Cooke
- Department of Radiology, University of California, San Francisco, California
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative care, University of California, San Francisco, California
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9
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Flower M, Chern B. A case report of successful treatment of high-output heart failure secondary to hereditary haemorrhagic telangiectasia with bevacizumab. Oxf Med Case Reports 2019; 2019:omz046. [PMID: 31214358 PMCID: PMC6568199 DOI: 10.1093/omcr/omz046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/24/2019] [Accepted: 04/24/2019] [Indexed: 11/23/2022] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a rare autosomal dominant disorder resulting in uncontrolled multisystem angiogenesis. The pathogenesis of this disease is thought to relate to elevated levels of transforming growth factor beta and vascular endothelial growth factor (VEGF). The frail arteriovenous malformations (AVMs) give rise to complications including haemorrhage and shunting. These have classically included recurrent epistaxis and gastrointestinal bleeding and associated iron-deficiency anaemia. More recently, high-output heart failure has been recognized in patients with significant hepatic involvement. This is thought to occur as a result of low systemic resistance due to shunting of blood through liver AVMs with an associated compensatory increase in cardiac output. Bevacizumab is a humanized monoclonal that acts to cause VEGF inhibition. Previously, this drug has been shown to benefit patients with HHT by reducing transfusion requirements and frequency of epistaxis. In addition, there is a growing body of evidence that bevacizumab may be associated with amelioration of high-output cardiac failure associated with HHT-induced hepatic shunting. We believe this case supports the use of bevacizumab in this context.
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Affiliation(s)
- Mark Flower
- Redcliffe hospital, Anzac Ave, Qld Australia
| | - Boris Chern
- The University of Queensland, Herston, Australia
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10
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Flemming J, Cameron S. Small bowel capsule endoscopy: Indications, results, and clinical benefit in a University environment. Medicine (Baltimore) 2018; 97:e0148. [PMID: 29620627 PMCID: PMC5902276 DOI: 10.1097/md.0000000000010148] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Capsule endoscopy (CE) opened a new method for visualization of the small intestine. We here further explore its clinical implications.We retrospectively analyzed the clinical benefit of CE in view of medical history, diagnostics, and therapy. Our patient collective consisted of 203 patients. CE was investigated in the context of bleeding, anemia, abdominal pain, diarrhea, Crohn's disease, and suspected tumors.The study collective consisted of 118 male and 85 female patients with a mean age of 58 years (range 8-90 years). Complete bowel transit took place in 82% of the patients. The diagnostic yield in the detection of obscure gastrointestinal bleeding was 80% and for anemia 78%. Mucosal lesions were the most common finding (43%). Unclear abdominal pain had the lowest diagnostic yield (41%). Ensuing therapeutic interventions were mostly medical (66%), and to a minor extent surgical (4.4%) as well as endoscopic (4%).In conclusion, small intestinal CE is a secure method to clarify small intestinal diseases, especially obscure gastrointestinal bleeding, even in pre-operated patients without stenosis symptoms. Our study emphasizes in a collective of patients with extensive prior diagnostics that due to CE therapeutic measures resulted in 73%.
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Affiliation(s)
- Juliane Flemming
- Clinic for Gastroenterology and Gastrointestinal Oncology, University Medicine Göttingen, Göttingen
- St. Joseph Hospital, Berlin Tempelhof, Berlin, Germany
| | - Silke Cameron
- Clinic for Gastroenterology and Gastrointestinal Oncology, University Medicine Göttingen, Göttingen
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11
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Bertoli LF, Lee PL, Lallone L, Barton JC. Intravenous Bevacizumab Therapy in a Patient with Hereditary Hemorrhagic Telangiectasia, ENG E137K, Alcoholic Cirrhosis, and Portal Hypertension. Case Rep Gastroenterol 2017. [PMID: 28626375 PMCID: PMC5471789 DOI: 10.1159/000475748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Intravenous bevacizumab decreased mucosal bleeding in some patients with hereditary hemorrhagic telangiectasia (HHT). We treated a 47-year-old male who had HHT, severe epistaxis, and gastrointestinal bleeding, alcoholic cirrhosis, and portal hypertension with intravenous bevacizumab 2.5 mg/kg every 2 weeks. We tabulated these measures weekly during weeks 1–33 (no bevacizumab); 34–57 (bevacizumab); and 58–97 (no bevacizumab): hemoglobin (Hb) levels; platelet counts; units of transfused packed erythrocytes (PRBC units); and quantities of iron infused as iron dextran to support erythropoiesis. We performed univariate and multivariable analyses. We sequenced his ENG and ACVRL1 genes. Epistaxis and melena decreased markedly during bevacizumab treatment. He reported no adverse effects due to bevacizumab. Mean weekly Hb levels were significantly higher and mean weekly PRBC units and quantities of intravenous iron were significantly lower during bevacizumab treatment. We performed a multiple regression on weekly Hb levels using these independent variables: bevacizumab treatment (dichotomous); weekly platelet counts; weekly PRBC units; and weekly quantities of intravenous iron. There was 1 positive association: (bevacizumab treatment; p = 0.0046) and 1 negative association (PRBC units; p = 0.0004). This patient had the novel ENG mutation E137K (exon 4; c.409G→A). Intravenous bevacizumab treatment 2.5 mg/kg every 2 weeks for 24 weeks was well-tolerated by a patient with HHT due to ENG E137K and was associated with higher weekly Hb levels and fewer weekly PRBC units.
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Affiliation(s)
- Luigi F Bertoli
- Department of Medicine, Brookwood Medical Center, Birmingham, Alabama, USA.,Brookwood Biomedical, Birmingham, Alabama, USA
| | - Pauline L Lee
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, California, USA
| | | | - James C Barton
- Department of Medicine, Brookwood Medical Center, Birmingham, Alabama, USA.,Southern Iron Disorders Center, Birmingham, Alabama, USA.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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12
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Ou G, Galorport C, Enns R. Bevacizumab and gastrointestinal bleeding in hereditary hemorrhagic telangiectasia. World J Gastrointest Surg 2016; 8:792-795. [PMID: 28070235 PMCID: PMC5183923 DOI: 10.4240/wjgs.v8.i12.792] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/07/2016] [Accepted: 10/18/2016] [Indexed: 02/06/2023] Open
Abstract
We report a case of severe, refractory gastrointestinal (GI) bleeding in a patient with hereditary hemorrhagic telangiectasia (HHT) whose massive transfusion dependence was lifted shortly after treatment with bevacizumab, an anti-vascular endothelial growth factor. The patient’s bleeding had been refractory to repeated endoscopic interventions, tranexamic acid, and tamoxifen. However, following treatment with bevacizumab at 5 mg/kg every other week, nearly 300 units of packed red blood cell transfusions were avoided in one year’s time. Despite its relatively high cost, bevacizumab may have a more active role in the management of severe GI bleeding in HHT if such remarkable response can be consistently demonstrated.
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13
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Peng HL, Yi YF, Zhou SK, Xie SS, Zhang GS. Thalidomide Effects in Patients with Hereditary Hemorrhagic Telangiectasia During Therapeutic Treatment and in Fli-EGFP Transgenic Zebrafish Model. Chin Med J (Engl) 2016; 128:3050-4. [PMID: 26608985 PMCID: PMC4795244 DOI: 10.4103/0366-6999.169068] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease characterized by recurrent epistaxis, mucocutaneous telangiectasia, and arteriovenous malformations. The efficacy of traditional treatments for HHT is very limited. The aim of this study was to investigate the therapeutic role of thalidomide in HHT patients and the effect in FLI-EGFP transgenic zebrafish model. METHODS HHT was diagnosed according to Shovlin criteria. Five HHT patients were treated with thalidomide (100 mg/d). The Epistaxis Severity Score (ESS), telangiectasia spots, and hepatic computed tomography angiography (CTA) were used to assess the clinical efficacy of thalidomide. The Fli-EGFP zebrafish model was investigated for the effect of thalidomide on angiogenesis. Dynamic real-time polymerase chain reaction assay, ELISA and Western blotting from patient's peripheral blood mononuclear cells and plasma were used to detect the expression of transforming growth factor beta 3 (TGF-β3) messenger RNA (mRNA) and vascular endothelial growth factor (VEGF) protein before and after 6 months of thalidomide treatment. RESULTS The average ESS before and after thalidomide were 6.966 ± 3.093 and 1.799 ± 0.627, respectively (P = 0.009). The "telangiectatic spot" on the tongue almost vanished; CTA examination of case 2 indicated a smaller proximal hepatic artery and decreased or ceased hepatic artery collateral circulation. The Fli-EGFP zebrafish model manifested discontinuous vessel development and vascular occlusion (7 of 10 fishes), and the TGF-β3 mRNA expression of five patients was lower after thalidomide therapy. The plasma VEGF protein expression was down-regulated in HHT patients. CONCLUSIONS Thalidomide reverses telangiectasia and controls nosebleeds by down-regulating the expression of TGF-β3 and VEGF in HHT patients. It also leads to vascular remodeling in the zebrafish model.
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Affiliation(s)
| | | | | | | | - Guang-Sen Zhang
- Division of Hematology, Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
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Kiyeng JC, Siika A, Koech C, Bloomfield GS. Definite hereditary hemorrhagic telangiectasia in a 60-year-old black Kenyan woman: a case report. J Med Case Rep 2016; 10:126. [PMID: 27225226 PMCID: PMC4880959 DOI: 10.1186/s13256-016-0909-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 04/25/2016] [Indexed: 12/28/2022] Open
Abstract
Background Hereditary hemorrhagic telangiectasia is a rare autosomal dominant inherited disease characterized by vascular dysplasia. To the best of our knowledge, we report the first case in the literature of definite hereditary hemorrhagic telangiectasia diagnosed in western Kenya, a resource-limited setting with limited treatment options. Case presentation A 60-year-old black Kenyan woman was admitted 1 year ago to a hospital in western Kenya with an 11-year history of recurrent spontaneous epistaxis. Her physical examination revealed that she had telangiectasias on the tongue and hard palate, severe pallor, and hepatomegaly. A chest radiograph revealed right middle lobe opacity. After a positive saline contrast echocardiography, she underwent contrast-enhanced chest computed tomography, which revealed a large pulmonary arteriovenous malformation and multiple hepatic arteriovenous malformations. Therefore, she fulfilled criteria for definite hereditary hemorrhagic telangiectasia. She was managed with nasal packing, tranexamic acid, oral ferrous sulfate, and blood transfusions, as other treatment options were unavailable in this setting. Conclusions This rare case of hereditary hemorrhagic telangiectasia demonstrates that it occurs in an African population and that diagnostic challenges in resource-limited settings can be surmounted. Treatment options remain limited in these settings. Electronic supplementary material The online version of this article (doi:10.1186/s13256-016-0909-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joan Chepkorir Kiyeng
- Department of Internal Medicine, College of Health Sciences, School of Medicine, Moi University, P.O Box 4606, Eldoret, Kenya.
| | - Abraham Siika
- Department of Internal Medicine, College of Health Sciences, School of Medicine, Moi University, P.O Box 4606, Eldoret, Kenya
| | - Cornelius Koech
- Department of Internal Medicine, College of Health Sciences, School of Medicine, Moi University, P.O Box 4606, Eldoret, Kenya
| | - Gerald S Bloomfield
- Division of Cardiology, Duke University Medical Center, 2400 Pratt Street, Durham, NC, 27705, USA
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Arizmendez NP, Rudmik L, Poetker DM. Intravenous bevacizumab for complications of hereditary hemorrhagic telangiectasia: a review of the literature. Int Forum Allergy Rhinol 2015. [PMID: 26202958 DOI: 10.1002/alr.21587] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a multisystem disease that is marked by mutations regulating vasculature formation. Epistaxis is the most commonly reported symptom, but gastrointestinal bleeding, anemia, hepatic issues, and pulmonary disease are also common. There is a growing body of evidence in the literature concerning using the monoclonal antibody against vascular endothelial growth factor (VEGF), bevacizumab, in patients with HHT. This treatment is gaining support for managing HHT because it directly inhibits the VEGF proteins that can be elevated as a result of the HHT mutations. We reviewed the current literature on the outcomes from intravenous bevacizumab treatment for HHT with a focus on epistaxis outcomes. METHODS A systematic review of the literature was performed using Ovid MEDLINE, Scopus, and Cochrane databases. English citations, both national and international, were reviewed and filtered for relevance. RESULTS Eighteen studies were included in this review. The majority of citations were case reports. All studies reported improvements. Specifically, 14 reported improvements in epistaxis, and 11 reported hemoglobin improvement following intravenous (IV) bevacizumab. Lack of uniformity in data presentation prevented a meta-analysis. CONCLUSION This is the first systematic review analyzing the data involving HHT patients treated with bevacizumab. The results show that patients treated with bevacizumab have global improvements as well as specific improvements in hemoglobin levels. Although all of the studies reported improvements, there are several limitations, including inconsistencies in outcome reporting. A large, randomized, controlled study is needed to further investigate hemorrhage and epistaxis outcomes in HHT patients treated with intravenous bevacizumab.
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Affiliation(s)
- Natalia P Arizmendez
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI.,Department of Surgery, Division of Otolaryngology, Zablocki VA Medical Center, Milwaukee, WI
| | - Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - David M Poetker
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI.,Department of Surgery, Division of Otolaryngology, Zablocki VA Medical Center, Milwaukee, WI
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Wee JW, Jeon YW, Eun JY, Kim HJ, Bae SB, Lee KT. Hereditary hemorrhagic telangiectasia treated with low dose intravenous bevacizumab. Blood Res 2014; 49:192-5. [PMID: 25325040 PMCID: PMC4188786 DOI: 10.5045/br.2014.49.3.192] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 12/12/2012] [Accepted: 07/09/2014] [Indexed: 12/14/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder that leads to mucocutaneous telangiectasias, epistaxis, and gastrointestinal bleeding. Depending on the severity and manifestation of the disease, various therapeutic modalities have been used, from local bleeding control to surgery or concomitant drug therapy. Several articles under review have presented guidelines for treatment of HHT with bevacizumab as a direct anti-angiogenesis strategy. Still, neither the exact optimal dose nor the minimum effective dose of intravenous bevacizumab in patients with severe HHT has been reported. A 55-year-old man presented with long-standing epistaxis, recent melena, dizziness, and a three-generation family history of chronic epistaxis, anemia, and regular blood transfusions. Treatment with argon plasma coagulation (APC) for the gastrointestinal bleeding failed to raise hemoglobin levels, we considered using the bevacizumab. We report a patient with severe HHT, who was treated with low-dose bevacizumab (2 mg/kg) and improved substantially.
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Affiliation(s)
- Jee Wan Wee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Young Woo Jeon
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jun Young Eun
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Han Jo Kim
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Sang Byung Bae
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Kyu Taek Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Brain arteriovenous malformation modeling, pathogenesis, and novel therapeutic targets. Transl Stroke Res 2014; 5:316-29. [PMID: 24723256 DOI: 10.1007/s12975-014-0343-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/24/2014] [Accepted: 03/25/2014] [Indexed: 02/07/2023]
Abstract
Patients harboring brain arteriovenous malformation (bAVM) are at life-threatening risk of rupture and intracranial hemorrhage (ICH). The pathogenesis of bAVM has not been completely understood. Current treatment options are invasive, and ≈ 20 % of patients are not offered interventional therapy because of excessive treatment risk. There are no specific medical therapies to treat bAVMs. The lack of validated animal models has been an obstacle for testing hypotheses of bAVM pathogenesis and testing new therapies. In this review, we summarize bAVM model development and bAVM pathogenesis and potential therapeutic targets that have been identified during model development.
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A review of contemporary options for medical management of hemangiomas, other vascular tumors, and vascular malformations. Pharmacol Ther 2013; 139:327-33. [DOI: 10.1016/j.pharmthera.2013.05.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 04/26/2013] [Indexed: 01/06/2023]
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Kanellopoulou T, Alexopoulou A. Bevacizumab in the treatment of hereditary hemorrhagic telangiectasia. Expert Opin Biol Ther 2013; 13:1315-23. [DOI: 10.1517/14712598.2013.813478] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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