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NORMAL IgG AND IgA LEVELS IN IgM-DEFICIENT PATIENTS: A REVIEW OF 93 CASES
NORMAL IgG AND IgA LEVELS IN IgMDEFICIENT PATIENTS: A REVIEW OF 93 CASES To the Editor: The study by Goldstein and colleagues1 provides great detail on individual cases in which an IgM deficiency was noted in their patients. Although they found that the group average values for IgA and IgG were within the reference ranges at 186 and 937 mg/dL, respectively, for the 36 cases of IgM deficiency extracted from their database of 13,700 patients, a trend toward subnormal values in a subpopulation cannot be completely excluded from the data presented in their article. Therefore, IgG values for each case were graphed herein in relation to the corresponding IgA values; this analysis also included data from 57 other published cases found in Table 2.1 As shown in Figure 1, no definite subpopulations of abnormally low IgG or IgA values were found in IgMdeficient individuals (reference ranges, 694 –1,618 and 81– 463 mg/dL, respectively). The mean (SD) values in this combined group of 93 IgM-deficient cases were 1,230 (512) mg/dL for IgG and 263 (146) mg/dL for IgA. This type of graphic analysis strengthens the conclusion of Goldstein et al1 that their cases truly represent a selective IgM deficiency and do not represent common variable hypogammaglobulinemia or other overlap conditions in which there is a variably low IgM or IgA level as well. MICHAEL ANDREW MEYER, MD SUNY Buffalo School of Medicine Buffalo, NY
REFERENCE 1. Goldstein MF, Goldstein AL, Dunsky EH, Dvorin DJ, Belecanech GA, Shamir K. Selective IgM immunodeficiency: ret-
rospective analysis of 36 adult patients with review of the literature. Ann Allergy Asthma Immunol. 2006;97:717–730.
IS ANGIOEDEMA A CLASS ADVERSE EFFECT OF THE ANGIOTENSIN-CONVERTING ENZYME INHIBITORS? To the Editor: We read with great interest the article by Malde et al1 about the angioedema caused by angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). In this study, none of the 6 patients, whose angioedema was attributed to an ACEI and who then received an ARB, developed recurrent angioedema in more than 8.1 patient-years of follow-up. However, we have reported the case of a 57-year-old white man who was admitted to the hospital because of severe dyspnea due to angioedema.2 The intense swelling of the lips and the tongue did not allow intubation, and emergency tracheotomy was performed to relieve airway obstruction. This patient was treated for hypertension with an ACEI, ramipril (2.5 mg/d), without any adverse effect during the last 3 years. His blood pressure was not well controlled, and a family physician decided to change ramipril to another ACEI, trandolapril (2.0 mg/d). Two days later the patient presented with symptoms of angioedema. This adverse effect is not considered an allergic reaction and can occur after many years of uneventful drug use.3 Many patients do not report mild and self-limited symptoms and continue to receive their drugs. If the diagnosis is missed, recurrent and potentially life-threatening episodes may occur. It must be kept in mind that uneventful treatment with an ACEI does not rule out the occurrence of angioedema with another drug of the same family, a fact that indicates that angioedema may not be a class adverse effect. ASTERIOS KARAGIANNIS, MD KONSTANTINOS TZIOMALOS, MD VASSILIOS G. ATHYROS, MD Second Propedeutic Department of Internal Medicine Medical School, Aristotle University of Thessaloniki Hippokration Hospital Thessaloniki, Greece REFERENCES
Figure 1. IgG vs IgA values for 93 cases of IgM deficiency summarized by Goldstein et al.1
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1. Malde B, Regalado J, Greenberger PA. Investigation of angioedema associated with the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Ann Allergy Asthma Immunol. 2007;98:57– 63. 2. Karagiannis A, Pyrpasopoulou A, Tziomalos K, Florentin M, Athyros V. Angioedema may not be a class side-effect of the angiotensin-converting-enzyme inhibitors. Q J Med. 2006;99: 197–198. 3. Agostoni A, Cicardi M. Drug-induced angioedema without urticaria. Drug Saf. 2001;24:599 – 606.
ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY
REFERENCE 1. Goldstein MF, Goldstein AL, Dunsky EH, Dvorin DJ, Belecanech GA, Shamir K. Selective IgM immunodeficiency: ret-
rospective analysis of 36 adult patients with review of the literature. Ann Allergy Asthma Immunol. 2006;97:717–730.
IS ANGIOEDEMA A CLASS ADVERSE EFFECT OF THE ANGIOTENSIN-CONVERTING ENZYME INHIBITORS? To the Editor: We read with great interest the article by Malde et al1 about the angioedema caused by angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). In this study, none of the 6 patients, whose angioedema was attributed to an ACEI and who then received an ARB, developed recurrent angioedema in more than 8.1 patient-years of follow-up. However, we have reported the case of a 57-year-old white man who was admitted to the hospital because of severe dyspnea due to angioedema.2 The intense swelling of the lips and the tongue did not allow intubation, and emergency tracheotomy was performed to relieve airway obstruction. This patient was treated for hypertension with an ACEI, ramipril (2.5 mg/d), without any adverse effect during the last 3 years. His blood pressure was not well controlled, and a family physician decided to change ramipril to another ACEI, trandolapril (2.0 mg/d). Two days later the patient presented with symptoms of angioedema. This adverse effect is not considered an allergic reaction and can occur after many years of uneventful drug use.3 Many patients do not report mild and self-limited symptoms and continue to receive their drugs. If the diagnosis is missed, recurrent and potentially life-threatening episodes may occur. It must be kept in mind that uneventful treatment with an ACEI does not rule out the occurrence of angioedema with another drug of the same family, a fact that indicates that angioedema may not be a class adverse effect. ASTERIOS KARAGIANNIS, MD KONSTANTINOS TZIOMALOS, MD VASSILIOS G. ATHYROS, MD Second Propedeutic Department of Internal Medicine Medical School, Aristotle University of Thessaloniki Hippokration Hospital Thessaloniki, Greece REFERENCES
Figure 1. IgG vs IgA values for 93 cases of IgM deficiency summarized by Goldstein et al.1
502
1. Malde B, Regalado J, Greenberger PA. Investigation of angioedema associated with the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Ann Allergy Asthma Immunol. 2007;98:57– 63. 2. Karagiannis A, Pyrpasopoulou A, Tziomalos K, Florentin M, Athyros V. Angioedema may not be a class side-effect of the angiotensin-converting-enzyme inhibitors. Q J Med. 2006;99: 197–198. 3. Agostoni A, Cicardi M. Drug-induced angioedema without urticaria. Drug Saf. 2001;24:599 – 606.
ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY