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Droege F, König J, Lang KS, Jablonska J, Pylaeva E, Huckenbeck C, Wrobeln A, Duerig I, Thangavelu K, Lang S, Geisthoff U. Increased Risk for Infections and Allergic Disease in Hereditary Hemorrhagic Telangiectasia. J Clin Med 2024; 13:3752. [PMID: 38999318 PMCID: PMC11242906 DOI: 10.3390/jcm13133752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/19/2024] [Accepted: 06/22/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Hereditary hemorrhagic telangiectasia (HHT) is a rare disorder characterized by dilated blood vessels. Different immunological changes have been described in these patients. In this study, the predisposition of patients with HHT to infections and allergic diseases was assessed. Methods: Patients with HHT completed an online survey in English or German. Their data were compared to non-affected partners or friends. Results: A total of 430 out of 588 respondents with HHT answered our questions about infections and allergies. Patients with HHT suffered significantly more often from various types of allergies than their partners, especially type I allergies (n = 226/276, 82%), and had a higher risk for sinusitis, urinary tract infections, pulmonary infections, and abscesses. A total of 38% of the patients took antibiotics prior to dental or surgical procedures (n = 57/152), and, in 10% of these patients, pulmonary arteriovenous malformations (PAVMs) were not detected. On the other hand, 51% of patients with PAVM did not report a prophylactic antibiotic intake (n = 40/79). The patients who needed iron supplementations suffered more often from sepsis (OR: 9.00, 95%CI: 0.92-88.16). Conclusions: Compared to their non-affected controls, patients with HHT showed an increased risk for infections in different organs and allergic diseases. There is a need for campaigns raising greater awareness recommending prophylactic antibiotic intake in patients with PAVM.
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Affiliation(s)
- Freya Droege
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, 55101 Mainz, Germany;
| | - Karl S. Lang
- Institute of Immunology, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany;
| | - Jadwiga Jablonska
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Ekaterina Pylaeva
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Carolin Huckenbeck
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Anna Wrobeln
- Institute of Physiology, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany;
| | - Inga Duerig
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Kruthika Thangavelu
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, University Hospital of Marburg, Philipps-University of Marburg, Baldingerstrasse, 35042 Marburg, Germany; (K.T.); (U.G.)
| | - Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, Essen University Hospital, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany; (J.J.); (E.P.); (C.H.); (I.D.); (S.L.)
| | - Urban Geisthoff
- Department of Otorhinolaryngology, Head and Neck Surgery and VASCERN HHT Reference Centre, University Hospital of Marburg, Philipps-University of Marburg, Baldingerstrasse, 35042 Marburg, Germany; (K.T.); (U.G.)
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Jain K, McCarley SC, Mukhtar G, Ferlin A, Fleming A, Morris-Rosendahl DJ, Shovlin CL. Pathogenic Variant Frequencies in Hereditary Haemorrhagic Telangiectasia Support Clinical Evidence of Protection from Myocardial Infarction. J Clin Med 2023; 13:250. [PMID: 38202257 PMCID: PMC10779873 DOI: 10.3390/jcm13010250] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/20/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
Hereditary haemorrhagic telangiectasia (HHT) is a vascular dysplasia inherited as an autosomal dominant trait, due to a single heterozygous loss-of-function variant, usually in ACVRL1 (encoding activin receptor-like kinase 1 [ALK1]), ENG (encoding endoglin [CD105]), or SMAD4. In a consecutive single-centre series of 37 positive clinical genetic tests performed in 2021-2023, a skewed distribution pattern was noted, with 30 of 32 variants reported only once, but ACVRL1 c.1231C>T (p.Arg411Trp) identified as the disease-causal gene in five different HHT families. In the same centre's non-overlapping 1992-2020 series where 110/134 (82.1%) HHT-causal variants were reported only once, ACVRL1 c.1231C>T (p.Arg411Trp) was identified in nine further families. In a 14-country, four-continent HHT Mutation Database where 181/250 (72.4%) HHT-causal variants were reported only once, ACVRL1 c.1231C>T (p.Arg411Trp) was reported by 12 different laboratories, the adjacent ACVRL1 c.1232G>A (p.Arg411Gln) by 14, and ACVRL1 c.1120C>T (p.Arg374Trp) by 18. Unlike the majority of HHT-causal ACVRL1 variants, these encode ALK1 protein that reaches the endothelial cell surface but fails to signal. Six variants of this type were present in the three series and were reported 6.8-25.5 (mean 8.9) times more frequently than the other ACVRL1 missense variants (all p-values < 0.0039). Noting lower rates of myocardial infarction reported in HHT, we explore potential mechanisms, including a selective paradigm relevant to ALK1's role in the initiating event of atherosclerosis, where a plausible dominant negative effect of these specific variants can be proposed. In conclusion, there is an ~9-fold excess of kinase-inactive, cell surface-expressed ACVRL1/ALK1 pathogenic missense variants in HHT. The findings support further examination of differential clinical and cellular phenotypes by HHT causal gene molecular subtypes.
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Affiliation(s)
- Kinshuk Jain
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
| | - Sarah C. McCarley
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
| | - Ghazel Mukhtar
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
| | - Anna Ferlin
- Clinical Genetics and Genomics Laboratory, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Trust, London SE1 7EH, UK; (A.F.); (A.F.)
| | - Andrew Fleming
- Clinical Genetics and Genomics Laboratory, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Trust, London SE1 7EH, UK; (A.F.); (A.F.)
| | - Deborah J. Morris-Rosendahl
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
- Clinical Genetics and Genomics Laboratory, Royal Brompton Hospital, Guy’s and St Thomas’ NHS Trust, London SE1 7EH, UK; (A.F.); (A.F.)
| | - Claire L. Shovlin
- National Heart and Lung Institute, Imperial College London, London W12 0NN, UK; (K.J.); (S.C.M.); (G.M.); (D.J.M.-R.)
- Specialist Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK
- Social, Genetic and Environmental Determinants of Health, NIHR Imperial Biomedical Research Centre, London W2 1NY, UK
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Sekiguchi N, Yamada D, Kobayashi S, Sasaki K, Iwagami Y, Tomimaru Y, Noda T, Takahashi H, Doki Y, Eguchi H. Partial hepatectomy for a patient with Rendu-Osler-Weber disease: a case report. Surg Case Rep 2023; 9:7. [PMID: 36656420 PMCID: PMC9852366 DOI: 10.1186/s40792-023-01588-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/07/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Rendu-Osler-Weber disease (Osler disease) is a genetic disease with an autosomal dominant inheritance pattern. It is characterized by widespread telangiectasia in multiple organs. Liver involvement of FNH is relatively common, but liver cancer is very rare, and there are few reports on hepatectomy or postoperative complications. We report a very rare case in which hepatectomy was performed for a patient with Osler disease. CASE PRESENTATION The patient was a 39-year-old man with Osler disease who had been previously diagnosed with multiple FNH and who had been followed for 8 years. During follow-up, the diameter of an S6 lesion gradually increased from 30 to 50 mm; no other lesions increased in size. We decided to perform partial liver resection as total biopsy for the growing tumor, due to the possibility that the growing tumor lesion included malignant components. The pathological examination revealed no obvious malignancy, which was finally diagnosed FNH. The postoperative course was uneventful and he was discharged on the 14th day after surgery. In the second month after discharge, he was transferred to our hospital with sudden abdominal pain in the right hypochondrium with severe tenderness. CT showed extravasation of contrast medium from the hepatic dissection surface in S6, and the hematoma extended to the pelvic floor. Emergency IVR was performed and revealed leakage of the contrast medium from the A6 branch. We embolized the A6 with Lipiodol. After embolization, there were no major problems, and the patient was discharged on the 9th day after the treatment. CONCLUSIONS Postoperative hemorrhage often occurs within 24 h after surgery, and 2 months after surgery is considered to be the late stage of the wound healing process, and postoperative hemorrhage at this timepoint is considered rare. This unexpected delayed postoperative hemorrhage may have been related to the etiology and pathology of Osler disease, nevertheless, case reports of hepatectomy for patients with Osler disease are limited. We, therefore, report the present case with a review of the relevant literature.
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Affiliation(s)
- Naoko Sekiguchi
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Daisaku Yamada
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Shogo Kobayashi
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Kazuki Sasaki
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Yoshifumi Iwagami
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Yoshito Tomimaru
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Takehiro Noda
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Hidenori Takahashi
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Yuichiro Doki
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Hidetoshi Eguchi
- grid.136593.b0000 0004 0373 3971Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2, Yamadaoka, Suita, Osaka 565-0871 Japan
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4
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SARS-CoV-2 Infection in Hereditary Hemorrhagic Telangiectasia Patients Suggests Less Clinical Impact Than in the General Population. J Clin Med 2021; 10:jcm10091884. [PMID: 33925423 PMCID: PMC8123859 DOI: 10.3390/jcm10091884] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 02/08/2023] Open
Abstract
At the moment of writing this communication, the health crisis derived from the COVID-19 pandemic has affected more than 120 million cases, with 40 million corresponding to Europe. In total, the number of deaths is almost 3 million, but continuously rising. Although COVID-19 is primarily a respiratory disease, SARS-CoV-2 infects also endothelial cells in the pulmonary capillaries. This affects the integrity of the endothelium and increases vascular permeability. In addition, there are serious indirect consequences, like disruption of endothelial cells’ junctions leading to micro-bleeds and uncontrolled blood clotting. The impact of COVID-19 in people with rare chronic cardiovascular diseases is unknown so far, and interesting to assess, because the virus may cause additional complications in these patients. The aim of the present work was to study the COVID-19 infection among the patients with Hereditary Hemorrhagic Telangiectasia (HHT). A retrospective study was carried out in a 138 HHT patients’ sample attending an Ear Nose and Throat (ENT) reference consult. The evaluation of the COVID-19 infection in them reveals milder symptoms; among the 25 HHT patients who were infected, only 3 cases were hospitalized, and none of them required ICU or ventilation assistance. The results are discussed in the light of macrophage immune response.
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5
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Ollauri-Ibáñez C, Ayuso-Íñigo B, Pericacho M. Hot and Cold Tumors: Is Endoglin (CD105) a Potential Target for Vessel Normalization? Cancers (Basel) 2021; 13:1552. [PMID: 33800564 PMCID: PMC8038031 DOI: 10.3390/cancers13071552] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 12/15/2022] Open
Abstract
Tumors are complex masses formed by malignant but also by normal cells. The interaction between these cells via cytokines, chemokines, growth factors, and enzymes that remodel the extracellular matrix (ECM) constitutes the tumor microenvironment (TME). This TME can be determinant in the prognosis and the response to some treatments such as immunotherapy. Depending on their TME, two types of tumors can be defined: hot tumors, characterized by an immunosupportive TME and a good response to immunotherapy; and cold tumors, which respond poorly to this therapy and are characterized by an immunosuppressive TME. A therapeutic strategy that has been shown to be useful for the conversion of cold tumors into hot tumors is vascular normalization. In this review we propose that endoglin (CD105) may be a useful target of this strategy since it is involved in the three main processes involved in the generation of the TME: angiogenesis, inflammation, and cancer-associated fibroblast (CAF) accumulation. Moreover, the analysis of endoglin expression in tumors, which is already used in the clinic to study the microvascular density and that is associated with worse prognosis, could be used to predict a patient's response to immunotherapy.
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Affiliation(s)
| | | | - Miguel Pericacho
- Renal and Cardiovascular Research Unit, Group of Physiopathology of the Vascular Endothelium (ENDOVAS), Biomedical Research Institute of Salamanca (IBSAL), Department of Physiology and Pharmacology, University of Salamanca, 37007 Salamanca, Spain; (C.O.-I.); (B.A.-Í.)
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Hereditary Hemorrhagic Telangiectasia (HHT) and Survival: The Importance of Systematic Screening and Treatment in HHT Centers of Excellence. J Clin Med 2020; 9:jcm9113581. [PMID: 33172103 PMCID: PMC7694763 DOI: 10.3390/jcm9113581] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 10/31/2020] [Accepted: 11/03/2020] [Indexed: 01/18/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), an autosomal dominant disease, is characterized by telangiectases and arteriovenous malformations (AVMs). Untreated AVMs, especially in the lungs—pulmonary AVMs (PAVMs)—can result in morbidity with a decreased life expectancy. We have investigated whether HHT patients, systematically screened for HHT-related organ involvement and treated if needed, have a similar survival as persons without HHT. We included all individuals screened for HHT between 2004 and 2016 with a genetically or clinically confirmed diagnosis (HHT group) or excluded diagnosis (non-HHT control group). The social security number was used to confirm status as dead or alive in December 2019. We included 717 HHT patients and 471 controls. There was no difference in survival between the HHT and the non-HHT control group. The HHT group had a life expectancy of 75.9 years (95% confidence interval (CI) 73.3–78.6), comparable to the control group (79.3 years, 95% CI 74.8–84.0, Mantel–Cox test: p = 0.29). In conclusion, the life expectancy of HHT patients systematically screened for HHT-related organ involvement and treated if needed in an HHT center of excellence was similar compared to their controls, justifying systematic screening and treatment in HHT patients.
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7
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Dhooge M, Baert-Desurmont S, Corsini C, Caron O, Andrieu N, Berthet P, Bonadona V, Cohen-Haguenauer O, De Pauw A, Delnatte C, Dussart S, Lasset C, Leroux D, Maugard C, Moretta-Serra J, Popovici C, Buecher B, Colas C, Noguès C. National recommendations of the French Genetics and Cancer Group - Unicancer on the modalities of multi-genes panel analyses in hereditary predispositions to tumors of the digestive tract. Eur J Med Genet 2020; 63:104080. [PMID: 33039684 DOI: 10.1016/j.ejmg.2020.104080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 12/13/2022]
Abstract
In case of suspected hereditary predisposition to digestive cancers, next-generation sequencing can analyze simultaneously several genes associated with an increased risk of developing these tumors. Thus, "Gastro Intestinal" (GI) gene panels are commonly used in French molecular genetic laboratories. Lack of international recommendations led to disparities in the composition of these panels and in the management of patients. To harmonize practices, the Genetics and Cancer Group (GGC)-Unicancer set up a working group who carried out a review of the literature for 31 genes of interest in this context and established a list of genes for which the estimated risks associated with pathogenic variant seemed sufficiently reliable and high for clinical use. Pancreatic cancer susceptibility genes have been excluded. This expertise defined a panel of 14 genes of confirmed clinical interest and relevant for genetic counseling: APC, BMPR1A, CDH1, EPCAM, MLH1, MSH2, MSH6, MUTYH, PMS2, POLD1, POLE, PTEN, SMAD4 and STK11. The reasons for the exclusion of the others 23 genes have been discussed. The paucity of estimates of the associated tumor risks led to the exclusion of genes, in particular CTNNA1, MSH3 and NTHL1, despite their implication in the molecular pathways involved in the pathophysiology of GI cancers. A regular update of the literature is planned to up-grade this panel of genes in case of new data on candidate genes. Genetic and epidemiological studies and international collaborations are needed to better estimate the risks associated with the pathogenic variants of these genes either selected or not in the current panel.
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Affiliation(s)
- Marion Dhooge
- APHP.Centre (Cochin Hospital), Paris University, Paris, France.
| | - Stéphanie Baert-Desurmont
- Normandie Univ, UNIROUEN, Inserm U1245 and Rouen University Hospital, Department of Genetics, Normandy Center for Genomic and Personalized Medicine, Rouen, France
| | - Carole Corsini
- Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Olivier Caron
- Gustave-Roussy University Hospital, Villejuif, France
| | - Nadine Andrieu
- Institut Curie, PSL Research University, Department of Tumor Biology, Paris, France; Unité Inserm, Institut Curie, Paris, France
| | | | | | | | - Antoine De Pauw
- Institut Curie, PSL Research University, Department of Tumor Biology, Paris, France
| | | | | | | | - Dominique Leroux
- Grenoble University Hospital, Couple-Enfant Hospital, Grenoble, France
| | | | - Jessica Moretta-Serra
- Institut Paoli-Calmettes, Department of Clinical Cancer Genetics, Aix Marseille Univ, INSERM, IRD, SESSTIM, Marseille, France
| | - Cornel Popovici
- Institut Paoli-Calmettes, Department of Clinical Cancer Genetics, Aix Marseille Univ, INSERM, IRD, SESSTIM, Marseille, France
| | - Bruno Buecher
- Institut Curie, PSL Research University, Department of Tumor Biology, Paris, France
| | - Chrystelle Colas
- Institut Curie, PSL Research University, Department of Tumor Biology, Paris, France
| | - Catherine Noguès
- Institut Paoli-Calmettes, Department of Clinical Cancer Genetics, Aix Marseille Univ, INSERM, IRD, SESSTIM, Marseille, France
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8
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Park R, Philp A, Nagji AS, Kasi A. Pathologically Complete Response after Triple Therapy in Locally Advanced Esophageal Cancer in a Hereditary Hemorrhagic Telangiectasia Patient. Case Rep Oncol 2020; 13:176-181. [PMID: 32231541 PMCID: PMC7098335 DOI: 10.1159/000505832] [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: 01/03/2020] [Accepted: 01/07/2020] [Indexed: 11/19/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a disorder characterized by vascular manifestations including mucocutaneous and visceral telangiectasias and arteriovenous malformations. Herein we present the case of a relatively young patient with HHT with an incidentally discovered locally advanced esophageal cancer on endoscopic screening and pathologically complete response after neoadjuvant chemoradiation. This case highlights an unusual tumor response to chemoradiation in locally advanced esophageal cancer, and the surveillance care of HHT patients.
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Affiliation(s)
- Robin Park
- Department of Medicine, MetroWest Medical Center, Framingham, Massachusetts, USA
| | - Alisdair Philp
- Department of Medicine, Division of Medical Oncology, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Alykhan S Nagji
- Department of Cardiovascular and Thoracic Surgery, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Anup Kasi
- Department of Medicine, Division of Medical Oncology, Kansas University Medical Center, Kansas City, Kansas, USA
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9
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Ortega-Torres A, Sánchez-Díaz G, Villaverde-Hueso A, Posada de la Paz M, Alonso-Ferreira V. Mortalidad atribuida a telangiectasia hemorrágica hereditaria y variabilidad geográfica en España (1981-2016). GACETA SANITARIA 2020; 34:37-43. [DOI: 10.1016/j.gaceta.2018.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 11/17/2022]
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10
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Morii K, Uematsu R, Yamamoto T, Nakamura S, Okushin H, Nishiwaki N, Watanabe T, Kai K, Sato S. Hepatocellular Carcinoma in a Patient with Hereditary Hemorrhagic Telangiectasia. Intern Med 2018; 57:3545-3549. [PMID: 30146556 PMCID: PMC6355409 DOI: 10.2169/internalmedicine.1056-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 76-year-old woman with hereditary hemorrhagic telangiectasia (HHT) showed elevated serum hepatobiliary enzyme levels, and abdominal imaging studies revealed a hepatic tumor. Her serum alpha-fetoprotein level was 759.5 ng/mL. A pathological examination after hepatectomy confirmed a diagnosis of hepatocellular carcinoma (HCC). An examination of the surrounding liver revealed dilated vessels and thickened endothelial cells without inflammations. HHT patients without other risk factors (like this patient) reportedly have a lower incidence of common cancers, including HCC, in comparison to the unaffected population. One intriguing hypothesis that might explain the hepatocarcinogenesis in this situation is the ischemic liver cirrhosis theory, which suggests that chronic ischemia may cause parenchymal strain and promote inappropriate hepatocyte proliferation.
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Affiliation(s)
- Kazuhiko Morii
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Japan
| | - Riku Uematsu
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Japan
| | - Takeharu Yamamoto
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Japan
| | | | - Hiroaki Okushin
- Department of Hepatology, Japanese Red Cross Society Himeji Hospital, Japan
| | - Noriyuki Nishiwaki
- Department of Hepatobiliary and Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Takanori Watanabe
- Department of Hepatobiliary and Pancreatic Surgery, Japanese Red Cross Society Himeji Hospital, Japan
| | - Kyohei Kai
- Department of Hepatobiliary and Pancreatic Surgery, Japanese Red Cross Society Himeji Hospital, Japan
| | - Shiso Sato
- Department of Hepatobiliary and Pancreatic Surgery, Japanese Red Cross Society Himeji Hospital, Japan
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11
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Kühnel T, Wirsching K, Wohlgemuth W, Chavan A, Evert K, Vielsmeier V. Hereditary Hemorrhagic Telangiectasia. Otolaryngol Clin North Am 2018; 51:237-254. [PMID: 29217066 DOI: 10.1016/j.otc.2017.09.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Hereditary hemorrhagic telangiectasia (HHT) describes the presenting manifestations of a disorder that is characterized by pathologic blood vessels. HHT is inherited as an autosomal dominant trait with variable penetrance. The abnormal vascular structures (dysplasias) can affect all the organs in the human body. The link between a physical stimulus and new lesion development has been established for mucosal trauma owing to nasal airflow turbulence, for ultraviolet exposure to the fingers, and for mechanical trauma to the dominant hand. The pressing question then is whether HHT treatment constitutes a stimulus that is sufficient to trigger new lesion development.
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Affiliation(s)
- Thomas Kühnel
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany.
| | - Kornelia Wirsching
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Walter Wohlgemuth
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Ajay Chavan
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Katja Evert
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Veronika Vielsmeier
- University of Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
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12
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Droege F, Thangavelu K, Stuck BA, Stang A, Lang S, Geisthoff U. Life expectancy and comorbidities in patients with hereditary hemorrhagic telangiectasia. Vasc Med 2018; 23:377-383. [DOI: 10.1177/1358863x18767761] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
There are only a few published studies that demonstrate associations between life expectancy, severe comorbidities, and their complications in patients with hereditary hemorrhagic telangiectasia (HHT). Relatives of 73 deceased patients with suspected HHT completed a questionnaire about causes of death, and symptoms and comorbidities that the patients had developed. We compared the data for 55 cases where HHT had been clinically confirmed with the general population. Patients suffering from HHT lost, on average, 19 years (SD 11 years) of potential life compared to the general population. Among the deceased HHT patients, 35% (95% CI: 23–48%) died from sepsis, 26% (95% CI: 16–38%) from cardiac failure, 20% (95% CI: 9–28%) from a severe bleeding episode, and 13% (95% CI: 6–24%) from terminal cancer. Congestive heart failure (69%, 95% CI: 56–80%) and pulmonary hypertension (23%, 95% CI: 14–36%) were the main non-fatal comorbidities in patients with HHT. Patients with HHT appear to have a lower life expectancy than the general population. Sepsis and cardiac failure were the main causes of death. Optimized and targeted screening programs for the most frequent comorbidities followed by improved management of infectious complications may increase life expectancy.
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Affiliation(s)
- Freya Droege
- Department of Otorhinolaryngology, Head and Neck Surgery, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Kruthika Thangavelu
- Department of Otorhinolaryngology, Head and Neck Surgery, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Boris A Stuck
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Andreas Stang
- Center of Clinical Epidemiology, Institute of Medical Informatics, Biometry and Epidemiology, Essen University Hospital, Essen, Germany
| | - Stephan Lang
- Department of Otorhinolaryngology, Head and Neck Surgery, Essen University Hospital, University Duisburg-Essen, Essen, Germany
| | - Urban Geisthoff
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
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Sacco KM, Barkley TW. Hereditary Hemorrhagic Telangiectasia: A Primer for Critical Care Nurses. Crit Care Nurse 2018; 36:36-48. [PMID: 27252100 DOI: 10.4037/ccn2016270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Hereditary hemorrhagic telangiectasia is a rare, autosomal dominant genetic disease that causes abnormal growth of blood vessels and, subsequently, life-threatening arteriovenous malformations in vital organs. Epistaxis may be one of the initial clues that a patient has more serious, generalized arteriovenous malformations. Recommended treatment involves careful evaluation to determine the severity and risk of spontaneous rupture of the malformations and the management of various signs and symptoms. The disease remains undiagnosed in many patients, and health care providers may miss the diagnosis until catastrophic events happen in multiple family members. Prompt recognition of hereditary hemorrhagic telangiectasia and early intervention can halt the dangerous course of the disease. Critical care nurses can assist with early diagnosis within families with this genetic disease, thus preventing early death and disability.
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Affiliation(s)
- Kathleen M Sacco
- Kathleen M. Sacco is the director, Intensive Care Unit and Cardiopulmonary Services, Simi Valley Hospital, Simi Valley, California.Thomas W. Barkley, Jr, is president of Barkley and Associates, West Hollywood, California.
| | - Thomas W Barkley
- Kathleen M. Sacco is the director, Intensive Care Unit and Cardiopulmonary Services, Simi Valley Hospital, Simi Valley, California.Thomas W. Barkley, Jr, is president of Barkley and Associates, West Hollywood, California
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Shovlin CL, Condliffe R, Donaldson JW, Kiely DG, Wort SJ. British Thoracic Society Clinical Statement on Pulmonary Arteriovenous Malformations. Thorax 2017; 72:1154-1163. [DOI: 10.1136/thoraxjnl-2017-210764] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/01/2017] [Accepted: 09/04/2017] [Indexed: 01/02/2023]
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15
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Dupuis-Girod S, Cottin V, Shovlin CL. The Lung in Hereditary Hemorrhagic Telangiectasia. Respiration 2017; 94:315-330. [PMID: 28850955 DOI: 10.1159/000479632] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is a dominantly inherited genetic vascular disorder with an estimated prevalence of 1 in 6,000, characterized by recurrent epistaxis, cutaneous telangiectasia, and arteriovenous malformations (AVMs) that affect many organs including the lungs, gastrointestinal tract, liver, and brain. Its diagnosis is based on the Curaçao criteria, and is considered definite if at least 3 of the 4 following criteria are fulfilled: (1) spontaneous and recurrent epistaxis, (2) telangiectasia, (3) a family history, and (4) pulmonary, liver, cerebral, spinal, or gastrointestinal AVMs. The focus of this review is on delineating how HHT affects the lung.
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Affiliation(s)
- Sophie Dupuis-Girod
- Service de génétique - centre de référence national pour la maladie de Rendu-Osler, Hôpital Femme-Mère-Enfants, Hospices Civils de Lyon, Bron, France
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16
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Ollauri-Ibáñez C, López-Novoa JM, Pericacho M. Endoglin-based biological therapy in the treatment of angiogenesis-dependent pathologies. Expert Opin Biol Ther 2017; 17:1053-1063. [PMID: 28656781 DOI: 10.1080/14712598.2017.1346607] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Alterations in the process of angiogenesis, either by excess or by defect, are present in different common pathologies. For this reason, great efforts are being made toward the development of pro- and anti-angiogenic therapies. Since endoglin levels are enhanced in tissues undergoing angiogenesis, and changes in its expression lead to alterations in vessel formation, endoglin has become an ideal target for these types of therapies. Areas covered: In this review, the role of endoglin in angiogenesis is summarized. In addition, the authors review pro- and anti-angiogenic therapies that are currently being used and new approaches that target endoglin. The article includes therapies that are both in preclinical and clinical development. Expert opinion: Endoglin is a very good target for anti-angiogenic therapy, as demonstrated by the positive results obtained with anti-endoglin antibodies. However, although endoglin in pro-angiogenic therapies has been successful in vitro, its use has not yet reached clinical settings. Moreover, the authors believe that establishing the exact role of endoglin in angiogenesis is essential and that this should be the next step in this field in the coming years.
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Affiliation(s)
- Claudia Ollauri-Ibáñez
- a Department of Physiology and Pharmacology , University of Salamanca , Salamanca , Spain.,b Biomedical Research Institute of Salamanca (IBSAL) , Salamanca , Spain
| | - José M López-Novoa
- a Department of Physiology and Pharmacology , University of Salamanca , Salamanca , Spain.,b Biomedical Research Institute of Salamanca (IBSAL) , Salamanca , Spain
| | - Miguel Pericacho
- a Department of Physiology and Pharmacology , University of Salamanca , Salamanca , Spain.,b Biomedical Research Institute of Salamanca (IBSAL) , Salamanca , Spain
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Kjeldsen A, Aagaard KS, Tørring PM, Möller S, Green A. 20-year follow-up study of Danish HHT patients-survival and causes of death. Orphanet J Rare Dis 2016; 11:157. [PMID: 27876060 PMCID: PMC5120428 DOI: 10.1186/s13023-016-0533-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/07/2016] [Indexed: 11/17/2022] Open
Abstract
Background Hereditary Haemorrhagic Telangiectasia (HHT) is a dominantly inheritable disorder, with a wide variety of clinical manifestations due to presence of multiple arteriovenous manifestations. The most common mutations are found in HHT1 (ENG) and HHT2 (ACVRL1) patients, causing alterations in the TGF-β pathway which is responsible for angiogenesis. Modulations of angiogenesis may influence cancer rates. The objective of the study was to evaluate 20-year survival according to HHT subtype, as well as to evaluate differences in causes of death comparing HHT patients and controls. We also wanted to investigate whether cancer morbidity among HHT patients differs from that among controls. Results We included all HHT patients in the County of Fyn, Denmark, prevalent as of January 1st 1995 in total 73 HHT patients. In addition three age- and sex- matched controls per HHT patient were evaluated, in total 218 controls (one was lost due to registration failure). The controls were defined at start of follow-up in 1995. Information on lifestyle factors was not available. A total of 32 (44%) HHT patients and 97 (44%) controls passed away during follow-up. The survival curves were evenly distributed showing similar survival rates in the two groups. Cancer diagnoses had been registered in the follow-up period in 4 (5%) HHT patients and in 38 (17%) controls. Conclusion The mortality was not increased among Danish HHT patients compared to controls. This study is based on a clinical unselected series of HHT patients with the whole spectrum of severity, independent of need for medical care. Our data also suggest that HHT patients to a lesser degree than the background population are affected by cancer. Electronic supplementary material The online version of this article (doi:10.1186/s13023-016-0533-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anette Kjeldsen
- HHT-center OUH, Department of Otorhinolaryngology, Odense, Denmark. .,Clinical Institute, University of Southern Denmark, Odense, Denmark.
| | | | | | - Sören Möller
- OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Anders Green
- OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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18
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Cancer and hereditary haemorrhagic telangiectasia. J Cancer Res Clin Oncol 2016; 143:369-370. [DOI: 10.1007/s00432-016-2298-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/26/2016] [Indexed: 11/27/2022]
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Shovlin CL, Gilson C, Busbridge M, Patel D, Shi C, Dina R, Abdulla FN, Awan I. Can Iron Treatments Aggravate Epistaxis in Some Patients With Hereditary Hemorrhagic Telangiectasia? Laryngoscope 2016; 126:2468-2474. [PMID: 27107394 PMCID: PMC5095791 DOI: 10.1002/lary.25959] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 01/31/2016] [Accepted: 02/10/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS To examine whether there is a rationale for iron treatments precipitating nosebleeds (epistaxis) in a subgroup of patients with hereditary hemorrhagic telangiectasia (HHT). STUDY DESIGN Survey evaluation of HHT patients, and a randomized control trial in healthy volunteers. METHODS Nosebleed severity in response to iron treatments and standard investigations were evaluated by unbiased surveys in patients with HHT. Serial blood samples from a randomized controlled trial of 18 healthy volunteers were used to examine responses to a single iron tablet (ferrous sulfate, 200 mg). RESULTS Iron tablet users were more likely to have daily nosebleeds than non-iron-users as adults, but there was no difference in the proportions reporting childhood or trauma-induced nosebleeds. Although iron and blood transfusions were commonly reported to improve nosebleeds, 35 of 732 (4.8%) iron tablet users, in addition to 17 of 261 (6.5%) iron infusion users, reported that their nosebleeds were exacerbated by the respective treatments. These rates were significantly higher than those reported for control investigations. Serum iron rose sharply in four of the volunteers ingesting ferrous sulfate (by 19.3-33.1 μmol/L in 2 hours), but not in 12 dietary controls (2-hour iron increment ranged from -2.2 to +5.0 μmol/L). High iron absorbers demonstrated greater increments in serum ferritin at 48 hours, but transient rises in circulating endothelial cells, an accepted marker of endothelial damage. CONCLUSIONS Iron supplementation is essential to treat or prevent iron deficiency, particularly in patients with pathological hemorrhagic iron losses. However, in a small subgroup of individuals, rapid changes in serum iron may provoke endothelial changes and hemorrhage. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2468-2474, 2016.
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Affiliation(s)
- Claire L Shovlin
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
- Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom.
| | - Clare Gilson
- Respiratory Medicine, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Mark Busbridge
- Clinical Chemistry, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Dilip Patel
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Chenyang Shi
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Roberto Dina
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - F Naziya Abdulla
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College London School of Medicine, London, United Kingdom
| | - Iman Awan
- Cardiovascular Sciences, National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College London School of Medicine, London, United Kingdom
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20
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Shovlin C, Awan I, Cahilog Z, Abdulla F, Guttmacher A. Reported cardiac phenotypes in hereditary hemorrhagic telangiectasia emphasize burdens from arrhythmias, anemia and its treatments, but suggest reduced rates of myocardial infarction. Int J Cardiol 2016; 215:179-85. [DOI: 10.1016/j.ijcard.2016.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/02/2016] [Indexed: 01/17/2023]
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21
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Neurological Symptoms in a Cancer Patient With Osler-Weber-Rendu Syndrome. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2016. [DOI: 10.1097/ipc.0000000000000353] [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]
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22
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Geisthoff UW, Nguyen HL, Röth A, Seyfert U. How to manage patients with hereditary haemorrhagic telangiectasia. Br J Haematol 2015. [PMID: 26205234 DOI: 10.1111/bjh.13606] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Hereditary haemorrhagic telangiectasia is a rare systemic autosomal dominantly inherited disorder of the fibrovascular tissue with a wide variety of clinical manifestations. Diagnosis is based on the clinical Curaçao criteria or molecular genetic testing. Dilated vessels can develop into telangiectases or larger vascular malformations in various organs, calling for an interdisciplinary approach. Epistaxis and gastrointestinal bleeding can result from these vascular defects. Various conservative and interventional treatments have been described for these conditions. However, no optimal therapy exists. Treatment can become especially difficult due to progressive anaemia or when anticoagulant or anti-thrombotic therapy becomes necessary. Screening for pulmonary arteriovenous malformations (PAVM) should be performed in all confirmed and suspected patients. Treatment by percutaneous transcatheter embolotherapy and antibiotic prophylaxis is normally effective for PAVM. Cerebral or hepatic vascular malformations and rare manifestations need to be evaluated on a case-by-case basis to determine the best course of action for treatment.
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Affiliation(s)
- Urban W Geisthoff
- Department of Otorhinolaryngology, Essen University Hospital, Essen, Germany
| | - Ha-Long Nguyen
- Laboratory of Human Molecular Genetics, de Duve Institute, Université catholique de Louvain, Brussels, Belgium
| | - Alexander Röth
- Department of Haematology and Haemostaseology, Essen University Hospital, Essen, Germany
| | - Ulrich Seyfert
- Medical Practice for Haemostaseology and Transfusion Medicine, Saarbrücken, Germany
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Shovlin CL. Pulmonary arteriovenous malformations. Am J Respir Crit Care Med 2014; 190:1217-28. [PMID: 25420112 PMCID: PMC4315816 DOI: 10.1164/rccm.201407-1254ci] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 10/20/2014] [Indexed: 11/16/2022] Open
Abstract
Within the past decade, pulmonary arteriovenous malformations (PAVMs) have evolved from rare curiosities to not uncommon clinical states, with the latest estimates suggesting a prevalence of ~1 in 2,600. PAVMs provide anatomic right-to-left shunts, allowing systemic venous blood to bypass gas exchange and pulmonary capillary bed processing. Hypoxemia and enhanced ventilatory demands result, although both are usually asymptomatic. Paradoxical emboli lead to strokes and cerebral abscesses, and these commonly occur in individuals with previously undiagnosed PAVMs. PAVM hemorrhage is rare but is the main cause of maternal death in pregnancy. PAVM occlusion by embolization is the standard of care to reduce these risks. However, recent data demonstrate that currently recommended management protocols can result in levels of radiation exposure that would be classified as harmful. Recent publications also provide a better appreciation of the hematologic and cardiovascular demands required to maintain arterial oxygen content and oxygen consumption in hypoxemic patients, identify patient subgroups at higher risk of complications, and emphasize the proportion of radiologically visible PAVMs too small to treat by embolization. This review, therefore, outlines medical states that exacerbate the consequences of PAVMs. Chief among these is iron deficiency, which is commonly present due to concurrent hereditary hemorrhagic telangiectasia: iron deficiency impairs hypoxemia compensations by restricting erythropoiesis and increases the risk of ischemic strokes. Management of periodontal disease, dental interventions, pulmonary hypertension, and pregnancy also requires specific consideration in the setting of PAVMs. The review concludes by discussing to what extent previously recommended protocols may benefit from modification or revision.
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Affiliation(s)
- Claire L. Shovlin
- NHLI Cardiovascular Sciences, Imperial College, London; and
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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24
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Garg N, Khunger M, Gupta A, Kumar N. Optimal management of hereditary hemorrhagic telangiectasia. J Blood Med 2014; 5:191-206. [PMID: 25342923 PMCID: PMC4206399 DOI: 10.2147/jbm.s45295] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known by the eponym Osler-Weber-Rendu syndrome, is a group of related disorders inherited in an autosomal dominant fashion and characterized by the development of arteriovenous malformations (AVM) in the skin, mucous membranes, and/or internal organs such as brain, lungs, and liver. Its prevalence is currently estimated at one in 5,000 to 8,000. Most cases are due to mutations in the endoglin (HHT1) or ACVRLK1 (HHT2) genes. Telangiectasias in nasal and gastrointestinal mucosa generally present with recurrent/chronic bleeding and iron deficiency anemia. Larger AVMs occur in lungs (~40%-60% of affected individuals), liver (~40%-70%), brain (~10%), and spine (~1%). Due to the devastating and potentially fatal complications of some of these lesions (for example, strokes and brain abscesses with pulmonary AVMs), presymptomatic screening and treatment are of utmost importance. However, due to the rarity of this condition, many providers lack an appreciation for the whole gamut of its manifestations and complications, age-dependent penetrance, and marked intrafamilial variation. As a result, HHT remains frequently underdiagnosed and many families do not receive the appropriate screening and treatments. This article provides an overview of the clinical features of HHT, discusses the clinical and genetic diagnostic strategies, and presents an up-to-date review of literature and detailed considerations regarding screening for visceral AVMs, preventive modalities, and treatment options.
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Affiliation(s)
- Neetika Garg
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Monica Khunger
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Arjun Gupta
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Nilay Kumar
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
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