[Catastrophic antiphospholipid syndrome during pregnancy]

Antiphospholipid syndrome (APS) had been previously diagnosed in three pregnant women aged 32, 27 and 36 years, respectively. All three of them were using low-molecular weight heparin for the prevention of thromboembolic complications. The first two women were admitted because of foetal growth retardation. In the first patient, either HELLP syndrome or exacerbation of APS was suspected. A caesarean section was performed due to foetal distress. The patient's condition deteriorated further postoperatively. Multiple infarctions in liver and placenta were identified. Catastrophic antiphospholipid syndrome (CAPS) was diagnosed. Despite intensive medical treatment including anticoagulation the patient died of massive pulmonary embolism. The second patient suffered from thrombocytopaenia, disturbances in hepatic function and epigastric pain. CAPS was diagnosed. The condition improved after treatment with glucocorticoids, but because of a poor foetal prognosis, delivery was induced and a lifeless son was born. The third woman was admitted due to pyelonephritis. Shortly thereafter, symptoms of HELLP syndrome developed and she was administered glucocorticoids. Hepatic infarcts and petechiae developed, indicating CAPS. Delivery was induced and a girl was born. Glucocorticoid treatment was resumed and combined with immunoglobulins and plasmapheresis. The patient recovered and was discharged together with her daughter. CAPS is a life-threatening variation of APS. It is characterised by multiple thromboses and rapidly progressive multi-organ failure. Mortality is high, but seems to diminish with treatment by immunosuppressive therapy. In pregnancy, clinical signs of CAPS are similar to those of HELLP syndrome. Since the treatment for HELLP syndrome is different from CAPS, a correct diagnosis is essential. Because of the rarity of this condition in combination with high rates of perinatal and maternal mortality, care for pregnant patients with APS should be centralised in academic centres and close cooperation between obstetricians and internal medicine is necessary.

Second-impact syndrome and a small subdural hematoma: an uncommon catastrophic result of repetitive head injury with a characteristic imaging appearance

There have been a handful of previously published cases of athletes who were still symptomatic from a prior head injury, and then suffered a second injury in which a thin, acute subdural hematoma (SDH) with unilateral hemisphere vascular engorgement was demonstrated on CT scan. In those cases, the cause of the brain swelling/dysautoregulation was ascribed to the presence of the acute SDH rather than to the acceleration/deceleration forces that caused the SDH. We believe that the brain swelling is due to "second-impact dysautoregulation," rather than due to the effect of the SDH on the underlying hemisphere. To support our hypothesis, we present 10 additional cases of acute hemispheric swelling in association with small SDHs in athletes who received a second head injury while still symptomatic from a previous head injury. The clinical history and the unique neuroimaging features of this entity on CT are described and illustrated in detail. The CT findings included an engorged cerebral hemisphere with initial preservation of grey-white matter differentiation, and abnormal mass effect and midline shift that appeared disproportionately greater than the size of the SDH. In addition, the imaging similarities between our patients and those with non-accidental head trauma (shaken-baby syndrome) will be discussed.

Update on the diagnosis, treatment, and prognosis of the catastrophic antiphospholipid syndrome

The catastrophic antiphospholipid syndrome (APS) is a potentially life-threatening condition, the diagnosis of which requires a high degree of clinical awareness on the part of attending physicians. Patients with APS present with 1) clinical evidence of multiple organ involvement developed over a very short time; 2) histopathologic evidence of multiple small-vessel occlusions; and 3) laboratory confirmation of the presence of antiphospholipid antibodies, usually in high titer. A combination of anticoagulants, corticosteroids, intravenous immunoglobulins, and plasma exchanges is the basic treatment for all patients with this severe condition. Unfortunately, despite current therapies, the mortality rate is still high (around 30%). However, once patients with catastrophic APS have recovered, they usually follow a stable course with continued anticoagulation and few patients present with a relapse of the catastrophic episode.

Catastrophic calciphylaxis in a patient with lupus nephritis and recent onset of end-stage renal disease

Painful violaceous skin lesions that progress to non-healing ulceration and gangrene characterize calciphylaxis. These lesions are associated with secondary hyperparathyroidism and generally occur in patients on dialysis for more than one year. Hyperphosphatemia and hypoalbuminemia are the major risk factors for calciphylaxis. It is usually resistant to medical treatment although parathyroidectomy can help in controlling the disease. The mortality rate of calciphylaxis is very high due to uncontrollable sepsis. In our case, a young female with systemic lupus erythematosus (SLE) developed calciphylaxis within a short period after the onset of hemodialysis; she had a short period of hyperphosphatemia prior to dialysis. The serum phosphate was 4.24 mmol/L, calcium was 1.66 mmol/L, parathormone was 38 and calcium-phosphate was 7.0 mmol/L. It is likely that SLE provoked the development of calciphylaxis. The patient was treated medically but unfortunately died secondary to sepsis.

Clinical course of high-risk patients diagnosed with antiphospholipid syndrome

BACKGROUND

The characteristics and the clinical course of antiphospholipid syndrome (APS) in high-risk patients that are positive for all three recommended tests that detect the presence of antiphospholipid (aPL) antibodies have not been described.

METHODS

This retrospective analysis of prospectively collected data examined patients referred to Italian Thrombosis Centers that were diagnosed with definite APS and tested positive for aPL [lupus anticoagulant (LA), anti-cardiolipin (aCL), and anti-beta2-glycoprotein I (beta2GPI) antibodies]. Laboratory data were confirmed in a central reference laboratory.

RESULTS

One hundred and sixty patients were enrolled in this cohort study. The qualifying events at diagnosis were venous thromboembolism (76 cases; 47.5%), arterial thromboembolism (69 cases; 43.1%) and pregnancy morbidity (11 cases; 9.7%). The remaining four patients (2.5%) suffered from catastrophic APS. The cumulative incidence of thromboembolic events in the follow-up period was 12.2% (95% CI, 9.6-14.8) after 1 year, 26.1% (95% CI, 22.3-29.9) after 5 years and 44.2% (95% CI, 38.6-49.8) after 10 years. This was significantly higher in those patients not taking oral anticoagulants as compared with those on treatment (HR=2.4 95% CI 1.3-4.1; P<0.003). Major bleeding associated with oral anticoagulant therapy was low (0.8% patient/years). Ten patients died (seven were cardiovascular deaths).

CONCLUSIONS

Patients with APS and triple positivity for aPL are at high risk of developing future thromboembolic events. Recurrence remains frequent despite the use of oral anticoagulants, which significantly reduces the risk of thromboembolism.

Damage control: cavoatrial anastomosis during a catastrophic right intrapericardial pneumonectomy

While undergoing an intrapericardial pneumonectomy for a massive right pulmonary inflammatory pseudotumor that had invaded the mediastinum, an 18-year-old woman experienced a nearly fatal iatrogenic complication. Dense scarring adjacent to the pseudotumor had drawn in the superior vena cava posterolaterally and fused the right main pulmonary artery to the right superior pulmonary vein within the pericardium. The failure of a linear stapler to secure the pulmonary vessels led to torrential hemorrhage. Attempts to control the bleeding resulted in inadvertent superior vena cava occlusion and central venous pressure elevation. Because cardiopulmonary bypass might not have been reliably established in time to avoid irreversible cerebral ischemia, we borrowed a technique from congenital heart surgery and rapidly fashioned a cavoatrial connection. The patient survived the operation without negative neurologic or cardiac sequelae, recovered fully, and had no recurrence of the pseudotumor. Herein, we describe the intraoperative decisions that were made under intense time pressure to avert catastrophe.

[A case of hemolytic-uremic syndrome with development of catastrophic antiphospholipid syndrome: diagnosis and clinical tactics]

The paper describes a case of practically simultaneous development of the hemolytic-uremic syndrome (HUS) and the catastrophic antiphospholipid syndrome (CAPS) complicated by mesenteric vessel thrombosis and small bowel necrosis. Multimodality treatment comprising volume plasmapheresis, fresh frozen plasma transfusion, hemodialysis, anticoagulant and disaggregant therapy could relieve thrombogenic events, such as pulmonary artery thromboembolism and intestinal necrosis.

Catastrophic right ventricular rupture prevented by coincident coronary artery bypass grafting: the pivotal role of cardiac magnetic resonance imaging

WEB SITE FEATURE

Catastrophic antiphospholipid syndrome presenting as ischemic pancreatitis in systemic lupus erythematosus

CONTEXT

Antiphospholipid syndrome is often associated with systemic lupus erythematosus. Both syndromes have different clinical manifestations based on organ involvement. Antiphospholipid syndrome commonly causes spontaneous abortions, cerebral vascular occlusion, and deep venous thrombosis. Catastrophic antiphospholipid syndrome occurs when three or more organ systems are affected by thromboses in less than a week.

CASE REPORT

We report a unique case of a young woman with a history of systemic lupus erythematosus and antiphospholipid syndrome who presented with recurrent ischemic pancreatitis. Pancreatitis was refractory to anticoagulation and low dose steroids. Secondary to recurrence of pancreatitis and other organ involvement, she was treated as a presumed case of catastrophic antiphospholipid syndrome. Aggressive treatment with plasmapheresis, corticosteroids, cyclophosphamide, and anticoagulation eventually led to her recovery.

CONCLUSION

Awareness of this rare, rapidly fatal medical condition prompts vital, early intervention to improve patients' survival. This case report aims to add to the limited therapeutic data available as well as suggest a possible approach to treating this rare syndrome with very high morbidity and mortality.

Health insurance and catastrophic illness: a report on the New Cooperative Medical System in rural China

The overall goal of the paper is to understand the progress of the design and implementation of China's New Cooperative Medical System (NCMS) program between 2004 (the second year of the program) and 2007. In the paper we seek to assess some of the strengths and weaknesses of the program using a panel of national-representative, household survey data that were collected in 2005 and early 2008. According to our data, we confirm the recent reports by the Ministry of Health that there have been substantial improvements to the NCMS program in terms of coverage and participation. We also show that rural individuals also perceive an improvement in service by 2007. While the progress of the NCMS program is clear, there are still weaknesses. Most importantly, the program clearly does not meet one of its key goals of providing insurance against catastrophic illnesses. On average, individuals that required inpatient treatment in 2007 were reimbursed for 15% of their expenditures. Although this is higher than in 2004, on average, as the severity of the illness (in terms of expenditures on health care) rose, the real reimbursement rate (reimbursement amount/total expenditure on medical care) fell. The real reimbursement rate for illnesses that required expenditures between 4000 and 10,000 yuan (over 10,000 yuan) was only 11% (8%). Our analysis shows that one of the limiting factors is constrained funding.

Catastrophic antiphospholipid syndrome

Antiphospholipid syndrome (APS) is an autoimmune disease with clinical manifestations of arterial and venous thrombosis, concomitant fetal loss and the presence of antiphospholipid antibodies (APLA). This report focuses on the challenges of optimal treatment involving plasma exchange and intravenous human immunoglobulin infusions that is administered in patients with catastrophic APS (CAPS). CAPS is a rare variant of APS defined as acute failure of at least three tissues, organs or systems caused predominantly by small vessel thrombosis confirmed by histopathologic evidence. CAPS develops rapidly and leads to death in 50% of cases. We present the case of a 39-year-old male patient with APS with worsening renal function. Positive lupus anticoagulant, markedly high concentrations of anticardiolipin and anti-beta 2-glikoprotein I antibodies have been observed. According to the criteria introduced by Asherson, a catastrophic form of APS was diagnosed and the patient had been treated with low-molecular-weight heparin, glucocorticosteroids, and plasmapheresis. In order to maintain clinical improvement, the patient was given human immunoglobulins i.v. (1 g/kg body weight). After the procedure, gradual clinical improvement was observed and renal function remained stable (serum creatinine level of 1.5 mg/dl).

Psychological characteristics of people with spinal cord injury-related persisting pain referred to a tertiary pain management center

This study examines the psychological characteristics of a cohort of individuals with spinal cord injury (SCI) and persisting pain referred to a tertiary pain management center. Forty-five individuals completed measures of pain, mood, disability, and both pain- and SCI-related psychological variables such as self-efficacy and catastrophizing. Compared with a general pain clinic population attending the same tertiary pain management center (n = 5,941), the sample was found to have lower pain intensity, comparable pain catastrophizing levels, and less activity interference due to pain. In contrast, those with SCI pain reported poorer mood. Pain catastrophizing was associated with anxiety, depression, and activity interference due to pain; pain self-efficacy was close to being significantly associated with these variables also. SCI acceptance and self-efficacy were also associated with some of these variables. These findings suggest that the biopsychosocial model of pain is applicable in this sample and that further treatment benefits could be obtained through use of interventions targeting psychological and social variables within this model.

[Antiphospholipid syndrome - an update on diagnosis and treatment]

Antiphospholipid syndrome (APS) was described by Hughes et al in 1986 and then by Harris et al in 1987. The symptoms of disease are related to the presence of autoantibodies directed against plasma and serum proteins that form complexes with phospholipids of cell membranes. The immunologic process involving vascular endothelium, thrombocytes and coagulation factors is responsible for enhancement of procoagulation mechanisms and as a result - venous and arterial thrombosis. Actual criteria of recognition of APS were published in 2006 as a result of 11th International Congress on Antiphospholipid Antibodies which was taking place in 2004 in Sydney. Multiorgan symptoms of disease, criteria of recognition and methods of treatment were discussed in the present paper.

[Catastrophic left leg V.A.C. Therapy First Prize in 2008. Second convocation]

This report received the V.A.C. Therapy Prize, second convocation, in the clinical case category of note is the spectacular nature of its results.

Catastrophic antiphospholipid syndrome: report of 4 cases

Catastrophic antiphospholipid syndrome (CAPS), described by Asherson in 1992, is a rare form of antiphospholipid syndrome resulting in multiorgan failure with a mortality rate of about 50%. The syndrome occurs in patients with either systemic lupus erythematosus and other rheumatic diseases (systemic sclerosis, rheumatoid arthritis, primary Sjogren syndrome) or alone. Whereas in "classic" antiphospholipid syndrome (APS), medium-large vessels are involved, a diffuse small vessel ischemia and thrombosis (microangiopathic disease) leading to a severe multiorgan dysfunction is predominant in CAPS. "Trigger" factors have been demonstrated in 45% of patients, but in the majority, they remain unknown. Not infrequently, CAPS arises in patients without any previous thrombotic history. The kidney is the organ most commonly affected, followed by the lung, the central nervous system, the heart and the skin. Disseminated intravascular coagulation occurs in approximately 13% of patients. The present study reports the clinical and serological features of 4 patients affected by this rare form of antiphospholipid syndrome. Nephrologists should be aware of the possibility of this syndrome as a cause of multiorgan failure since prompt recognition is essential for effective treatment.

Catastrophic early drug eluting stents thrombosis and aspirin hypersensitivity

Stent thrombosis is a feared complication of percutaneous coronary intervention. Promises and problems, late complications and early stent thrombosis have been reported after drug eluting stents implantation too. Moreover some patients with imperative cardiologic indications for combination therapy with aspirin and clopidogrel (stent placement and/or acute coronary syndrome) have a history of allergy to aspirin. We present a case of catastrophic early drug eluting stents thrombosis in a 79-year-old Italian woman with aspirin hypersensitivity.

Delayed catastrophic antiphospholipid syndrome after massive cerebral infarction

INTRODUCTION

Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening disorder urgent for aggressive treatment, and its characterized systemic thromboses and coagulopathy prompt for a rapid diagnosis.

CASE REPORT

A woman fell into unconsciousness two weeks after a stable course of massive cerebral ischemia was identified due to CAPS with Sjogren syndrome. Her thrombocyte count and coagulation times were was normal at initial. A high blood anti-beta(2)-glycoprotein I antibody level was found. Plasmapheresis rapidly reversed her consciousness and coagulation function.

CONCLUSIONS

A normal hemostatic parameters should not exclude CAPS. A favorable prognosis depends on the rapidity of appropriate treatment.

A Realistic Model for Catastrophic External Haemorrhage Training

External haemorrhage is a significant cause of combat morbidity and mortality. UK DMS have introduced topical haemostatic agents (HemCon, QuikClot) for use as an adjunct to control catastrophic external haemorrhage. Realistic training in new equipment is essential. A model is described that is simple, reproducible, valid, realistic and currently unique in its opportunity to train soldiers to deal with life-threatening external bleeding, without recourse to live animal training. The model has been used successfully to train UK DMS medics, nurses and doctors in Afghanistan.

Catastrophic Antiphospholipid Syndrome: Lessons from the "CAPS Registry" A Tribute to the Late Josep Font

Although less than 1% of patients with the antiphospholipid syndrome (APS) develop the catastrophic variant, its potentially lethal outcome emphasizes its importance in clinical medicine today. However, the rarity of this variant makes it extraordinarily difficult to study in any systematic way. In order to put together all the published case reports as well as the new diagnosed cases from all over the world, an international registry of patients with catastrophic APS ("CAPS Registry") was created in 2000 by the European Forum on Antiphospholipid Antibodies. Currently, it documents the entire clinical, laboratory, and therapeutic data of more than 300 patients whose data have been fully registered. This registry can be freely consulted at the Internet (www.med.ub.es/MIMMUN/FORUM/CAPS.HTM) and it is expected that the periodical analysis of these data will allow us to increase our knowledge of this condition.

Peripheral Vascular Occlusions Leading to Gangrene and Amputations in Antiphospholipid Antibody Positive Patients

Twenty-one cases from several medical centers (Brazil, Italy, Serbia, South Africa, Israel, and the United Kingdom) with severe peripheral vascular disease progressing to amputations of limbs/digits, all of whom tested positive for antiphospholipid antibodies, are documented. The patients were suffering from either systemic lupus erythematosus, discoid LE, "primary" antiphospholipid syndrome (PAPS), "lupus-like" disease, undifferentiated connective tissue disease. A high frequency of livedo reticularis preceding the arterial occlusions in our series of patients who subsequently progressed to ischemic necrosis and amputation of limbs/digits was noted. Five of the 10 patients, in whom histopathological studies had been performed, demonstrated the typical vasculopathy seen with the antiphospholipid syndrome ("APS vasculopathy"). Complicating vasculitis was present in seven of the patients. Five of the patients developed severe peripheral vascular disease during the course of the catastrophic antiphospholipid (Asherson's) syndrome.