Introduction
Background
Angioedema is most commonly associated with acquired urticaria. The evaluation and management are similar to those for urticaria. Two distinct syndromes unassociated with urticaria are described below. Both distinct types of acquired angioedema (AAE) without urticaria are characterized by painless, nonpruritic, nonpitting swelling of the skin. They are classified into 2 forms: acquired angioedema type I (AAE-I) and acquired angioedema type II (AAE-II). Acquired angioedema type I is associated with other diseases, most commonly B-cell lymphoproliferative disorders. Acquired angioedema type II is an autoimmune process defined by the presence of an autoantibody directed against the C1 inhibitor molecule (C1-INH).
Pathophysiology
The gene for C1-INH (SERPING1) has been mapped to chromosome 11 (11q12-q13.1). C1-INH is a multifunctional serine protease inhibitor that is normally present in high concentrations in plasma. It is the only plasma inhibitor of C1r and C1s, the activated proteases of the first component of complement. It is also the major plasma inhibitor of activated Hageman factor, the first protease in the contact system. Additionally, C1-INH is one of the major inhibitors of plasma kallikrein, the contact system protease that cleaves kininogen and releases bradykinin.
Presumably, uncontrolled activation of the contact system allows for release of kininlike mediators, resulting in vascular permeability with edema of subcutaneous and mucosal tissues.
Although the issue of which vasoactive peptide is ultimately responsible for these changes remain controversial, direct evidence supports the importance of bradykinin in the clinical manifestations of angioedema. Other kinins may also be pathogenic. The specific trigger responsible for inducing the release of these vasoactive peptides is unclear. Factor XII activation (Hageman factor) may be secondary to phospholipid release from damaged or apoptotic cells and may be important in the generation of bradykinin from endothelial activation. This hypothesis encompasses the role of illness or tissue injury in the generation of bradykinin.
Supporting the importance of bradykinin in acquired angioedema, vascular permeability has been shown to increase in mice deficient in C1-INH, but not in mice with a deficiency in both C1-INH and the bradykinin B2 receptor.1 The precise pathophysiology of acquired angioedema type I remains to be defined. C1-INH levels diminish as a result of its increased catabolism and excessive activation of the classic complement pathway.
Although the current classification of acquired angioedema is being readdressed, in acquired angioedema type I, the associated disorders (usually lymphoproliferative malignancies) produce complement-activating factors, idiotype/anti-idiotype antibodies, or other immune complexes that destroy C1-INH function. Neoplastic lymphatic tissue has been found to play an active role in the consumption of C1-INH and the complement components of the classic pathway. The most commonly associated malignancy, B-cell lymphoma, has shown that anti-idiotypic antibody attached to immunoglobulin on the surface of B-cells causes C1-INH deficiency. Increased consumption of C1q followed by C2 and C4 results in subsequent release of vasoactive peptides that act on postcapillary venules.
In acquired angioedema type II, a normal 105-kd C1-INH molecule is synthesized in adequate amounts, but, because of an unknown event, a subpopulation of B cells secretes autoantibodies to the C1-INH molecule. This autoantibody, which may be any of the major immunoglobulin classes, binds to the reactive center of C1-INH. After binding to C1-INH and altering its structure, its regulatory capacity is diminished or abrogated.
In all reported cases of C1-INH deficiency caused by an autoantibody, C1-INH circulates in the blood in a form that has been cleaved by target proteases from its native molecule to a 95-kd fragment. Because of the higher affinity of the autoantibody for native C1-INH, the 95-kd antibody/C1-INH complex dissociates, and the freed antibody can bind to another native C1-INH molecule, allowing for the further depletion of C1-INH.
The distinction between acquired angioedema type I and acquired angioedema type II may be difficult to make at times and it is imperative to stress that overlap does occur. For instance, cases of monoclonal gammopathy of undetermined significance (MGUS) have shown the monoclonal immunoglobulin itself to be the C1-INH antibody. Regarding malignancies and/or other diseases associated with acquired angioedema type I, it has been demonstrated that these patients may initially present with autoantibodies to C1-INH, or they may develop as the disease progresses.
Frequency
International
Acquired angioedema is rare, with approximately 150 cases reported in the medical literature worldwide.
Mortality/Morbidity
Although mortality may occur because of laryngeal edema, it is more likely due to the complications of the associated disorder.
Race
Presumably, persons of any race can be affected by acquired angioedema.
Sex
Both men and women may be affected by acquired angioedema.
Age
The onset of acquired angioedema is most common after the fourth decade of life, whereas the onset of hereditary acquired angioedema (HAE) is in the second decade.
Clinical
History
- A family history for hereditary angioedema is not obtained, which distinguishes acquired angioedema from hereditary acquired angioedema.
- Regarding angioedema, symptoms are referable to 3 prominent sites: subcutaneous tissues (eg, face, hands, arms, legs, genitals, buttocks); abdominal organs (eg, stomach, intestines, bladder), which may manifest as nausea, vomiting, and/or colicky pain and mimic a surgical emergency; and the upper airway (eg, larynx), which may result in laryngeal edema.
- Occasionally, acquired angioedema patients may experience heat and pain in the affected areas.
- Other symptoms of acquired angioedema may be related to underlying disorders, such as lymphoproliferative malignancies or connective tissue disease.
Physical
- Physical signs of acquired angioedema include overt, noninflammatory swelling of the skin and mucous membranes.
- Although urticaria does not usually occur, occasionally, erythema or mild urticarial eruptions may precede the edema.
Causes
Acquired angioedema type I is most frequently associated with B-cell lymphoproliferative disease. To date, only 2 reports of a T-cell lymphoma associated with acquired angioedema type I have been documented. Other disorders have included multiple myeloma, chronic lymphocytic leukemia, myelofibrosis, Waldenström macroglobulinemia, non-Hodgkin lymphoma, MGUS, rectal carcinoma, essential cryoglobulinemia, erythrocyte sensitization, livedo reticularis, cold urticaria, lupus anticoagulant, and infection with Helicobacter pylori or Echinococcus granulosis.
By definition, acquired angioedema type II is not associated with any specific disorder but rather by the presence of the autoantibody directed against C1-INH. Most of these antibodies work by binding the epitopes around the reactive center of INH.2 However, the occasional existence of features of both acquired angioedema type I and acquired angioedema type II has been noted, most notably with a MGUS.
One case of acquired angioedema with C1-INH deficiency state was identified in association with liver transplantation. The status of the liver donor was unknown, but it is speculated that the donor may have been C1-INH deficient.
Another case of acquired angioedema was reported with acute upper airway angioedema in association with the local anesthetic articaine.
More on Angioedema, Acquired |
 Overview: Angioedema, Acquired |
| Differential Diagnoses & Workup: Angioedema, Acquired |
| Treatment & Medication: Angioedema, Acquired |
| Follow-up: Angioedema, Acquired |
| References |
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Leiden, The Netherlands. Biotech company Pharming Group NV ("Pharming" or "the Company") (NYSE Euronext: PHARM) today announces that, in agreement with the European Medicines Agency (EMEA), the dossier for the European Marketing Authorisation Application (MAA) of Rhucin(R) will be submitted in September 2009. CheckOrphan. Available at http://www.checkorphan.org/news/pharming_confirms_rhucin_european_maa_filing_timeline. Accessed 8/5/2009.
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Further Reading
Keywords
angioedema, acquired angioedema, AAE, Caldwell syndrome, acquired angioedema
