Familial hypercholesteremia (FH) is a genetic disorder that is due to LDLR, APOB, and PCSK9 gene mutations resulting in very elevated levels of low-density lipoprotein cholesterol (LDL-C) causing premature cardiovascular disease (1). Lowering LDL-C in these patients is vital to reduce risk of atherosclerotic cardiovascular disease later in life. This is attempted through dietary modification and multimodal pharmaceutical lipid- lowering therapies. In those with recalcitrant elevated LDL-C despite maximal therapy with statins and other LDLC-lowering agents, lipoprotein apheresis (LA) is recommended (2). LA lowers serum LDL-C by selectively filtering the apolipoprotein B-100 (apoB) containing lipoproteins using extracorporeal filtration. The LA system used in this patient was the Kaneka LA-15 with Liposorber columns, which bind ApoB proteins by means of dextran sulfate coated polystyrene beads (the only type of LA columns currently available in the United States) (3).

There is a roughly 0.2 to 0.4% risk of adverse reactions during LA, including nausea, vomiting, and anaphylactoid reactions (i.e. general cutaneous flushing, nausea/vomiting, tongue swelling, lightheadedness, and hypotension) which may be mediated by several different mechanisms, such as dextran-specific IgG, activated complement factors, and elevated levels of bradykinin and/or pro-inflammatory cytokines. (4,5) LA with dextran sulfate coated polystyrene beads has been shown to dramatically increase serum concentration of bradykinin, which likely contribute to systemic angioedema like reactions. Icatibant is a bradykinin B2 receptor antagonist indicated for acute attacks of hereditary angioedema, but in case reports has been used to also block systemic reactions from LA (6,7). We describe the first case, to the best of our knowledge, of successful icatibant treatment of systemic reactions to LA after recovery from COVID-19. Written informed consent was obtained from the subject for the publication of this case report.