Misdiagnosis trends in patients with hereditary angioedema from the real-world clinical setting

BACKGROUND

Hereditary angioedema due to C1 inhibitor deficiency (C1-INH-HAE) causes swelling in the skin and upper airways and pain in the abdomen because of mucosal swelling. C1-INH-HAE is frequently misdiagnosed, leading to delays in diagnosis, inadequate treatment, and unnecessary procedures.

OBJECTIVE

To evaluate the history of misdiagnosis in patients participating in the Icatibant Outcome Survey (IOS).

METHODS

The IOS is an observational study in which safety and effectiveness of icatibant have been evaluated since 2009. As part of the IOS, patients record any misdiagnoses received before being diagnosed as having C1-INH-HAE.

RESULTS

In January 2016, a total of 418 of 633 IOS patients with C1-INH-HAE type I or II had provided misdiagnosis data. Of these, 185 of 418 (44.3%) received 1 or more prior misdiagnoses. The most common misdiagnoses were allergic angioedema (103 of 185) and appendicitis (50 of 185). A variety of other misdiagnoses were reported, including a substantial number of gastrointestinal disorders (excluding appendicitis). Misdiagnosis rates were similar between males (41.1%) and females (46.5%) and between C1-INH-HAE type I (43.7%) and type II (51.6%). Patients with family members diagnosed as having C1-INH-HAE were significantly less likely to be misdiagnosed than patients without a family history (140 of 366 [41.7%] vs 38 of 58 [65.5%], respectively; P = .001). Patients with a prior misdiagnosis had longer median delay to C1-INH-HAE diagnosis (13.3 years) than patients without (1.7 years; P < .001).

CONCLUSION

From this large database, approximately 50% of patients with C1-INH-HAE type I or II have previously had their conditions misdiagnosed, most commonly as allergic angioedema or appendicitis. Misdiagnosis results in marked delays in receiving the correct diagnosis, during which time patients cannot access effective, lifesaving treatment.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01034969.

Prevalence of fecal incontinence in a cohort of systemic sclerosis patients within a regional referral network

Background

The prevalence of gastrointestinal involvement in systemic sclerosis is higher than 75%. The estimated prevalence of fecal incontinence varies from 22% to 77%, but suffers from recruitment bias and patient reluctance. Our goal was to evaluate the prevalence of fecal incontinence in systemic sclerosis, and to identify associated risk factors.

Methods

Patients were recruited in the referral systemic sclerosis network of the Lyon University Hospitals, using self-administered questionnaires including constipation, fecal incontinence and Bristol Stool scales, quality of life, anxiety and depression. The cohort was compared with the historical ORALIA cohort that established the prevalence of fecal incontinence in the general population of the Rhône-Alpes region (France).

Results

Seventy-seven patients were included (mean age: 60 years, range: 32-84), and 86% were female. These were compared to 153 ORALIA individuals matched for age and sex. Fecal incontinence was present in 38% of patients and 6% of the general population. A longer duration of systemic sclerosis was the only characteristic associated with fecal incontinence. Abnormal stool consistency was more frequent in patients with fecal incontinence.

Conclusion

Fecal incontinence and abnormal stool consistency are common in systemic sclerosis and should be systematically addressed.

[Familial epilepsy seizure disclosing long QT syndrome]

The Romano-Ward syndrome shows a congenital prolonged QT on the electrocardiogram. It is often revealed by syncopes, sudden death and, in rare cases, by an epileptic attack. We report the cases of two sisters presenting this syndrome. One of them presented an inaugural epileptic attack. The electrocardiogram returned to normal and the seizures disappeared after a treatment with beta-bloquants.

[Vascular and/or cardiac manifestations of type IV Ehlers-Danlos syndrome. 9 cases]

Type IV Ehlers-Danlos syndrome, a rare disease caused by abnormal synthesis of type III collagen, often leads to vascular fragility. We report 9 cases (6 men and 3 women, mean age 35 years). For 7 of the patients, the inaugural signs were arterial complications including haemoperitoneum in 2 patients with multiple aneurysmal dystrophy of the abdominal arteries, one case of ruptured subclavian artery, two dissections of the renal artery, one case with rupture of a cerebral aneurysm, one rupture of the mesenteric artery and a haematoma after arterial puncture. Other vascular manifestations were acrosyndrome (n = 4), varicose veins (n = 3), and prolapsus of the mitral valve (n = 2). In addition, 8 of the 9 patients presented extravascular signs. There was a history of familial disease in 5 cases. Pregnancy was completed to term in three patients: a cesarean section was required in one case and intra-uterine growth retardation was seen in 2. Morbidity was important with hemiparesia, blindness and paraparesis sequellae. One patient died from haemorrhage. This series of patients with type IV Ehlers-Danlos syndrome illustrates the severity of this disease whose prevalence is often underestimated. The disease is transmitted by autosomal dominant inheritance, underscoring the importance of familial testing for early diagnosis. Clinicians should be aware of the vascular manifestations and avoid invasive punctures or operations except in exceptional indications.

[Triple association: extramembranous glomerulonephritis, renal adenocarcinoma and splenic hamartoma. Apropos of a case]

We report the case of a 36 year old woman who presented a renal cell carcinoma, associated to a membranous nephropathy as a paraneoplastic syndrome. The concomitant association with a splenic hamartoma was probably fortuitous. Five years after nephrectomy, the patient was asymptomatic and her proteinuria was very low. We studied in the literature 93 cases which reported a such association between cancer, nephrotic syndrome and membranous nephropathy. Carcinoma of the lung and adenocarcinoma of the gastrointestinal tract are the most frequently implicated. This association can occur at every age and more often in men (75%) than in women. The survival is directly linked to the evolution of the cancer. Proteinuria and membranous nephropathy can totally disappear after surgical resection of the carcinoma. The glomerular injury is mediated by immune complexes composed at least in part of tumour associated antigens. The development of several types of glomerular injury in patients with carcinoma have been described but membranous glomerulonephritis is the most commonly observed.

[Cytoplasm antibodies of polynuclear neutrophils in Wegener's granulomatosis and systemic vasculitis]

In retrospective and prospective studies the sera of 442 patients recruited from an Internal Medicine department were examined by acetone indirect immunofluorescence and immunoblot in search of anti-neutrophil cytoplasm antibodies (ANCA). Twenty-three patients had Wegener's granulomatosis, and 419 had various control diseases including connective tissue diseases, vasculitis and granulomatosis. The sera from 100 healthy blood donors were used as controls. Among the 23 patients with generalized (n = 15) or localized (n = 8) Wegener's granulomatosis (active in 21/23), the indirect immunofluorescence test was positive in 92 percent of those with the generalized form and in 62 percent of those with the localized form. Nine of the 13 sera examined by immunoblot (69 percent) were positive (31 +/- 57 kDa bands). On the other hand, the sera from 38 (6.9 percent) patients with control diseases were positive at immunofluorescence: vasculitis (14 cases, 50 percent), connective tissue diseases (4 cases, 14.3 percent) and miscellaneous diseases including 3 neoplasms (10 cases, 35.7 percent). Only 6 of these 28 sera showed a 1/100th titer of ANCA. The sera of all healthy controls were negative. The sensitivity of ANCA for Wegener's granulomatosis at all stages was 72.2 percent, and its specificity 94.4 percent. This study confirms the value of ANCA as third diagnostic criterion of Wegener's granulomatosis, after the clinical and histological criteria.

Concentrations of cefodizime in bronchial secretions after single intravenous administration

The concentrations of cefodizime (HR 221, CAS 69739-16-8) in bronchial secretions were measured after administration of a single intravenous bolus of 2 g in 19 patients requiring fibreoptic bronchoscopy for diagnostic purposes or as therapeutic follow-up. These concentrations, which were obtained in absence of inflammation of the mucosa, were compared to serum concentrations obtained simultaneously. The penetration into bronchial secretions was rapid, maximum levels of between 1 and 5 mg/kg being already observed 1 h after injection. Most concentrations remained about 1 mg/kg throughout the whole observation period of about 5.5 h. The percent penetration amounted to about 1.5% of the corresponding serum concentrations.

CONCLUSION

Concentrations well above the MIC90s of the relevant respiratory pathogens--S. pneumoniae, M. catarrhalis, H. influenzae, K. pneumoniae--and Enterobacteriaceae were reached in bronchial secretions after intravenous injection of a single 2 g dose of cefodizime. Even higher levels may be expected in the usual condition of inflamed bronchial mucosa as found in respiratory infections.