1
|
Jindal AK, Barman P, Basu S, Tyagi R, Sil A, Chawla S, Machhua S, Kaur G, Sharma S, Dhaliwal M, Bishnoi A, Vinay K, Vignesh P, Pilania RK, Suri D, Garg R, Rawat A, Kumaran SM, Dogra S, Farkas H, Longhurst H, Singh S. Clinical profile and management of pediatric hereditary angioedema in resource-constrained settings: our experience from a single centre in North India. Immunol Res 2024:10.1007/s12026-024-09547-9. [PMID: 39317852 DOI: 10.1007/s12026-024-09547-9] [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] [Accepted: 09/16/2024] [Indexed: 09/26/2024]
Abstract
Hereditary angioedema (HAE) is a rare genetic disorder. The pattern of HAE is different in children as compared to adults. There is limited literature from developing countries where all first-line treatments are either unavailable or not easily accessible. Data of children with HAE were retrieved from medical records of patients registered in the Pediatric Immunodeficiency Clinic at our institute. Of the 206 patients with HAE, 61 were diagnosed before the age of 18 years. Male: female ratio was 1.1:1. Median age at onset of symptoms and diagnosis were 6.2 years (range 1-17 years) and 10.7 years (range 1.5-18 years) respectively. Median delay in diagnosis was 4.9 years (range 0-16 years). The commonest presentation was facial swelling (51/61) followed by swelling of extremities (47/61). Laryngeal edema and abdominal symptoms were reported in 28/61 and 31/61 patients respectively. Abdominal attacks were found to be less common in children as compared to adults. Most patients in our cohort received fresh-frozen plasma (n = 5/61) as on-demand therapy. Long-term prophylaxis included attenuated androgens (n = 25/61) and tranexamic acid (n = 23/61). Median duration of follow-up was 2242 patient months. One patient died on follow-up in this cohort. This is the largest single-centre cohort of pediatric HAE from resource-constrained settings. Facial attacks were more common, and there were significant delays in diagnosis when the age of onset of symptoms was younger. Gastrointestinal symptoms were less common in children than adults. HIGHLIGHTS: One of the largest single-centre cohorts of pediatric HAE and the only one from resource-constrained settings. There were significant delays in diagnosis when the age of onset of symptoms was younger. Abdominal attacks were found to be less common in children as compared to adults.
Collapse
Affiliation(s)
- Ankur Kumar Jindal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Prabal Barman
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Suprit Basu
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Reva Tyagi
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Archan Sil
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sanchi Chawla
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sanghamitra Machhua
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Gurjit Kaur
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Saniya Sharma
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Manpreet Dhaliwal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anuradha Bishnoi
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Keshavmurthy Vinay
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pandiarajan Vignesh
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Rakesh Kumar Pilania
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Deepti Suri
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Ravinder Garg
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Amit Rawat
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sendhil M Kumaran
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Henriette Farkas
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Hilary Longhurst
- Auckland District Health Board, Auckland, New Zealand
- Department of Allergy and Immunology, University College Hospitals, London, UK
| | - Surjit Singh
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| |
Collapse
|
2
|
Ballonová L, Souček P, Slanina P, Réblová K, Zapletal O, Vlková M, Hakl R, Bíly V, Grombiříková H, Svobodová E, Kulíšková P, Štíchová J, Sobotková M, Zachová R, Hanzlíková J, Vachová M, Králíčková P, Krčmová I, Jeseňák M, Freiberger T. Myeloid lineage cells evince distinct steady-state level of certain gene groups in dependence on hereditary angioedema severity. Front Genet 2023; 14:1123914. [PMID: 37470035 PMCID: PMC10352584 DOI: 10.3389/fgene.2023.1123914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 06/23/2023] [Indexed: 07/21/2023] Open
Abstract
Hereditary angioedema (HAE) is a rare genetic disorder with variable expressivity even in carriers of the same underlying genetic defect, suggesting other genetic and epigenetic factors participate in modifying HAE severity. Recent knowledge indicates the role of immune cells in several aspects of HAE pathogenesis, which makes monocytes and macrophages candidates to mediate these effects. Here we combined a search for HAE phenotype modifying gene variants with the characterization of selected genes' mRNA levels in monocyte and macrophages in a symptom-free period. While no such gene variant was found to be associated with a more severe or milder disease, patients revealed a higher number of dysregulated genes and their expression profile was significantly altered, which was typically manifested by changes in individual gene expression or by strengthened or weakened relations in mutually co-expressed gene groups, depending on HAE severity. SERPING1 showed decreased expression in HAE-C1INH patients, but this effect was significant only in patients carrying mutations supposedly activating nonsense-mediated decay. Pro-inflammatory CXC chemokine superfamily members CXCL8, 10 and 11 were downregulated, while other genes such as FCGR1A, or long non-coding RNA NEAT1 were upregulated in patients. Co-expression within some gene groups (such as an NF-kappaB function related group) was strengthened in patients with a severe and/or mild course compared to controls. All these findings show that transcript levels in myeloid cells achieve different activation or depression levels in HAE-C1INH patients than in healthy controls and/or based on disease severity and could participate in determining the HAE phenotype.
Collapse
Affiliation(s)
- Lucie Ballonová
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czechia
| | - Přemysl Souček
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
- Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Peter Slanina
- Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Kamila Réblová
- Central European Institute of Technology, Masaryk University, Brno, Czechia
| | - Ondřej Zapletal
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
- Faculty of Medicine, Masaryk University, Brno, Czechia
| | | | - Roman Hakl
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Allergology and Clinical Immunology, St. Anne’s University Hospital in Brno, Brno, Czechia
| | - Viktor Bíly
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
| | - Hana Grombiříková
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
| | - Eliška Svobodová
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czechia
| | - Petra Kulíšková
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
- Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Julie Štíchová
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Allergology and Clinical Immunology, St. Anne’s University Hospital in Brno, Brno, Czechia
| | - Marta Sobotková
- Department of Immunology, Second Medical School Charles University and University Hospital Motol, Brno, Czechia
| | - Radana Zachová
- Department of Immunology, Second Medical School Charles University and University Hospital Motol, Brno, Czechia
| | - Jana Hanzlíková
- Department of Immunology and Allergology, University Hospital Pilsen, Pilsen, Czechia
| | - Martina Vachová
- Department of Immunology and Allergology, University Hospital Pilsen, Pilsen, Czechia
- Department of Immunology and Allergology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czechia
| | - Pavlína Králíčková
- Institute of Clinical Immunology and Allergy, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czechia
| | - Irena Krčmová
- Institute of Clinical Immunology and Allergy, University Hospital Hradec Kralove, Charles University, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czechia
| | - Miloš Jeseňák
- National Centre for Hereditary Angioedema, Department of Pediatrics, Jessenius Faculty of Medicine, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovakia
- Department of Pulmonology and Phthisiology, Jessenius Faculty of Medicine, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovakia
- Depatment of Clinical Immunology and Allergology, Comenius University in Bratislava, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovakia
| | - Tomáš Freiberger
- Centre for Cardiovascular Surgery and Transplantation, Brno, Czechia
- Faculty of Medicine, Masaryk University, Brno, Czechia
| |
Collapse
|
3
|
Ajewole O, Lanlokun M, Dimanche S, Craig T. Short-term prophylaxis for children and adolescents with hereditary angioedema. Allergy Asthma Proc 2021; 42:205-213. [PMID: 33980333 DOI: 10.2500/aap.2021.42.210006] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background: Hereditary Angioedema (HAE) is a rare, autosomal dominant, life threatening disease, secondary to the deficiency of C1-inhibitor, dysfunction of C1-inhibitor or inadequate control of the contact pathway. Presentation includes recurrent swelling of the skin, upper airway and the abdomen. Trauma can precipitate attacks, which in the airway can lead to asphyxia. For this reason, short term prophylaxis (STP) may be indicated before medical, surgical and dental procedures. The goal of the manuscript is to review short term prophylaxis for children of all ages. Methods: We searched the following search words: children, pediatric, adolescent, plasma derived C1-inhibitor, recombinant C1-inhibitor, surgery, medical procedures, prophylaxis, dental, Hereditary Angioedema, tranexamic acid, androgens, fresh frozen plasma, short term prophylaxis, lanadelumab, subcutaneous C1-inhibitor in Google Scholar and in PubMed to develop our results. Results: STP should be discussed at every visit. Plans should be individualized based upon the procedure, therapies available and shared decision making with patient/parent. For high risk procedures plasma derived C1-inhibitor should be used at 20 units/kg just prior to the procedure. Alternative agents for STP include recombinant C1-inhibitor, fresh frozen plasma, androgens, or tranexamic acid. In all cases, with or without the use of STP, 2 doses of on-demand therapy should be available in case of an attack. Conclusion: Herein, we review the published data on STP for pediatric patients with HAE and discuss first-line options, and off label use of medications, as well as review the guidelines pertaining to short term prophylaxis.
Collapse
Affiliation(s)
| | - Mosopefoluwa Lanlokun
- Division of Allergy and Immunology, Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Timothy Craig
- Section of Allergy, Asthma and Immunology, Department of Medicine and Pediatrics, Penn State University, Hershey, PA
| |
Collapse
|
4
|
Bailey CE, Carr MM. Pediatric hereditary angioedema: what the otolaryngologist should know. Curr Opin Otolaryngol Head Neck Surg 2020; 27:499-503. [PMID: 31592791 DOI: 10.1097/moo.0000000000000589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To review pediatric hereditary angioedema for otolaryngologists, with emphasis on articles within the past 12-18 months. RECENT FINDINGS Biologic therapies are accepted for adult hereditary angioedema (HAE), but have been studied less for pediatric HAE. Recent literature supports expanded use of biologic agents in pediatrics as acute treatment and prophylaxis. Available agents include plasma-derived C1 esterase inhibitors (C1-INH) (Berinert, Haegarda, Cinryze), recombinant C1-INH (Ruconest), bradykinin B2 receptor inhibitor (Icatibant), and kallikrein inhibitors (Ecallantide and lanadelumab). Of these, only Berinert is Food and Drug Administration (FDA) approved for acute therapy for children under 12 years of age. Ruconest is approved for treatment of acute attacks over age 13. Ecallantide also has FDA approval as acute treatment for age 12 and older, while lanadelumab and Haegarda are prophylactic agents for adolescents. Icatibant lacks FDA approval in patients under 18 years of age. Cinryze has FDA approval only for prophylaxis for children as young as 6 years old. SUMMARY Pediatric HAE is a potentially life-threatening disease. Targeted biologic agents have gained acceptance in treatment of acute attacks, and their use as prophylactic agents is changing the focus of management from acute intervention to preventive management. While intubation or surgical airway management may still be necessary, early intervention or prophylaxis can decrease morbidity and improve quality of life.
Collapse
Affiliation(s)
- C Eric Bailey
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | | |
Collapse
|
5
|
Shin S, Lee YT, Lee KY, Park J, Lee JH, Yang EA. Complement 4 levels of a 4-year-old girl with angioedema. Clin Exp Pediatr 2020; 63:30-31. [PMID: 31999916 PMCID: PMC7027345 DOI: 10.3345/kjp.2019.00241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 11/03/2019] [Indexed: 11/27/2022] Open
Affiliation(s)
- Soyoung Shin
- Department of Laboratory Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Yoon Tae Lee
- Department of Pediatrics, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Kyung Yil Lee
- Department of Pediatrics, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Joonhong Park
- Department of Laboratory Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Jae Ho Lee
- Department of Pediatrics, Joey Hospital, Daejeon, Korea
| | - Eun Ae Yang
- Department of Pediatrics, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| |
Collapse
|
6
|
Hwang JR, Hwang G, Johri A, Craig T. Oral plasma kallikrein inhibitor BCX7353 for treatment of hereditary angioedema. Immunotherapy 2019; 11:1439-1444. [PMID: 31635497 DOI: 10.2217/imt-2019-0128] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hereditary angioedema (HAE) is rare disorder caused by a SERPING1 gene mutation that triggers severe swelling of the skin and upper airway. Treatment options for HAE with deficient and dysfunctional C1-inhibitor are expanding to include small-molecule drugs that inhibit protein interactions in the kallikrein-kinin system. Discovered by BioCryst Pharmaceuticals, BCX7353 is a synthetic, once-daily, small molecule drug that can be taken as an oral capsule to treat HAE attacks and for prophylaxis. This article will summarize recent and current BCX7353 clinical trials. Overall, results indicate BCX7353 is a promising form of therapy with a rapid 1 h onset of action, long duration of action, and acceptable tolerance.
Collapse
Affiliation(s)
| | - Gloria Hwang
- Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Ansh Johri
- Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
| | - Timothy Craig
- Department of Medicine & Pediatrics, College of Medicine, Allergy, Asthma & Immunology, Pennsylvania State University, Hershey, PA 17033, USA
| |
Collapse
|