Protocolo de actuación en el tratamiento odontológicoquirúrgico en pacientes con angioedema hereditario. Revisión de la literatura / Management protocol of dental treatment in patients with hereditary angioedema. A literature review

El angioedema hereditario (AEH) es una enfermedad genética rara de transmisión autosómica dominante, en la que existe un déficit de la encima C1-INH. Cursa con episodios recurrentes y autolimitados de edema, causados por aumento de la permeabilidad vascular. Tiene unas importantes implicaciones para los profesionales de la salud bucodental, ya que determinados procedimientos odontológicos y quirúrgicos pueden desencadenar episodios de angioedema, potencialmente mortales al producirse edema en las vías respiratorias superiores. El objetivo de este trabajo es aportar información y recomendaciones a los odontólogos a la hora de tratar a estos pacientes con el fin de minimizar las complicaciones. Los resultados han aportado un total de 48 pacientes y se realizaron un total de 90 intervenciones, siendo el tratamiento más frecuente las extracciones dentales. El AEH tipo I es el más frecuente de los tres tipos con una incidencia de entorno al 85% y el tipo III es el menos común y conocido, ya que se ha identificado en los últimos años. La profilaxis a corto plazo es un método preventivo que ha de realizarse en todos los pacientes con AEH antes de cualquier intervención quirúrgica odontológica. El tratamiento de estos pacientes implica, en la mayoría de las ocasiones, una profilaxis a largo y corto plazo con el fin de disminuir los ataques. Siendo aconsejable realizar los procedimientos odontológicos-quirúrgicos en ambiente hospitalario

Hereditary angioedema (HAE) is a rare genetic disease of autosomal dominant transmission, in which there is a deficit of C1-INH enzyme. It runs with recurrent and self-limited episodes of edema to increase vascular permeability. There are some important complications for oral health professionals because many dental and surgical procedures can trigger angioedema episodes which can be a potentially life-threating condition due to edema in the upper respiratory tract. The objective of this research is to provide information and recommendations to dentists for treating these patients in order to minimize complications. 48 patients have been reported and a total of 90 interventions were performed, being extractions the most frequent treatment. HAE type 1 is the most frequent of the three types with an 85% of incidence, and type III is the least common and known, it has been identified in recent years. Shortterm prophylaxis is a preventive method that must be done in all HAE patients before any dental surgery. The treatment of these patients implies, in most cases, a long- and short-term prophylaxis in order to reduce attacks. It is recommended to realize dental-surgical procedures in a hospital environment

Diagnostic biologique des angioedèmes bradykiniques : les recommandations du CREAK.

Bradykinin mediated angioedema (BK-AE) can be associated either with C1Inhibitor deficiency (hereditary and acquired forms), either with normal C1Inh (hereditary form and drug induced AE as angiotensin converting enzyme inhibitors…). In case of high clinical suspicion of BK-AE, C1Inh exploration must be done at first: C1Inh function and antigenemy as well as C4 concentration. C1Inh deficiency is significant if the tests are below 50 % of the normal values and controlled a second time. In case of C1Inh deficiency, you have to identify hereditary from acquired forms. C1q and anti-C1Inh antibody tests are useful for acquired BK-AE. SERPING1 gene screening must be done if a hereditary angioedema is suspected, even if there is no family context (de novo mutation 15 %). If a hereditary BK-AE with normal C1Inh is suspected, F12 and PLG gene screening is suitable.

Brazilian Guidelines for Hereditary Angioedema Management - 2017 Update Part 1: Definition, Classification and Diagnosis.

Hereditary angioedema is an autosomal dominant disease characterized by recurrent angioedema attacks with the involvement of multiple organs. The disease is unknown to many health professionals and is therefore underdiagnosed. Patients who are not adequately diagnosed and treated have an estimated mortality rate ranging from 25% to 40% due to asphyxiation by laryngeal angioedema. Intestinal angioedema is another important and incapacitating presentation that may be the main or only manifestation during an attack. In this article, a group of experts from the "Associação Brasileira de Alergia e Imunologia (ASBAI)" and the "Grupo de Estudos Brasileiro em Angioedema Hereditário (GEBRAEH)" has updated the Brazilian guidelines for the diagnosis and treatment of hereditary angioedema.

Brazilian Guidelines for Hereditary Angioedema Management - 2017 Update Part 1: Definition, Classification and Diagnosis

Hereditary angioedema is an autosomal dominant disease characterized by recurrent angioedema attacks with the involvement of multiple organs. The disease is unknown to many health professionals and is therefore underdiagnosed. Patients who are not adequately diagnosed and treated have an estimated mortality rate ranging from 25% to 40% due to asphyxiation by laryngeal angioedema. Intestinal angioedema is another important and incapacitating presentation that may be the main or only manifestation during an attack. In this article, a group of experts from the "Associação Brasileira de Alergia e Imunologia (ASBAI)" and the "Grupo de Estudos Brasileiro em Angioedema Hereditário (GEBRAEH)" has updated the Brazilian guidelines for the diagnosis and treatment of hereditary angioedema.

Type I and Type II Hereditary Angioedema: Clinical and Laboratory Findings in Iranian Patients.

BACKGROUND: Hereditary angioedema (HAE) is a rare autosomal dominant disorder characterized by C1-INH (C1 esterase inhibitor), low serum levels (type I), dysfunction (type II) or normal serum levels and function (type III), which lead to subcutaneous and submucosal edema attacks. The aim of this study was to investigate the demographic, clinical and laboratory findings of Iranian patients with HAE. METHODS: The patients with a history or symptoms of angioedema who were referred to Immunology, Asthma and Allergy Research Institute (IAARI) between Jan 2006 and Jan 2014, were assessed based on a specific questionnaire and laboratory evaluation. The patients with a definite diagnosis of HAE type I and type II were entered into this study. RESULTS: Among 51 patients, 63.3% were diagnosed with HAE type I and 36.7% with HAE type II. Fifteen patients were under 18 years and 36 were adults. The mean age of symptoms onset and diagnosis were 12.33 ± 10.20 years and 24.48 ± 14.64 years, respectively. The mean delay of diagnosis was 11.02 ± 11.60 years. The most commonly involved locations of edema were hands, face and genitalia. Moreover, laryngeal edema was observed in 61.2% of patients, which led to death in two patients during this study. CONCLUSION: Hereditary angioedema is a life threatening disease with considerable morbidity and mortality. The outcomes of this study can be used to inform clinicians and health care providers about HAE, which can help earlier diagnosis and better management of the patients, specifically in life threatening attacks.

[Algorithm for diagnosis and treatment of hereditary angioedema as a tool for management]. / Algoritmo de diagnóstico y tratamiento del angioedema hereditario como herramienta para su manejo.

INTRODUCTION: Hereditary angioedema is a disease with low prevalence and high heterogeneity with regards to the severity of the clinical picture, which makes the diagnosis difficult and requires the need for early start of specific treatment in order to prevent complications. OBJECTIVE: To propose a decision algorithm for hereditary angioedema (HAE), based on the evidence available on the diagnosis, clinical assessment, and treatment. The aim is to present the available therapeutic options as well as a decision algorithm to select the most efficient therapy at each time. MATERIAL AND METHODS: Literature search by means of PubMed and other relevant sources. RESULTS: four decision algorithms have been developed for HAE; diagnosis of bradikinin-mediated angioedema, treatment of acute attacks and short and long-term prophylaxis for HAE due to C1 inhibitor deficiency. CONCLUSIONS: The application of a decision algorithm based on the clinical variables helps to select the most efficient therapeutic option at each time and may be a useful tool for the therapeutic approach.

Introducción: El angioedema hereditario es una enfermedad rara de baja prevalencia y gran heterogeneidad en la gravedad del cuadro clínico, lo que dificulta su diagnóstico, y establece la necesidad de iniciar un tratamiento precoz y específico con el fin de evitar complicaciones. Objetivo: Proponer un algoritmo de decisión en el angioedema hereditario (AEH), basado en la evidencia disponible, sobre el diagnóstico, valoración clínica y tratamiento. Se trata de presentar opciones terapéuticas disponibles, así como un algoritmo de decisión para seleccionar el tratamiento más eficiente en cada momento. Material y Métodos: Revisión bibliográfica mediante una búsqueda a través de PubMed y otras fuentes de interés. Resultados: Se han desarrollado cuatro algoritmos de decisión para el AEH; diagnóstico de angioedema mediado por bradicinina, tratamiento del ataque agudo y profilaxis a corto y largo plazo del AEH por déficit del inhibidor C1. Conclusiones: La aplicación de un algoritmo de decisión, en función de unas variables clínicas, ayuda a la selección de la opción terapéutica más eficiente en cada momento y puede ser un instrumento de utilidad en el abordaje terapéutico.

[Diagnostics and exclusion of hereditary angioedema : a standarized approach for the practice]. / Diagnostik und Ausschluss des hereditären Angioödems : Ein standardisierter Ansatz für die Praxis.

The differentiation between mast cell mediator-mediated and bradykinin-mediated forms of angioedema can be difficult. Bradykinin-mediated hereditary angioedema is a rare autosomal dominant hereditary disease which is characterized by recurrent edema attacks of varying magnitude. The edema occurs in the skin and mucous membranes and can be temporarily disfiguring, very painful and life-threatening by attacks in the laryngeal region. Because of the multitude of differential diagnoses, a final diagnosis is only achieved after an average duration of more than 10 years. The anamnestic and laboratory diagnostic algorithm presented here is designed to assist a simpler differentiation of the various forms of angioedema and to reach the correct diagnosis more quickly.

Analysis of SERPING1 expression on hereditary angioedema patients: quantitative analysis of full-length and exon 3 splicing variants.

Hereditary angioedema (HAE) due to C1-inhibitor (C1-Inh) deficiency is an autosomal dominant disease caused by mutations in the SERPING1 locus. According to protein levels in plasma, two HAE phenotypes have been described: Type I, with low circulating protein levels in plasma, and Type II, where the protein is present but dysfunctional. Although more than 200 mutations have been described to date, studies on the molecular basis of this autosomic dominant trait are scarce. Previous studies demonstrated that C1-Inh mRNA expression was decreased in HAE patients. Herein, we have confirmed these findings in a large series of Spanish patients. Moreover, when our data were analyzed taking into account the type of mutation carried by the patient (i.e., missense, frameshift,…), significant differences were amongst the control, nonsense and splicing mutations groups (P<0.05). By opposite, no differences in C1-Inh mRNA expression were found between the control and HAE Type II groups, nor between treated and untreated patients groups, although a significant difference was observed between controls and untreated HAE Type I patients. An alternative splicing event has been described in the SERPING1 locus resulting in two different transcripts: the full-length and a shorter variant with skipping of exon 3. In order to investigate a possible role for this splicing in HAE, we quantified both mRNA variants in a series of 28 patients. No statistical differences were found in the expression of both variants between controls and patients when compared. However, a separate analysis considering each type of mutation evidenced a significant decrease (P: 0.0156) in the expression of the exon 3 skipping variant in those HAE Type I patients carrying nonsense mutations. Besides, median of the full variant's copy number was statistically decreased on the splicing group when compared with either stop and/or missense groups. The results of these studies provide new data about C1 inhibitor expression in HAE patients and shed more light on the transcriptional regulation of the SERPING1 locus. Quantitative analysis of splicing variants could help to determine the eventual variations of these two transcripts and their possible role under inflammatory stimuli.

Hereditary angioedema with normal C1 inhibitor function: consensus of an international expert panel.

A new form of hereditary angioedema (HAE) with normal C1 inhibitor (C1INH) was first described in 2000. The lack of clear diagnostic criteria, the heterogeneity among affected patients, and the varying names given to this disease have led to substantial confusion among both physicians and patients. This study was designed to bring more clarity to the diagnosis and potential treatment of HAE with normal C1INH. An international symposium of experts was convened to review the field and develop consensus opinions that could help clinicians who evaluate and manage these patients. Criteria were developed for the diagnosis of HAE with normal C1INH in patients with recurrent angioedema in the absence of concurrent urticaria. In addition, potential therapeutic strategies are discussed. The consensus criteria developed during this symposium will allow physicians to better diagnose and treat patients with HAE with normal C1INH.

[Hereditary angioedema]. / Perinnöllinen angioödeema.

Hereditary angioedema (HAE) is a rare autosomal dominant disease characterized by episodic swelling of the face, extremities, larynx, gastrointestinal tract or genitals. Three different subtypes have been identified so far. Type I and II HAE are caused by mutations in the C1 inhibitor gene leading to decreased or dysfunctional C1 inhibitor, respectively. Type III is caused by a mutation in the coagulation factor XII. In addition, acquired forms or forms with no known etiology exist. Increased bradykinin production leading to increased vessel permeability is common to all HAE types. Treatment of HAE has evolved dramatically during the last years as self-administration of C1 inhibitor concentrate and bradykinin-2 receptor antagonist icatibant have become available.

[National prevalence survey of hereditary angioedema in Japan].

BACKGROUND: The prevalence of hereditary angioedema (HAE) is estimated to be approximately 1 case per 50000 persons in English literatures. However, neither disease prevalence nor epidemiologic features of HAE has been surveyed in Japan. METHODS: A nation-wide prevalence survey of HAE in Japan was conducted in 2009. We mailed questionnaires to hospitals with 200 or more beds (1389 hospitals and 5240 departments including Dermatology, Otolaryngology, Emergency Medical Care, Internal Medicine, Pulmonary Medicine, Allergy & Rheumatology), to ask numbers, disease types, symptoms and treatments of angioedema of patients visited to their hospitals. RESULTS: In total, 1128 replies were obtained and 411 patients of angioedema including 52 HAE type1 or type2 patients were reported. In the HAE type1 or type2 patients, 54% patients have experienced cutaneous swelling on face, 42% patients have experienced throat discomfort and 37% had experienced abdominal symptoms. In acute attacks of HAE, 29% patients had been treated with C1-inhibitor concentrates. CONCLUSION: The prevalence of HAE in Japan may be lower than the estimated prevalence mainly in Europe and North America. Many patients with HAE may not be appropriately treated especially for their acute attacks. Further studies by genomic analysis should be performed to reveal the penetrance of the C1 inhibitor gene deficiency and occurrence of HAE type3 in Japan.

Hereditary angioedema: classification, pathogenesis, and diagnosis.

Hereditary angioedema (HAE) is a rare autosomal dominant genetic disorder associated with a deficiency in C1 inhibitor. More than 200 mutations in this gene, located on chromosome 11, have been identified. Although HAE is often inherited, 20-25% of cases are from new spontaneous mutations and they have no family history of swelling. Decreased C1 inhibitor activity leads to inappropriate activation of multiple pathways, including the complement and contact systems and the fibrinolysis and coagulation systems. Reduced C1 inhibitor activity results in increased activation of plasma kallikrein-kinin system proteases and increased bradykinin levels. Bradykinin is felt to be the main mediator of symptoms in HAE. Patients with HAE have recurrent episodes of swelling of the extremities, abdomen, face, and upper airway. Angioedema involving the gastrointestinal tract can lead to intestinal wall edema, which results in abdominal pain, nausea, vomiting, and diarrhea. Laryngeal swelling is life-threatening and may lead to asphyxia. Common triggers of an attack include trauma, stress, infection, menstruation, oral contraceptives, hormone replacement therapy, and angiotensin-converting enzyme inhibitors. Laboratory testing including C4, C1 inhibitor level, and function is needed to confirm or rule out the diagnosis of HAE. The treatment of HAE has improved significantly in recent years with the availability of several safe and effective therapies. Several consensus guidelines have been created to further assist in the management of HAE patients. This review will provide an update on the classification, pathophysiology, clinical presentation, and diagnosis of HAE.

[Hereditary angioedema--neglected diagnosis]. / Hereditární angioedem--opomíjená diagnóza.

Hereditary angioedema caused by C1 esterase inhibitor deficiency is a rare autosomal dominant inherited disorder. It is characterized by recurrent episodes of potentially life-threatening swellings without itching localized in the dermis and submucosa. We report a case of 41 years old woman with hereditary angioedema manifested as episodes of localized skin swellings and painful gastrointestinal colics. This report underlines the fact that hereditary angioedema is underdiagnosed in differential diagnoses. If hereditary angioedema is correctly diagnosed, effective treatment highly improving patients' quality of life is available.

New insights into hereditary angio-oedema: Molecular diagnosis and therapy.

Hereditary angio-oedema (HAE) is a rare but potentially life-threatening condition. Three types are now recognized. Types I and II HAE involve mutations in the C1NH (SERPING1) gene, encoding the C1 inhibitor protein, whereas type III HAE involves mutations in the F12 gene, encoding coagulation factor XII (Hageman factor). They share a common final pathway leading to increased bradykinin formation. HAE must be distinguished from acquired angio-oedema with C1 esterase inhibitor deficiency, angiotensin-converting enzyme inhibitor-induced angio-oedema and the much more common histaminergic angio-oedema, occurring with or without weals. Understanding the pathogenesis of HAE is leading to the introduction of new therapies that target the bradykinin receptor or inhibit kallikrein activity, innovations that will hopefully reduce morbidity and mortality in this group of severe genetic disease.

Hereditary angioedema caused by missense mutations in the factor XII gene: clinical features, trigger factors, and therapy.

BACKGROUND: Hereditary angioedema caused by mutations in the factor XII gene is a recently described disease entity that occurs mainly in women. It differs from hereditary angioedema caused by C1 inhibitor deficiency. OBJECTIVE: To assess the clinical symptoms, factors triggering acute attacks, and treatments of this disease. METHODS: Thirty-five female patients with hereditary angioedema and the factor XII mutations p.Thr309Lys and p.Thr309Arg who came from 13 unrelated families were studied. The observation period was 8.4 years on average (range, 2-26 years). RESULTS: Patients had on average 12.7 +/- 7.9 angioedema attacks per year. Recurrent facial swellings occurred in all patients; skin swellings other than facial, abdominal pain attacks, tongue swellings, and laryngeal edema occurred less frequently. Some factors that triggered angioedema attacks were trauma, physical pressure, and emotional stress. Clinical symptoms started mainly after intake of oral contraceptives (17 women) or pregnancy (3 women). Exacerbation of the symptoms occurred after oral contraceptive use (8 women), pregnancy (7 women), hormone replacement therapy (3 women), intake of angiotensin-converting enzyme inhibitors (2 women), and an angiotensin 1 receptor blocker (1 woman). Effective treatments included C1 inhibitor concentrate for angioedema attacks (6 women) and, for prophylaxis, progesterone (8 women), danazol (2 women), and tranexamic acid (1 woman). No difference between mutation p.Thr309Arg and p.Thr309Lys was found. CONCLUSIONS: Facial swelling is a cardinal symptom of this condition. Estrogens may have a great influence, but this influence is highly variable. Various treatment options are available.