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Mumneh N, Tick M, Borum M. Angioedema with severe acute abdominal pain: Think of hereditary angioedema. Clin Res Hepatol Gastroenterol 2021; 45:101702. [PMID: 33864899 DOI: 10.1016/j.clinre.2021.101702] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/08/2021] [Accepted: 03/30/2021] [Indexed: 02/04/2023]
Abstract
Angioedema can be either mast cell-(histamine-)mediated or bradykinin-mediated. Treatment approaches for the two types are very different, making differential diagnosis critical. Severe acute abdominal pain caused by intestinal angioedema is commonly misdiagnosed, especially when associated with bradykinin-mediated angioedema. After describing a typical clinical scenario and diagnostic journey of a patient with recurrent, undiagnosed abdominal pain due to hereditary angioedema (HAE), a rare variant of bradykinin-mediated angioedema, we delve into the classification and differential diagnosis of the various types of angioedema and provide an overview of appropriate management with an emphasis on the bradykinin-mediated types. Bradykinin-induced angioedema may be inherited or acquired and is infrequent compared to mast cell-mediated angioedema. HAE is a rare disease characterized by recurrent attacks of non-urticarial, nonpruritic edema usually affecting the face, respiratory tract, extremities, gastrointestinal tract, and genitalia. Unlike mast cell-mediated angioedema, painful abdominal symptoms are prevalent in bradykinin-mediated angioedema and are sometimes the only manifestation of an attack, increasing the likelihood of initial misdiagnosis as appendicitis or other forms of acute abdomen. It is important for gastroenterologists to be vigilant for the possibility of angioedema pathology in patients presenting with undiagnosed, recurrent, abdominal symptoms to facilitate accurate diagnosis and effective treatment.
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Affiliation(s)
- Nayla Mumneh
- Medical Director Respiratory, Novartis Pharmaceuticals Corp, 1 Health Plaza, East Hanover, NJ, United States.
| | - Matthew Tick
- Gastroenterology Fellow, The George Washington University, 2121 I St NW, Washington, DC, United States
| | - Marie Borum
- Division of Gastroenterology and Liver Disease, The George Washington University, 3131 I St NW, Washington, DC, United States
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Maurer M, Aygören-Pürsün E, Banerji A, Bernstein JA, Balle Boysen H, Busse PJ, Bygum A, Caballero T, Castaldo AJ, Christiansen SC, Craig T, Farkas H, Grumach AS, Hide M, Katelaris CH, Li HH, Longhurst H, Lumry WR, Magerl M, Martinez-Saguer I, Riedl MA, Zhi Y, Zuraw B. Consensus on treatment goals in hereditary angioedema: A global Delphi initiative. J Allergy Clin Immunol 2021; 148:1526-1532. [PMID: 34048855 DOI: 10.1016/j.jaci.2021.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 05/06/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hereditary angioedema (HAE) is a rare, life-threatening genetic disorder characterized by recurrent episodes of subcutaneous or submucosal angioedema. The ultimate goals of treatment for HAE remain ill-defined. OBJECTIVES The aim of this Delphi process was to define the goals of HAE treatment and to examine which factors should be considered when assessing disease control and normalization of the patient's life. METHODS The Delphi panel comprised 23 participants who were selected based on involvement with scientific research on HAE or coauthorship of the most recent update and revision of the World Allergy Organization/European Academy of Allergy and Clinical Immunology guideline on HAE. The process comprised 3 rounds of voting. The final round aimed to aggregate the opinions of the expert panel and to achieve consensus. RESULTS Two direct consensus questions were posed in round 2, based on the responses received in round 1, and the panel agreed that the goals of treatment are to achieve total control of the disease and to normalize the patient's life. For the third round of voting, 21 statements were considered, with the participants reaching consensus on 18. It is clear from the wide-ranging consensus statements that the burdens of disease and treatment should be considered when assessing disease control and normalization of patients' lives. CONCLUSIONS The ultimate goal for HAE treatment is to achieve no angioedema attacks. The availability of improved treatments and disease management over the last decade now makes complete control of HAE a realistic possibility for most patients.
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Affiliation(s)
- Marcus Maurer
- Angioedema Center of Reference and Excellence, Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Emel Aygören-Pürsün
- Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, Mass
| | - Jonathan A Bernstein
- Department of Medicine, Division of Immunology/Allergy Section, University of Cincinnati, Cincinnati, Ohio
| | | | - Paula J Busse
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Anette Bygum
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark; Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Teresa Caballero
- Allergy Department, Hospital Universitario La Paz, Hospital La Paz Institute for Health Research, Centre for Biomedical Network Research on Rare Diseases, Madrid, Spain
| | | | - Sandra C Christiansen
- US HAE Association Angioedema Center, Department of Medicine, University of California, San Diego, La Jolla, Calif
| | - Timothy Craig
- Department of Medicine, Pediatrics and Graduate Studies, Penn State University, Hershey, Pa
| | - Henriette Farkas
- Hungarian Angioedema Center of Reference and Excellence, Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Anete S Grumach
- Clinical Immunology, Faculdade de Medicina, Centro Universitário Saude ABC, São Paulo, Brazil
| | - Michihiro Hide
- Department of Dermatology, Hiroshima University, Hiroshima, Japan
| | - Constance H Katelaris
- Department of Medicine, Campbelltown Hospital and Western Sydney University, Campbelltown, Australia
| | - H Henry Li
- Institute for Asthma and Allergy, Chevy Chase, Md
| | - Hilary Longhurst
- Auckland City Hospital, Auckland, New Zealand; University College Hospital, London, United Kingdom
| | - William R Lumry
- Department of Internal Medicine, Allergy/Immunology Division, Southwestern Medical School, University of Texas, Dallas, Tex; Allergy and Asthma Research Association Research Center, Dallas, Tex
| | - Markus Magerl
- Angioedema Center of Reference and Excellence, Dermatological Allergology, Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Marc A Riedl
- US HAE Association Angioedema Center, Department of Medicine, University of California, San Diego, La Jolla, Calif
| | - Yuxiang Zhi
- Department of Allergy and Clinical Immunology, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Disease, Beijing, China
| | - Bruce Zuraw
- US HAE Association Angioedema Center, Department of Medicine, University of California, San Diego, La Jolla, Calif; San Diego Veterans Affairs Healthcare, San Diego, Calif
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Zanichelli A, Azin GM, Wu MA, Suffritti C, Maggioni L, Caccia S, Perego F, Vacchini R, Cicardi M. Diagnosis, Course, and Management of Angioedema in Patients With Acquired C1-Inhibitor Deficiency. J Allergy Clin Immunol Pract 2017; 5:1307-1313. [PMID: 28284781 DOI: 10.1016/j.jaip.2016.12.032] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/13/2016] [Accepted: 12/21/2016] [Indexed: 02/09/2023]
Abstract
BACKGROUND Acquired angioedema due to C1-inhibitor deficiency (C1-INH-AAE) is a rare disease with no prevalence data or approved therapies. OBJECTIVE To report data on patients with C1-INH-AAE followed at Angioedema Center, Milan (from 1976 to 2015). METHODS Diagnostic criteria included history of recurrent angioedema without wheals; decreased C1-INH antigen levels and/or functional activity of C1-INH and C4 antigen less than 50% of normal; late symptom onset (>40 years); no family history of angioedema and C1-INH deficiency. RESULTS In total, 77 patients (58% females; median age, 70 years) were diagnosed with C1-INH-AAE and 675 patients with hereditary angioedema due to C1-INH deficiency (C1-INH-HAE) (1 patient with C1-INH-AAE/8.8 patients with C1-INH-HAE). Median age at diagnosis was 64 years. Median time between symptom onset and diagnosis was 2 years. Sixteen patients (21%) died since diagnosis, including 1 because of laryngeal edema. Angioedema of the face was most common (N = 63 [82%]), followed by abdomen (N = 51 [66%]), peripheries (N = 50 [65%]), and oral mucosa and/or glottis (N = 42 [55%]). Forty-eight of 71 patients (68%) had autoantibodies to C1-INH. In total, 56 patients (70%) used on-demand treatment for angioedema including intravenous pdC1-INH 2000 U (Berinert, CSL Behring, Marburg, Germany) (N = 49) and/or subcutaneous icatibant 30 mg (Firazyr, Shire; Milano, Italy) (N = 27). Eventually, 8 of 49 patients receiving pdC1-INH became nonresponsive; all had autoantibodies. Thirty-four patients received long-term prophylaxis with tranexamic acid (effective in 29) and 20 with androgens (effective in 8). CONCLUSIONS The incidence of C1-INH-AAE was 1 for every 8.8 patients with C1-INH-HAE. Thirty percent of the deaths were related to the disease. Treatments approved for C1-INH-HAE are effective in C1-INH-AAE, although with minimal differences.
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Affiliation(s)
- Andrea Zanichelli
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy.
| | - Giulia Maria Azin
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Maddalena Alessandra Wu
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Chiara Suffritti
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Lorena Maggioni
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Sonia Caccia
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Francesca Perego
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Romualdo Vacchini
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy
| | - Marco Cicardi
- Department of Biomedical and Clinical Sciences, Luigi Sacco Hospital, University of Milan, Milan, Italy; ASST Fatebenefratelli Sacco, Milan, Italy
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Henao MP, Kraschnewski JL, Kelbel T, Craig TJ. Diagnosis and screening of patients with hereditary angioedema in primary care. Ther Clin Risk Manag 2016; 12:701-11. [PMID: 27194914 PMCID: PMC4859422 DOI: 10.2147/tcrm.s86293] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hereditary angioedema (HAE) is a rare autosomal dominant disease that commonly manifests with episodes of cutaneous or submucosal angioedema and intense abdominal pain. The condition usually presents due to a deficiency of C1 esterase inhibitor (C1-INH) that leads to the overproduction of bradykinin, causing an abrupt increase in vascular permeability. A less-understood and less-common form of the disease presents with normal C1-INH levels. Symptoms of angioedema may be confused initially with mast cell-mediated angioedema, such as allergic reactions, and may perplex physicians when epinephrine, antihistamine, or glucocorticoid therapies do not provide relief. Similarly, abdominal attacks may lead to unnecessary surgeries or opiate dependence. All affected individuals are at risk for a life-threatening episode of laryngeal angioedema, which continues to be a source of fatalities due to asphyxiation. Unfortunately, the diagnosis is delayed on average by almost a decade due to a misunderstanding of symptoms and general lack of awareness of the disease. Once physicians suspect HAE, however, diagnostic methods are reliable and available at most laboratories, and include testing for C4, C1-INH protein, and C1-INH functional levels. In patients with HAE, management consists of acute treatment of an attack as well as possible short- or long-term prophylaxis. Plasma-derived C1-INH, ecallantide, icatibant, and recombinant human C1-INH are new treatments that have been shown to be safe and effective in the treatment of HAE attacks. The current understanding of HAE has greatly improved in recent decades, leading to growing awareness, new treatments, improved management strategies, and better outcomes for patients.
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Affiliation(s)
- Maria Paula Henao
- Department of Medicine, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Jennifer L Kraschnewski
- Department of Medicine, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Theodore Kelbel
- Division of Allergy and Immunology, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
| | - Timothy J Craig
- Department of Medicine and Pediatrics, Pennsylvania State University College of Medicine at Hershey Medical Center, Hershey, PA, USA
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Kaur R, Williams AA, Swift CB, Caldwell JW. Rituximab therapy in a patient with low grade B-cell lymphoproliferative disease and concomitant acquired angioedema. J Asthma Allergy 2014; 7:165-7. [PMID: 25506230 PMCID: PMC4259552 DOI: 10.2147/jaa.s68548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Acquired angioedema is often associated with significant morbidity. An underlying lymphatic malignancy, autoimmune disorder, adenocarcinoma, or other malignancy may be present. Screening for these disorders should occur in all patients with acquired angioedema as treatment may result in resolution of angioedema.
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Affiliation(s)
- Ravdeep Kaur
- Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Aerik Anthony Williams
- Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Catherine Baker Swift
- Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Jason W Caldwell
- Wake Forest University School of Medicine, Wake Forest University, Winston-Salem, NC, USA
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