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Diagnosing hereditary angioedema and for monitoring response to therapy
C1 inhibitor (C1-INH) is a multispecific, protease inhibitor that is present in normal human plasma and serum, and which regulates enzymes of the complement, coagulation, fibrinolytic, and kinin-forming systems. The enzymes (proteases) regulated by this protein include the C1r and C1s subunits of the activated first component of complement, activated Hageman factor (factor XIa), kallikrein (Fletcher factor), and plasmin.
A deficiency of functionally active C1-INH may lead to life-threatening angioedema. Two major forms of C1-INH deficiency have been reported: the congenital form, termed hereditary angioedema (HAE), and the acquired form that is associated with a variety of diseases, including lymphoid malignancies.
HAE is characterized by transient but recurrent attacks of nonpruritic swelling of various tissues throughout the body. The symptomatology depends upon the organs involved. Intestinal attacks lead to a diversity of symptoms including pain, cramps, vomiting, and diarrhea. The most frequent cause of death in this disease is airway obstruction secondary to laryngeal edema occurring during an attack. There are 2 types of HAE that can be distinguished biochemically. Patients with the more common type (85% of HAE patients) have low levels of functional C1-INH and C1-INH antigen. Patients with the second form (15% of HAE patients) have low levels of functional C1-INH but normal or increased levels of C1-INH antigen that is dysfunctional.
The variable nature of the symptoms at different time periods during the course of the disease makes it difficult to make a definitive diagnosis based solely on clinical observation.
>67% normal (normal)
41-67% normal (equivocal)
<41% normal (abnormal)
Hereditary angioedema (HAE) can be definitely diagnosed by laboratory tests demonstrating a marked reduction in C1 inhibitor (C1-INH) antigen or abnormally low functional C1-INH levels in a patient's plasma or serum that has normal or elevated antigen.
Nonfunctional results are consistent with HAE.
Patients with current attacks will also have low C2 and C4 levels due to C1 activation and complement consumption.
Patients with acquired C1-INH deficiency have a low C1q in addition to low C1-INH.
No significant cautionary statements
1. Stoppa-Lyonnet D, Tosi M, Laurent J, et al: Altered C1 inhibitor genes in type I hereditary angioedema. N Engl J Med 1987;317:1-6
2. Frigas E: Angioedema with acquired deficiency of the C1 inhibitor: a constellation of syndromes. Mayo Clin Proc 1989;64:1269-1275