|
|
|
Overview |
|
|
Definition |
|
Angioedema is a well-circumscribed, nonpitting swelling of the subcutaneous
tissues of the skin and mucosa, which is typically nonpruritic. Sites of
involvement include eyelids, lips, tongue, larynx, palms, soles, genitalia, and
gastrointestinal tract. The condition results from the activity of inflammatory
mediators that cause dilation and enhanced permeability of venules and
capillaries. Sources of these inflammatory mediators include:
- Increased activity of the kinin pathway
- Abnormalities of complement metabolism
- Activation of mast cells in the dermis
The latter is typically associated with urticaria and pruritis. Angioedema
may be distinguished clinically from other types of edema (e.g., congestive
heart failure, hypoalbuminemia) by the rapidity of onset (minutes to hours) and
by a distribution that is asymmetric and not localized to dependent areas of the
body.
Both acquired and inherited forms of the illness exist. Acquired angioedema
(AAE) may be acute or chronic (longer than 6 weeks in duration) whereas
hereditary angioedema (HAE) is typically chronic and recurrent. Acute AAE is
reported to occur in approximately 10% to 20% of the population, while HAE is
reported to occur in approximately 0.01% of the population. However, the
frequency of angioedema is likely higher than reported because of the
self-limited nature of most attacks. |
|
|
Etiology |
|
HAE
Hereditary angioedema is an autosomal dominant disorder caused by
abnormalities in the amount or function of C1 inhibitor (C1
INH)—a plasma protein that degrades the first component
of the complement cascade, thereby preventing excessive complement activation.
- Type I HAE results from insufficient production of C1 INH, leading to
decreased or absent levels of this protein (85% of cases). It is the most
commonly identified genetic defect of the complement system.
- Type II HAE is caused by a dysfunctional C1 INH protein; C1 INH levels
are normal or elevated.
AAE
Acute AAE has a number of causes including:
- IgE-mediated mast cell activation due to exposure to: various foods
(e.g., fish, nuts); naturally occurring dyes (e.g., annatto, carmine); contact
lens solution (papain enzyme—also found in meat
tenderizer and used to clarify beer); radiocontrast dyes (may also lead to
angioedema through nonimmunologic mechanisms as well); insect venom; pollen;
cold (e.g., in association with cold-induced urticaria)
- Treatment with angiotensin-converting enzyme (ACE) inhibitors, which
results in decreased degradation of bradykinin, a potent vasodilator. This
adverse drug reaction occurs in 0.1% to 0.2% of patients, generally within 1
hour to 1 week of exposure, but possibly months to years following start of this
medication; lingual swelling common
- Other drugs (e.g., nonsteroidal anti-inflammatory drugs including
aspirin and indomethacin)
- Idiopathic
Chronic and recurrent AAE results from an acquired deficiency of C1 INH.
Although both sexes and all ages may be affected, this form of angioedema
typically occurs in women aged 40 to 50 years. The average duration of the
illness is 5 years, though cases lasting up to 20 years have been reported.
Specific causes of chronic AAE include:
- B-cell lymphoproliferative disorders (e.g., leukemia, Hodgkin's) that
may be associated with excessive complement activation resulting in consumption
of C1 INH (AAE may precede diagnosis of one of these disorders.)
- Benign oligoclonal or monocolonal gammopathies with autoantibodies to
C1 INH—rare
- Connective tissue disorders (primarily SLE)
- Angioedema-eosinophilia syndrome (also known as episodic with
eosinophilia)— rare, non-life-threatening
- Idiopathic
|
|
|
Risk Factors |
|
- Trauma, even minor
- Sudden temperature change
- Intense physical exercise
- Dental procedures/oropharyngeal instrumentation
- Stress/anxiety
- Puberty and menses—increased disease activity
- Anaphylaxis
- ACE inhibitors—avoid in people with history
of angioedema, regardless of cause
- Cystic ovaries—women with HAE often have
cystic ovaries
|
|
|
Signs and Symptoms |
|
- Subcutaneous and submucosal edema—burning,
painful, tensely swollen, typically nonpruritic; progresses in 24 to 48 hours,
regresses in <72 hours
- Dyspnea, hoarseness
- Throat tightness
- Upper airway—buccal, lingual, then
oropharyngeal edema that does not extend below the larynx; airway obstruction
- Gastrointestinal—anorexia, vomiting,
abdominal pain, diarrhea with resolution; more common with HAE
- Cutaneous lesions—extremities, face,
genitalia most common; mottling or faint rash
- Conjunctival or periorbital edema
- Angioedema-eosinophilia syndrome—urticaria,
pruritus, fever, myalgias, oliguria, weight gain, leukocytosis
|
|
|
Differential
Diagnosis |
|
- Anaphylaxis
- Urticaria
- Periorbital cellulitis
- Contact sensitivities
- Atopic dermatitis
- Cutaneous or systemic mastocytosis
- Alcoholism
- Foreign body in airway
- Myocardial infarction
- Brain stem infarct or
ischemia
|
|
|
Diagnosis |
|
|
Physical Examination |
|
Tight, swollen skin may be apparent at site. Abdominal rigidity or guarding
occurs with gastrointestinal involvement. |
|
|
Laboratory Tests |
|
- Urinalysis to check for increased excretion of histamine
HAE Type I
Serum C4 is chronically, profoundly low (best diagnostic test). If low, the
following tests should be performed:
- C1 INH assay—low levels or absence confirms
diagnosis
- 15% to 20% of patients will have normal or increased C1 INH levels; in
these cases functional assays should be decreased
- Other complement proteins: C2 low (especially during an attack), C1,
C3, and C5 normal or near normal
HAE Type II
- C1 INH decreased function
- Antigenic C1 INH protein is normal or elevated
AAE
- C1 protein depression—distinguishes it from
HAE
- Anti-C1 antibodies
- Diminished C1 INH accompanied by low levels of C1q, CH50,
C1, C2, C3, and C4 activity
- Angioedema-eosinophilia syndrome—elevated WBC
count, predominance of eosinophils; skin biopsy reveals perivascular CD4+ T
lymphocyte infiltration
|
|
|
Pathology/Pathophysiology |
|
HAE
- Edema of bowel wall, luminal narrowing and possibly
obstruction
|
|
|
Treatment Options |
|
|
Treatment Strategy |
|
During an attack, the first priority is to ensure patency of airway; CPR and
transportation to an emergency facility may be necessary. Remove all known or
potentially offending agents. In the case of laryngeal edema, tracheostomy
should be performed. Between attacks, some patients require chronic maintenance
therapy, while others with infrequent episodes may elect to manage attacks as
they arise and avoid toxic medications. Most attacks abate within 4 days whether
or not medication is administered. Children are more responsive to treatment
with epinephrine, corticosteroids, or antihistamines than are adults. Following
stabilization and treatment of acute situation, all possible etiologic factors
(e.g., food, drugs) should be identified and eliminated. Long-term management
may require referral to an allergist, dermatologist, or another specialist.
|
|
|
Drug Therapies |
|
HAE
- Epinephrine—for acute attacks (0.3 mL
1:1000); generally poor response; self-administration kits
- Fresh frozen plasma transfusions—necessary
for acute, life-threatening attacks; may be used as prophylaxis as well as
before provocation (2 units 12 to 24 hours before exposure)
- Systemic glucocorticoids
- Vapor-heated infusions of C1 INH
inhibitor—used in acute, life-threatening attacks
although may be used as prophylaxis as well; significantly reduces abdomen and
genitourinary tract symptoms and severity of edema; not widely
available
- Androgens (danazol, 200 to 600 mg/day, or stanozolol, 2 to 5
mg/day)—stimulate C1 INH synthesis by the normal gene,
causing C4 level to return to normal; for chronic maintenance therapy or may be
used 1 week prior to a procedure as prophylaxis; titrate dose to lowest
effective level; potential side effects include menstrual irregularities, weight
gain, muscle cramps, myalgias, and elevated transaminases. Should not be used in
children or during pregnancy.
- Fibrinolysis inhibitors (e.g., aminocaproic acid, tranexamic
acid)—inhibit plasmin, which may activate C1; replace
androgens for children and during pregnancy; can be used for short- and
long-term prophylaxis
AAE
- Epinephrine (see above for dosing) or antihistamines (e.g.,
hydroxyzine)—for acute attacks
- Plasmapheresis; immunosuppressive agents
- Glucocorticoids—for idiopathic;
angioedema-eosinophilia syndrome
- Androgens (see above for dosing and side
effects)—for lymphoproliferative disorders, connective
tissue disorders, autoimmunities
|
|
|
Complementary and Alternative
Therapies |
|
Angioedema may respond favorably to long-term nutritional and herbal support
as prophylaxis. In addition, it may be effective to use herbs and supplements to
alleviate mild symptoms, particularly for chronic and recurrent forms of
angioedema. In an emergency setting, protection of airway remains the top
priority and no new substances, including herbs or supplements, should be
introduced until the person is stable. Dietary intervention, such as the
elimination of inciting foods or food additives, may help reduce or eliminate
recurrent angioedema (Farnam and Grant 1985; Paganelli et al. 1991). If used
prophylactically, homeopathic remedies may be useful in alleviating mild
symptoms and reducing the frequency and severity of episodes.
|
|
|
Nutrition |
|
Oligoallergenic Diet and Other General Dietary Guidelines
As outlined in the section on Etiology, certain foods and food
additives may elicit angioedema in susceptible individuals. In addition, both
immunologic and nonimmunologic mechanisms have been implicated (Farnam and Grant
1985).
- Most food-related angioedema occurs from an IgE-mediated reaction
following ingestion of common inciting agents such as seafood, nuts, legumes
(e.g., peanuts), eggs, chocolate, milk, and berries.
- Direct mast cell degranulation and release of histamine or other
mediators may occur with certain foods, including egg whites, citrus fruits, and
strawberries.
- Food additives such as tartrazine (FD&C yellow dye No. 5) may
cross-react with specific drugs (namely aspirin and other nonsteroidal
anti-inflammatory medications) possibly leading to angioedema.
- Sulfites, used as antioxidant or freshening agents (preservatives) in
many foods and beverages, can cause angioedema in sensitive
individuals.
A detailed history of foods or food preservatives recently added to the diet
(including substances such as gum, toothpaste, vitamins, or laxatives) is
important in the workup of those with suspected food sensitivities. Most
physicians agree that certain clinical and laboratory tests are needed before a
patient can be diagnosed with chronic angioedema. These tests include food
diaries, skin testing, elimination diets, and double-blind food challenges with
suspicious foods (Farnam and Grant 1985). Elimination diets remove suspected
foods or food additives from the diet and symptoms are monitored for
improvement. Special care must be taken with provocation or reintroduction
studies in patients with prior or potential anaphylactic reactions.
As outlined in the section on Signs and Symptoms, persons with
urticaria and angioedema may have variability in presentation and treatment
response. The finding that some patients have increased gastrointestinal
permeability to food antigens may help identify a subgroup of angioedemic
patients who could benefit from an oligoallergenic diet. Gastrointestinal
symptoms, more common with HAE, include anorexia, abdominal pain, nausea,
vomiting, and diarrhea. Elucidating specific pathophysiologic mechanisms in
select groups of patients with different features may help guide future research
and treatments (Paganelli et al. 1991).
Flavonoids
- Quercetin (a naturally occurring flavonoid), 200 to 400 mg tid before
meals, has been used clinically for prevention of allergic reactions such as
angioedema because of its ability to modify IgE-mediated reactions by inhibiting
mast cell degranulation.
- Citrus-based flavonoids, such as rutin, hesperidin, quercitrin
(converted to quercetin in the gastrointestinal tract), and naringin (found in
grapefruit juice), should be avoided in the case of citrus sensitivity and when
taking calcium channel-blockers because the natural substances tend to increase
bioavailability of this class of drugs (Pizzorno and Murray 1999).
|
|
|
Herbs |
|
- Bromelain (a proteolytic enzyme derived from pineapple [Ananas
comosus]), 80 to 320 mg tid, has been used clinically because of its ability
to reduce inflammation by reducing plasma kininogen, thereby inhibiting
production of kinins (Pizzorno and Murray 1999). Some recommend use with
turmeric (Curcuma longa, 250 to 500 mg tid), which may potentiate the
effects.
- Devil's Claw Root. Although not studied for angioedema in particular,
Devil's claw root (Harpagophytum procumbens) is approved by the
Commission E for use as an anti-inflammatory (which may include allergy-based
inflammation) (Blumenthal et al. 2000).
- Ginkgo biloba extract, 120 mg bid of extract standardized to
24% ginkgo flavone glycosides and 6% terpenes, has been used clinically as an
anti-allergenic agent and anti-inflammatory. Monitor carefully with concurrent
use of anticoagulants (Pizzorno and Murray 1999). In rare instances, ginkgo may
cause an allergic reaction, generally confined to the skin (Blumenthal et al.
2000).
- Goldenseal (Hydrastis canadensis), 500 to 2000 mg tid, has been
used clinically for food allergies.
- Licorice root (Glycyrrhiza glabra) is recognized by the World
Health Organization for its traditional use as an anti-inflammatory to treat
allergic reactions. Licorice root is also thought of as an herb that may help
normalize immune function (Blumenthal et al. 2000).
|
|
|
Homeopathy |
|
Apis has been used traditionally for urticaria and angioedema and may
be useful for acute treatment and for prevention of chronic, recurrent cases of
these conditions. Because angioedema has a wide variety of presentations and
causes, an experienced homeopath should be consulted to determine the correct
remedy and potency for each individual case. |
|
|
Acupuncture |
|
Although not confirmed by scientific literature, some clinicians report that
acupuncture may help reestablish overall balance of immune system, thereby
lessening the frequency and severity of allergic responses such as angioedema.
|
|
|
Patient Monitoring |
|
Closely monitor patients for airway obstruction during attacks.
|
|
|
Other
Considerations |
|
|
Prevention |
|
- Wear bracelet identifying condition
- Eliminate known triggers once identified (e.g., ACE inhibitors, foods,
vibratory stimuli); allergy testing with a trained specialist may aid in this
identification
|
|
|
Complications/Sequelae |
|
- Laryngeal edema—major cause of mortality
- May progress to anaphylaxis
|
|
|
Prognosis |
|
- Upper airway obstruction—30% mortality rate
- Idiopathic, autoimmune, episodic with
eosinophilia—good prognosis
|
|
|
Pregnancy |
|
- Hereditary—fewer attacks during pregnancy
- Avoid androgens; use fibrinolysis inhibitors for
prophylaxis
|
|
|
References |
|
Blumenthal M, Goldberg A, Brinckmann J, eds. Herbal Medicine: Expanded
Commission E Monographs. Newton, Mass: Integrative Medicine Communications;
2000:84-87, 160-169, 233-239.
Cicardi M, Bergamaschini L, Cugno M, et al. Pathogenic and clinical aspects
of C1 inhibitor deficiency. Immunobiology. 1998;199(2):366-376.
Farnam J, Grant JA. Angioedema. Dermatol Clin. 1985;3(1):85-95.
Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.
Greaves M, Lawlor F. Angioedema: manifestations and management. J Am Acad
Dermatol. 1991;25(1 pt 2):155-161.
Kumar SA, Martin BL. Urticaria and angioedema: diagnostic and treatment
considerations. J Am Osteopath Assoc. 1999;99:(3 suppl):S1-S4.
Middleton E, ed. Allergy: Principles and Practice. 5th ed. St. Louis,
Mo: Mosby-Year Book; 1998.
Paganelli R, Fagiolo U, Cancian M, Scala E. Intestinal permeability in
patients with chronic urticaria-angioedema with and without arthralgia.Ann
Allergy. 1991;66(2):181-184.
Pizzorno JE Jr, Murray MT. Textbook of Natural Medicine. Vol. 1. 2nd
ed. New York, NY: Churchill Livingstone; 1999:619-623, 746-749, 751-759.
Shah UK, Jacobs IN. Pediatric angioedema: ten years' experience. Arch
Otolaryngol Head Neck Surg. 1999;125(7):791-795.
Wagner WO. Angioedema: frightening and frustrating. Cleve Clin J Med.
1999;66(4):203-205.
Waytes AT, Rosen FS, Frank MM. Treatment of hereditary angioedema with a
vapor-heated C1 inhibitor concentrate. N Engl J Med.
1996;334(25):1630-1634.
Zuraw BL. Urticaria, angioedema, and autoimmunity. Clin Lab Med.
1997;17(3):559-569. |
|
Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |