Chlorpromazine-induced lupus anticoagulant and associated immunologic abnormalities

Antipsychotic-Related DRESS Syndrome: Analysis of Individual Case Safety Reports of the WHO Pharmacovigilance Database

INTRODUCTION

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is gaining attention in pharmacovigilance, but its association with antipsychotics, other than clozapine, is still unclear.

METHODS

We conducted a case/non-case study with disproportionality analysis based on the World Health Organization (WHO) global spontaneous reporting database, VigiBase®. We analyzed individual case safety reports of DRESS syndrome related to antipsychotics compared to (1) all other medications in VigiBase®, (2) carbamazepine (a known positive control), and (3) within classes (typical/atypical) of antipsychotics. We calculated reporting odds ratio (ROR) and Bayesian information component (IC), with 95% confidence intervals (CIs). Disproportionate reporting was prioritized based on clinical importance, according to predefined criteria. Additionally, we compared characteristics of patients reporting with serious/non-serious reactions.

RESULTS

A total of 1534 reports describing DRESS syndrome for 19 antipsychotics were identified. The ROR for antipsychotics as a class as compared to all other medications was 1.0 (95% CI 0.9-1.1). We found disproportionate reporting for clozapine (ROR 2.3, 95% CI 2.1-2.5; IC 1.2, 95% CI 1.1-1.3), cyamemazine (ROR 2.3, 95% CI 1.5-3.5; IC 1.2, 95% CI 0.5-1.7), and chlorpromazine (ROR 1.5, 95% CI 1.1-2.1; IC 0.6, 95% CI 0.1-1.0). We found 35.7% of cases with co-reported anticonvulsants, and 25% with multiple concurrent antipsychotics in serious compared to 8.6% in non-serious cases (p = 0.03). Fatal cases were 164 (10.7%).

CONCLUSIONS

Apart from the expected association with clozapine, chlorpromazine and cyamemazine (sharing an aromatic heteropolycyclic molecular structure) emerged with a higher-than-expected reporting of DRESS. Better knowledge of the antipsychotic-related DRESS syndrome should increase clinicians' awareness leading to safer prescribing of antipsychotics.

A rare case of schizophrenia coexistence with antiphospholipid syndrome, β-thalassemia, and monoclonal gammopathy of undetermined significance

A patient with schizophrenia who was treated with chlorpromazine developed lupus anticoagulant (LA) and antiphospholipid syndrome (APS). On protein electrophoresis, a monoclonal immunoglobulin A peak was seen in this patient, defining a condition of monoclonal gammopathy of undetermined significance. Additionally, β-thalassemia was diagnosed with the CD41-42 genotype. This condition is extremely rare, particularly in patients with schizophrenia and APS. We present a case of a patient with schizophrenia and secondary APS who had a positive LA, a significantly prolonged activated partial thromboplastin time, endogenous coagulation factor deficiency and inhibitor, no bleeding, and an unexpected finding of β-thalassemia and monoclonal IgA. Following that, a literature review on the disorders was presented.

Life-threatening chlorpromazine-induced acquired haemophilia A in a patient with a cavernous malformation involving the medulla oblongata

INTRODUCTION

Chlorpromazine is a commonly used drug in several medical conditions associated with a wide range of side effects. Few cases of hemostatic disorder have been reported in the literature.

CASE REPORT

A 39-year-old man had previously been diagnosed with a cavernous malformation of the medulla oblongata. Chlorpromazine was started to treat persistent hiccups. Twenty days later, the patient presented hepatitis and a pruritic rash. Haemostasis tests revealed a prolonged partial thromboplastin time associated with isolated decrease of factor VIII level and anti-factor VIII antibodies. Magnetic resonance imaging revealed recent asymptomatic bleeding. Introduction of eptacog alfa and prednisone allowed clinical and biological improvement as well as a prolonged remission after 12 months of follow-up.

Prevalence of Anti-Nuclear Antibodies and Anti-Phospholipid Antibodies in an Egyptian Cohort with Schizophrenia: A Case-Control Study

BACKGROUND

Psychiatric disorders, including schizophrenia could herald other manifestation(s) of systemic lupus erythematosus (SLE) potentially hindering timely and optimal management. Moreover, schizophrenia is among the described 'extra-criteria' manifestations of anti-phospholipid syndrome (APS). Hence, screening schizophrenia patients for SLE and APS may pose diagnostic and therapeutic implications.

OBJECTIVES

Examine schizophrenia patients with no overt connective tissue disease(s) manifestation(s) for clinical and/or serologic evidence of SLE and/or APS.

METHODS

The study included 92 schizophrenia patients [61 (66.3%) males] and 100 age- and gender-matched healthy controls. Both groups were tested for anti-nuclear antibodies (ANAs), anti-double stranded deoxyribonucleic acid (anti-dsDNA) antibodies, complement 3 (C3) and C4, and criteria anti-phospholipid antibodies (aPL) [anticardiolipin Immunoglobulin (Ig) G and IgM, anti-beta-2-glycoprotein I IgG and IgM, and lupus anticoagulant (LAC)].

RESULTS

The patients' mean age and disease duration were 28.8 ± 8.1 and 5.7 ± 2.2 years, respectively. The prevalence of ANA positivity, height of titre, and pattern was comparable between patients and controls (p = 0.9, p = 0.8 and p = 0.1, respectively). Anti-dsDNA antibodies and hypocomplementemia were absent in both groups. A significantly higher frequency of positive LAC was observed among patients compared with controls (7.6 % vs. 1 %, p = 0.02), whereas other aPL were comparable between both groups. None of the patients or controls demonstrated clinically meaningful (medium or high) aPL titres.

CONCLUSION

In our study, schizophrenia was solely associated with LAC. Thus, in the absence of findings suggestive of SLE or APS, routine screening for both diseases is questionable.

Zonal cortical scarring and tubular thyroidization in kidney biopsies of patients with SLE-histologic indicator for antiphospholipid antibodies

Antiphospholipid antibody syndrome (APS) is an acquired prothrombotic autoimmune disease caused by the presence of antibodies against anionic phospholipids or plasma proteins bound to phospholipids on cell membranes. It can be a primary disease or secondary to other autoimmune diseases, most commonly systemic lupus erythematosus (SLE). Laboratory testing for antiphospholipid antibodies (aPL) may be only transiently positive, so APS could be missed until a catastrophic thrombotic episode or pregnancy morbidity occurs. In the kidneys, this manifests as thrombotic microangiopathy (TMA), and patients present with hypertensive urgency and acute kidney injury. However, APS may not always have a catastrophic presentation but instead a more smoldering course. Kidney biopsy may not show obvious active TMA lesions but rather only chronic injury in the form of zonal cortical scarring and tubular thyroidization. Still, it may warrant anticoagulation therapy. So it is important to recognize this pattern of injury in the biopsy. Herein, we retrospectively study the correlation between presence of this histologic feature in kidney biopsies of SLE patients and positive aPL testing results (anticardiolipin antibodies and/or lupus anticoagulant). Kidney biopsies of SLE patients from 2004 to 2015 ( n = 186) were screened for presence or absence of zonal cortical scarring. Their electronic medical records were reviewed for aPL results. Our study showed low sensitivity (33%) but higher positive predictive value (62%), specificity (89%) and negative predictive value (71%). This histologic finding is therefore not a sensitive screening tool, but if present, greatly increases the likelihood of underlying aPL. We want to emphasize that recognition of this histologic feature in the biopsies of SLE patients is important so as not to miss the opportunity to treat with anticoagulation therapy and possibly slow down the chronic renal damage.

The significance of anti-neuronal antibodies for acute psychiatric disorders: a retrospective case-controlled study

Background

The clinical significance of anti-neuronal antibodies in patients with psychiatric disorders, but without encephalitis, remains unknown. In patients admitted to acute psychiatric inpatient care we aimed to identify clinical features distinguishing anti-neuronal antibody positive patients from matched controls.

Results

Patients who were serum-positive to N-methyl d-aspartate receptor (NMDAR) (n = 21), contactin-associated protein 2 (CASPR2) (n = 14) and/or glutamic acid decarboxylase 65 (GAD65) (n = 9) antibodies (cases) were age and sex matched (1:2) with serum-negative patients from the same cohort (controls). The prevalence and severity of psychiatric symptoms frequently encountered in NMDAR, CASPR2 and GAD65 antibody associated disorders were compared in cases and controls. NMDAR, CASPR2 and GAD65 antibody positive patients did not differ in their clinical presentation from matched serum negative controls.

Conclusion

In this cohort, patients with and without NMDAR, CASPR2 and GAD65 antibodies admitted to acute psychiatric inpatient care had similar psychiatric phenotypes. This does not exclude their clinical relevance in subgroups of patients, and studies further investigating the clinical significance of anti-neuronal antibodies in patients with psychiatric symptomatology are needed.

Electronic supplementary material

The online version of this article (10.1186/s12868-018-0471-7) contains supplementary material, which is available to authorized users.

The prevalence of antinuclear antibodies in patients with schizophrenia spectrum disorders: results from a large cohort study

Background:

An increased prevalence of autoantibodies has been found in patients with schizophrenia, suggesting a role for autoimmunity in schizophrenia pathogenesis.

Methods:

We examined the presence of antinuclear antibodies (ANAs), with further determination of specific antibodies, in 368 patients with a schizophrenia spectrum disorder and 283 healthy controls.

Results:

No significant difference in prevalence of ANAs between patients (8%) and controls (11%) was found.

Conclusion:

We did not find an association between ANAs and schizophrenia spectrum disorders. We discuss potential reasons for the discrepancy with some previous studies, such as inclusion of patients using chlorpromazine, which can induce ANAs.

Drug-induced lupus erythematosus: incidence, management and prevention

The generation of autoantibodies and autoimmune diseases such as systemic lupus erythematosus has been associated with the use of certain drugs in humans. Early reports suggested that procainamide and hydralazine were associated with the highest risk of developing lupus, quinidine with a moderate risk and all other drugs were considered low or very low risk. More recently, drug-induced lupus has been associated with the use of the newer biological modulators such as tumour necrosis factor (TNF)-α inhibitors and interferons. The clinical features and laboratory findings of TNFα inhibitor-induced lupus are different from that of traditional drug-induced lupus or idiopathic lupus, and standardized criteria for the diagnosis of drug-induced lupus have not been established. The mechanism(s) responsible for the development of drug-induced lupus may vary depending on the drug or even on the patient. Besides lupus, other autoimmune diseases have been associated with drugs or toxins. Diagnosis of drug-induced lupus requires identification of a temporal relationship between drug administration and symptom development, and in traditional drug-induced lupus there must be no pre-existing lupus. Resolution of symptoms generally occurs after cessation of the drug. In this review, we will discuss those drugs that are more commonly associated with drug-induced lupus, with an emphasis on the new biologicals and the difficulty of making the diagnosis of drug-induced lupus against a backdrop of the autoimmune diseases that these drugs are used to treat. Stimulation of the immune system by these drugs to cause autoimmunity may in fact be associated with an increased effectiveness in treating the pathology for which they are prescribed, leading to the dilemma of deciding which is worse, the original disease or the adverse effect of the drug. Optimistically, one must hope that ongoing research in drug development and in pharmacogenetics will help to treat patients with the maximum effectiveness while minimizing side effects. Vigilance and early diagnosis are critical. The purpose of this review is to summarize the most recent developments in our understanding of the incidence, pathogenesis, diagnosis and treatment of drug-induced lupus.

European attempts for the standardisation of the antiphospholipid antibodies

According to the Sydney criteria, antiphospholipid syndrome (APS) diagnosis is closely related to the demonstration of antiphospholipid antibodies (aPL) in patients sera. For this purpose, three different assays are conventionally accepted: lupus anticoagulant (LA), anticardiolipin (aCL) and anti-β2 glycoprotein I (β2GPI) antibodies. LA, described in the 1950s is a coagulation-based functional assay, which indirectly detects the presence of aPL. The aCL ELISA was developed in 1985; the identification of β2GPI as a major target of aPL, allowed the introduction of anti-β2GPI ELISA. Even if the diagnostic criteria for APS have been well defined, the laboratory detection of aPL is not always reproducible for many reasons. To achieve a univocal diagnostic definition of APS, efforts were made to reduce the inter- and/or intra-laboratory variability of the diagnostic tests. In this article, we analyse the studies performed to standardise aPL assays that were developed within the European Forum on Antiphospholipid Antibodies.

HIV-1, lipid rafts, and antibodies to liposomes: implications for anti-viral-neutralizing antibodies (Review)

The human immunodeficiency virus type 1 (HIV-1) is an enveloped virus with a lipid bilayer that contains several glycoproteins that are anchored in, or closely associated with, the membrane surface. The envelope proteins have complex interactions with the lipids both on the host cells and on the target cells. The processes of budding from host cells and entry into target cells occur at sites on the plasma membrane, known as lipid rafts, that represent specialized regions that are rich in cholesterol and sphingolipids. Although the envelope glycoproteins are antigenic molecules that potentially might be used for development of broadly neutralizing antibodies in a vaccine to HIV-1, the development of such antibodies that have broad specificities against primary field isolates of virus has been largely thwarted to date by the ability of the envelope proteins to evade the immune system through various mechanisms. In this review, the interactions of HIV-1 with membrane lipids are summarized. Liposomes are commonly used as models for understanding interactions of proteins with membrane lipids; and liposomes have also been used both as carriers for vaccines, and as antigens for induction of antibodies to liposomal lipids. The possibility is proposed that liposomal lipids, or liposome-protein combinations, could be useful as antigens for inducing broadly neutralizing antibodies to HIV-1.

Anticardiolipin and anti-beta-2-glycoprotein I antibodies

The anticardiolipin (aCL) antibody test was first established in 1983, using cardiolipin (negatively charged phospholipid) as an antigen in a solid-phase immunoassAy. It was first applied to the study of systemic lupus erythematosus patients, and was found associated with thromboses and recurrent pregnancy losses. The wide use of this test was determinant in the definition of the "aCL or antiphospholipid syndrome" (APS).Later, it was demonstrated that aCL antibodies do not recognize anionic phospholipids but are directed against plasma proteins bound to anionic phospholipids, mainly beta-2-glycoprotein I, which is now considered as the autoantigen in APS. Anti-beta-2-glycoprotein I (anti-beta2GPI) is not yet accepted as a serological criterion for APS, but most investigators would consider a patient with anti-beta2GPI antibodies and clinical features of APS to have the syndrome. aCL and anti-beta2GPI are a heterogeneous group of antibodies with different clinical significances and can be present in different autoimmune diseases as well as in infectious diseases.

Antibodies to lipids and liposomes: immunology and safety

Naturally occurring antibodies to phospholipids and cholesterol are widespread; they occur commonly during the course of acute infections; they are not causally related to the anti-phospholipid syndrome; they have been associated with other clinical entities only as an epiphenomenon; and they have not been implicated as causing any clinical syndrome or disease. There are theoretical and experimental reasons to believe that normal cells and tissues are protected from binding of antibodies to bilayer lipids by steric hindrance due to adjacent larger molecules, such as large or charged adjacent glycolipids or proteins on the cell surface. There are also reasons to believe that certain natural antibodies to lipids can even serve useful normal functions. Antibodies to liposomal lipids induced by liposomes containing lipid A appear to have characteristics that are similar or identical to naturally occurring antibodies to lipids, and it is therefore believed that such antibodies would not cause adverse clinical effects. Numerous Phase I and II human clinical trials of experimental vaccines containing liposomes and lipid A have shown a high level of safety.

Reduced anticardiolipin antibodies in first episode and chronic schizophrenia

The objective of this study was to measure anticardiolipin antibodies (aCL) in major psychiatric diseases. In Experiment 1, 96 subjects were evaluated: 20 first episode schizophrenia patients, [SCZ1] 20 chronic schizophrenia patients in acute exacerbation [SCZ2], l9 bipolar patients, 20 schizoeffective patients and 17 healthy age matched controls. In Experiment 2, 97 subjects were studied: 20 first episode schizophrenia patients [SCZ1], 60 chronic schizophrenia patients in acute exacerbation [SCZ2] and 17 healthy matched controls. Diagnosis was performed according to DSM-IV. Serum samples were tested for aCL in parallel by enzyme-linked immunosorbent assay in the presence of bovine serum. Five positive control samples with high levels of aCL were run in parallel. Background binding to wells uncoated with cardiolipin (CL) was also measured. In Experiment 1, aCL levels were similar in the control, bipolar and schizoeffective groups. In contrast, aCL levels in the SCZ1 and SCZ2 groups were significantly lower than in controls. In Experiment 2, Significantly lower levels of aCL antibodies were found in all schizophrenic patients versus controls. Interestingly, background levels in both experiments were higher in the schizophrenic groups than in controls. Serum aCL levels are lower in schizophrenic patients, and especially in first episode cases, than in controls. One possible explanation for the lower levels of aCL in schizophrenic patients is the consumption of these antibodies in the acute phase and exacerbation of the disease. The higher background levels in schizophrenic patients may indicate a high level of antibodies to some serum component in schizophrenic patients that is still unclear and needs further elucidation.

Clinical laboratory testing for the antiphospholipid syndrome

The first aCL test was developed in 1983 and subsequently standardized. Although in the last 6 to 7 years, new and more specific tests have become available, the aCL ELISA and the LA tests are still the first choice to be used in diagnosis of APS. While there is now doubt that the anticardiolipin test is useful in the diagnosis of APS, limitations of the assay have caused uncertainty and misinterpretation of the value of the test. Utilization of validated ELISA kits with well-tested calibrators and an "in-house standard" may enable more reproducible measurements. Reporting results semiquantitatively preserves the clinical utilize of the test without the misinterpretation of a quantitative result that may lack precision. The development of newer tests such as the beta2GPI ELISA and the APhL ELISA Kit, utilizing the phospholipid mixture, give promise to a more specific and reliable diagnosis of APS, while retaining good sensitivity. Other tests such as ELISA for prothrombin antibodies and annexin V antibodies are still under development and will require standardization and extensive evaluation. The aCL test should continue to be done and included in the Sapporo criteria. The aCL test is not as specific as the anti-beta2GPI test, but it is very sensitive and together with the LA test should capture the majority of the APS patients. IgA aCL and anti-beta2GPI positivity alone is rare but occasionally found and shown to be associated with major clinical manifestations of APS. Therefore, it is now recommended to include both tests, IgA aCL and IgG, IgM and IgA anti-beta2GPI to confirm diagnosis of APS.

Incidence of arteriovenous thrombosis and the role of anticardiolipin antibodies in hemodialysis patients

INTRODUCTION

Fistula thrombosis in patients on maintenance hemodialysis is an important morbidity factor. Arterial or venous thrombotic events have been described as complications in patients on regular hemodialysis and positive titers of anticardiolipin antibodies (ACLA). This study was designed to evaluate the prevalence of ACLA in hemodialysis patients and it's relation to arteriovenous fistula (AVF) thrombosis.

METHODS

218 patients with AVF on maintenance hemodialysis were studied prospectively during a period of 14 months for any episode of AVF thrombosis (AVFT), after ACLA was assayed by ELISA in 171 ones. Other risk factors for thrombosis such as presence of diabetes, hypotension during dialysis, using of erythropoietin (rEpo), fistula site, gender, age, dialysis duration, and type of dialyser membrane were accessed.

RESULTS

56% of the patients had IgG ACLA = 10 GPL which was significantly correlated with dialysis duration (23.18 +/- 24.56 months in patients with ACLA = 10 GPL vs 37.73 +/- 36.35 months in patients with 20 = IgG ACLA < 40 GPL). Within 14 months follow up, 39 episodes of AVFT occurred in 34 patients (15.8%). Dialysis duration prior to start of study was 29.16 +/- 22.04 months. In our patients radiocephalic AVFs showed more thrombosis than brachiocephalic ones (23% vs 10%, p = 0.01 by Chi-square). Age more than 50 years old was a risk factor for AVFT (p = 0.034 by Chi-square). Also erythropoietin use (p = 0.011 by chi-square) and ultrafiltration more than 3 liters (average value of 14 months) were correlated with AVFT (p = 0.042 by Chi-square), but there wasn't any correlation between diabetes, presence of ACLA, hypotension during dialysis, gender, and dialysis membranes with AVFT. Ultimately, logistic regression analysis of factors associated with thrombosis was done and only fistula site (p = 0.015, O.R. = 2.87), and Eprex use (p = 0.031, O.R. = 4.05) showed significant correlation with AVFT.

CONCLUSION

Although incidence of anticardiolipin antibodies was high in our patients, we found no correlation between IgG ACLA and AVFT. Instead, we found that radiocephalic fistulas and Eprex injection were risk factors for AVFT.

Are antiphospholipid antibodies an independent risk factor for atherosclerosis?

The purpose of this study was to check whether antiphospholipid antibodies (aPL) could be an independent risk factor for atherosclerosis. Eighty-five subjects were studied: 45 with primitive antiphospholipid antibody syndrome and 40 controls affected by deep vein thrombosis secondary to known causes. The two groups were homogeneous for age, sex, and risk factors for atherosclerosis. All the subjects submitted to echo-color doppler of the carotid arteries, femoral arteries, and abdominal aorta. The cases were then subdivided into three subgroups on the basis of the positivity to the three subpopulations of aPL. Results demonstrate that there is no correlation between aPL and atherosclerosis. The different positivity to aPL does not modify this conclusion.

Antiphospholipid antibody syndrome: rapid, sensitive, and specific flow cytometric assay for determination of anti-platelet phospholipid autoantibodies

A rapid, sensitive and specific flow cytometric assay has been developed for the determination of autoantibodies directed against platelet anionic phospholipids in antiphospholipid antibody syndrome (APLAS). The method is based on demonstrable competition between the placental anticoagulant protein I, annexin V, and the patients' autoantibodies on the platelet anionic phospholipids (the binding site for the prothrombinase complex; prothrombin and factors Va and Xa). The method is practical and rapid, uses readily available reagents, and involves standard equipment. The assay is inexpensive and cost-effective for both single and multiple samples. Results are provided within 2 hours from obtaining blood samples, thereby supporting clinical decision-making and management. Ten serum samples from patients with the clinical diagnosis of APLAS (48 tests), 10 from normal individuals (35 tests), and 10 from patients with immune thrombocytopenia (33 tests) were tested. Platelet preparations preincubated with normal sera showed high binding of fluorescein-labeled annexin V with an average fluorescence of 202.9 +/- 22.0 (arbitrary units). Patients with immune thrombocytopenia exhibited similar results, with an average fluorescence of 192.5 +/- 32.1 (P >.05). In contrast, incubation with sera from patients with APLAS resulted in a marked decline in the binding of annexin V to an average fluorescence of only 14.6 +/- 7.4 (P <.001). Preincubation with annexin V followed by the addition of patients' sera showed displacement of annexin V to a similar degree. Because annexin V attenuates procoagulant activity by competing with factors Va and Xa on the platelet anionic phospholipids, its displacement by patients' antibodies may result in the acceleration of procoagulant activity, thereby promoting thrombogenesis in APLAS.

Anti-cardiolipin, anti-cardiolipin plus bovine, or human beta(2)glycoprotein-I and anti-human beta(2)glycoprotein-I antibodies in a healthy infant population

BACKGROUND

Pathogenic antiphospholipid antibodies studies are usually conducted on populations of adults. Studies involving normal children are scant.

METHODS

Antibody reactivity against CL alone (true aCL), CL-complexed to bovine beta(2)GP-I (aCL-bovine beta(2)GP-I), or human (aCL-human beta(2)GP-I) beta(2)GP-I, or to phospholipid-free human beta(2)GP-I (anti-human beta(2)GP-I) was determined by ELISA in serum samples from 360 Mexican children ranging from 1 month through 8 years of age.

RESULTS

Statistical analysis of variance and rankings of Kruskal-Wallis demonstrated no significant difference in all tested antibody activities between ages and genders of the study population. Values are presented as a percentile distribution included between 5 and 99, corresponding to the percentages of the studied population. Normal arbitrary units (AU) for IgG, IgA, and IgM true aCL that correspond to the 95 and 99 percentiles are as follows: 2.15 and 3.5; 2.35 and 5.0, and 3.15 and 4.5, respectively. IgG, IgA, and IgM aCL-bovine beta(2)GP-I activities are 2.6 and 5.0, 3.0 and 5.0, and 2.7 and 6.0 AU, respectively, while IgG activities of aCL-bovine and human beta(2)GP-I are 1.45 and 1.80, respectively. Normal values for IgG anti-human beta(2)GP-I are 1.85 AU.

CONCLUSIONS

While elevated serum levels of antibodies to CL and/or beta(2)GP-I have been associated with thrombotic and hematologic manifestations, the majority of reports deal with adult populations. We report the cut-off values (in AU, international PL units, and international units for beta(2)GP-I) of the specific serologic response of true aCL, aCL-bovine beta(2)GP-I, aCL-human beta(2)GP-I, and anti-human beta(2)GP-I in healthy Mexican children.

Testing for antiphospholipid antibodies: problems and solutions

The first aCL test was developed in 1983 and subsequently standardized. Although new and more specific tests have become available, the aCL ELISA and the LA tests are still the first choice to be used in diagnosis of APS. Newer tests such as the anti beta 2 GP1 ELISA and the APhL ELISA Kit (Louisville APL Diagnostics) use somewhat different antigens and likely provide a more specific (and possibly more reliable) diagnosis of APS while retaining good-to-excellent sensitivity. Other tests, such as ELISA for prothrombin antibodies and annexin V antibodies, are still undergoing development and will require standardization and extensive evaluation. We thank Dr Isabel Abreu and Dr Mittermeyer B. Santiago for performing some of the studies reported in this review.

Opposite beta2-glycoprotein I requirement for the binding of infectious and autoimmune antiphospholipid antibodies to cardiolipin liposomes is associated with antibody avidity

The aim of this study was to investigate the interaction of antiphospholipid antibodies (aPL) from two different populations (patients with autoimmune or infectious disorders) with cardiolipin (CL) arranged in a defined bilayer. beta2-Glycoprotein I (beta2GPI), an apolipoprotein that plays a critical role in the aPL binding to phospholipids, was quantified by dot blot in purified IgG-aPL samples, further classified according to apparent avidity to CL. In solid-phase assays, beta2GPI increased, preferentially, the binding of low-avidity autoimmune aPL to CL but inhibited the binding of low-avidity syphilitic aPL. In the absence of beta2GPI, both autoimmune and infectious aPL induced the leakage of the entrapped fluorescent probe, carboxyfluorescein (CF), from small unilamellar vesicles containing CL. aPL-induced probe leakage was protein concentration-dependent and characterized by a lag-phase onset of 100-120 min. beta2GPI increased the leakage rate induced by low-avidity autoimmune aPL only and inhibited the leakage induced by all syphilitic aPL. The following conclusions were provided: (1) in the absence of beta2GPI, autoimmune and infectious aPL bind to CL in a bilayer, inducing liposome leakage; (2) the leakage mechanism induced by aPL is suggested to be intravesicular; (3) beta2GPI requirement for phospholipid binding in both solid and fluid phase is associated to aPL avidity; (4) CL alone or the CL-beta2GPI complex are the most likely epitopes for autoimmune aPL; (5) aPL from syphilis patients can only form the CL-aPL complex, supporting that beta2GPI is not (part of) the target epitope.

Origin and pathogenesis of antiphospholipid antibodies

Antiphospholipid antibodies (aPL) are a heterogeneous group of antibodies that are detected in the serum of patients with a variety of conditions, including autoimmune (systemic lupus erythematosus), infectious (syphilis, AIDS) and lymphoproliferative disorders (paraproteinemia, myeloma, lymphocytic leukemias). Thrombosis, thrombocytopenia, recurrent fetal loss and other clinical complications are currently associated with a subgroup of aPL designating the antiphospholipid syndrome. In contrast, aPL from patients with infectious disorders are not associated with any clinical manifestation. These findings led to increased interest in the origin and pathogenesis of aPL. Here we present the clinical features of the antiphospholipid syndrome and review the origin of aPL, the characteristics of experimentally induced aPL and their historical background. Within this context, we discuss the most probable pathogenic mechanisms induced by these antibodies.

Elevated anticardiolipin antibodies in autoimmune haemolytic anaemia irrespective of underlying systemic lupus erythematosus

In patients with systemic lupus erythematosus (SLE) and concomitant Coombs positive autoimmune haemolytic anaemia (AIHA) anticardiolipin antibodies (aCL) are found more frequently and at higher titres than in SLE patients without AIHA. In order to assess if aCL elevation is primarily associated with the underlying SLE, or with AIHA itself, we examined AIHA patients with and without underlying SLE for the presence of aCL. aCL (IgG and IgM) were determined by ELISA in 74 SLE patients without AIHA, 22 SLE patients with AIHA, 50 patients with idiopathic AIHA (warm-reactive autoantibodies), 52 patients with idiopathic AIHA (cold-reactive autoantibodies) and 50 healthy controls. The mean IgG and IgM aCL titres in SLE patients without AIHA (IgG 37.0 U/ml, IgM 8.9 U/ml) were significantly elevated compared with the values in healthy controls (IgG 9.1 U/ml, IgM 3.2 U/ml; P < 0.005). The mean aCL levels in SLE patients with AIHA (IgG 53.2 U/ml, IgM 28.2 U/ml) were higher than in SLE patients without AIHA (P = 0.09 for IgG, P < 0.005 for IgM). Interestingly, the mean aCL levels of patients with idiopathic AIHA (warm-reactive autoantibody type: IgG 29.2 U/ml, IgM 19.3 U/ml; cold-reactive autoantibody type: IgG 27.4 U/ml, IgM 18.9 U/ml) were also significantly elevated compared with healthy controls P < 0.001). As aCL are elevated not only in SLE (with and without concomitant AIHA) but also in idiopathic AIHA it can be speculated that aCL are involved in the pathomechanism of autoantibody-induced erythrocyte destruction per se irrespective of an underlying SLE.

Antiphospholipid antibodies and the antiphospholipid antibody syndrome

The antiphospholipid antibody syndrome is a multiple-system disorder characterized by persistently elevated antiphospholipid antibodies and/or arterial or venous thrombosis, thrombocytopenia, or recurrent spontaneous abortion. Anticardiolipin antibodies and the lupus anticoagulant are different classes of antiphospholipid antibodies associated with this disorder. Cutaneous manifestations are common and may be the presenting sign of the underlying disease. This article reviews the clinical manifestations, laboratory assays, histopathologic features, and treatment of the antiphospholipid antibody syndrome.

Leukocytes and organ-nonspecific autoantibodies in schizophrenics and their siblings: markers of vulnerability or disease?

To determine whether leukocyte counts and organ-nonspecific autoantibodies mark familial vulnerability for schizophrenia and/or the disease itself, we examined 92 patients with schizophrenia and 94 unrelated, demographically balanced, healthy individuals. In addition, for 19 of the probands, one of their nonschizophrenia, full siblings also was recruited. At the time of the blood draw, most probands (87%) had been free of medications for a minimum of 2 weeks and about half were neuroleptic-naive, first-episode patients. Results indicate that a relative lymphopenia in the context of a relative granulocytosis appears to mark familial vulnerability for schizophrenia, whereas an absolute monocytosis appears to mark spectrum manifestations of the clinical phenotype. The former observation is consistent with the hypothesis that the etiology of schizophrenia is immunologically mediated, whereas the latter is consistent with emerging evidence that an inflammatory process is associated with the expression of the disorder. Neither antinuclear antibody nor rheumatoid factor emerged as liability or disease markers.

A case of Budd-Chiari syndrome with high antiphospholipid antibody in a patient with systemic lupus erythematosus

Antiphospholipid syndrome is characterized by recurrent episodes of arterial and venous thrombosis, spontaneous fetal losses, thrombocytopenia and persistently elevated levels of antiphospholipid antibodies. We experienced a case of Budd-Chiari syndrome in a 32-year old female lupus patient who was presented with left leg edema, ascites and esophageal varix. The clinical and laboratory findings were compatible with the cirteria for systemic lupus erythematosus (SLE) and she was found to have anticardiolipin antibody, thrombocytopenia and prolonged partial thromboplastin time. Initially, she was treated with intravenous heparin and uroki nase and she was followed up with warfarin, baby aspirin and steroids.

Anticardiolipin antibodies and acute alcoholic intoxication

Many clinical features have been associated with the antiphospholipid antibodies. In a preliminary prospective study, among 1014 consecutive patients admitted to a Medicine Department, 72 (7.1%) patients were found to be anticardiolipin antibodies (aCL) positive. Eight (11%) of these aCL positive patients had alcoholic intoxication. Chronic alcoholism is known to be associated with a high prevalence of autoimmune disorders. The objective of this study was to determine the prevalence of aCL in patients with acute alcoholic intoxication. Sixty two patients (13 women; 49 men), mean age 35 years (range 17-63 years) referred to the emergency care unit were studied. A control population of 62 apparently healthy subjects, age and sex matched, were also tested. Alcoholaemia, aCL, antinuclear antibodies (ANA), Venereal Disease Research Laboratory (VDRL) and Treponema pallidum immobilisation (TPHA) were determined. The mean alcoholaemia among all patients tested was 2.35 gl-1 (range 0.1-4). aCL were found positive in 10 patients (16%); eight men and two women. Seven patients had aCL IgG level of > or = 15 UG PL/ml while two had IgM level of > or = 12.5 UMPL/ml. One had both elevated aCL IgG and IgM. Statistical analysis confirmed that aCL positivity is more frequently encountered in alcoholic patients compared with an age and sex matched population (P = 0.0298). Among alcoholic patients, 12 (19%) had ANA. Four of them were VDRL positive while all were TPHA negative. Two of the 62 control subjects were found aCL positive. From these data, it can be concluded that increased aCL levels are frequently associated with acute alcoholic abuse.

Lupus anticoagulant in the elderly may be associated with both quinine and quinidine usage

Thirty-one patients aged over 60 yrs and with lupus anticoagulant (LA) were reviewed for their drug intake. Twenty-three (73%) were taking cinchona alkaloids, 10 (32%) quinine for night cramps, 11 (35%) quinidine for cardiac arrhythmia and 2 (6%) were taking both. These frequencies of drugs usage differed significantly from age and sex matched controls (p < 0.001). Five patients had features suggestive of the antiphospholipid syndrome. Repeat testing showed persistent LA activity in all but 2 of 5 patients in whom the relevant drug had been ceased. This is the first description of a possible causal association between LA and quinine therapy.

The antiphospholipid syndrome. Diagnosis, management, and pathogenesis

Much more is known about the APLS than 15 yr ago, but more needs to be done. Clinically, major characteristics of the disorder have been defined, but the course of the disease and its relationship to other disorders, such as systemic lupus erythematosus (SLE), need to be defined. Good progress has been made in standardizing anticardiolipin and, to a lesser extent, LA. However, problems with interlaboratory and inter-assay variation need to be addressed. Doctors are getting a better idea of how to manage these patients with a view to preventing recurrences of thrombosis or pregnancy losses, but prospective studies are still desirable to give more definitive answers. Attention has turned to the pathogenesis of the disorder. It seems likely that antibodies mediate the clinical disorders with which they are associated, but the mechanisms by which this occurs still require further study.

Antiphospholipid antibodies and the antiphospholipid syndrome

The study of aPL antibodies and the APS has appealed to large numbers of investigators over the last decade. This accounts, in part, for the great degree of apparently contradictory data being published. What seems certain is that these antibodies are associated with thrombosis and recurrent pregnancy loss, and animal data suggest a direct role in pathogenesis. In vitro studies demonstrate that these antibodies have a variety of functional effects on the hemostatic system, giving further credence to an antibody role in thrombosis. Further studies will doubtless give better insight into the mechanisms of antibody action and this will provide a more rational basis for treatment.

Anticardiolipin antibodies are elevated in drug-free, multiply affected families with schizophrenia

The objective of this study was to measure anticardiolipin antibodies in patients and healthy relatives in multicase families with schizophrenia. Twenty-eight (28) multicase families with schizophrenia were examined. One hundred three drug-free patients and 66 first-degree relatives consented to evaluation by DSM-III-R criteria. Criteria for patient definition included the following: age > or = 16, a confirmed hospital diagnosis of schizophrenia, knowledge of biological parents, and consent to participate. Additional data were drawn from family history and medical records. Serum samples were tested separately for IgG and IgM anticardiolipin by enzyme-linked immunosorbent assay (ELISA) and designated positive/negative by comparison to the reactivity of an age-matched control group. IgG anticardiolipin antibodies were significantly more common in both patients and relatives compared to controls. IgM anticardiolipin antibodies were significantly more common in patients. In 75% of families at least one member was anticardiolipin positive and this positivity correlated with patient positivity. The relevance of anticardiolipin antibodies in both patients and healthy relatives of some multicase families to the pathogenesis of schizophrenia is discussed.

Antihistone and anti-dsDNA autoantibodies in Alzheimer's disease and vascular dementia

In order to evaluate their prevalence in senile dementias, serum titer of antibodies against histones and double stranded deoxyribonucleic acid (dsDNA) were measured by means of the ELISA test in patients suffering from vascular dementia (VD), presenile Alzheimer's disease (AD), and senile dementia of the Alzheimer's type (SDAT). Only three subjects out of 87 had dsDNA autoantibodies. On the contrary, VD and SDAT showed high titers of antibodies against histones when compared to healthy controls. A significant relationship was also found between antihistone serum titer and degree of dementia in AD. Results were not influenced by gender, age, or duration of illness. Presence of antihistone antibodies in dementias might reflect an alteration of membrane fluidity and integrity with leakage of nuclear immunogens or disturbances of immune functions, as frequently observed in dementia disorders.

Is clubbing a feature of the anti-phospholipid antibody syndrome?

A patient with the anti-phospholipid antibody syndrome and digital clubbing is described. No recognized cause for the clubbing was found. It is suggested that platelet aggregation and microthrombi formation as a result of anti-phospholipid antibody may be involved in the pathogenesis of the digital clubbing. This may be a new feature of the anti-phospholipid antibody.

Interleukin-1 alpha and interleukin-2 in cerebrospinal fluid of schizophrenic subjects

1. It has been postulated that the interrelated processes of neurodegeneration, neuroplasticity, and neuroimmunological abnormalities may play a role in the pathophysiology of schizophrenia. Since, interleukins are produced in the central nervous system and have cytokine and growth promoting properties, they are an obvious choice to consider in these neural processes. 2. Cerebrospinal fluid obtained from schizophrenic patients, on and off medications, and from normal controls was assayed for interleukin-1 alpha (IL-1 alpha) and interleukin-2 (IL-2) using a sensitive enzyme-linked immunoassay. 3. IL-1 alpha concentration were below the detection limits of the assay in both controls and schizophrenics. 4. IL-2 levels were under 1 ng/ml CSF in nearly all subjects. There was no significant difference in IL-2 levels between medicated and medication-free schizophrenics or when patients were compared to controls.

Spinal subdural haematoma in a parturient after attempted epidural anaesthesia

We report a case of spinal subdural haematoma with neurological deficit in a 36-yr-old woman following Caesarean section for severe preeclampsia and placental abruption. She had been taking chronic trifluoperazine treatment for depression. Her activated partial thromboplastin time (aPTT) was 49 sec (normal = 26-36) but all other tests of coagulation were normal. Epidural anaesthesia was attempted but, despite a negative test dose, injection of local anaesthetic resulted in a generalized seizure and general anaesthesia was induced. Seventy-two hours after delivery, she was found to have bilateral leg weakness, urinary incontinence, absent rectal sphincter tone and asymmetrical leg reflexes. The diagnosis of spinal haematoma was confirmed by magnetic resonance imaging. She underwent emergency laminectomy and made a full neurological recovery.

What do we really know about autoantibody abnormalities and reproductive failure: a critical review

CONDENSATION

The diagnosis and treatment of autoantibody-associated forms of reproductive failure is critically reviewed.

OBJECTIVE

To critically evaluate the published literature in reference to autoantibody-associated forms of reproductive failure.

LOCATION

Medical School-affiliated private Infertility Center.

MATERIALS

A review of over 200 published papers reflecting on the topic.

RESULTS

Autoantibody associated reproductive failure, characterized by a decrease in fecundity and an increase in the risk of pregnancy loss, appears established. Autoantibody abnormalities, as routinely detected by standard laboratory assays, are, however, neither immunologically nor biologically specific since cross reactivities between autoantibodies are frequent and a specific autoantibody may cause a biological effect in one but not in another affected individual.

CONCLUSIONS

The evaluation of autoantibody abnormalities in all cases of suspected autoimmune-associated reproductive failure is valuable and will improve clinical care of affected patients. Clinicians need, however, to recognize the limitations of autoantibody testing and have to adjust their clinical management to the degree and quality of autoantibody evaluation available to them in their community.