Gi. Kleiner et al., Unmasking of acquired autoimmune C1-inhibitor deficiency by an angiotensin-converting enzyme inhibitor, ANN ALLER A, 86(4), 2001, pp. 461-464
Background: A majority of angioedema arise from unknown etiologies. Angioed
ema may also arise from medications or deficiency of C1-esterase inhibitor
(C1-INH); either of these may lead to recurrent, sometimes life-threatening
attacks of subcutaneous or submucosal edema if the angioedema involves the
tongue, throat, or larynx. We describe a patient with unknown acquired C1-
INH deficiency, who experienced only mild attacks of angioedema before trea
tment with an angiotensin-converting enzyme (ACE) inhibitor. This therapy l
ed to life-threatening respiratory distress.
Objective: To investigate this patient's life-threatening angioedema.
Methods: Serum protein electrophoresis and immunofixation were performed. T
he titer of anti-C1-inhibitor autoantibody was determined by ELISA, and the
specificity of the autoantibody demonstrated by using purified C1-INH to b
lock binding in the ELISA. Finally, fractions from the immunoelectrophoresi
s gel were tested for C1-INH autoantibody by ELISA.
Results: Complement activation was documented by reduced C1-INH, C1q, and C
4, and the patient was found to have an autoantibody of IgG2 isotype specif
ic for C1-INH. After discontinuation of the ACE inhibitor, he continued to
have decreased C1-INH and positive C1-INH autoantibodies.
Conclusions: This case describes a patient who had a history of mild facial
and extremity swelling with abdominal symptoms before ACE inhibitor treatm
ent; this medication resulted in life-threatening respiratory distress. The
use of the ACE inhibitor may have unmasked this patient's acquired autoimm
une CI-INH deficiency.