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Oliver ET, Saini SS. Chronic Spontaneous Urticaria: Etiology and Pathogenesis. Immunol Allergy Clin North Am 2024; 44:421-438. [PMID: 38937007 DOI: 10.1016/j.iac.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Urticaria, also known as hives, is a common condition thought to affect up to 20% of individuals worldwide in their lifetime. This skin condition is characterized by the appearance of pruritic, erythematous papules or plaques with superficial swelling of the dermis. The major complaint is the symptom of pruritus. Angioedema, which involves a deeper swelling of dermal or mucosal tissues, may accompany urticaria. Urticaria can be classified by both time course of symptoms and the underlying etiology.
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Affiliation(s)
- Eric T Oliver
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Circle/ Room 3A. 18A, Baltimore, MD 21224, USA
| | - Sarbjit S Saini
- Division of Allergy and Clinical Immunology, Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Circle, Room 2B. 71B, Baltimore, MD 21224, USA.
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2
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Estaris J, Ostroukhova M. Extremely Late Diagnosis of Hereditary Angioedema Type I in an Elderly Female. Cureus 2024; 16:e57303. [PMID: 38690445 PMCID: PMC11059123 DOI: 10.7759/cureus.57303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 05/02/2024] Open
Abstract
This case presents an instance of an extremely delayed diagnosis of hereditary angioedema (HAE) type I in an elderly female with no significant past medical history. The patient had a prolonged history of recurrent lip swelling and itchiness dating back to her teenage years, leading to multiple visits to the emergency room (ER). These recurrent episodes were characterized by random onset and accompanied by generalized pruritus and urticaria. During these ER visits, the patient would be inappropriately treated for presumed hypersensitivity reaction due to her confounding environmental allergies presenting with urticaria, complicating and significantly delaying her diagnosis. The patient was adopted, and the family history was unknown. There was no history of medication use suggestive of acquired angioedema. At the time of the visit, she had signs of chronic lip changes and atopy. After an extensive workup, it showed severely low levels of C1 esterase inhibitor and borderline low to normal C4 and C1q, consistent with the diagnosis of HAE type I. Initial treatment with an on-demand C1 esterase inhibitor reduced the recurrence of lip swelling and transitioned to long-term prophylaxis use. Overall, the treatment outcome was generally successful, with less recurrence of lip swelling and ER visits.
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Taguchi H, Shirota S, Sumitomo S, Hara S, Ohmura K, Nishioka H. Immunoglobulin-A vasculitis manifesting as edema in the scalp, face, and sternocleidomastoid muscle. Int J Rheum Dis 2024; 27:e14950. [PMID: 37875280 DOI: 10.1111/1756-185x.14950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/10/2023] [Accepted: 10/14/2023] [Indexed: 10/26/2023]
Affiliation(s)
- Hirokazu Taguchi
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
- Department of Rheumatology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shogo Shirota
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shuji Sumitomo
- Department of Rheumatology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shigeo Hara
- Department of Pathology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Koichiro Ohmura
- Department of Rheumatology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hiroaki Nishioka
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
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4
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Buttgereit T, Vera C, Aulenbacher F, Church MK, Hawro T, Asero R, Bauer A, Bizjak M, Bouillet L, Dissemond J, Fomina D, Giménez-Arnau AM, Grattan C, Gregoriou S, Kulthanan K, Kasperska-Zajac A, Kocatürk E, Makris M, Kolkhir P, Weller K, Magerl M, Maurer M. Patients With Chronic Spontaneous Urticaria Who Have Wheals, Angioedema, or Both, Differ Demographically, Clinically, and in Response to Treatment-Results From CURE. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3515-3525.e4. [PMID: 37604426 DOI: 10.1016/j.jaip.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/19/2023] [Accepted: 08/05/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Patients with chronic spontaneous urticaria (CSU) have spontaneous wheals (W), angioedema (AE), or both, for longer than 6 weeks. Clinical differences between patients with standalone W, standalone AE, and W and AE (W+AE) remain incompletely understood. OBJECTIVE To compare W, AE, and W+AE CSU patients regarding demographics, disease characteristics, comorbidities, disease burden, and treatment response. METHODS Baseline data from 3,698 CSU patients in the ongoing, prospective, international, multicenter, observational Chronic Urticaria REgistry (CURE) were analyzed (data cut: September 2022). RESULTS Across all CSU patients, 59%, 36%, and 5% had W+AE, W, and AE, respectively. The W+AE patients, compared with W and AE patients, showed the lowest male-to-female ratio (0.33), higher rates of concomitant psychiatric disease (17% vs 11% vs 6%, respectively), autoimmune disease (13% vs 7% vs 9%, respectively), and nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity (9% vs 5% vs 2%, respectively) and the highest disease impact. The W patients, compared with W+AE and AE patients, showed the lowest rates of concomitant hypertension (15% vs 21% vs 40%, respectively) and obesity (11% vs 16% vs 17%, respectively), the highest rate of concomitant inducible urticaria (24% vs 22% vs 6%, respectively), and shorter W duration. The AE patients, compared with W+AE and W patients, were older at disease onset, showed longer AE duration, and the best response to increased doses of H1-antihistamines (58% vs 24% vs 31%, respectively) and omalizumab (92% vs 67% vs 60%, respectively). CONCLUSIONS Our findings provide a better understanding of CSU phenotypes and may guide patient care and research efforts that aim to link them to pathogenic drivers.
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Affiliation(s)
- Thomas Buttgereit
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Institute of Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Carolina Vera
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Institute of Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Felix Aulenbacher
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Institute of Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Martin K Church
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Institute of Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Tomasz Hawro
- Institute and Comprehensive Center for Inflammation Medicine, Department of Dermatology, Allergology and Venerology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Riccardo Asero
- Department of Allergology, Clinica San Carlo, Paderno Dugnano, Milan, Italy
| | - Andrea Bauer
- Department of Dermatology, University Hospital, Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Mojca Bizjak
- Division of Allergy, University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Laurence Bouillet
- CREAK (Centre national de référence des angioedèmes), Internal Medicine, CHU Grenobles Alpes, Grenoble, France
| | - Joachim Dissemond
- Department of Dermatology, Venerology and Allergology, University of Essen, Essen, Germany
| | - Daria Fomina
- Center of Allergy and Immunology, Clinical State Hospital 52, Moscow Healthcare Ministry, Moscow, Russian Federation; I. M. Sechenov First Moscow State Medical University (Sechenov University), Department of Clinical Immunology and Allergology, Moscow, Russian Federation
| | - Ana M Giménez-Arnau
- Department of Dermatology, Institut Mar de Investigacions Mèdiques, Universitat Pompeu Fabra, Barcelona, Spain
| | - Clive Grattan
- Guy's Hospital, St. John's Institute of Dermatology, London, UK
| | - Stamatios Gregoriou
- National and Kapodistrian University of Athens, 1st Department of Dermatology-Venereology, Andreas Sygros Hospital. Athens, Greece
| | - Kanokvalai Kulthanan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Alicja Kasperska-Zajac
- European Center for Diagnosis and Treatment of Urticaria/Angioedema (GA(2)LEN UCARE Network), Medical University of Silesia in Katowice, Katowice, Poland
| | - Emek Kocatürk
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Institute of Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany; Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey
| | - Michael Makris
- Allergy Unit "D. Kalogeromitros", 2nd Department, Dermatology and Venereology, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Pavel Kolkhir
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Institute of Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Karsten Weller
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Institute of Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Markus Magerl
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Institute of Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany
| | - Marcus Maurer
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Institute of Allergology, Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany.
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Aksakal S. Isolated angioedema due to face mask and other cases of isolated angioedema. Postgrad Med J 2023; 99:1167-1172. [PMID: 37474797 DOI: 10.1093/postmj/qgad057] [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: 05/31/2023] [Revised: 06/17/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023]
Abstract
Isolated angioedema can be divided into two groups as mast cell-mediated angioedema and bradykinin-mediated angioedema according to the known mechanisms of occurrence. However, angioedema can also occur with mechanisms whose cause is unknown. Treatment varies according to the mechanism of angioedema formation. In this prospective study, we present the causes of 80 isolated angioedema cases admitted to our clinic during the pandemic period. We would like to emphasize the causes that we found in our cases but which are rare in the literature. For example: angioedema due to allergy to nickel in the mask used during the pandemic period, T cell-mediated angioedema, alpha adrenergic receptor blocker use, and patients diagnosed with collagen tissue disease presenting with angioedema as the first clinical finding.
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Affiliation(s)
- Sengul Aksakal
- Department of Immunology and Allergy, Samsun Training and Research Hospital, Samsun, 55090, Turkey
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6
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Jasti VV, Anderson J, Abdujelil I. Angioedema without urticaria after recent initiation of celecoxib. BMJ Case Rep 2023; 16:e255446. [PMID: 37739445 PMCID: PMC10533717 DOI: 10.1136/bcr-2023-255446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023] Open
Abstract
Angioedema is potentially life-threating swelling of integument and mucosa that has multiple potential aetiologies with varying mechanisms. Drug-induced angioedema is often easily correlated with the offending agent and can be prevented with discontinuation of the medication. Many medications have now been implicated in drug-induced angioedema but the two most common are ACE inhibitors and non-steroidal anti-inflammatory drugs (NSAIDs). This case highlights severe angioedema secondary to celecoxib and reviews varying aetiologies of angioedema and NSAID hypersensitivity reactions.
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Affiliation(s)
- Vivek Vardhan Jasti
- Internal Medicine, OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Jay Anderson
- Internal Medicine, OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Ifa Abdujelil
- Medical Education, Ohio University College of Osteopathic Medicine, Athens, Ohio, USA
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Katelaris CH, Grumach AS, Bork K. Angioedema With Normal Complement Studies: What Do We Know? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2309-2314. [PMID: 37343921 DOI: 10.1016/j.jaip.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
Angioedema is generally readily recognizable clinically and is characterized by localized nonpitting edema involving subcutaneous, submucosal, or deep dermal tissue caused by increased vascular permeability and extravasation of intravascular fluid. It can occur via a variety of mechanisms. A number of clinical conditions (masqueraders) are occasionally mistaken for angioedema. Clinical classification of the various angioedema forms begins with noting the presence or absence of concurrent urticaria or wheals. Pathogenesis can be considered through two broad categories: mast cell-mediated with release of vasoactive mediators causing angioedema usually associated with urticaria or in the context of an anaphylactic reaction; and bradykinin (BK)-driven, in which increased vascular permeability is mediated by BK. BK-mediated angioedema does not occur with urticaria, nor does it respond to antiallergic medications. The various forms of hereditary angioedema are included in this category, requiring specific tests of C4 and C1 inhibitor level and function to confirm the diagnosis. Angiotensin converting enzyme inhibitors, which impair the degradation of BK, account for up to a third of all patients with angioedema presenting to the emergency department. Finally, angioedema may occur by yet unknown mechanisms; under this circumstance, it is difficult to manage.
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Affiliation(s)
- Constance H Katelaris
- Immunology/Allergy Unit, Department of Medicine, Campbelltown Hospital and Faculty of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia.
| | - Anete S Grumach
- Clinical Immunology, Department of Clinical Medicine, Faculty of Medicine, Centro Universitario FMABC, Santo Andre, São Paulo, Brazil.
| | - Konrad Bork
- Department of Dermatology, University Medical Center, Johannes Gutenberg University, Mainz, Germany
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8
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Kochvar AP, Cobb G, Bernabe CC, Levine T. Acquired Non-histaminergic Angioedema With C1q Autoantibody and Urticaria: A Case Report. Cureus 2023; 15:e43841. [PMID: 37736455 PMCID: PMC10510307 DOI: 10.7759/cureus.43841] [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] [Accepted: 08/20/2023] [Indexed: 09/23/2023] Open
Abstract
Acquired angioedema (AAE) is a rare disease with life-threatening complications. This pathology has classically been associated with medication use and B cell lymphoproliferative disorders. In this report, we describe a 61-year-old man with a six-year history of angioedema, unrelated to any known triggers or malignancy. Extensive workup has led to a diagnosis of idiopathic nonhistaminergic AAE with normal C1 inhibitor. The patient is currently being treated with lanadelumab, which has resolved the patient's symptoms. This case provides insight into the onset, exploration, treatment, and outcomes of an extremely rare disease process.
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Affiliation(s)
- Andrew P Kochvar
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | - Gavin Cobb
- College of Osteopathic Medicine, Kansas City University, Kansas City, USA
| | - Celina C Bernabe
- Allergy and Immunology, Allergy & Asthma Care, P.A., Overland Park, USA
| | - Terry Levine
- Allergy and Immunology, Allergy & Asthma Care, P.A., Overland Park, USA
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Douillard M, Deheb Z, Bozon A, Raison-Peyron N, Dereure O, Moulis L, Soria A, Du-Thanh A. Over diagnosis of bradykinin angioedema in patients treated with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. World Allergy Organ J 2023; 16:100809. [PMID: 37638360 PMCID: PMC10458346 DOI: 10.1016/j.waojou.2023.100809] [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: 04/24/2023] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 08/29/2023] Open
Abstract
Background Bradykinin angioedemas are a potentially serious side effect of angiotensin-converting enzyme inhibitors (ACEI) and more controversially of angiotensin II receptor blockers (ARB). Their challenging diagnosis is based on the absence of any recurrence after more than 6 months of drug discontinuation; otherwise mast-cell driven angioedemas as a differential diagnosis must be considered. Objective The aim of this study was to determine the prevalence of recurrent angioedema in patients referred for ACEI/ARB-induced bradykinin angioedema, after more than 6 months of drug discontinuation. Methods We included ACEI/ARB-treated patients referred for angioedema(s) without hives and unresponsive to antihistamines, after they discontinued ACEI/ARB for at least 6 months. Any C1-inhibitor deficiency was excluded. The primary endpoint was the prevalence of patients with recurrent angioedema after more than 6 months of drug discontinuation and/or developing hives during follow-up. The secondary endpoint was the identification of epidemiological factors associated with any final diagnosis. Results Thirty-eight of 93 patients (41%) with a suspicion of ACEI/ARB-induced bradykinin angioedema still had recurrent angioedema (n = 27) or developed hives (n = 2) or both (n = 9) after 6 months of drug discontinuation. Good response to icatibant and facial but not oral localization were predictive for the final diagnosis of ACEI/ARB-induced bradykinin angioedema and mast-cell driven angioedema, respectively. Conclusion In patients referred for acquired angioedema without wheals occurring during ACEI/ARB therapy, 59% finally had a diagnosis of ACEI/ARB-induced bradykinin angioedema whereas 41% were rather diagnosed with mast-cell driven angioedema. The overdiagnosis of ACEI/ARB-induced bradykinin angioedema may deteriorate the management of severe cardiovascular conditions.
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Affiliation(s)
- Marie Douillard
- Department of Dermatology, St Eloi Hospital, 34000, Montpellier, France
| | - Zineb Deheb
- Médecine Sorbonne Université, Service de Dermatologie et Allergologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Agathe Bozon
- Department of Dermatology, St Eloi Hospital, 34000, Montpellier, France
| | | | - Olivier Dereure
- Department of Dermatology, St Eloi Hospital, 34000, Montpellier, France
| | - Lionel Moulis
- Clinical and Epidemiological Research Unit, CHU, Montpellier, 34000, France
| | - Angèle Soria
- Médecine Sorbonne Université, Service de Dermatologie et Allergologie, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Cimi-Paris, INSERM 1135, Paris, France
| | - Aurélie Du-Thanh
- Department of Dermatology, St Eloi Hospital, 34000, Montpellier, France
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Liotti L, Pecoraro L, Mastrorilli C, Castagnoli R, Saretta F, Mori F, Arasi S, Barni S, Giovannini M, Caminiti L, Miraglia Del Giudice M, Novembre E. Pediatric Angioedema without Wheals: How to Guide the Diagnosis. Life (Basel) 2023; 13:life13041021. [PMID: 37109550 PMCID: PMC10141554 DOI: 10.3390/life13041021] [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: 02/27/2023] [Revised: 03/17/2023] [Accepted: 03/28/2023] [Indexed: 04/29/2023] Open
Abstract
Angioedema (AE) is a vascular reaction of subcutaneous and submucosal tissues that identifies various clinical pictures and often is associated with wheals. AE without wheals (AEwW) is infrequent. The ability to distinguish between AEwW mediated by mast cells and bradykinin-mediated or leukotriene-mediated pathways is often crucial for a correct diagnostic-therapeutic and follow-up approach. AEwW can be hereditary or acquired. Factors typically correlated with hereditary angioedema (HAE) are a recurrence of episodes, familiarity, association with abdominal pain, onset after trauma or invasive procedures, refractoriness to antiallergic therapy, and lack of pruritus. The acquired forms of AE can present a definite cause based on the anamnesis and diagnostic tests. Still, they can also have an undetermined cause (idiopathic AE), distinguished according to the response to antihistamine in histamine-mediated and non-histamine-mediated forms. Usually, in childhood, AE responds to antihistamines. If AEwW is not responsive to commonly used treatments, it is necessary to consider alternative diagnoses, even for pediatric patients. In general, a correct diagnostic classification allows, in most cases, optimal management of the patient with the prescription of appropriate therapy and the planning of an adequate follow-up.
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Affiliation(s)
- Lucia Liotti
- Pediatric Unit, Department of Mother and Child Health, Salesi Children's Hospital, 60123 Ancona, Italy
| | - Luca Pecoraro
- Pediatric Unit, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, 37126 Verona, Italy
| | - Carla Mastrorilli
- Pediatric Hospital Giovanni XXIII, Pediatric and Emergency Department, AOU Policlinic of Bari, 70126 Bari, Italy
| | - Riccardo Castagnoli
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Francesca Saretta
- Pediatric Department, Latisana-Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, 33100 Udine, Italy
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Stefania Arasi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital [IRCCS], 00165 Rome, Italy
| | - Simona Barni
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Lucia Caminiti
- Department of Human Pathology in Adult and Development Age "Gaetano Barresi", Allergy Unit, Department of Pediatrics, AOU Policlinico Gaetano Martino, 98124 Messina, Italy
| | - Michele Miraglia Del Giudice
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy
| | - Elio Novembre
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
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Muacevic A, Adler JR, Prathiraja O, Jena R, Coffie-Pierre JA, Agyei J, Silva MS, Kayani AMA, Siddiqui OS. A Comprehensive Review of Bradykinin-Induced Angioedema Versus Histamine-Induced Angioedema in the Emergency Department. Cureus 2022; 14:e32075. [PMID: 36600855 PMCID: PMC9803396 DOI: 10.7759/cureus.32075] [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] [Accepted: 11/30/2022] [Indexed: 12/05/2022] Open
Abstract
Angioedema (AE) is a condition that is frequently encountered in the emergency department (ED). It is a rare condition with localized, asymmetrical swelling of the skin and/or mucosa that is frequently nonpruritic and primarily affects locations with loose connective tissue. Physicians must have a thorough understanding of this condition since it can cause fatal airway compromise, which might be the presenting symptom. Histamine-mediated AE is the most common type of AE seen in EDs. However, ED physicians must be on the lookout for the less common bradykinin-mediated types of AE as these do not respond to the same therapy as histamine-mediated AE. Hospitals may lack specialized drugs or protocols, and many ED staff may be unable to identify or treat bradykinin-mediated AE. It is crucial to understand the pathophysiology of the various kinds of AE in order to optimize treatment. The goal of this review paper is to provide an overview of the pathophysiology, clinical manifestations, and treatment options for bradykinin and histamine-induced AE in the ED.
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12
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Kesh S, Bernstein JA. Isolated Angioedema: A Review of Classification and Update on Management. Ann Allergy Asthma Immunol 2022; 129:692-702. [PMID: 35988876 DOI: 10.1016/j.anai.2022.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this article is to review the various types of angioedema including diagnosis and treatment. DATA SOURCES PubMed search of articles in the English language various types of angioedema STUDY SELECTION: Articles on the subject matter were selected and reviewed. RESULTS Herein, a case based approach is presented for discussing the major types of angioedema including: hereditary angioedema (HAE) TypesI/II and normal complement, acquired angioedema, Angiotensin converting enzyme (ACE) induced angioedema, as well as histaminergic and non-histaminergic angioedema. Emerging treatments of HAE including targets of pre-kalikrein, DNA vector technology replacing C1INH protein, and CRIPSR technology targeting PKK among many others are explored. In addition, other causes as well as mimickers of angioedema are briefly reviewed. Finally, a novel algorithm is proposed to help guide the treating physician through the work up and management of patients with suspected idiopathic angioedema unresponsive to conventional therapy with antihistamines. CONCLUSION Over the years, many strides have been made in both understanding the pathophysiology of various types of angioedema as well as expansion of treatment options. It is important for clinicians to be aware of current and emerging treatment options. We provide a novel practical algorithm to guide clinicians in challenging cases of idiopathic angioedema refractory to antihistamines.
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Affiliation(s)
- Susamita Kesh
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, Division of Immunology and Allergy
| | - Jonathan A Bernstein
- University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section; Bernstein Allergy Group.
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13
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Simon N, Bocquet A, Boccon-Gibod I, Bouillet L. Profile of serious angioedema requiring an urgent advice from a national reference call center. Medicine (Baltimore) 2022; 101:e29513. [PMID: 35945783 PMCID: PMC9351904 DOI: 10.1097/md.0000000000029513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Angioedema (AE) is a reason for emergency care when it is severe. Care is difficult when the diagnostic is not known before the attack: mast cell (MC) or bradykinin (BK) mediated. One is very common but often benign, the other rare but potentially fatal. The French national reference center of angioedema (CREAK) provides emergency physicians with a hotline and a guideline to help them manage their patients. This study aimed to describe the clinical features of AE episodes prompting a call on the CREAK hotline and classify patients depending on the suspected cause of the AE. This is a retrospective study between March and August 2019. Each physician calling on the CREAK hotline was asked to fill a clinical description form for the AE emergency. Known patients of CREAK was excluded. Eighty four patients were included. Forty one (48.8%) in the angiotensin converting enzyme inhibitors induced acquired angioedema (ACEi-AAE), 39 (46.4%) in the mast cell induced angioedema, and 4 (4.8%) in the Bradykinin mediated angioedema. The mast cell induced angioedema patients have more history of hives (29.3%) than ACEi-AAE (2.4%, P = .0004). ACEi-AAE mainly affected the tongue (58.5% vs 25.6%, P = .003) and larynx (29.3% vs 13%, P = .001). In 65.5% of cases, the etiological diagnosis was not mentioned by the appellant, but made by the hotline. In 31% of cases, the hotline suggested the administration of a specific treatment not previously provided by the caller. All the doctors who called the hotline appreciate this tele-expertise especially in case of ACEi-AAE presumptions. In addition to providing rapid AE expertise, this service also allows to educate physicians in the management of AE irrespective of its origin.
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Affiliation(s)
- Nicolas Simon
- National Reference Center for Angioedema (CREAK), Grenoble University Hospital (CHUGA), Grenoble, France
| | - Alexis Bocquet
- National Reference Center for Angioedema (CREAK), Grenoble University Hospital (CHUGA), Grenoble, France
| | - Isabelle Boccon-Gibod
- National Reference Center for Angioedema (CREAK), Grenoble University Hospital (CHUGA), Grenoble, France
| | - Laurence Bouillet
- National Reference Center for Angioedema (CREAK), Grenoble University Hospital (CHUGA), Grenoble, France
- Grenoble Alpes University (UGA), France
- *Correspondence: Laurence Bouillet, National Reference Center for Angioedema (CREAK), Internal Medicine Department, Grenoble University Hospital, CS 10217, 38043 Grenoble cedex 09, France (e-mail: )
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14
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Goswamy V, Lee KE, McKernan EM, Fichtinger PS, Mathur SK, Viswanathan RK. Omalizumab for Treatment of Idiopathic Angioedema. Ann Allergy Asthma Immunol 2022; 129:605-611.e1. [PMID: 35914662 DOI: 10.1016/j.anai.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/10/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Omalizumab has been shown to improve outcomes in patients with chronic spontaneous urticaria (CSU). Idiopathic angioedema (IAE) is increasingly being recognized as a condition with similar underlying mechanisms as CSU and a form of CSU. We hypothesized that add-on therapy with omalizumab would benefit patients with uncontrolled IAE. OBJECTIVE To study the safety and efficacy of omalizumab for the treatment of IAE in adults. METHODS We conducted a randomized, placebo-controlled trial to study the efficacy of omalizumab in adults with two or more episodes of angioedema (AE) in the past 6 months for which no clinical or laboratory cause of AE could be found. Ten patients were randomized on a 1:1 basis to receive omalizumab 300 mg SQ or placebo every 4 weeks for 24 weeks with a 12 week follow up period. The primary endpoint was the change in the Angioedema Activity Score (AAS). Secondary endpoints included the Angioedema Quality of Life Questionnaire (AE-QoL), the Visual Analog Scale (VAS) and the number of angioedema episodes per month. RESULTS We observed improvement in the AAS score (-2.93 ln odds; 95% confidence interval (CI) -4.84, -1.02; p = 0.003), VAS (-3.49 ln odds; 95% CI -6.58, -0.40; p = 0.03), AE-QoL (-9.43 score; 95% CI -17.63, -1.24; p = 0.028) and number of angioedema episodes per month (-1.93 ln count; 95% CI -3.23, -0.63; p = 0.005) in patients that received omalizumab vs placebo. CONCLUSION This study provides preliminary prospective evidence that omalizumab improves outcomes in patients with IAE.
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Affiliation(s)
- Vinay Goswamy
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health.
| | - Kristine E Lee
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health
| | - Elizabeth M McKernan
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health
| | - Paul S Fichtinger
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health
| | - Sameer K Mathur
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health
| | - Ravi K Viswanathan
- Division of Allergy, Pulmonary and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health
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15
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Baeza ML, González-Quevedo T, Caballero T, Guilarte M, Lleonart R, Varela S, Castro M, Díaz C, Escudero E, García MG, Laffond E, Muñoz-Bellido FJ, Núñez R, Prior N, Sala-Cunill A, Sáenz de San Pedro B, Prieto-García A. Angioedema Due to Acquired Deficiency of C1-Inhibitor: A Cohort Study in Spain and a Comparison With Other Series. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1020-1028. [PMID: 34844023 DOI: 10.1016/j.jaip.2021.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/25/2021] [Accepted: 11/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Data on acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE) from 4 European countries (France, Italy, Germany, and Hungary) were recently published. OBJECTIVE To report data from a group of 50 patients with acquired C1-INH deficiency from Spain, of whom 46 had angioedema, and compare them with other European series. METHODS We performed a retrospective observational study of 46 patients with C1-INH-AAE and 4 asymptomatic patients. Clinical and biological characteristics and associated diseases were assessed and compared with other European series. RESULTS Women accounted for 73.9% of cases. The prevalence of C1-INH-AAE related to hereditary forms was 1/10.1. Overall, 8.7% patients were aged <40 years. Diagnostic delay was 1.1 years. Angioedema mainly affected the face (91.3%), followed by the oropharynx (63%), extremities (50%), and abdomen (37%). Only 1 patient underwent orotracheal intubation. Erythema marginatum was present in 1 patient. A hematologic disorder was recorded in 50% of patients. Angioedema preceded all benign conditions, mostly monoclonal gammopathy of undetermined significance, but appeared very close to or after malignant hematologic diseases (median, 2.2 and 0.29 years). Autoimmune diseases were associated in 50% (autoimmune thyroiditis, 21.5%; systemic lupus erythematosus, 10.9%). Half of them coexisted with hematologic disorders. Anti-C1-INH antibodies were found in 67% of tested patients and were not related to the associated disease. Long-term prophylaxis was necessary in 52.2%, most of whom responded to tranexamic acid. CONCLUSIONS This study emphasizes the possibility of C1-INH-AAE in patients younger than 40 and in autoimmune diseases other than systemic lupus erythematosus such as autoimmune thyroiditis.
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Affiliation(s)
- Maria L Baeza
- Hospital General Universitario Gregorio Marañón, Allergy Section, Madrid, Spain; Biomedical Research Network on Rare Diseases (CIBERER, U761), Madrid, Spain; Institute for Health Research Gregorio Marañón, Madrid, Spain.
| | - Teresa González-Quevedo
- Hospital Universitario Virgen del Rocío, Allergy Section, Sevilla, Spain; Instituto de Biomedicina de Sevilla, Sevilla, Spain
| | - Teresa Caballero
- Hospital Universitario La Paz, Allergy Section, Madrid, Spain; Hospital La Paz Institute for Health Research (IdiPaz), Madrid, Spain; Biomedical Research Network on Rare Diseases (CIBERER, U754), Madrid, Spain
| | - Mar Guilarte
- Hospital Universitari Vall d'Hebron, Allergy Section, Barcelona, Spain; Vall d'Hebron Research Institute, Allergy Section, Barcelona, Spain
| | - Ramon Lleonart
- Hospital Universitario Bellvitge de L'Hospitalet de Llobregat, Allergy Section, Barcelona, Spain
| | - Susana Varela
- Complexo Hospitalario de Ourense, Allergy Section, Ourense, Spain
| | - Monica Castro
- Complejo Hospitalario Universitario de Ferrol, Allergy Section, Ferrol, Spain
| | - Carmen Díaz
- Hospital Universitario Central de Asturias, Allergy Section, Oviedo, Spain
| | - Elena Escudero
- Complejo Hospitalario de Pontevedra, Allergy Section, Pontevedra, Spain
| | - Marimar G García
- Complexo Hospitalario de Ourense, Allergy Section, Ourense, Spain
| | - Elena Laffond
- Complejo Asistencial Universitario de Salamanca, Allergy Section, Salamanca, Spain
| | | | - Ramon Núñez
- Hospital Universitario Lucus Augusti, Allergy Section, Lugo, Spain
| | - Nieves Prior
- Hospital Universitario Severo Ochoa de Leganés, Allergy Section, Madrid, Spain
| | - Anna Sala-Cunill
- Hospital Universitari Vall d'Hebron, Allergy Section, Barcelona, Spain; Vall d'Hebron Research Institute, Allergy Section, Barcelona, Spain
| | | | - Alicia Prieto-García
- Hospital General Universitario Gregorio Marañón, Allergy Section, Madrid, Spain; Institute for Health Research Gregorio Marañón, Madrid, Spain
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16
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Grumach AS, Veronez CL, Csuka D, Farkas H. Angioedema Without Wheals: Challenges in Laboratorial Diagnosis. Front Immunol 2021; 12:785736. [PMID: 34956216 PMCID: PMC8694242 DOI: 10.3389/fimmu.2021.785736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/03/2021] [Indexed: 11/13/2022] Open
Abstract
Angioedema is a prevailing symptom in different diseases, frequently occurring in the presence of urticaria. Recurrent angioedema without urticaria (AE) can be hereditary (HAE) and acquired (AAE), and several subtypes can be distinguished, although clinical presentation is quite similar in some of them. They present with subcutaneous and mucosal swellings, affecting extremities, face, genitals, bowels, and upper airways. AE is commonly misdiagnosed due to restricted access and availability of appropriate laboratorial tests. HAE with C1 inhibitor defect is associated with quantitative and/or functional deficiency. Although bradykinin-mediated disease results mainly from disturbance in the kallikrein–kinin system, traditionally complement evaluation has been used for diagnosis. Diagnosis is established by nephelometry, turbidimetry, or radial immunodiffusion for quantitative measurement of C1 inhibitor, and chromogenic assay or ELISA has been used for functional C1-INH analysis. Wrong handling of the samples can lead to misdiagnosis and, consequently, mistaken inappropriate approaches. Dried blood spot (DBS) tests have been used for decades in newborn screening for certain metabolic diseases, and there has been growing interest in their use for other congenital conditions. Recently, DBS is now proposed as an efficient tool to diagnose HAE with C1 inhibitor deficiency, and its use would improve the access to outbound areas and family members. Regarding HAE with normal C1 inhibitor, complement assays’ results are normal and the genetic sequencing of target genes, such as exon 9 of F12 and PLG, is the only available method. New methods to measure cleaved high-molecular-weight kininogen and activated plasma kallikrein have emerged as potential biochemical tests to identify bradykinin-mediated angioedema. Validated biomarkers of kallikrein–kinin system activation could be helpful in differentiating mechanisms of angioedema. Our aim is to focus on the capability to differentiate histaminergic AE from bradykinin-mediated AE. In addition, we will describe the challenges developing specific tests like direct bradykinin measurements. The need for quality tests to improve the diagnosis is well represented by the variability of results in functional assays.
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Affiliation(s)
- Anete S Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitario Faculdade de Medicina ABC (FMABC), Santo Andre, Brazil
| | - Camila L Veronez
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California San Diego, San Diego, CA, United States.,Research Service, San Diego Veterans Affairs Healthcare, San Diego, CA, United States
| | - Dorottya Csuka
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Henriette Farkas
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
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17
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Aronovich A, Snast I, Lapidoth M, Leshem YA, Enk CD, Tal Y, Mimouni D, Hodak E, Levi A. Isolated solar angioedema: A systematic review of the literature. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2021; 37:431-438. [PMID: 33738834 DOI: 10.1111/phpp.12677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 03/14/2021] [Indexed: 11/30/2022]
Abstract
Solar urticaria is a well-recognized photodermatosis, sometimes accompanied by angioedema. However, isolated solar angioedema (ISA) is a rare and unrecognized entity. The purpose of our work was to systematically review the available data on ISA. Therefore, a systematic review of studies evaluating ISA was performed. Additionally, a case of a 21-years-old patient from our photodermatosis service is presented. The search yielded 421 publications, with 3 eligible for review. Together with our case, 5 cases were included overall. All patients were female. Four out of 5 patients first experienced ISA at childhood or early adulthood (age range 6-22 years). UVA photoprovocation was positive in the 3 out of the 4 patients who were tested. Improvement was noted following NB-UVB hardening (2 out of 5 patients) or a short course of oral prednisone (3 out of 5 patients) combined with regular sunscreen application. To conclude, ISA is an extremely rare entity, although it may be underdiagnosed due to lack of awareness. The clinician must consider ISA in the differential diagnosis of angioedema since it can have a detrimental effect on quality of life. Besides sun avoidance, there is no consensus regarding treatment.
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Affiliation(s)
- Anna Aronovich
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Igor Snast
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Moshe Lapidoth
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Yael A Leshem
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Claes D Enk
- Department of Dermatology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yuval Tal
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Daniel Mimouni
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Emmilia Hodak
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Assi Levi
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
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18
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Sabaté-Brescó M, Rodriguez-Garijo N, Azofra J, Baeza ML, Donado CD, Gaig P, Guilarte M, Herrera-Lasso V, Labrador-Horrillo M, Sala-Cunill A, Veleiro B, Gil MP, Kaplan A, Ferrer M. A Comparative Study of Sex Distribution, Autoimmunity, Blood, and Inflammatory Parameters in Chronic Spontaneous Urticaria with Angioedema and Chronic Histaminergic Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2284-2292. [PMID: 33831619 DOI: 10.1016/j.jaip.2021.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recurrent idiopathic histaminergic angioedema is currently classified as a subtype of angioedema, as well as a subtype of chronic spontaneous urticaria (CSU), based on the fact that both are mast cell-mediated and respond to the same treatments. OBJECTIVE In the present work, we sought to verify whether chronic histaminergic angioedema (CHA) is an entity distinct from CSU or represents a CSU subtype that lacks hives. METHODS We performed a prospective study comparing 68 CHA patients, angioedema without hives, with 63 CSU patients, with hives and angioedema, from whom we collected demographic and clinical data, as well as blood and serum markers. RESULTS We found key pathogenic features that differentiate CHA from CSU: gender distribution, basophil number, and antibodies against the IgE receptor. The male/female ratio in CHA was 0.78, whereas in CSU it was 0.36 (P = .0466). Basopenia was more often seen in CSU (n = 13 [20%]) than in CHA (n = 5 [7%]). Finally, 31.15% of CSU sera induced basophil activation, whereas no CHA sera were able to activate normal basophils. By contrast, nonspecific inflammation or immune markers, for example, erythrocyte sedimentation rate, C-reactive protein, or IgG antithyroid antibodies, were very similar between both groups. IgE anti-IL-24 could not be assessed because a control population did not differ from CSU. CONCLUSIONS Inclusion of CHA as part of the spectrum of CSU is an assumption not evidence-based, and when studied separately, important differences were observed. Until there is further evidence, CHA and CSU should not necessarily be considered the same disorder, and it is our opinion that review articles and guidelines should reflect that possibility.
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Affiliation(s)
- Marina Sabaté-Brescó
- Department of Allergy and Clinical Immunology, Clínica Universidad de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain; RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain
| | | | - Julian Azofra
- Allergy Section, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Maria Luisa Baeza
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Biomedical Research Network on Rare Diseases (CIBERER)-U761, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Carmen D Donado
- Allergy Section, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Pere Gaig
- Allergy Section, Hospital Universitari Joan XXIII de Tarragona, Tarragona, Spain; Departament de Medicina i Cirurgia, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Tarragona, Spain
| | - Mar Guilarte
- RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain; Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Valeria Herrera-Lasso
- Allergy Section, Hospital Universitari Joan XXIII de Tarragona, Tarragona, Spain; Departament de Medicina i Cirurgia, Institut d'Investigació Sanitària Pere Virgili, Universitat Rovira i Virgili, Tarragona, Spain
| | - Moisés Labrador-Horrillo
- RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain; Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Anna Sala-Cunill
- RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain; Allergy Section, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Beatriz Veleiro
- Department of Allergy and Clinical Immunology, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - María Pilar Gil
- Department of Dermatology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Allen Kaplan
- Department of Medicine, The Medical University of South Carolina, Charleston, SC
| | - Marta Ferrer
- Department of Allergy and Clinical Immunology, Clínica Universidad de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain; RETIC de Asma, Reacciones Adversas y Alérgicas (ARADYAL), Madrid, Spain.
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19
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Angioedema. Interdisciplinary diagnostic and therapeutic recommendations of the Polish Dermatological Society (PTD) and Polish Society of Allergology (PTA). Postepy Dermatol Alergol 2020; 37:445-451. [PMID: 32994763 PMCID: PMC7507159 DOI: 10.5114/ada.2020.98226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 11/17/2022] Open
Abstract
Angioedema is a non-inflammatory oedema of the subcutaneous tissue and/or mucosal membranes. It most commonly coexists with urticaria wheals and is considered to be a deep form of urticaria. Less commonly, it occurs in isolation and can take two basic forms: acquired angioedema and hereditary angioedema. Currently, there are 4 defined types of acquired angioedema and 7 types of hereditary angioedema. Treatment of angioedema depends on its form and etiological factors. Especially the genetic form, i.e. hereditary angioedema, is a considerable challenge for medical specialists, particularly dermatologists and allergists.
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20
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Minowa T, Sumikawa Y, Kumagai A, Kamiya T, Uhara H. Two cases of angioedema without wheals induced by exercising or bathing. Allergol Int 2020; 69:648-649. [PMID: 32451176 DOI: 10.1016/j.alit.2020.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/10/2020] [Accepted: 04/19/2020] [Indexed: 10/24/2022] Open
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21
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Pall AH, Lomholt AF, von Buchwald C, Bygum A, Rasmussen ER. Clinical Features and Disease Course of Primary Angioedema Patients in a Tertiary Care Hospital. J Asthma Allergy 2020; 13:225-236. [PMID: 32764994 PMCID: PMC7373665 DOI: 10.2147/jaa.s245161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/05/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose To give a better understanding of primary AE, the clinical characteristics and the possible therapeutic approaches. Background Angioedema (AE) is a non-pitting, non-itching swelling of skin or mucosa. The symptom can become life-threatening if located in the airways. Primary (monosymptomatic) AE is a manifestation of several different diseases and the diagnosis is not always straight-forward. The aetiological and pathophysiological factors of primary AE are not completely clarified. There is a need for further investigation. Patients and Methods This was a retrospective cohort study of patients referred to an outpatient dermatology clinic in a tertiary care hospital for clinical assessment due to primary AE in the period from 1996 to 2014. Results A total of 315 patients were identified with primary AE. The most frequent subtype was idiopathic AE (42.5%) and the second most common was angiotensin-converting enzymeinhibitor (ACEi)-induced AE (31.1%). Three patients were diagnosed with hereditary AE and one patient was diagnosed with acquired C1-inhibitor deficiency. At least 107 (34.0%) patients had established histaminergic AE. More than 1/3 of the patients were treated in an emergency room or hospitalized due to AE. A 98.1% of patients had experienced AE in the head and neck area. Seven patients were in the need of acute airway intervention. Six of these had ACEi-induced AE. Female sex and smoking were found to be risk factors for developing AE. Conclusion The most frequent diagnoses were histaminergic-, non-histaminergic idiopathic AE and ACEi-induced AE, whereas complement C1-inhibitor deficiency was rare. Histaminergic AE made up a substantial group of patients with primary AE. Even though there are different pathophysiological causes of AE, many cases have overlapping clinical manifestations, which make diagnosis and treatment difficult.
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Affiliation(s)
- Amalie Hartvig Pall
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Anne Fog Lomholt
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Anette Bygum
- OPEN - Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Dermatology and Allergy Centre, Odense University Hospital, Odense 5000, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense 5000, Denmark
| | - Eva Rye Rasmussen
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark.,OPEN - Open Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
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22
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Idiopathic nonhistaminergic acquired angioedema in a patient with coronavirus disease 2019. Ann Allergy Asthma Immunol 2020; 125:600-602. [PMID: 32621992 PMCID: PMC7327466 DOI: 10.1016/j.anai.2020.06.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 12/11/2022]
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23
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Mihaela Leru P, Florin Anton V, Bocsan C, Muntean A, Boda D. Acquired angioedema induced by angiotensin-converting enzyme inhibitors - experience of a hospital-based allergy center. Exp Ther Med 2020; 20:68-72. [PMID: 32508996 DOI: 10.3892/etm.2020.8474] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/17/2020] [Indexed: 12/20/2022] Open
Abstract
Angiotensin-converting enzyme inhibitors (ACEIs) represent an important group of pharmacological compounds, largely prescribed for more than 30 years. They have been extensively evaluated in clinical trials, demonstrating significant reduction of morbidity and mortality of patients with cardiovascular diseases, mainly high blood pressure, myocardial infarction, heart failure and stroke. Besides their beneficial effects and a general good safety profile, it was proven that ACEIs might also induce adverse effects in some patients, most notably angioedema (AE) and chronic cough. The occurrence rate of adverse events induced by ACEIs is low, but the number of suffering patients is relatively high, since ACEIs is one of the most frequently prescribed medication worldwide. The aim of our study was to evaluate clinical pattern, risk factors and general management of ACEI-induced angioedema in a cohort of patients addressed for allergist evaluation in one university hospital in Romania, during a period of 32 months. It was found that ACEI-induced angioedema (ACEI-AE) represented more than half of the total number of patients addressed for angioedema without urticaria, with variable clinical and time-patterns. Most of the patients were referred by general practitioners (GPs) with diagnosis of urticaria or other skin allergy and continued to take ACEIs for months and years after onset of angioedema. We concluded that the awareness of acquired, non-allergic angioedema induced by ACEI therapy in medical practice is still low and there is a need for improved knowledge and interdisciplinary collaboration in this field.
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Affiliation(s)
- Polliana Mihaela Leru
- Family Medicine Department, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Internal Medicine Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Vlad Florin Anton
- Internal Medicine Department, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Corina Bocsan
- Department of Pharmacology, Toxicology and Clinical Pharmacology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania
| | - Adriana Muntean
- Department of Immunology and Allergology, 'Iuliu Hațieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania.,Allergy Department, 'Professor Doctor Octavian Fodor' Regional Institute of Gastroenterology and Hepatology, 400162 Cluj-Napoca, Romania
| | - Daniel Boda
- Dermatology Research Laboratory, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania.,Dermatology Department, 'Prof. N. Paulescu' National Institute of Diabetes, Nutrition and Metabolic Diseases, 011233 Bucharest, Romania
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Abstract
A red swollen face can be a skin sign of a potentially life-threatening condition. We present in detail the main clinical presentations, diagnostic tests, and management of some of the most severe conditions that can frequently present as a red and swollen face: acute or recurrent angioedema, mast cell-driven or bradykinin-mediated angioedema, nonhereditary and hereditary angioedema, allergic or photoallergic facial contact dermatitis, contact urticaria, severe adverse drug reactions (particularly drug reaction with eosinophilia and systemic symptoms [DRESS]), skin infections (erysipelas, cellulitis, necrotizing fasciitis), and autoimmune diseases (dermatomyositis). There are many other conditions that also have to be considered in the differential diagnosis of a red swollen face.
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Affiliation(s)
- Mariana Batista
- Dermatology Department, Coimbra University Hospital, Coimbra, Portugal
| | - Margarida Gonçalo
- Dermatology Department, Coimbra University Hospital, Coimbra, Portugal; Clinic of Dermatology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal.
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25
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Abdel-Samad NN, Kokai JS. A Case of Acquired Angioedema with Low C1 Inhibitor (C1-INH) Associated with Splenic Marginal Zone Lymphoma. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1476-1481. [PMID: 31588119 PMCID: PMC6792468 DOI: 10.12659/ajcr.915558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Patient: Male, 68 Final Diagnosis: AAE Symptoms: Angioedema Medication: — Clinical Procedure: — Specialty: Hematology
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Affiliation(s)
- Nizar N Abdel-Samad
- Department of Internal Medicine, Division of Hematology and Medical Oncology, The Moncton Hospital, Moncton, New Brunswick, Canada
| | - Judit S Kokai
- Dr. Sheldon H. Rubin Oncology Clinic, Clinical Trials, The Moncton Hospital - Horizon Health Network, Moncton, New Brunswick, Canada
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26
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Abstract
Angioedema is a clinical entity defined as self-limiting edema localized in the deeper layers of the skin and mucosa and lasting for several days. Angioedema can be provoked by bradykinin and/or mast cell mediators, including histamine. Four types of acquired and three types of hereditary angioedema have been identified. The most obvious form of angioedema associated with other systemic disease is acquired angioedema due to C1-inhibitor deficiency. It is characterized by acquired consumption of C1 inhibitor and various underlying disorders, such as multiple myeloma, chronic lymphocytic leukemia, rectal carcinoma, and non-Hodgkin lymphoma. Suspected cases need an accurate differential diagnosis to exclude all other types of acquired and hereditary angioedema.
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27
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Rosenberg DL, Mathur SK, Viswanathan RK. Characterization of idiopathic angioedema in a university-based allergy/immunology practice. Ann Allergy Asthma Immunol 2019; 123:403-404. [PMID: 31376488 DOI: 10.1016/j.anai.2019.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/16/2019] [Accepted: 07/24/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Daniel L Rosenberg
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, H4/620 CSC, MC 9988, 600 Highland Ave, Madison, WI 53792.
| | - Sameer K Mathur
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, H4/620 CSC, MC 9988, 600 Highland Ave, Madison, WI 53792
| | - Ravi K Viswanathan
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, H4/620 CSC, MC 9988, 600 Highland Ave, Madison, WI 53792
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28
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Hofman ZLM, van West N, Hack CE, Knulst AC, Maas C, Röckmann H. High occurrence of antihistamine resistance in patients with recurrent idiopathic angioedema. Clin Transl Allergy 2019; 9:35. [PMID: 31338156 PMCID: PMC6625121 DOI: 10.1186/s13601-019-0274-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/20/2019] [Indexed: 11/30/2022] Open
Abstract
Antihistamines are the most prescribed therapy in recurrent idiopathic angioedema, yet little is known about their efficacy. Herein, we report on clinical improvement with antihistamine therapy in 120 patients evaluating angioedema attack frequency. A high incidence (36%) of antihistamine refractory cases was observed. Forty percent of patients on antihistamine prophylaxis suffered from 1 or more angioedema attacks per month. Our findings stress the need for additional treatment options for recurrent idiopathic angioedema.
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Affiliation(s)
- Zonne L M Hofman
- 1Laboratory of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,2Laboratory for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nikki van West
- 3Department of Dermatology/Allergology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - C Erik Hack
- 2Laboratory for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - André C Knulst
- 2Laboratory for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,3Department of Dermatology/Allergology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Coen Maas
- 1Laboratory of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Heike Röckmann
- 3Department of Dermatology/Allergology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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29
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Long BJ, Koyfman A, Gottlieb M. Evaluation and Management of Angioedema in the Emergency Department. West J Emerg Med 2019; 20:587-600. [PMID: 31316698 PMCID: PMC6625683 DOI: 10.5811/westjem.2019.5.42650] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 05/09/2019] [Accepted: 05/28/2019] [Indexed: 01/14/2023] Open
Abstract
Angioedema is defined by non-dependent, non-pitting edema that affects several different sites and is potentially life-threatening due to laryngeal edema. This narrative review provides emergency physicians with a focused overview of the evaluation and management of angioedema. Two primary forms include histamine-mediated and bradykinin-mediated angioedema. Histamine-mediated forms present similarly to anaphylaxis, while bradykinin-mediated angioedema presents with greater face and oropharyngeal involvement and higher risk of progression. Initial evaluation and management should focus on evaluation of the airway, followed by obtaining relevant historical features, including family history, medications, and prior episodes. Histamine-mediated angioedema should be treated with epinephrine intramuscularly, antihistaminergic medications, and steroids. These medications are not effective for bradykinin-mediated forms. Other medications include C1-INH protein replacement, kallikrein inhibitor, and bradykinin receptor antagonists. Evidence is controversial concerning the efficacy of these medications in an acute episode, and airway management is the most important intervention when indicated. Airway intervention may require fiberoptic or video laryngoscopy, with preparation for cricothyrotomy. Disposition is dependent on patient's airway and respiratory status, as well as the sites involved.
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Affiliation(s)
- Brit Jeffrey Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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30
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Nettis E, Di Leo E, Racanelli V, Macchia L, Vacca A. Idiopathic nonhistaminergic angioedema: A single-center real-life experience from Italy. Allergy 2019; 74:1389-1392. [PMID: 30740715 DOI: 10.1111/all.13737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Eustachio Nettis
- Department of Emergency and Organ Transplantation; School and Chair of Allergology and Clinical Immunology; University of Bari- Aldo Moro; Bari Italy
| | - Elisabetta Di Leo
- Section of Allergy and Clinical Immunology; Unit of Internal Medicine-“F. Miulli” Hospital; Acquaviva delle Fonti, Bari Italy
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology Unit of Internal Medicine “G. Baccelli”; University of Bari Medical School - Aldo Moro; Bari Italy
| | - Luigi Macchia
- Department of Emergency and Organ Transplantation; School and Chair of Allergology and Clinical Immunology; University of Bari- Aldo Moro; Bari Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology Unit of Internal Medicine “G. Baccelli”; University of Bari Medical School - Aldo Moro; Bari Italy
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31
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Bygum A. Hereditary Angio-Oedema for Dermatologists. Dermatology 2019; 235:263-275. [PMID: 31167185 DOI: 10.1159/000500196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/08/2019] [Indexed: 11/19/2022] Open
Abstract
Among angio-oedema patients, hereditary angio-oedema (HAE) should not be overlooked. Besides skin swellings, these patients might have very painful abdominal attacks and potentially life-threatening angio-oedema of the upper airway. They will not respond to traditional anti-allergic therapy with antihistamines, corticosteroids, and adrenaline, and instead need specific drugs targeting the kallikrein-kinin pathway. Classically, patients with HAE have a quantitative or qualitative deficiency of the C1 inhibitor (C1INH) due to different mutations in SERPING1, although a new subtype with normal C1INH has been recognised more recently. This latter variant is diagnosed based on clinical features, family history, or molecular genetic testing for mutations in F12, ANGPT1,or PLG.The diagnosis of HAE is often delayed due to a general unfamiliarity with this orphan disease. However, undiagnosed patients are at an increased risk of unnecessary surgical interventions or life-threatening laryngeal swellings. Within the last decade, new and effective therapies have been developed and launched for acute and prophylactic therapy. Even more drugs are under evaluation in clinical trials. It is therefore of utmost importance that patients with HAE are diagnosed as soon as possible and offered relevant therapy with orphan drugs to reduce morbidity, prevent mortality, and improve quality of life.
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Affiliation(s)
- Anette Bygum
- Department of Dermatology and Allergy Centre, Odense University Hospital, Odense, Denmark,
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32
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Dermendjiev S, Blagoeva VS. Angioedema - Our Experience Focused On Socio-Demographic, Etiological and Clinical Characteristics of the Condition and Its Management. Open Access Maced J Med Sci 2019; 7:341-346. [PMID: 30833998 PMCID: PMC6390144 DOI: 10.3889/oamjms.2019.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 12/22/2018] [Accepted: 12/23/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND: Angioedema (AE) is acute oedema of the skin and mucous surfaces, involving the respiratory and gastrointestinal tracts. AE could be a life-threatening medical condition. Regardless of its growing clinical importance, many aspects of its aetiology and pathogenesis remain poorly understood. Its incidence, demographic characteristics, diagnosis and therapy, need further investigation. AIM: This study reports our experience with angioedema concerning its social and demographic characteristics, aetiology, clinical features, diagnosis and treatment outcomes. Study design: Eighty-eight patients with AE were enrolled. The study is a retrospective analysis of patients treated in our Clinics. METHODS: All participants were asked on a voluntary basis to fill out a specially designed questionnaire on the day of their discharge. Other important data sources included: patients’ history and notes during the hospital stay, information from previous admissions, etc. Parametric and non-parametric statistical methods were used for data processing. Data analysis was performed using SPSS (SPSS Inc., IBM SPSS Statistica) version 20.0 RESULTS: Based on our results, AE affects more frequently patients over 50 years of age, regardless of their sex. Urban residents prevail, among them - more commonly working women. Non-steroidal anti-inflammatory drugs (NSAIDs), hormones and antibiotics were among the most common triggers – in 8%, 4.5% and 11.4% of the cases respectively. In 9.09% of the patients, food-induced AE was seen, the most common foods reported, were – nuts, eggs and egg products. The common sites of involvement were periorbital area and lips. In only 9.1% of the patients, oedema progressed to spread to the upper respiratory tract. Cardiac conditions were the most frequent underlying disorders – 33%, of the patients, auto-immune thyroiditis was the second most common-14.8%, followed by musculo- skeletal disorders (10.2%) and diabetes (4.5%) Family history of allergy was seen in 8.4% of the patients, the most frequent allergic disorder, reported, was asthma. In patients with HAE, family history was present in 2.9% of the patients. CONCLUSIONS: All patients received therapy with steroids and antihistamines, resulting in resolution of symptoms and no invasive procedures were necessary. Based on our results, the diagnosis of AE is often difficult and delayed and requires specialist evaluation. If recognised on time and adequately treated, the outcomes are favourable.
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Affiliation(s)
- Svetlan Dermendjiev
- Division of Occupational Disorders and Toxicology, 2nd Medicine Department, Medical Faculty, Medical University, Plovdiv, Bulgaria
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33
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Leru PM, Anton VF, Bumbea H. Nine year follow-up of a rare case of angioedema due to acquired C1-inhibitor deficiency with late onset and good response to attenuated androgen. Allergy Asthma Clin Immunol 2018; 14:69. [PMID: 30386386 PMCID: PMC6201569 DOI: 10.1186/s13223-018-0274-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 07/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Angioedema due to acquired deficiency of C1-inhibitor (C1-INH-AAE) is a rare disease sharing some clinical and laboratory similarities with hereditary angioedema, but with late onset and no positive family history. The underlining cause may be malignant or due to autoimmune diseases, but some cases remain idiopathic. Case presentation We report a case of a 75 year old woman suffering from recurrent episodes of angioedema since the age of 66, considered first induced by treatment with angiotensin-converting-enzyme inhibitors (ACEI). She continued to have angioedema attacks during 6 years after discontinuation of ACEI, until evaluation in our clinic in 2014, when C1 inhibitor esterase (C1-INH) deficiency was confirmed. The extended medical evaluation for inflammatory, allergic, autoimmune and neoplasic diseases was negative. C1-INH and complement fraction C4 plasma levels were significantly decreased at all measurements, but no diagnostic criteria for diseases known to induce C1-INH deficiency could be found. We first initiated daily prophylactic treatment with tranexamic acid, with no amelioration after 3 months. During the last and most severe attack, with the first facial and laryngeal edema, we have switched to attenuated androgen danazol. The evolution was very good, with prompt remission of angioedema and significant increase of C1-INH and C4 plasma levels after 2 weeks of daily danazol use. She completed 3 years of continuous treatment with low daily maintenance dose of danazol (ongoing), with no angioedema attack. We closely monitored C1-INH and C4 plasma levels, possible danazol side effects and any signs suggesting late onset of C1-INH deficiency causal disease. Conclusion We reported a particular case of rare angioedema due to acquired deficiency of C1-inhibitor, which has no clear cause after long follow-up, but good response to attenuated androgen. We concluded that the awareness of angioedema due to C1-INH deficiency should be increased within medical community and therapeutic options should be more clearly indicated and available for all diagnosed cases.
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Affiliation(s)
- Polliana Mihaela Leru
- 1Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari, no. 8, District 5, 050474 Bucharest, Romania.,2Internal Medicine Department, Colentina Clinical Hospital, Sos. Stefan cel Mare, no. 19-21, District 2, 020125 Bucharest, Romania
| | - Vlad Florin Anton
- 2Internal Medicine Department, Colentina Clinical Hospital, Sos. Stefan cel Mare, no. 19-21, District 2, 020125 Bucharest, Romania
| | - Horia Bumbea
- 1Carol Davila University of Medicine and Pharmacy, Bulevardul Eroii Sanitari, no. 8, District 5, 050474 Bucharest, Romania.,3Emergency University Hospital, Splaiul Independentei, no. 169, District 5, 050098 Bucharest, Romania
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Intérêt de l’acide tranexamique en traitement d’urgence de première intention des crises d’angiœdème bradykinique sous IEC. Rev Med Interne 2018; 39:772-776. [DOI: 10.1016/j.revmed.2018.04.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 04/11/2018] [Accepted: 04/15/2018] [Indexed: 11/22/2022]
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Magen E, Chikovani T. Development of angio-oedema after omalizumab injections in a patient with chronic spontaneous urticaria. Clin Exp Dermatol 2018; 43:825. [DOI: 10.1111/ced.13616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2018] [Indexed: 11/27/2022]
Affiliation(s)
- E. Magen
- Medicine C Department; Clinical Immunology and Allergy Unit; Ben Gurion University of Negev; Barzilai University Medical Center; Ashkelon Israel
| | - T. Chikovani
- Department of Immunology; Tbilisi State Medical University; Georgia
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36
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Stephenson G, Lotfipour S, Lahham S. Threatened Respiratory Compromise in the Setting of Isolated Angioedema. Clin Pract Cases Emerg Med 2018; 2:291-293. [PMID: 30443608 PMCID: PMC6230343 DOI: 10.5811/cpcem.2018.9.39548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/30/2018] [Accepted: 09/06/2018] [Indexed: 11/11/2022] Open
Abstract
Isolated angioedema of the uvula, or Quincke’s disease, is a rare condition that can cause respiratory compromise. Although typically self-limiting, episodes of angioedema may require prompt therapy to prevent obstruction of the proximal airway. In this case report we review the appropriate steps for initial evaluation of patients with suspected angioedema, primary etiologies, and appropriate initial therapy.
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Affiliation(s)
- Graham Stephenson
- University of California, Irvine, School of Medicine, Irvine, California
| | - Shahram Lotfipour
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Shadi Lahham
- University of California, Irvine, Department of Emergency Medicine, Orange, California
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37
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Acquired and hereditary forms of recurrent angioedema: Update of treatment. Allergol Select 2018; 2:121-131. [PMID: 31826031 PMCID: PMC6881848 DOI: 10.5414/alx1561e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 09/07/2012] [Indexed: 02/01/2023] Open
Abstract
The aim of treatment of hereditary angioedema (HAE) due to C1 esterase inhibitor deficiency (HAE-C1-INH) is either treating acute attacks or preventing attacks by using prophylactic treatment. For treating acute attacks, plasma-derived C1 inhibitor (C1-INH) concentrates, a bradykinin B2 receptor antagonist, and a recombinant human C1-INH are available in Europe. In the United States, a plasma-derived C1-INH concentrate, a bradykinin B2 receptor antagonist, and a plasma kallikrein inhibitor were approved for the treatment of acute attacks. Fresh frozen plasma is also available for treating acute attacks. Short-term prophylactic treatment focuses on C1-INH and attenuated androgens. Long-term prophylactic treatments include attenuated androgens such as danazol, stanozolol, and oxandrolone, antifibrinolytics, and a plasma-derived C1-INH concentrate. Plasma-derived C1-INH and a bradykinin B2 receptor antagonist are admitted for self-administration and home therapy. So the number of management options increased considerably within the last few years thus helping to diminish the burden of HAE.
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38
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Idiopathic Nonhistaminergic Acquired Angioedema Versus Hereditary Angioedema. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1205-1208. [PMID: 29715562 DOI: 10.1016/j.jaip.2018.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 04/09/2018] [Accepted: 04/17/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The mechanism of idiopathic nonhistaminergic acquired angioedema (InH-AAE) has not yet been precisely elucidated. This condition is characterized by recurrent angioedema without wheals. OBJECTIVE To study the clinical features of InH-AAE, and to make, for the first time, independent comparisons with hereditary angioedema of unknown origin (U-HAE), as well as with hereditary angioedema with C1-inhibitor deficiency (C1-INH-HAE). METHODS We compared the clinical parameters of 46 patients with InH-AAE with those of 27 patients suffering from U-HAE, as well as of 73 patients with C1-INH-HAE. RESULTS The mean age at the onset of symptoms was 36 years in InH-AAE, 13 years in C1-INH-HAE, and 29 years in U-HAE. More than 12 edematous episodes occurred over a year in 56% of patients with InH-AAE, in 59% of those with C1-INH-HAE, and in 48% of those with U-HAE. Edema of the extremities, of the upper airways, and of the gastrointestinal tract was more common in patients with C1-INH-HAE (92%, 51%, and 75%, respectively). These manifestations occurred less frequently in patients with InH-AAE (54%, 28%, and 20%) and in patients with U-HAE (37%, 29%, and 20%). By contrast, facial edema occurred in only 15% of patients with C1-INH-HAE, but in 67% of patients with InH-AAE and in 59% of patients with U-HAE. CONCLUSIONS The clinical manifestations of patients with InH-AAE were different from those of patients with C1-INH-HAE. This may indicate different processes underlying edema formation in these disease forms. The close resemblance of the clinical manifestations in InH-AAE and U-HAE might suggest a similarity between the pathophysiology of these conditions.
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Kuperstock JE, Pritchard N, Horný M, Xiao CC, Brook CD, Platt MP. Inhalant allergen sensitization is an independent risk factor for the development of angioedema. Am J Otolaryngol 2018; 39:111-115. [PMID: 29310846 DOI: 10.1016/j.amjoto.2017.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVE The etiology and risk factors for angioedema remain poorly understood with causative triggers often going undiagnosed despite repeated reactions. The purpose of this study was to determine the relationship between inhalant allergen sensitization and angioedema. METHODS A retrospective review of patients who had in vitro inhalant allergy testing from 2006 to 2010 was performed. Patients with a diagnosis of angioedema who underwent inhalant allergy testing were identified. Analyses for co-morbidities, class of sensitization, seasonal timing of angioedema, and concurrent use of known hypertensive medications that can cause angioedema were performed. RESULTS There were 1000 patients who underwent inhalant allergy testing and qualified for the study. 37/1000 had at least one episode of angioedema and of these patients, 34 had positive inhalant sensitization testing results. Multivariate regression models showed overall sensitization status, seasonal allergen and epidermal/mite sensitization as independent risk factors (p<0.001, p=0.005, p=0.025 respectively) when controlling for ACE inhibitor use and other covariates. Tree, and epidermal/mite sensitizations were independent risk factors for angioedema in mono-sensitized subject analysis (p=0.028, p=0.029, respectively). CONCLUSION Both seasonal and perennial allergen sensitizations are independent risk factors for the development of angioedema. In patients with angioedema and an unknown trigger, inhalant allergen sensitization should be considered as a potential contributing factor to the development of angioedema.
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40
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Bucher MC, Petkovic T, Helbling A, Steiner UC. Idiopathic non-histaminergic acquired angioedema: a case series and discussion of published clinical trials. Clin Transl Allergy 2017; 7:27. [PMID: 28861213 PMCID: PMC5577688 DOI: 10.1186/s13601-017-0164-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 07/17/2017] [Indexed: 01/03/2023] Open
Abstract
Background Idiopathic non-histaminergic acquired angioedema (InH-AAE) is a rare disease for which there are no available laboratory parameters to clearly define the disorder. Therapy is often difficult and various treatment options have been proposed. In this paper, we have evaluated the most effective therapies for InH-AAE on the basis of current literature and report the therapeutic effect of omalizumab in three patients with InH-AAE. Methods Literature was searched with a combination of MeSH/EMTREE terms and freetext search for angioedema and therapy/omalizumab in the databases Medline (Ovid), PubMed/Premedline, Embase, Cochrane library and Scopus with no time or language restrictions. In three patients affected by InH-AAE the therapeutic effect of omalizumab was demonstrated by clinical outcome. In one patient the FcεRI receptor density on basophils was monitored under therapy with omalizumab. Results From the review of the current literature, 25 out of 286 publications dealing with relevant therapeutic recommendations for InH-AAE were analyzed. Six publications with 98 patients referred to tranexamic acid, of which 27 had a complete, 70 a partial and 1 no response. In three case reports ecallantide showed 2 patients with a complete and 1 a partial response. In four case reports for Icatibant 2 had a complete and 3 a partial response. When evaluated in three reports, C1-INH found complete and partial responses in 2 patients each. One patient had a complete response to progestin. Omalizumab was described in 6 reports with 20 patients, all of whom showed a complete response. All three patients described in our study responded to omalizumab with a complete remission. Density of FcεRI receptors on basophils, monitored in patient 1 on a long-term course of 31 months, decreased from 74,051.61 to a minimal level of 1907 receptors per cell. Conclusions Omalizumab seems to be the most effective therapy in InH-AAE. The continuous decrease of FcεRI-receptor density on basophils under therapy with omalizumab along with clinical improvement observed in one patient, could serve as a new approach for further studies to evaluate FcεRI-receptor density as a surrogate marker for therapeutic efficacy and for dosing and determining injection intervals of omalizumab. Trial registration BASEC-Nr. Req-2016-00692. Retrospectively registered 24.11.2016. Electronic supplementary material The online version of this article (doi:10.1186/s13601-017-0164-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martin Christian Bucher
- Department of Clinical Immunology, University Hospital Zurich, Gloriastrasse 23, 8091 Zurich, Switzerland
| | - Tatjana Petkovic
- Adverse Drug Reaction-Analysis and Consulting (ADR-AC) GmbH, Bern, Switzerland
| | - Arthur Helbling
- Department of Rheumatology, Immunology and Allergology, Inselspital, University Bern, Bern, Switzerland
| | - Urs Christian Steiner
- Department of Clinical Immunology, University Hospital Zurich, Gloriastrasse 23, 8091 Zurich, Switzerland
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Abstract
PURPOSE OF REVIEW The aims of this study are to update the clinician on current understanding of angioedema as it presents in the pediatric population and to review proper diagnostic techniques and treatment modalities for various types of angioedema. RECENT FINDINGS Angioedema is still best classified by whether it is likely histaminergic or kinin-mediated. New guidelines have been published around the world to help diagnose and treat both forms (urticaria/angioedema and hereditary angioedema). The vast majority of the studies on treatment have been conducted in the adult population; however, there are data available in the pediatric population. In the realm of hereditary angioedema, there are multiple new therapies that have been studied in the pediatric population (down to 2 years in some studies) in recent years and offer the clinician options for treatment. Angioedema (whether occurring with or without urticaria) is common in the pediatric population. The majority of the recent studies has been conducted in hereditary angioedema, and now, the clinician should have various options to treat all forms of angioedema. Many treatment options, especially for hereditary angioedema, are further being examined specifically in the pediatric population.
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Affiliation(s)
- Debendra Pattanaik
- Department of Internal Medicine, Division of Rheumatology, The University of Tennessee Health Science Center, 51 North Dunlap, Suite 400, Memphis, TN, 38105, USA
| | - Jay Adam Lieberman
- Department of Pediatrics, Division of Allergy & Immunology, The University of Tennessee Health Science Center, 51 North Dunlap, Suite 400, Memphis, TN, 38105, USA.
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Wong BN, Vadas P. Angioedema suppressed by a combination of anti-histamine and leukotriene modifier. Allergy Asthma Clin Immunol 2017; 13:28. [PMID: 28616043 PMCID: PMC5469062 DOI: 10.1186/s13223-017-0201-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 05/26/2017] [Indexed: 12/14/2022] Open
Abstract
Rationale Angioedema without co-existent urticaria is due to a limited number of causes, including hereditary and acquired C1 esterase inhibitor deficiency, drug-induced angioedema or idiopathic histaminergic or non-histaminergic angioedema. We describe a cohort of patients with recurrent angioedema whose clinical features and response to medications are distinct from the causes above. Methods Patients were accrued retrospectively from an academic allergy practice between 2007 and 2014. After institutional research ethics board approval, patients’ charts were reviewed and demographic, clinical and laboratory data were extracted. Results A total of 11 patients were recruited. The mean age at presentation was 54.9 years (range 19–70 years) and 6 of 11 were male. The mean number of episodes per year was 18.7 (range 2–60) and mean duration of episodes was 22.4 h (range 4–96). About half of episodes (52%) began overnight. Areas of involvement were lips (73%), tongue (64%), eyelids (18%), feet (36%) and hands (27%). None of the patients had low C3, C4, or CH50; none had significantly positive ANA; C1 esterase inhibitor level and function and C1q were normal in all patients tested. In these 11 patients, complete suppression of recurrences by the combination of cetirizine 20 mg daily and montelukast 10 mg daily was reported by 9 (82%) of patients; whereas 2 (18%) of patients had a partial response to this combination of medications. Conclusions Herein, we report a form of angioedema without urticaria, mediated by a combination of histamine and leukotrienes. Clinical, demographic and therapeutic characteristics differentiate this from other recognized causes of angioedema.
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Affiliation(s)
- Brendan N Wong
- Division of Allergy and Clinical Immunology, Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - Peter Vadas
- Division of Allergy and Clinical Immunology, Department of Medicine, St. Michael's Hospital, Toronto, Canada
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Abstract
Acquired angioedema due to C1-INH deficiency (C1-INH-AAE) can occur when there are acquired (not inherited) deficiencies of C1-INH. A quantitative or functional C1-INH deficiency with negative family history and low C1q is diagnostic of C1-INH-AAE. The most common conditions associated with C1-INH-AAE are autoimmunity and B-cell lymphoproliferative disorders. A diagnosis of C1-INH-AAE can precede a diagnosis of lymphoproliferative disease and confers an increased risk for developing non-Hodgkin lymphoma. Treatment focuses on symptom control with therapies that regulate bradykinin activity (C1-INH concentrate, icatibant, ecallantide, tranexamic acid, androgens) and treatment of any underlying conditions.
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Affiliation(s)
- Iris M Otani
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, UCSF Medical Center, 400 Parnassus Avenue, Box 0359, San Francisco, CA 94143, USA.
| | - Aleena Banerji
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Cox 201 Allergy Associates, Boston, MA 02114, USA
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Hofman Z, de Maat S, Hack CE, Maas C. Bradykinin: Inflammatory Product of the Coagulation System. Clin Rev Allergy Immunol 2017; 51:152-61. [PMID: 27122021 PMCID: PMC5025506 DOI: 10.1007/s12016-016-8540-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Episodic and recurrent local cutaneous or mucosal swelling are key features of angioedema. The vasoactive agents histamine and bradykinin are highly implicated as mediators of these swelling attacks. It is challenging to assess the contribution of bradykinin to the clinical expression of angioedema, as accurate biomarkers for the generation of this vasoactive peptide are still lacking. In this review, we will describe the mechanisms that are responsible for bradykinin production in hereditary angioedema (HAE) and the central role that the coagulation factor XII (FXII) plays in it. Evidently, several plasma parameters of coagulation change during attacks of HAE and may prove valuable biomarkers for disease activity. We propose that these changes are secondary to vascular leakage, rather than a direct consequence of FXII activation. Furthermore, biomarkers for fibrinolytic system activation (i.e. plasminogen activation) also change during attacks of HAE. These changes may reflect triggering of the bradykinin-forming mechanisms by plasmin. Finally, multiple lines of evidence suggest that neutrophil activation and mast-cell activation are functionally linked to bradykinin production. We put forward the paradigm that FXII functions as a ‘sensor molecule’ to detect conditions that require bradykinin release via crosstalk with cell-derived enzymes. Understanding the mechanisms that drive bradykinin generation may help to identify angioedema patients that have bradykinin-mediated disease and could benefit from a targeted treatment.
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Affiliation(s)
- Zonne Hofman
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.,Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven de Maat
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - C Erik Hack
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Coen Maas
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Angioedema Due to ACE Inhibitors. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0099-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Misra L, Khurmi N, Trentman TL. Angioedema: Classification, management and emerging therapies for the perioperative physician. Indian J Anaesth 2016; 60:534-41. [PMID: 27601734 PMCID: PMC4989802 DOI: 10.4103/0019-5049.187776] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Angioedema is a rare condition which manifests as sudden localised, non-pitting swelling of certain body parts including skin and mucous membranes. It is vital that anaesthesiologists understand this condition, as it may present suddenly in the perioperative period with airway compromise. To identify literature for this review, the authors searched the PubMed, Medline, Embase, Scopus and Web of Science databases for English language articles covering a 10-year period, 2006 through 2016. Angioedema can be either mast-cell mediated or bradykinin-induced. Older therapies for histaminergic symptoms are well known to anaesthesiologists (e.g., adrenaline, anti-histamines and steroids), whereas older therapies for bradykinin-induced symptoms include plasma and attenuated androgens. New classes of drugs for bradykinin-induced symptoms are now available, including anti-bradykinin, plasma kallikrein inhibitor and C1 esterase inhibitors. These can be used prophylactically or as rescue medications. Anaesthesiologists are in a unique position to coordinate perioperative care for this complex group of patients.
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Affiliation(s)
- Lopa Misra
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
| | - Narjeet Khurmi
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
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Andersen MF, Longhurst HJ, Rasmussen ER, Bygum A. How Not to Be Misled by Disorders Mimicking Angioedema: A Review of Pseudoangioedema. Int Arch Allergy Immunol 2016; 169:163-70. [DOI: 10.1159/000445835] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Bekos C, Perkmann T, Krauth M, Raderer M, Lechner K, Jaeger U. Acquired C1 esterase inhibitor deficiency in lymphomas: prevalence, symptoms, and response to treatment. Leuk Lymphoma 2016; 57:2033-6. [PMID: 26795750 DOI: 10.3109/10428194.2015.1131273] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We retrospectively studied the prevalence of C1 esterase inhibitor (C1 INH) deficiency in 131 patients with various lymphomas. We determined C1 INH activity, C1 INH antigen, and C4 concentration at diagnosis and after chemotherapy. In follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL) and chronic lymphocytic leukemia (CLL) consecutive patients were studied. In these entities, the prevalence of C1 INH deficiency was 10.2% in DLBCL, 4.1% in CLL, and 0% in FL and Hodgkin lymphoma. In indolent lymphomas, we identified only single cases of C1 INH deficiency, predominantly in splenic marginal zone lymphomas (SMZL) (four cases). Only three patients were symptomatic while the majority (11 cases) was asymptomatic. In DLBCL patients who were successfully treated with chemotherapy, complete normalization of C1 INH activity and C4 was observed. In contrast, C1 INH deficiency remained in SMZL patients after splenectomy. We conclude that C1 INH deficiency in lymphomas is frequently asymptomatic and responsive to immunochemotherapy.
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Affiliation(s)
- Christine Bekos
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
| | - Thomas Perkmann
- b Clinical Institute of Laboratory Medicine and Clinical Chemistry, Medical University of Vienna , Vienna , Austria
| | - Maria Krauth
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
| | - Markus Raderer
- c Department of Medicine I, Division of Clinical Oncology , Comprehensive Cancer Center, Medical University of Vienna , Vienna , Austria
| | - Klaus Lechner
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
| | - Ulrich Jaeger
- a Department of Medicine I, Division of Hematology and Hemostaseology , Medical University of Vienna , Vienna , Austria
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Angioedema Triggered by Medication Blocking the Renin/Angiotensin System: Retrospective Study Using the French National Pharmacovigilance Database. J Clin Immunol 2015; 36:95-102. [PMID: 26707788 DOI: 10.1007/s10875-015-0228-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 12/14/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Bradykinin-mediated angioedema (AE) is a rare side effect of some medications, including angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB). In France, side-effects to treatments are reported to the national pharmacovigilance database. METHODS The national MedDRA database was searched using the term "angioedema". Patients were included if they met the clinical criteria corresponding to bradykinin-mediated AE, if their C1-inhibitor levels were normal, and if they were treated with an ACEi or an ARB. RESULTS 7998 cases of AE were reported between 1994 and 2013. Among these, 112 met the criteria for bradykinin-mediated AE with normal C1-inhibitor levels. On the 112 drug-AE, patients were treated with an ARB in 21% of cases (24 patients), or an ACEi in 77% of cases (88 patients), in combination with another treatment in 17 cases (mTORi for 3 patients, iDPP-4 for 1 patient, hormonal treatment for 7 patients). ENT involvement was reported in 90% of cases (tongue: 48.2%, larynx: 23.2%). The median duration of treatment before the first attack was 720 days, and the mean duration of attacks was 36.6 h. Forty-one percent (19/46) of patients relapsed after discontinuing treatment. CONCLUSION Angioedema triggered by medication blocking the renin/angiotensin system is rare but potentially severe, with a high risk of recurrence despite cessation of the causative drug.
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