Anetoderma and its prothrombotic abnormalities

BACKGROUND

Anetoderma is characterized by circumscribed areas of flaccid skin due to the loss of elastic tissue in the dermis. It may be primary or secondary to various dermatoses. The primary form has been reported in association with autoimmune diseases and recently with antiphospholipid antibodies. Its etiology remains unknown.

OBJECTIVES

To analyze clinical and laboratory data from a series of patients with anetoderma referred in our university reference center for connective tissue disorders.

PATIENTS AND METHODS

All the consecutive patients with histologically confirmed anetoderma followed in our clinic from 1996 to 2001 were enrolled in this study. Laboratory investigations included the screening for prothrombotic abnormalities and classical immunological investigations for systemic lupus erythematosus. Clinical and laboratory data were analyzed retrospectively.

RESULTS

Anetoderma was primary in 9 cases and secondary to lupus profundus in 2 cases. Prothrombotic abnormalities were detected in 10 patients (9/9 with primary and 1/2 with secondary anetoderma). Antiphospholipid antibodies were detected in 9 patients. Only 4 patients fulfilled criteria for definite antiphospholipid syndrome which was primary for 3 and associated with systemic lupus erythematosus in the other.

CONCLUSION

Patients with anetoderma should be evaluated for the possible presence of a prothrombotic state and warned of its potential risks when present.

Antiphospholipid antibodies

Antiphospholipid antibodies (APAs) have been associated with thromboembolic events. Since they were fi rst described in 1906, APAs have been the subject of multidisciplinary studies seeking to link them to potential pathophysiologic mechanisms. This review summarizes the different types of APAs, antigenic targets, clinical complications associated with APAs, and APA syndrome. In addition, the currently available methods for laboratory identification of lupus anticoagulants are discussed, as is the laboratory diagnosis of anticardiolipin antibodies.

Antibodies to tissue-type plasminogen activator (tPA) in patients with antiphospholipid syndrome: evidence of interaction between the antibodies and the catalytic domain of tPA in 2 patients

The causes of thrombosis and pregnancy loss in antiphospholipid syndrome (APS) are still unknown, although several hypotheses have been proposed and hypofibrinolysis has been implicated. Anti-tissue-type plasminogen activator (tPA) antibodies may induce fibrinolytic defects and preliminary data indicate an association with thrombosis in APS. We measured plasma anti-tPA antibody levels in 91 consecutive patients with APS, 91 healthy controls, 40 patients with antiphospholipid antibodies without APS symptoms, and 23 patients with systemic lupus erythematosus (SLE) without antiphospholipid antibodies and APS symptoms. Patients with APS had anti-tPA antibody levels higher than controls (P = .0001), patients with SLE (P = .0001), and asymptomatic antiphospholipid patients (P = .05). A subgroup of 53 patients had plasma levels of tPA antigen higher (P = .0001) and tPA activity lower (P = .05) than controls, with an inverse correlation (r = -0.454; P = .003) between anti-tPA antibody levels and tPA activity and no correlation with tPA antigen. The 2 patients with the highest antibody levels had tPA activity below the normal range. Their antibodies were, respectively, IgG1 and IgG3; both recognized human tPA, recombinant tPA, and the catalytic domain of tPA, but not beta 2-glycoprotein I, prothrombin, or plasminogen. Our data indicate that anti-tPA antibodies specifically interacting with the catalytic domain of tPA can be found in patients with APS, representing a possible cause of hypofibrinolysis.

Antiphospholipid/antiprotein antibodies, hemostasis-related autoantibodies, and plasma homocysteine as risk factors for a first early pregnancy loss: a matched case-control study

Maternal hypercoagulability is a possible cause of miscarriage during the eighth and ninth weeks of pregnancy, when the placenta replaces the yolk sac. We thus examined associations between putative markers of an acquired hypercoagulable state and the risk of first miscarriage. We conducted a case-control study comparing 743 women who miscarried in weeks 8 and 9 with 743 women who underwent a first provoked abortion, matched for age, number of pregnancies, and time elapsed since abortion. Levels of plasma homocysteine and of various antiphospholipid/antiprotein and hemostasis-related autoantibodies were categorized in 4 strata (percentiles 1-80, 81-95, 96-99, 100 among control patients) and analyzed in conditional logistic regression models. Pregnancy loss was independently associated with positive lupus anticoagulant (matched odds ratio [OR], 2.6; 95% confidence interval [CI], 1.1-6.0), high levels of immunoglobulin M (IgM) antibodies against cardiolipin (OR for percentile 100 versus 0-80, 3.5; CI, 1.2-10.1) and against phosphatidylethanolamine (OR, 4.7; CI, 1.9-12.1), high levels of IgG antibodies against annexin V (OR, 3.2; CI, 1.1-9.1) and against tissue-type plasminogen activator (OR, 19.5; CI, 7.9-48.0), and high homocystinemia (OR, 4.1; CI, 1.3-12.5). A first early pregnancy loss is associated with increased levels of several autoantibodies and of homocysteine.

[IgM antiphospholipical antibodies in preeclampsia-eclampsia]

BACKGROUND

Antiphospholipid antibodies are associated with thrombocytopenia and fetal loss, and have been reported elevated in patients with preeclampsia-eclampsia. Site: Preeclampsia-Eclampsia Research Unit, Instituto Materno Infantil del Estado de Mexico, Toluca, Mexico and the Specialty Hospital Research Unit, La Raza Medical Center, Mexico City, Mexico.

OBJECTIVE

To determine the presence of anticardiolipin antibodies (IgG-IgM) as markers of acute endothelial damage in patients with preeclampsia.

MATERIAL AND METHODS

A randomized case control study composed of two groups: Group A (cases), 18 patients with preeclampsia-eclampsia and group B (control), 18 normal pregnancies. Antiphospholipid (anticardiolipin) antibodies were determined in both groups in addition to with coagulation tests and clinical variables in mother and newborn in day of admission and nine weeks after obstetrical resolution. We excluded patients with anticoagulant or dialysis therapy, taking NSAIDs or who recently required transfusion or plasmaferesis.

RESULTS

There were significant differences in levels of IgM and in weights and mortality among newborns between the two groups. In terms of maternal complications, we found HELLP syndrome as leading cause. We also observed in the case group significant differences in mean arterial pressure (MAP) and IgM levels between admission day and nine weeks later. Our results lead us to the conclusion that there must be exist immunologic mechanism that induces synthesis of anticardiolipin antibodies (IgM isotype) during acute state of the disease, accounting for vascular changes and prothrombotic state responsible for maternal and neonatal complications.

[Neurological aspects in antiphospholipid syndrome]

Antiphospholipid syndrome is considered to be a cause of an acquired hypercoagulable state leading to stroke and transient ischemic attack. Antiphospholipid antibodies (aPL) comprise a heterogeneous group of autoantibodies. Among them, lupus anticoagulant (LA) and beta 2-glycoprotein I dependent anticardiolipin antibody (beta 2-GPI aCL) are important and commonly measured. Recently, LA has been considered to be closely related to phosphatidylserine anti-prothrombin antibody. APL is an independent risk factor for first-ever ischemic stroke and a prognostic marker of recurrent stroke. The precipitating factors for the occurrence of stroke are the presence of beta 2-GPI-dependent aCL, a GPL aCL level of more than 40, and the simultaneous presence of lupus anticoagulant. Several mechanisms are believed to be involved in the thrombotic process in patients with antiphospholipid antibodies. Human activated protein C functions as a potent anticoagulant in human plasma by inhibiting the activity of coagulation cofactors Va and VIIIa. Activation of protein C is impaired in patients with aPL. Recently, the presence of aPL has been considered to be contributory factor for the development of atherosclerotic lesions. Transgenic mouse lacking the LDL receptor develop accelerated arteriosclerosis upon immunization with beta 2-GPL Several therapeutic options are available for the prevention of ischemic stroke in patients with aPL, such as antiplatelet, anticoagulant, and immunosuppressive therapy. The rate of recurrence in patients undergoing antiplatelet and anticoagulation combination therapy was found to be lower than that in patients receiving other forms of therapy. The WARSS-APASS collaborative study showed that there was no difference in the recurrence rate between aPL patients receiving antiplatelet or anticoagulation therapy alone. APL has been investigated in other neurological disorders such as multiple sclerosis, chorea, migraine and convulsion. The association of aPL with multiple sclerosis remains debatable. APL could be a contributory factor for the development of convulsion, but not for migraine.

[Antiphospholipid syndrome updating]

The antiphospholipid syndrome (APS) was defined 20 years ago by Hughes as a thrombosis (arterial and/or venous) state and/or recurrent pregnancy loss in the presence of antiphospholipid antibodies like lupic anticoagulant and/or anticardiolipin, which sometimes coexist with thrombocytopenia. Although the prevalence of APS is estimated to be 3 to 200 cases per 100,000 inhabitants, many cases remain without a proper diagnosis. Recurrent thrombosis events can happen at any site in the vascular tree, yet most common affected sites are deep veins and cerebral arteries. As a result of its vast and protean manifestations, APS is currently being dealt with by most medical specialties. But despite research advances and improvements in its knowledge, many features of this syndrome such as its etiology and pathophysiology are not well understood yet. Standard therapy for vascular and obstetric problems is difficult because of the absence of evidence-based guidance and continues to be based on antiplatelet and anticoagulation drugs. Yet some authors claim individual treatments according to the risk of thrombosis or fetal loss. In this review we offer, through an extensive bibliographical search of the subject over the last 2 years, a view of the state-of-the-art of APS including current criteria for diagnosis, molecular basis, main associated clinical manifestations, management and treatment.

A comparison of two intensities of warfarin for the prevention of recurrent thrombosis in patients with the antiphospholipid antibody syndrome

BACKGROUND

Many patients with the antiphospholipid antibody syndrome and recurrent thrombosis receive doses of warfarin adjusted to achieve an international normalized ratio (INR) of more than 3.0. However, there are no prospective data to support this approach to thromboprophylaxis.

METHODS

We performed a randomized, double-blind trial in which patients with antiphospholipid antibodies and previous thrombosis were assigned to receive enough warfarin to achieve an INR of 2.0 to 3.0 (moderate intensity) or 3.1 to 4.0 (high intensity). Our objective was to show that high-intensity warfarin was more effective in preventing thrombosis than moderate-intensity warfarin.

RESULTS

A total of 114 patients were enrolled in the study and followed for a mean of 2.7 years. Recurrent thrombosis occurred in 6 of 56 patients (10.7 percent) assigned to receive high-intensity warfarin and in 2 of 58 patients (3.4 percent) assigned to receive moderate-intensity warfarin (hazard ratio for the high-intensity group, 3.1; 95 percent confidence interval, 0.6 to 15.0). Major bleeding occurred in three patients assigned to receive high-intensity warfarin and four patients assigned to receive moderate-intensity warfarin (hazard ratio, 1.0; 95 percent confidence interval, 0.2 to 4.8).

CONCLUSIONS

High-intensity warfarin was not superior to moderate-intensity warfarin for thromboprophylaxis in patients with antiphospholipid antibodies and previous thrombosis. The low rate of recurrent thrombosis among patients in whom the target INR was 2.0 to 3.0 suggests that moderate-intensity warfarin is appropriate for patients with the antiphospholipid antibody syndrome.

The combination of different antiphospholipid antibody subgroups in the sera of patients with autoimmune diseases is a strong predictor for thrombosis. A retrospective study from a single center

OBJECTIVE

[corrected] To determine the distribution of different antiphospholipid antibodies (APL-Ab) and their association with thrombosis in patients with autoimmune diseases.

METHODS

Clinical data and laboratory features of 30 patients with different autoimmune diseases with positive APL-Ab were retrospectively studied for a period of more than two years. Anti-cardiolipin (aCL), anti-phosphatidylserine (aPS) and anti-beta2-glycoprotein I (abeta2-GPI) antibodies were determined by ELISA.

RESULTS

Autoantibodies that target only PS were detected in 53.3% (n = 16) patients, aCL antibodies only were found in one patient (3,3%). In 43.3% (n = 13), aPS were associated with elevated levels of aCL and/or abeta2-GPI antibodies. No thrombotic event occurred in patients with aPS antibodies only compared to 6 patients from the group with different APL-Ab during 808 +/- 92 days of observation.

CONCLUSION

The combination of different antiphospholipid antibody subgroups seems to be a predictor for thrombosis. The presence of aPS antibodies without additional aCL or abeta2-GPI is not associated with thrombosis. The measurement of the APL specificities in addition to the aCL antibodies may be important to develop predictive markers for the risk to develop thrombotic events.

Nodular regenerative hyperplasia (NRH) of the liver--a manifestation of 'organ-specific antiphospholipid syndrome'?

Nodular regenerative hyperplasia (NRH) of the liver is a local hyperplastic response of hepatocytes, probably due to vascular abnormalities. Since it was shown in a few case reports that NRH may be associated with antiphospholipid antibodies (APA) we wanted to analyze the relevance of APA in patients with this disease. Sera from 13 patients with histologically defined NRH were tested for APA by an in-house ELISA using as antigens cardiolipin (CL), beta2-glycoprotein I (beta2-gp I), phosphatidylserine (PS), and thromboplastin (TP), a mixture of different phospholipids and phospholipid-binding proteins. As controls, sera from patients with serologically and histologically defined autoimmune liver diseases (primary biliary cirrhosis n = 14; autoimmune hepatitis n = 14) without histological evidence for NRH as well as from 14 healthy blood donors were analyzed. 77% of the NRH patients had APA. In 46% they were directed against CL. In contrast, only 14% of the patients with autoimmune liver diseases and 14% of the healthy controls had anti-CL antibodies (p < 0,05). Antibodies to beta2-gp I and TP did not discriminate between NRH and autoimmune liver diseases. Anti-PS antibodies were not observed. These data indicate that determination of anti-CL antibodies in NRH may help to identify a subgroup of patients in whom an 'organ-specific antiphosholipid syndrome' of the liver may be involved in the pathogenesis.

Inhibition of ras by farnesylthiosalicylate significantly reduces the levels of autoantibodies in two animal models of the antiphospholipid syndrome

BACKGROUND

Stimulation and proliferation of lymphocytes require activation of Ras. S-farnesylthiosalicylic acid (FTS) is a synthetic substance that detaches Ras from the inner cell membrane and induces its rapid degradation. Antiphospholipid antibodies (aPL) are a heterogeneous group of antibodies detected in patients with antiphospholipid syndrome (APS), which is associated with thrombosis, pregnancy losses, and thrombocytopenia.

OBJECTIVE

To examine the effect of FTS treatment on aPL levels in a genetic autoimmune model (the MRL/lpr mice) and in an induced model of APS.

METHODS

Female Balb/C mice immunized once with beta2-glycoprotein I (beta2-GPI) in complete Freund's adjuvant (CFA) and female MRL/lpr mice were treated intraperitoneally with either FTS (5 mg/Kg/day) or saline 3-5 times a week. aPL and anti-beta2-GPI antibodies were measured by ELISA.

RESULTS

FTS treatment 3 times a week resulted in significant decreases of aPL and anti-beta2-GPI antibodies in both animal models. In contrast, more frequent treatment (5 times a week) had no significant effect on autantibody levels in both animal models. We further compared 2 protocols in the induced APS model, one for alternate day treatment and the other for daily treatment on the first 3 days each week, and found a decrease in autoantibody levels only in the alternate day protocol.

CONCLUSIONS

Inhibition of Ras activation by FTS is effective in decreasing autoantibody levels in models of APS. The differential modulation of immune function by alternate day compared to daily treatment may provide better understanding of the role of Ras activation in this system.

Frequency and specificities of antiphospholipid antibodies (aPL) in volunteer blood donors

In the State of Indiana, blood donors are screened by a written questionnaire prior to donation to identify potential exposures to infectious diseases and to assess medications. The potential donor is not asked about aPL-related events. Animal experiments have shown, however, that passive transfer of aPL can produce aPL-associated pathology in the recipient. We determined the incidence of antiphospholipid antibodies (aPL) in 775 volunteer blood donors in Indiana. Tubing segments containing 2 ml of anticoagulated blood were obtained from donor units. The average donor age was 43 years (range 17-82); 45% were female. Our in-house aPL ELISA tested for IgG, IgA and IgM to cardiolipin (aCL), phosphatidylserine (aPS), phosphatidylethanolamine (aPE) and phosphatidylcholine (aPC). The plasmas were tested with and without supplemental phospholipid (PL)-binding plasma proteins from adult bovine plasma (ABP). A total of 24 tests were performed for each donor. Normal ranges were determined for 98% of the donors by calculating multiples of the means (MoM) of OD values for each antigen-isotype combination. No decimals were used, all MoMs were rounded up to the next whole number. An additional two MoMs were added to the calculated cutoff values to eliminate borderline positive values. Results revealed that 63 (8.1 %) donors had positive findings for one or more aPL. The relatively high number of aPL-positive individuals reflects the observation that different donors were often in the highest 2% of each antigen-isotype combination tested. The aPL specificities, isotypes, and PL-binding protein dependence are summarized in this report.

Antinuclear Antibody Reduces the Pregnancy Rate in the First IVF-ET Treatment Cycle but Not the Cumulative Pregnancy Rate without Specific Medication

PROBLEM

It has been shown that the presence of antinuclear antibody (ANA) might reduce pregnancy rates after in vitro fertilization-embryo transfer (IVF-ET). However, the mechanism of implantation failure by ANA has not yet been clarified. This study was performed to investigate the impact of ANA on pregnancy rates after IVF-ET, and the necessity of specific medication for infertile women who have ANA in their sera.

METHOD OF STUDY

A total of 108 infertile women were treated by IVF-ET or intracytoplasmic sperm injection (ICSI)-ET. ANA was examined by an indirect fluorescent antibody procedure. Data from women under 40 years old were analyzed retrospectively.

RESULTS

The implantation rates per embryo transferred in the first treatment cycles were 14.8% (eight of 54) and 32.4% (33 of 102), in women with and without ANA, respectively. There was a significant difference in the implantation rates between the two groups (P < 0.05). The pregnancy rates per ET in the first treatment cycles were 28% (seven of 25) and 54.2% (26 of 48), respectively. There was also a significant difference in the pregnancy rates between the two groups (P < 0.05). Afterwards, treatments with IVF-ET or ICSI-ET were repeatedly performed for unsuccessful patients, without any specific medication for ANA. The average ET cycles were 1.80 +/- 1.13 and 1.27 +/- 0.54, in women with and without ANA, respectively. The cumulative pregnancy rates per patient were 68% (17 of 25) and 55.6% (35 of 63), respectively. There was no significant difference in the overall pregnancy rates between the two groups.

CONCLUSIONS

These findings suggest that ANA might have an impact on implantation failure in women treated by IVF-ET or ICSI-ET. ANA reduced the pregnancy rates in the first IVF-ET or ICSI-ET cycles but not the cumulative pregnancy rates without medication. This indicates that the mechanisms of implantation failure by ANA could be solved, and effective and safe medication should be developed for better implantation rates, especially in the first treatment cycle.

Inhibition of annexin V binding to cardiolipin and thrombin generation in an unselected population with venous thrombosis

OBJECTIVE

To examine the effect on annexin V binding to cardiolipin (CL) and in vitro thrombin generation by plasma samples from an unselected population of patients with confirmed venous thrombosis and matched controls. The prevalence of autoimmune antiphospholipid antibodies (aPL) was also determined.

METHODS

A total of 111 patients who presented to a single emergency room with symptoms suggestive of venous thromboembolic (VTE) disease were studied. In 34 patients the diagnosis of lower limb deep venous thrombosis (DVT) and/or pulmonary embolus (PE) was confirmed (VTE+ group). In the remaining 77 patients the diagnostic workup was negative (VTE- group). Plasma samples were collected prior to the initiation of anticoagulation and examined for IgG anticardiolipin (aCL), IgG anti-beta2-glycoprotein I (GPI), and IgG anti-prothrombin (aPT antibodies) by ELISA. In addition, the effect of individual patient and control plasma samples on annexin V binding to CL and on in vitro thrombin generation was determined by a competitive ELISA and a chromogenic assay, respectively.

RESULTS

The prevalence and levels of IgG aCL, anti-beta2-GPI, and aPT antibodies were similar in the VTE+ and VTE- groups. However, plasma samples from the VTE+ group caused a significant inhibition of in vitro thrombin generation (mean +/- SD Z score: -0.66 +/- 0.97 vs 0.26 +/- 1.46; p < 0.001) and a concurrent but less impressive inhibition of annexin V binding to CL (mean +/- SD Z score: -2.53 +/- 1.44 vs -2.05 +/- 1.61; p = 0.123). Upon analyzing a panel of clinical and laboratory variables, only age and inhibition of thrombin generation were significantly associated with VTE disease.

CONCLUSION

Our findings suggest that subtle abnormalities in annexin V physiology may contribute to the procoagulant state in patients with idiopathic venous thrombosis.

Antiphospholipid antibodies and ischemic neuropathy following cardiac surgery

Sciatic nerve palsy is an uncommon complication of cardiac surgery and is thought to be induced by a combination of reduced femoral artery blood flow, small vessel vascular disease or prolonged hypoxia. We here describe a new case which is the first described with transient elevation of antiphospholipid antibodies. Although transient elevation of lupus coagulation inhibitor is known to occur frequently in patients treated in an intensive care unit, there are very few data about the possible role of antiphospholipid antibodies in the generation of ischemic neuropathies. We can not prove that the ischemic neuropathy in our case has been favored by the presence of lupus coagulation inhibitor and antiphospholipid antibodies as the occurrence of the symptoms seemed to precede the transient elevation of lupus coagulation inhibitor. This case suggests that antiphospholipid antibodies and lupus coagulation inhibitor should be included in the work up of patients who present nerve damage after cardiac surgery but further studies are needed to ascertain this association.

Transient lupus anticoagulant: an unusual cause of bruising in children

A child presented with excessive bruising and prolonged activated partial thromboplastin time. Mixing studies in plasma were positive for phospholipid dependence of the anticoagulant, confirming a diagnosis of lupus anticoagulant. Factor II level was reduced. Laboratory findings normalised after three months, with spontaneous resolution of bruising. This case demonstrates a transient antiphospholipid antibody syndrome as a rare presentation of bleeding diathesis in a previously healthy child, and should be considered in children with new onset bruising and prolonged activated partial thromboplastin time.

[Catastrophic antiphospholipid syndrome in the immediate puerperium]

We describe a female previously diagnosed of primary antiphospholipid antibody syndrome who presented a preclampsia in the second pregnancy. An urgent caesaria was made because of a worsening high blood pressure and oliguria. In the immediated puerperium she showed low platelets and persistent high blood pressure. Afterwards acute renal failure and neurological signs with a severe aortic valvulopathy were diagnosed. An haemolytic anemia was also detected. Definitive diagnosis was made by kidney biopsy with the result of a thrombotic microangiopathy. Treatment with low weight heparin and aspirin and systemic corticosteroids was started in the immediate puerperium and fresh frozen plasma was then added with a good response to treatment. Actually she is still with high blood pressure, aortic valvulopathy. Renal function is normal one year later.

Factor XII deficiency is strongly associated with primary recurrent abortions

OBJECTIVE

To evaluate factor XII deficiency in women with primary and secondary recurrent abortion.

DESIGN

Prospective case-control study.

SETTING

University hospital.

PATIENT(S)

Sixty-seven women with primary and 33 women with secondary recurrent abortion of unexplained nature and 49 healthy controls with no history of thrombotic disease or adverse pregnancy outcomes. MAIL OUTCOME MEASURE(S): Plasma factor XII activity, activated protein C resistance, factor V Leiden mutation analysis, protein C, protein S, antithrombin III, karyotyping, and anticardiolipin antibodies.

RESULT(S)

Ten of 67 women with primary recurrent abortion (14.9%) and 4 of 33 women (12.1%) with secondary recurrent abortion had reduced factor XII activity (<60%). These results are highly significant in the former group and showed a tendency toward significance in the latter group. All controls had normal factor XII activity.

CONCLUSION(S)

Factor XII deficiency is strongly associated with primary recurrent abortion, and women with secondary recurrent abortion show a tendency toward factor XII deficiency.

[Infective endocarditis with a huge mitral vegetation related to atopic dermatitis and high serum level of infection-related antiphospholipid antibody: a case report]

A 24-year-old woman with atopic dermatitis was admitted to our hospital with fever. Echocardiography showed a huge vegetation attached to the posterior mitral commissure without mitral valve dysfunction. Blood culture identified methicillin-sensitive Staphylococcus aureus. The serum level of antiphospholipid antibody was elevated. A splenic infarction occurred on the second hospital day. Surgery to resect the residual mobile vegetation was performed uneventfully on the 6th hospital day. The postoperative course was uneventful, and the patient was discharged after 4 weeks of antibiotic therapy. Preservation of the mitral valve is rare in the face of virulent Staphylococcus infection and the presence of a huge mobile vegetation. These findings were apparently related to the high serum level of infection-related antiphospholipid antibody and atopic dermatitis.