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Bitsadze V, Khizroeva J, Lazarchuk A, Salnikova P, Yagubova F, Tretyakova M, Grigoreva K, Gashimova N, Tsibizova V, Karpova A, Mostovoi A, Kapanadze D, Voskresenskaya O, Akinshina S, Di Renzo GC, Gris JC, Elalamy I, Makatsariya A. Pediatric antiphospholipid syndrome: is it the same as an adult? J Matern Fetal Neonatal Med 2024; 37:2390637. [PMID: 39155241 DOI: 10.1080/14767058.2024.2390637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/18/2024] [Accepted: 08/03/2024] [Indexed: 08/20/2024]
Abstract
IMPORTANCE Antiphospholipid syndrome in neonates and children is a rare, but in some cases life-threatening condition with arterial and/or venous thrombosis and/or non-thrombotic neurological, skin, ophthalmological and other manifestations. OBSERVATIONS This review highlights the available information about the features of pediatric APS, including the rare catastrophic form, the differences between pediatric and adult APS, and the role of genetic thrombophilia in APS manifestation. CONCLUSIONS AND RELEVANCE The clinical manifestations and treatment options for APS in children may differ from those in adults, and prescribing therapy can be challenging due to the unique clinical and morphological characteristics of the pediatric patient. Pediatric APS may be a predictor of the development of certain autoimmune diseases and classic manifestations of APS in adulthood, therefore, a revision of the existing criteria for the diagnosis and treatment of APS in children is necessary.
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Affiliation(s)
- Viсtoria Bitsadze
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Jamilya Khizroeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Arina Lazarchuk
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Polina Salnikova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Fidan Yagubova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Maria Tretyakova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Kristina Grigoreva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Nilufar Gashimova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Valentina Tsibizova
- The PREIS School (International and European School of Perinatal, Neonatal and Reproductive Medicine), Firenze, Italy
| | - Anna Karpova
- Moscow Healthcare Department, Vorokhobov City Clinical Hospital № 67, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Health Ministry of Russian Federation, Moscow, Russia
- Health Ministry of Russian Federation, Yaroslavl State Medical University, Yaroslavl, Russia
| | - Aleksei Mostovoi
- Moscow Healthcare Department, Vorokhobov City Clinical Hospital № 67, Moscow, Russia
- Russian Medical Academy of Continuous Professional Education, Health Ministry of Russian Federation, Moscow, Russia
- Health Ministry of Russian Federation, Yaroslavl State Medical University, Yaroslavl, Russia
| | | | - Olga Voskresenskaya
- Department of Nervous Diseases and Neurosurgery, N.V. Sklifosovsky Institute of Clinical Medicine, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Svetlana Akinshina
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Gian Carlo Di Renzo
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- The PREIS School (International and European School of Perinatal, Neonatal and Reproductive Medicine), Firenze, Italy
| | - Jean-Christophe Gris
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Faculty of Pharmaceutical and Biological Sciences, Montpellier University, Montpellier, France
| | - Ismail Elalamy
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Department Hematology and Thrombosis Center, Medicine Sorbonne University, Paris, France
- Hospital Tenon, Paris, France
| | - Alexander Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children's Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Zajc Avramovic M, Avcin T. Antiphospholipid syndrome in children. Best Pract Res Clin Rheumatol 2024:101986. [PMID: 39138042 DOI: 10.1016/j.berh.2024.101986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/22/2024] [Accepted: 07/18/2024] [Indexed: 08/15/2024]
Abstract
Antiphospholipid syndrome (APS) in children is a rare disease associated with significant morbidity and mortality. In comparison with APS in adults, pediatric APS has a more severe presentation with frequent recurrences of thrombotic events and a higher probability of life-threatening catastrophic APS. Nonthrombotic manifestations are also more common in the pediatric age group and can precede thrombosis. New classification criteria have been introduced recently and have not yet been assessed in pediatric patients with APS. In addition to anticoagulation drugs, other novel therapies have emerged including the use of B cell and complement inhibitors, especially in catastrophic APS. The purpose of this review is to provide a broad overview of aPL-related clinical manifestations in pediatric patients based on the analysis of published cohorts and data from the international pediatric APS registry. We also aim to illustrate APS in infants caused by transplacentally transferred maternal aPL, which is very rarely associated with acute thrombotic events in the perinatal period and more frequently with long-term neurodevelopmental abnormalities.
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Affiliation(s)
- Mojca Zajc Avramovic
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Center Ljubljana, Slovenia; Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Slovenia.
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Center Ljubljana, Slovenia; Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Slovenia.
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3
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Bosch A, Brunsvig Jarvis K, Brandão LR, Zou Y, Vincelli J, Amiri N, Avila L. The role of coagulation factors VIII, IX and XI in the prediction and mediation of recurrent thrombotic events in children with non-central venous catheter deep vein thrombosis. Thromb Res 2024; 236:228-235. [PMID: 38484629 DOI: 10.1016/j.thromres.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND The role of elevated coagulation factors VIII (FVIII), FIX, FXI for the prediction of recurrent thrombotic events in children after an index non-central venous catheter (non-CVC) related deep vein thrombosis (DVT) remains unclear. OBJECTIVE This study investigates the predictive role of FVIII, FIX, and FXI for recurrent thrombosis in children with index non-CVC DVTs, and the mediation effect of FVIII on chronic inflammation and recurrent thrombosis. METHODS Children aged 0-18 years diagnosed with an index non-CVC related DVT (1993-2020) were included in this single-center retrospective cohort study. Plasma levels of FVIII, FIX, FXI were measured cross-sectionally ≥30 days after the acute DVT. The association between the continuous variables FVIII, FIX, FXI and thrombosis recurrence was investigated using uni- and multivariable logistic regression, adjusting for age, sex, and chronic inflammation. Mediation analysis assessed the role of FVIII as a mediator between chronic inflammation and recurrent thrombosis. Ethics approval was obtained. RESULTS A total of 139 children with an index non-CVC related DVT were included. Thirty-eight (27 %) had a recurrent thrombosis at a median of 237 days (P25-P75 65-657 days) after the index DVT. In uni- and multivariable-analysis, FVIII, FIX or FXI did not predict thrombosis recurrence; However, chronic inflammation was an independent predictor. There was no evidence that FVIII mediated the effect of chronic inflammation on thrombosis recurrence. CONCLUSION We found no evidence that elevated FVIII, FIX or FXI predicted thrombosis recurrence, or evidence of a mediating role of FVIII. Underlying chronic inflammation predicted venous recurrent thrombotic events in this cohort.
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Affiliation(s)
- Alessandra Bosch
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; University Children's Hospital Zurich, Department of Haematology, Zurich, Switzerland.
| | - Kirsten Brunsvig Jarvis
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Oslo University Hospital, Department of Pediatric Hematology and Oncology, Oslo, Norway
| | - Leonardo R Brandão
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yushu Zou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Vincelli
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nour Amiri
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Laura Avila
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
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Radin M, Cecchi I, Arbrile M, Montin D, Farinasso L, Cioffi M, Foddai SG, Barinotti A, Menegatti E, Baldovino S, Sciascia S, Roccatello D. Pediatric Presentation of Antiphospholipid Syndrome: A Review of Recent Literature With Estimation of Local Prevalence. Semin Thromb Hemost 2024; 50:182-187. [PMID: 36940717 DOI: 10.1055/s-0043-1764472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
We aimed to investigate the epidemiology, the clinical and laboratory characteristics of the pediatric involvement of antiphospholipid syndrome (APS), by performing a review of the current evidence and reviewing local experience in the Northwest Italy. To achieve this, we performed a detailed literature search to identify articles describing clinical and laboratory characteristics of pediatric APS. In concomitance, we conducted a registry-based study collecting data from the Piedmont and Aosta Valley Rare Disease Registry including pediatric patients diagnosed with APS in the last 11 years. The literature review led to inclusion of six articles with a total of 386 pediatric patients (65% females, 50% with systemic lupus erythematosus (SLE) as concomitant diagnosis). Rates of venous and arterial thrombosis were 57 and 35%, respectively. "Extra-criteria manifestations" included mostly hematologic and neurologic involvement. Almost one-quarter of patients (19%) reported recurrent events and 13% manifested as catastrophic APS. A total of 17 pediatric patients (mean age 15.1 ± 2.8, 76% female) developed APS in the Northwest of Italy. In 29% of cases, SLE was a concomitant diagnosis. Deep vein thrombosis was the most frequent manifestation (28%) followed by catastrophic APS (6%). The estimated prevalence of pediatric APS in Piedmont and Aosta Valley Region is 2.5/100,000 people, whereas the estimated annual incidence is 0.2/100,000 inhabitants. In conclusion, clinical manifestations of pediatric APS seem to be more severe and with a high prevalence of noncriteria manifestations. International efforts are needed to better characterize this condition and to develop new specific diagnostic criteria to avoid missed/delayed diagnosis in children with APS.
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Affiliation(s)
- Massimo Radin
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Italy
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Irene Cecchi
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Italy
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Marta Arbrile
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Davide Montin
- Department of Public Health and Pediatrics, University of Turin, Pediatria Specialistica U, "Regina Margherita" Children Hospital, Turin, Italy
| | - Loredana Farinasso
- Department of Public Health and Pediatrics, University of Turin, Pediatria Specialistica U, "Regina Margherita" Children Hospital, Turin, Italy
| | - Michele Cioffi
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
| | - Silvia Grazietta Foddai
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
| | - Alice Barinotti
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
| | - Elisa Menegatti
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Simone Baldovino
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Italy
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Italy
| | - Dario Roccatello
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Italy
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Avila ML, Amiri N, Zavareh ZT, Al‐Saoud SA, Sabapathy C, Vincelli J, Moharir M, Silverman E, Williams S, Brandão LR, Levy D. Characterization of recurrent thrombosis in pediatric antiphospholipid syndrome. Am J Hematol 2022; 97:E268-E270. [PMID: 35389524 DOI: 10.1002/ajh.26565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Maria Laura Avila
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
- Child Health Evaluative Sciences Research Institute, The Hospital for Sick Children Toronto Ontario Canada
- Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
| | - Nour Amiri
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
- Child Health Evaluative Sciences Research Institute, The Hospital for Sick Children Toronto Ontario Canada
| | - Zahra Tofighi Zavareh
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
- Child Health Evaluative Sciences Research Institute, The Hospital for Sick Children Toronto Ontario Canada
| | - Sima Abu Al‐Saoud
- Faculty of Medicine, Department of Pediatrics Makassed Hospital, Al‐Quds University East Jerusalem Palestine
| | - Christine Sabapathy
- Department of Paediatrics McGill University Health Centre Montreal Quebec Canada
| | - Jennifer Vincelli
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
| | | | - Earl Silverman
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Suzan Williams
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
| | - Leonardo R. Brandão
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
- Child Health Evaluative Sciences Research Institute, The Hospital for Sick Children Toronto Ontario Canada
- Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
| | - Deborah Levy
- Department of Paediatrics The Hospital for Sick Children Toronto Ontario Canada
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Madison JA, Gockman K, Hoy C, Tambralli A, Zuo Y, Knight JS. Pediatric antiphospholipid syndrome: clinical features and therapeutic interventions in a single center retrospective case series. Pediatr Rheumatol Online J 2022; 20:17. [PMID: 35197077 PMCID: PMC8867616 DOI: 10.1186/s12969-022-00677-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND/PURPOSE Pediatric antiphospholipid syndrome (APS) is a thromboinflammatory disease characterized by the presence of circulating antiphospholipid antibodies and either thrombotic events or pregnancy morbidity. The objective of this study was to review a large institution's experience to better understand the characteristics of children with APS. METHODS We conducted a retrospective review of pediatric APS at a tertiary referral center. The electronic medical record system was queried from 2000 through 2019, and 21 cases were included based on meeting the revised Sapporo Classification criteria by age 18 or younger. Comparisons between primary and secondary APS patients were made with two-tailed t-tests. RESULTS Twenty-one patients were included with a median age at diagnosis of 16 years and median follow-up of 5.8 years. Secondary APS was slightly more common than primary APS (11 vs. 10 cases) and was primarily diagnosed in the context of systemic lupus erythematosus. Two thirds of patients (67%) also had "non-criteria" manifestations of APS including thrombocytopenia, autoimmune hemolytic anemia, and livedo reticularis/racemosa. Almost half of patients (43%) had recurrent thrombosis, typically when patients were subtherapeutic or non-adherent with anticoagulation. Damage Index in Patients with Thrombotic APS (DIAPS) scores indicated a chronic burden of disease in both primary and secondary APS patients. CONCLUSION This case series of pediatric APS provides important context regarding disease phenotypes displayed by children with APS. High prevalence of non-criteria clinical manifestations highlights the need to consider these characteristics when developing pediatric-specific classification criteria and when considering this relatively rare diagnosis in pediatric practice.
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Affiliation(s)
- Jacqueline A. Madison
- grid.214458.e0000000086837370Department of Pediatrics, Division of Pediatric Rheumatology, University of Michigan, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Kelsey Gockman
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Claire Hoy
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Ajay Tambralli
- grid.214458.e0000000086837370Department of Pediatrics, Division of Pediatric Rheumatology, University of Michigan, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Yu Zuo
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Jason S. Knight
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
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OUP accepted manuscript. Rheumatology (Oxford) 2022; 61:4465-4471. [DOI: 10.1093/rheumatology/keac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/19/2022] [Indexed: 11/14/2022] Open
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Hasbani GE, Taher AT, Sunji N, Sciascia S, Uthman I. Antiphospholipid antibodies and cerebrovascular thrombosis in the pediatric population: Few answers to many questions. Lupus 2021; 30:1365-1377. [PMID: 34082580 DOI: 10.1177/09612033211021488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Most of the knowledge in pediatric antiphospholipid syndrome (APS) is derived from studies performed on the adult population. As in adults, antiphospholipid antibodies (aPL) can contribute to thrombosis, especially cerebrovascular thrombosis, in neonates and children. Since aPL have the potential to cross the placental barrier, and since the pediatric population is prone to infections, re-testing for their positivity is essential to specify their role in cerebrovascular thrombosis.In this review, we aimed at assessing the prevalence of aPL, criteria or non-criteria, in neonatal and childhood ischemic stroke and sinovenous thrombosis trying to find an association between aPL and cerebrovascular thrombosis in the neonatal and pediatric population. Also, we looked into the effect of aPL and anticoagulants/antiplatelets on the long term neurological outcomes of affected neonates or children. The questions regarding the prevalence of aPL among pediatric patients with cerebrovascular thrombosis, the relationship between the titers of aPL and incidence and recurrence of cerebrovascular events, the predictability of the long term neurological outcomes, and the most optimal anticoagulation plan are still to be answered. However, it is crucial for clinicians to screen neonates and children with cerebrovascular thrombosis for aPL and confirm their presence if positive.
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Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadine Sunji
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy.,Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy.,Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Imad Uthman
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Rosina S, Chighizola CB, Ravelli A, Cimaz R. Pediatric Antiphospholipid Syndrome: from Pathogenesis to Clinical Management. Curr Rheumatol Rep 2021; 23:10. [PMID: 33511497 PMCID: PMC7843475 DOI: 10.1007/s11926-020-00976-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Elucidating the pathogenic mechanisms mediated by antiphospholipid antibodies (aPL) might exert important clinical implications in pediatric antiphospholipid syndrome (APS). RECENT FINDINGS aPL are traditionally regarded as the main pathogenic players in APS, inducing thrombosis via the interaction with fluid-phase and cellular components of coagulation. Recent APS research has focused on the role of β2 glycoprotein I, which bridges innate immunity and coagulation. In pediatric populations, aPL should be screened in appropriate clinical settings, such as thrombosis, multiple-organ dysfunction, or concomitant systemic autoimmune diseases. Children positive for aPL tests often present non-thrombotic non-criteria manifestations or asymptomatic aPL positivity. In utero aPL exposure has been suggested to result in developmental disabilities, warranting long-term follow-up. The knowledge of the multifaceted nature of pediatric APS should be implemented to reduce the risk of underdiagnosing/undertreating this condition. Hopefully, recent pathogenic insights will open new windows of opportunity in the management of pediatric APS.
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Affiliation(s)
- Silvia Rosina
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Cecilia Beatrice Chighizola
- Experimental Laboratory of Immunological and Rheumatologic Researches, Immunology and Rheumatology Unit, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, Cusano Milanino, 20095, Milan, Italy.
| | - Angelo Ravelli
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,University of Genoa, Genoa, Italy.,Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,RECAP_RD, University of Milan, Milan, Italy.,Pediatric Rheumatology Unit, ASST G. Pini & CTO, Milan, Italy
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10
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Safety of dabigatran etexilate for the secondary prevention of venous thromboembolism in children. Blood 2020; 135:491-504. [PMID: 31805182 DOI: 10.1182/blood.2019000998] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 11/21/2019] [Indexed: 02/07/2023] Open
Abstract
This open-label, single-arm, prospective cohort trial is the first phase 3 safety study to describe outcomes in children treated with dabigatran etexilate for secondary venous thromboembolism (VTE) prevention. Eligible children aged 12 to <18 years (age stratum 1), 2 to <12 years (stratum 2), and >3 months to <2 years (stratum 3) had an objectively confirmed diagnosis of VTE treated with standard of care (SOC) for ≥3 months, or had completed dabigatran or SOC treatment in the DIVERSITY trial (NCT01895777) and had an unresolved clinical thrombosis risk factor requiring further anticoagulation. Children received dabigatran for up to 12 months, or less if the identified VTE clinical risk factor resolved. Primary end points included VTE recurrence, bleeding events, and mortality at 6 and 12 months. Overall, 203 children received dabigatran, with median exposure being 36.3 weeks (range, 0-57 weeks); 171 of 203 (84.2%) and 32 of 203 (15.8%) took capsules and pellets, respectively. Overall, 2 of 203 children (1.0%) experienced on-treatment VTE recurrence, and 3 of 203 (1.5%) experienced major bleeding events, with 2 (1.0%) reporting clinically relevant nonmajor bleeding events, and 37 (18.2%) minor bleeding events. There were no on-treatment deaths. On-treatment postthrombotic syndrome was reported for 2 of 162 children (1.2%) who had deep vein thrombosis or central-line thrombosis as their most recent VTE. Pharmacokinetic/pharmacodynamic relationships of dabigatran were similar to those in adult VTE patients. In summary, dabigatran showed a favorable safety profile for secondary VTE prevention in children aged from >3 months to <18 years with persistent VTE risk factor(s). This trial was registered at www.clinicaltrials.gov as #NCT02197416.
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11
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Sarecka-Hujar B, Kopyta I. Antiphospholipid syndrome and its role in pediatric cerebrovascular diseases: A literature review. World J Clin Cases 2020; 8:1806-1817. [PMID: 32518771 PMCID: PMC7262698 DOI: 10.12998/wjcc.v8.i10.1806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/10/2020] [Accepted: 04/26/2020] [Indexed: 02/05/2023] Open
Abstract
Antiphospholipid syndrome (APS) or Hughes syndrome is an acquired thromboinflammatory disorder. Clinical criteria of APS diagnosis are large- and small-vessel thrombosis as well as obstetric problems; laboratory criteria are the presence of antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibodies and anti-β2-glycoprotein-1). The presence of at least 1 clinical and 1 laboratory criterion allows definitive diagnosis of APS. Primary APS is diagnosed in patients without features of connective tissue disease; secondary APS is diagnosed in patients with clinical signs of autoimmune disease. A high frequency of catastrophic APS as well as a high tendency to evolve from primary APS to secondary syndrome during the course of lupus and lupus-like disease is a feature of pediatric APS. The most characteristic clinical presentation of APS in the pediatric population is venous thrombosis, mainly in the lower limbs, and arterial thrombosis causing ischemic brain stroke. Currently, no diagnostic criteria for pediatric APS exist, which probably results in an underestimation of the problem. Similarly, no therapeutic procedures for APS specific for children have yet been established. In the present literature review, we discussed data concerning APS in children and its role in cerebrovascular diseases, including pediatric arterial ischemic stroke, migraine and cerebral venous thrombosis.
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Affiliation(s)
- Beata Sarecka-Hujar
- Department of Basic Biomedical Science, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, Sosnowiec 41200, Poland
| | - Ilona Kopyta
- Department of Paediatric Neurology, School of Medicine in Katowice, Medical University of Silesia in Katowice, Sosnowiec 41200, Poland
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12
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Abstract
PURPOSE OF REVIEW The purpose of this report is to review recent research findings on APS in children and neonates. RECENT FINDINGS European evidence-based recommendations for diagnosis and treatment of pediatric APS has recently been published by the SHARE Initiative. Recent studies have shown a high prevalence of non-thrombotic manifestations in children with aPL, domains 4/5 specificity of 'innocent' anti-β2GPI antibodies in infants, and a higher risk for developmental delays and learning disabilities, hence, the need for neurodevelopmental monitoring in children born to mothers with APS. An International effort on creating a new diagnostic criteria for APS is underway. Pediatric APS is a rare disease with significant differences from the APS in adults. Majority of the children with persistently positive aPL do not develop thrombotic events; however, relatively higher proportion of thrombosis in children is related to aPL positivity compared to adults; this may partly be due to the absence of common pro-thrombotic "second-hit" risk factors of adults such as atherosclerosis and cigarette smoking. Diagnosis of APS in children may be delayed or missed when adult APS criteria are used, because in pediatric APS, non-thrombotic clinical manifestations such as thrombocytopenia, hemolytic anemia, and neurological disorders such as migraine, epilepsy, and chorea may precede thrombotic manifestations. Around 20% of the children initially diagnosed with primary APS eventually develop SLE. Neonatal APS is rare; however, the offspring of mothers with APS are at a higher risk for developmental delays and learning disabilities; prematurity and IUGR may increase this risk. Regular assessment of neurodevelopmental status of these children should be performed. Thrombosis is a rare event in the offspring of mothers with APS; anticoagulation of such infants is not recommended. An international effort to create a new diagnostic criteria for APS is underway.
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Affiliation(s)
- Arzu Soybilgic
- Pediatric Rheumatology, Children's Hospital of University of Illinois, 840 S. Wood St, 1206 CSB, Chicago, 60612, USA.
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, Children's Hospital, University Medical Center, Faculty of Medicine, University of Ljubljana, Bohoriceva 20, 1525, Ljubljana, Slovenia
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13
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Madison JA, Zuo Y, Knight JS. Pediatric antiphospholipid syndrome. Eur J Rheumatol 2020; 7:S3-S12. [PMID: 31804173 PMCID: PMC7004270 DOI: 10.5152/eurjrheum.2019.19160] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022] Open
Abstract
Despite its potential to cause significant morbidity in children, pediatric antiphospholipid syndrome (APS) is an understudied condition. In this review, we will cover what is known about pediatric APS epidemiology and how the clinician might approach the diagnosis of pediatric APS. We will highlight similarities and differences with the adult disease, both for primary APS and in the context of lupus. Clinical manifestations beyond thrombosis, especially neurologic and hematologic in nature, will be discussed. We will also consider what unique implications antiphospholipid antibody-positivity may have for children with lupus and for neonates born to mothers with APS. The approach to treatment will be covered, including the unique impact of APS medications on children as compared with adults. Finally, the importance of future mechanistic research is emphasized as physicians endeavor to provide the personalized care that children with APS clearly deserve.
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Affiliation(s)
- Jacqueline A. Madison
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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14
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Giani T, Mauro A, Ferrara G, Cimaz R. Case Report: Infantile Ischemic Stroke and Antiphospholipid Antibodies, Description of Four Cases. Front Pediatr 2020; 8:596386. [PMID: 33330290 PMCID: PMC7732433 DOI: 10.3389/fped.2020.596386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/28/2020] [Indexed: 12/20/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a rare condition in childhood, but even more in the neonatal age. Most neonatal cases are considered a passively acquired autoimmune disease, due to a transplacental passage of maternal antiphospholipid antibodies (aPL) from mothers with primary or secondary APS or, more often, from asymptomatic aPL carriers. Exceedingly unusual is the neonatal de novo production of aPL. We present four infants with presumed perinatal stroke in presence of increased and persistent aPL levels, even after 6 months of life, opening the window on a gray zone related to the origin of these antibodies (maternal or neonatal) and on their role in the pathogenesis of stroke.
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Affiliation(s)
- Teresa Giani
- Azienda Ospedaliera Universitaria Meyer, Florence, Italy.,Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Angela Mauro
- Emergency Department Santobono-Pausilipon Children's Hospital, Naples, Italy
| | | | - Rolando Cimaz
- Azienda Socio Sanitaria Territoriale G-Pini, Milan, Italy.,Department of Clinical Sciences and Community Health and Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy
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15
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Noureldine MHA, Nour-Eldine W, Khamashta MA, Uthman I. Insights into the diagnosis and pathogenesis of the antiphospholipid syndrome. Semin Arthritis Rheum 2018; 48:860-866. [PMID: 30217394 DOI: 10.1016/j.semarthrit.2018.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/30/2018] [Accepted: 08/14/2018] [Indexed: 11/16/2022]
Abstract
The Antiphospholipid syndrome (APS), formerly known as Anticardiolipin or Hughes syndrome, is a systemic autoimmune disorder characterized by obstetrical complications and thrombotic events affecting almost every organ-system in patients persistently testing positive for antiphospholipid antibodies (aPL). The contribution of the extra-criteria aPL to the pathogenesis of APS have exceeded the expectations of a simple, direct pathologic 'hit' leading to thrombogenesis or obstetrical complications, and more pathologic pathways are being linked directly or indirectly to aPL. The value of extra-criteria aPL is on the rise, and these antibodies are nowadays evaluated as markers for risk assessment in the diagnostic approach to APS. A diagnosis of APS should be considered in pediatric patients with suggestive clinical and laboratory picture. Management of APS remains mostly based on anticoagulation, while other drugs are being tested for efficacy and side effects. Low-dose aspirin may have a role in the management of thrombotic and obstetric APS. Due to the high variability in disease severity and complication recurrence outcomes, new tools are being developed and validated to assess the damage index and quality of life of APS patients.
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Affiliation(s)
| | - Wared Nour-Eldine
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Imad Uthman
- Division of Rheumatology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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16
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Abstract
Antiphospholipid syndrome is characterized by the presence of antiphospholipid antibodies, specifically lupus anticoagulant, anticardiolipin antibodies, and anti-β2 glycoprotein-I antibodies. Antiphospholipid syndrome can occur on its own or in association with other autoimmune diseases, most commonly systemic lupus erythematosus (SLE). A connection between cigarette smoking and anti-phospholipid antibodies (aPL) was first reported in the late1980s. Systemic lupus erythematosus patients with aPL are more likely to be smokers than those without aPL. These patients have a particularly high frequency of vascular events. Recently, a potential link between periodontitis, tobacco, and aPL has been proposed. Research has also suggested that periodontitis and Porphyromonas gingivalis infection are associated with citrullination through the action of peptidylarginine deiminase. A strong correlation between smoking and the presence of citrillunated autoantibodies, which are characteristic of rheumatoid arthritis, has also been observed. While many studies have investigated possible links between infection and aPL in patients with autoimmune diseases, the association of smoking with aPL has not been systematically examined. The fact that both aPL and tobacco are risk factors for thrombosis has complicated efforts to evaluate these factors separately. Also, there has been great variability in measurement techniques, and laboratories lack routine methods for differentiating transient and persistent aPL; both of these factors can make interpretation of autoantibody results quite challenging. This review summarizes the clinical evidence supporting a posited link between aPL and smoking, both in patients with a systemic autoimmune disease and in patients with other medical conditions.
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Affiliation(s)
- Steven R Binder
- Clinical Diagnostics Group, Bio-Rad Laboratories, 4000 Alfred Nobel Drive 4-2115, Hercules, CA, 94547, USA.
| | - Christine M Litwin
- Medical University of South Carolina, 165 Ashley Ave, Suite 324G, MSC 908, Charleston, SC, 29425, USA
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17
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Wincup C, Ioannou Y. The Differences Between Childhood and Adult Onset Antiphospholipid Syndrome. Front Pediatr 2018; 6:362. [PMID: 30542645 PMCID: PMC6277799 DOI: 10.3389/fped.2018.00362] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/08/2018] [Indexed: 12/12/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a rare autoimmune disease of unknown etiology that represents a leading cause of acquired thromboembolism and recurrent miscarriage. It is characterized by the persistent elevated presence of pathogenic antiphospholipid auto-antibodies directed against cardiolipin, ß2-glycoprotein-I, and/or a positive lupus anticoagulant test. As with many autoimmune disorders, the pathogenesis of APS is believed to be the result of a complex interaction between environmental triggers and genetic predisposition. Although more common in adults, APS occasionally manifests in the neonatal period and throughout childhood. Adut-onset APS classification criteria are poorly validated to the pediatric population (in which pregnancy related complications are seldom seen) and as a result, assessment of the prevalence of the disease in childhood is difficult. Thromboembolic events seen in children include deep venous thrombosis in addition to stroke and pulmonary embolism, which can lead to significant long-term disability. The disease can be classified as either primary (when occurring in isolation) or secondary, in which the disease is diagnosed in the context of another underlying disease, most commonly systemic lupus erythematosus. A variety of laboratory and clinical difference are seen between pediatric and adult-onset APS. The marked female predominance seen in adult-onset disease is less evident in childhood where the gender split is more evenly spread. In addition, children with APS are at a higher risk of recurrent thromboembolism than adults. The treatment of childhood-onset APS is challenging due to a lack of large-scale prospective studies in the pediatric population. Therapeutic options are often based upon treatment guidelines that have been based upon literature from the adult-onset form of the disease. In the majority of cases, treatment is focused on the prevention of further thrombosis through treatment with long-term anti-coagulation therapy. The evidence for the use of antiplatelet agents (such as aspirin) and hydroxychloroquine is inconclusive. It is important to remember that anti-coagulation can have significant lifestyle implications for the child with APS and it is essential to consider potential implications relating to school and recreational activities, with contact sports often discouraged due to the increased risk of bleeding.
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Affiliation(s)
- Chris Wincup
- Department of Rheumatology, University College London, London, United Kingdom.,Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, United Kingdom
| | - Yiannis Ioannou
- Department of Rheumatology, University College London, London, United Kingdom.,Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, United Kingdom
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18
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Zia A, Russell J, Sarode R, Veeram SR, Josephs S, Malone K, Zhang S, Journeycake J. Markers of coagulation activation, inflammation and fibrinolysis as predictors of poor outcomes after pediatric venous thromboembolism: A systematic review and meta-analysis. Thromb Res 2017; 160:1-8. [PMID: 29078111 DOI: 10.1016/j.thromres.2017.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/28/2017] [Accepted: 10/03/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sequelae of venous thromboembolism (VTE) in children include recurrence, development of post thrombotic syndrome (PTS) when venous return from a limb is affected and chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism. Identification of laboratory-based risk factors may be useful for individualized risk assessment for VTE sequelae. Coagulation activation and inflammation may contribute to their pathophysiology. We performed a systematic review to investigate the association between biomarkers of coagulation activation, inflammation and fibrinolysis and adverse VTE outcomes in children and young adults. METHODS A systematic search of electronic databases, PubMed (NIH), EMBASE (Ovid), Web of Science (Thompson Reuters), and SCOPUS (Elsevier) for studies published through November 2016 was conducted using "VTE" including MeSH terms for "coagulation activation," "inflammation" and "fibrinolysis," with no limit on publication date. A study was eligible for inclusion when it evaluated patients (< 21years) with VTE and biomarkers of coagulation activation, inflammation, and fibrinolysis and assessed for their association with development of adverse thrombotic outcomes. A modified Newcastle Ottawa Scale was applied to examine the quality of included studies. RESULTS Our search strategy yielded 200 references. A total of 3 cohort studies representing 220 patients with VTE were included. Two authors independently assessed all references for inclusion. Three studies (2 prospective cohort and one mixed cohort study) were identified that reported on biomarkers of coagulation activation, inflammation and fibrinolysis, checked at least once after VTE diagnosis and assessed association with primary outcomes of recurrent VTE, PTS and CTEPH. Studies varied with regards to definition of outcomes, the type of biomarkers measured and time point of measurement. We were unable to meta-analyze results due to marked clinical heterogeneity and <3 studies available for each biomarker. Descriptively, a significant association was found for elevated plasma levels of FVIII and D-dimer for a compound outcome of PTS, recurrence and progression in one study, and positive lupus anticoagulant at DVT diagnosis and subsequent PTS by another study. No studies were found for CTEPH. CONCLUSIONS Elevated D-dimer, FVIII and lupus anticoagulant show promise for predicting recurrent VTE and PTS in children and young adults. Further research is needed to elucidate whether these markers might be useful to predict development of adverse outcomes after VTE in children.
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Affiliation(s)
- Ayesha Zia
- Division of Pediatric Hematology/Oncology; Children's Medical Center, United States; The University of Texas Southwestern Medical Center, United States.
| | - Joy Russell
- Health Sciences Digital Library and Learning Center; The University of Texas Southwestern Medical Center, United States
| | - Ravi Sarode
- Department of Pathology; The University of Texas Southwestern Medical Center, United States
| | - Surendranath R Veeram
- Children's Medical Center, United States; Division of Pediatric Interventional Cardiology; The University of Texas Southwestern Medical Center, United States
| | - Shellie Josephs
- Children's Medical Center, United States; Division of Pediatric Interventional Radiology; The University of Texas Southwestern Medical Center, United States
| | | | - Song Zhang
- The Department of Clinical Sciences; The University of Texas Southwestern Medical Center, United States
| | - Janna Journeycake
- Division of Pediatric Hematology/Oncology; Children's Medical Center, United States; The University of Texas Southwestern Medical Center, United States
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19
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Nagata H, Sato M, Ogura M, Yoshikawa T, Yamamoto K, Matsumura S, Kano Y, Saida K, Sako M, Kamei K, Yoshioka T, Ogata K, Ito S, Ishikura K. Coagulopathy as a complication of kidney biopsies in paediatric systemic lupus erythematosus patients with antiphospholipid syndrome. Nephrology (Carlton) 2017; 23:592-596. [PMID: 28976051 DOI: 10.1111/nep.13175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2017] [Indexed: 11/30/2022]
Abstract
Children with systemic lupus erythematosus (SLE) generally undergo a pretreatment kidney biopsy. However, some of these patients, especially those with antiphospholipid syndrome (APS), may experience serious coagulopathic complications. We report herein two cases of paediatric SLE with APS in which, despite normal blood test results, the disparate coagulopathic complications of haemorrhage and embolism developed following a kidney biopsy. Case 1 was, an 8-year-old male in whom, primary APS was initially diagnosed. Fourteen months later SLE was diagnosed. Based on a percutaneous kidney biopsy, International Society of Nephrology and the Renal Pathology Society (ISN/RPS) class III-A lupus nephritis was histologically diagnosed. On post-biopsy Day 9, a giant haematoma in the fascia of the left kidney developed and was accompanied by changes in the vital signs. Case 2, a 13-year-old male, initially received the diagnosis of SLE with APS and underwent two courses of pulse methylprednisolone therapy. His coagulation abnormalities improved, and a percutaneous needle kidney biopsy was performed, leading to the histological diagnosis of ISN/RPS class III-A lupus nephritis. Furthermore, thrombotic microangiopathy was also detected in the renal histopathology. On post biopsy Day 6, the patient experienced right leg pain. A contrast CT and lower extremity ultrasonography detected a massive deep vein thrombosis and partial left pulmonary artery thrombosis. A kidney biopsy in children with SLE and APS can cause lethal coagulopathic complications, and the risks to such patients should be weighed carefully before the procedure is performed.
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Affiliation(s)
- Hiroko Nagata
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Takahisa Yoshikawa
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kazuna Yamamoto
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Sohshi Matsumura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Yuji Kano
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Ken Saida
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Mayumi Sako
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Takako Yoshioka
- Department of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Kentaro Ogata
- Department, of Pathology, Federation of National Public Service Mutual Aid Associations, Tachikawa Hospital, Tokyo, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
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20
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Lehman LL, Beaute J, Kapur K, Danehy AR, Bernson-Leung ME, Malkin H, Rivkin MJ, Trenor CC. Workup for Perinatal Stroke Does Not Predict Recurrence. Stroke 2017; 48:2078-2083. [DOI: 10.1161/strokeaha.117.017356] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/09/2017] [Accepted: 06/14/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Laura L. Lehman
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Jeanette Beaute
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Kush Kapur
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Amy R. Danehy
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Miya E. Bernson-Leung
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Hayley Malkin
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Michael J. Rivkin
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
| | - Cameron C. Trenor
- From the Stroke and Cerebrovascular Center (L.L.L., J.B., A.R.D., M.E.B.-L., H.M., M.J.R., C.C.T.), Departments of Neurology (L.L.L., J.B., K.K., M.E.B.-L., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J.R.), and Division of Hematology/Oncology (H.M., C.C.T.), Boston Children’s Hospital, Harvard Medical School, MA
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21
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Clinical characteristics and thrombosis outcomes of paediatric antiphospholipid syndrome: analysis of 58 patients. Clin Rheumatol 2017; 37:1295-1303. [PMID: 28748509 DOI: 10.1007/s10067-017-3776-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 06/22/2017] [Accepted: 07/19/2017] [Indexed: 12/28/2022]
Abstract
The study aims to analyse the clinical and immunological manifestations of paediatric antiphospholipid syndrome (APS) in patients, based on the 2006 revised classification criteria of definite APS. Fifty-eight paediatric patients with APS were enrolled and analysed retrospectively. A total of 37 female and 21 male patients with a mean age of 14 ± 3 years at disease onset were included. Fourteen (24%) cases were primary APS, and 40 (69%) cases were secondary to systemic lupus erythaematosus (SLE). Anti-nuclear antibody (ANA) positivity and hypocomplementemia were more common in secondary APS than in primary APS. The most common manifestations of thrombosis were deep vein thrombosis of the lower extremities (25 cases, 37%). Non-thrombotic manifestations were mainly immunologic thrombocytopenia, autoimmune haemolytic anaemia, skin lesions, arthritis, pulmonary hypertension, heart valve vegetations and spontaneous abortion. LA, ACL and anti-β2GPI were positive in 42 (95%), 28 (64%) and 34 (77%) cases, respectively. Over half (23 cases, 52%) of the patients were triple-positive for antiphospholipid (aPL) antibodies. Among patients with single-positive LA and anti-β2GPI, the proportion with venous thrombosis was 100% (5 cases) and 0% (0 cases), respectively. The arterial thrombosis proportions were 22% (5 cases), 21% (3 cases) and 14% (1 case) in the triple-, double- and single-aPL-positive groups, respectively (P > 0.05). Fifty-three (91%) cases were followed up for 3 to 140 months, with a median time of 32 months. Seven (13%) cases had recurrences or appearances of thrombosis during follow-up, all of which were double- or triple-aPL positive. APS in the paediatric patients is mostly secondary to SLE. ANA positivity and hypocomplementemia are more common in secondary APS, but there are no differences in the other clinical manifestations between the primary and secondary APS groups. Deep vein thrombosis is the most common thrombotic event. Positive LA may increase the risk of venous thrombosis. Multiple-aPL positivity does not increase the proportion of thrombosis. Long-term anticoagulant or antiplatelet therapy is needed to prevent thrombosis recurrence in double- or triple-positive aPL cases.
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Meroni PL, Argolini LM, Pontikaki I. What is known about pediatric antiphospholipid syndrome? Expert Rev Hematol 2017; 9:977-85. [PMID: 27615277 DOI: 10.1080/17474086.2016.1235969] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by vascular thrombosis and/or pregnancy morbidity associated with the persistent presence of antiphospholipid antibodies (aPL) including lupus anticoagulant (LA), anticardiolipin antibodies (aCL), and anti-β2 glycoprotein I antibodies (aβ2GPI). AREAS COVERED APS is considered as the most common acquired hypercoagulation state of autoimmune origin in children. Unfortunately, data about incidence, prevalence, thrombosis risk and effective treatment in paediatric APS are limited and unmethodical. Expert commentary: This review summarizes recent clinical, laboratory and therapy characterization of paediatric APS and emphasizes the differences between paediatric and adult populations.
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Affiliation(s)
- Pier Luigi Meroni
- a Rheumatology , Gaetano Pini Institute, Center of Pediatric Rheumatology, Chair of Rheumatology, University of Milan , Milan , Italy.,b Experimental Laboratory of Immunorheumatology , IRCCS Istituto Auxologico Italiano , Cusano Milanino , Italy.,c Department of Clinical Sciences and Community Health , University of Milan , Milan , Italy
| | - Lorenza Maria Argolini
- a Rheumatology , Gaetano Pini Institute, Center of Pediatric Rheumatology, Chair of Rheumatology, University of Milan , Milan , Italy
| | - Irene Pontikaki
- a Rheumatology , Gaetano Pini Institute, Center of Pediatric Rheumatology, Chair of Rheumatology, University of Milan , Milan , Italy
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Groot N, de Graeff N, Avcin T, Bader-Meunier B, Dolezalova P, Feldman B, Kenet G, Koné-Paut I, Lahdenne P, Marks SD, McCann L, Pilkington CA, Ravelli A, van Royen-Kerkhof A, Uziel Y, Vastert SJ, Wulffraat NM, Ozen S, Brogan P, Kamphuis S, Beresford MW. European evidence-based recommendations for diagnosis and treatment of paediatric antiphospholipid syndrome: the SHARE initiative. Ann Rheum Dis 2017; 76:1637-1641. [PMID: 28473426 DOI: 10.1136/annrheumdis-2016-211001] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/13/2017] [Accepted: 03/25/2017] [Indexed: 12/14/2022]
Abstract
Antiphospholipid syndrome (APS) is rare in children, and evidence-based guidelines are sparse. Consequently, management is mostly based on observational studies and physician's experience, and treatment regimens differ widely. The Single Hub and Access point for paediatric Rheumatology in Europe (SHARE) initiative was launched to develop diagnostic and management regimens for children and young adults with rheumatic diseases. Here, we developed evidence-based recommendations for diagnosis and treatment of paediatric APS. Evidence-based recommendations were developed using the European League Against Rheumatism standard operating procedure. Following a detailed systematic review of the literature, a committee of paediatric rheumatologists and representation of paediatric haematology with expertise in paediatric APS developed recommendations. The literature review yielded 1473 articles, of which 15 were valid and relevant. In total, four recommendations for diagnosis and eight for treatment of paediatric APS (including paediatric Catastrophic Antiphospholipid Syndrome) were accepted. Additionally, two recommendations for children born to mothers with APS were accepted. It was agreed that new classification criteria for paediatric APS are necessary, and APS in association with childhood-onset systemic lupus erythematosus should be identified by performing antiphospholipid antibody screening. Treatment recommendations included prevention of thrombotic events, and treatment recommendations for venous and/or arterial thrombotic events. Notably, due to the paucity of studies on paediatric APS, level of evidence and strength of the recommendations is relatively low. The SHARE initiative provides international, evidence-based recommendations for diagnosis and treatment for paediatric APS, facilitating improvement and uniformity of care.
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Affiliation(s)
- Noortje Groot
- Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands.,Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Nienke de Graeff
- Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands
| | - Tadej Avcin
- University Children's Hospital, University Medical Centre, Ljubljana, Slovenia
| | | | - Pavla Dolezalova
- General University Hospital, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Brian Feldman
- The Hospital for Sick Children, University of Toronto, Canada
| | - Gili Kenet
- The Israel National Hemophilia Centre, Sackler Medical School, Sheba Medical Centre, Tel-Hashomer, Tel Aviv, Israel
| | | | - Pekka Lahdenne
- Hospital for Children and Adolescents, University of Helsinki, Finland
| | - Stephen D Marks
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Liza McCann
- Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
| | | | - Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genova, Italy
| | | | - Yosef Uziel
- Meir Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Sebastiaan J Vastert
- Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands
| | - Nico M Wulffraat
- Wilhelmina Children's Hospital, University Medical Centre, Utrecht, The Netherlands
| | - Seza Ozen
- Department of Pediatrics, Hacettepe University Medical Faculty, Ankara, Turkey
| | - Paul Brogan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sylvia Kamphuis
- Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Michael W Beresford
- Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, UK.,University of Liverpool, Liverpool, UK
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A retrospective review of pediatric antiphospholipid syndrome and thrombosis outcomes. Blood Coagul Fibrinolysis 2017; 28:205-210. [PMID: 27428014 DOI: 10.1097/mbc.0000000000000576] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
: Pediatric antiphospholipid syndrome (APS) is characterized by vascular thromboses and multisystem involvement associated with persistently positive antiphospholipid antibodies testing. There is limited literature regarding risk factors for development of thrombosis and long-term thrombotic outcomes in pediatric APS. The objective of our study was to review our institutional experience with pediatric APS and thrombosis outcomes. We conducted a 20-year retrospective review to study the clinical features, management, and long-term outcomes of patients between ages 6 months and 18 years diagnosed with APS. Seventeen patients (7 female; 10 male), with median age at first thrombosis being 15.3 years (range: 0.63-17.98 years) were included. The median follow-up period was 4.3 years (range: 0.8-16.9 years). Venous thrombosis was noted in 11 patients (64.7%) with arterial events occurring in six patients (35.3%). Nine (53%) patients were noted to have primary APS. Recurrent and/or progressive thrombotic events occurred in 10 patients (58.8%), which is higher than reported literature. The median time for recurrence/progression was 1.4 years (range: 0.37-11.85 years). At the time of recurrence/progression, only two (20%) patients were at therapeutic levels of anticoagulation. The high recurrence rate with majority of patients not being on therapeutic levels of anticoagulation at the time of the event along with 60% of recurrent events occurring at least 1 year from first vascular event suggests the possible need for long-term anticoagulation. However, larger pediatric studies are required to assess the need for long-term/indefinite anticoagulation.
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Rumsey DG, Myones B, Massicotte P. Diagnosis and treatment of antiphospholipid syndrome in childhood: A review. Blood Cells Mol Dis 2017; 67:34-40. [PMID: 28283251 DOI: 10.1016/j.bcmd.2017.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/23/2017] [Accepted: 02/26/2017] [Indexed: 01/14/2023]
Abstract
The antiphospholipid syndrome (APS) is a multisystem autoimmune disease characterized by recurrent fetal loss and thromboembolic events associated with the presence of elevated titres of antiphospholipid antibodies (aPL). The purpose of this review is to summarize what is currently known about the diagnosis and treatment of pediatric APS, to highlight key differences between APS presenting in adults versus children throughout, and to identify areas where future research is needed.
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Affiliation(s)
- Dax G Rumsey
- Department of Pediatrics, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada.
| | - Barry Myones
- Pediatric Rheumatology, 2119 Plantation Bend Drive, Sugar Land, TX 77478, USA
| | - Patti Massicotte
- Department of Pediatrics, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada
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Abstract
Juvenile systemic lupus erythematosus (JSLE) represents 15—20% of all SLE cases. The leading presenting symptoms of JSLE are constitutional and not specific such as fatigue, headache, weight loss or mood swings. They are also encountered in healthy adolescents, which explains frequent diagnosis delay. The frequency of irreversible damage is high in JSLE and involves especially the renal, musculoskeletal and neuropsychiatric systems. Although the overall prognosis has markedly improved, thanks to earlier diagnosis and new therapeutic approaches, cardiovascular, hematological events and chronic renal failure remain severe, and constitute the main disease-related causes of death. Treatment is based on hydroxycloroquine and corticosteroids. Immunosuppressive agents must be discussed to decrease the duration of corticosteroids use. New drugs and monoclonal antibodies targeting B-cells and B-cell related cytokines are being evaluated with encouraging results. Management of JSLE has to challenge three objectives: controlling disease progression, obtaining patient's adherence to treatment, and preventing consequences of medication side effects on growth, puberty, development and fertility. Patients' quality of life and psychosocial development have also to be taken into account, as well as the organization of a successful transition from paediatric to adult care. Lupus (2007) 16, 606—612.
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Affiliation(s)
- I Kone-Paut
- Department of Pediatrics and Pediatric Rheumatology, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France.
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Abstract
Pediatricians and other pediatric health care providers in primary care settings are often faced with the challenge of evaluating patients with suspected autoimmune disorders. The first and most important step in evaluating children with suspected autoimmune disorders is taking a detailed history and performing a thorough physical examination. This step helps narrow the diagnosis, and thus helps determine appropriate laboratory evaluations. The results of laboratory tests need to be interpreted within the clinical context. It is also important to recognize that the laboratory tests have different diagnostic values in children as compared to adults. [Pediatr Ann. 2016;45(7):e265-e271.].
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Abstract
Antiphospholipid syndrome (APS) is a multisystem autoimmune condition characterized by vascular thromboses associated with persistently positive antiphospholipid antibodies. There is currently a paucity of data (incidence, prevalence, thrombosis risk, and effective treatment) in pediatric APS. The purpose of this report is to review the current literature on APS in children and neonates, identify the gaps in current knowledge, and suggest avenues for studies to fill those gaps.
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Lehman LL, Watson CG, Kapur K, Danehy AR, Rivkin MJ. Predictors of Stroke After Transient Ischemic Attack in Children. Stroke 2015; 47:88-93. [PMID: 26556823 DOI: 10.1161/strokeaha.115.009904] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 10/14/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Transient ischemic attack (TIA) in children has received far less attention compared with TIA in adults. The risk factors of stroke after TIA in children are relatively unknown. We aimed to determine the percentage of children who have stroke after TIA and the risk factors associated with stroke after TIA. METHODS We searched the medical records at Boston Children's Hospital for the year 2010 to find children who were evaluated for TIA to determine associated risk factors of stroke after TIA. We included children who were evaluated in 2009 through 2010 for TIA and had magnetic resonance imaging. We examined follow-up imaging through August 2014 for subsequent stroke. Logistic regression was used to calculate odds ratios for factors in our cohort who are associated with stroke after presentation with TIA. RESULTS We identified 63 children who experienced a TIA. The mean time of imaging follow-up was 4.5 years after TIA presentation. Of the 63 children, 10 (16%) developed radiological evidence of ischemic cerebral injury within the follow-up period. Four of the 10 (6%) demonstrated diffusion abnormalities on magnetic resonance imaging at TIA presentation, whereas 8 (13%) had a stroke after their TIA. Arteriopathy, female sex, and autoimmune disorders were significantly associated with stroke after TIA. CONCLUSIONS In our cohort of children, stroke occurred after TIA at a rate similar to that seen in adults, but the risk factors for stroke after TIA in children are different.
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Affiliation(s)
- Laura L Lehman
- From the Departments of Neurology (L.L.L., C.G.W., K.K., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J. R.), Boston Children's Hospital, MA; and Departments of Radiology (A.R.D.) and Neurology (L.L.L., M.J.R.), Harvard Medical School, Boston, MA.
| | - Christopher G Watson
- From the Departments of Neurology (L.L.L., C.G.W., K.K., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J. R.), Boston Children's Hospital, MA; and Departments of Radiology (A.R.D.) and Neurology (L.L.L., M.J.R.), Harvard Medical School, Boston, MA
| | - Kush Kapur
- From the Departments of Neurology (L.L.L., C.G.W., K.K., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J. R.), Boston Children's Hospital, MA; and Departments of Radiology (A.R.D.) and Neurology (L.L.L., M.J.R.), Harvard Medical School, Boston, MA
| | - Amy R Danehy
- From the Departments of Neurology (L.L.L., C.G.W., K.K., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J. R.), Boston Children's Hospital, MA; and Departments of Radiology (A.R.D.) and Neurology (L.L.L., M.J.R.), Harvard Medical School, Boston, MA
| | - Michael J Rivkin
- From the Departments of Neurology (L.L.L., C.G.W., K.K., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J. R.), Boston Children's Hospital, MA; and Departments of Radiology (A.R.D.) and Neurology (L.L.L., M.J.R.), Harvard Medical School, Boston, MA
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Gordon O, Almagor Y, Fridler D, Mandel A, Qutteineh H, Yanir A, Reif S, Revel Vilk S. De novo neonatal antiphospholipid syndrome: A case report and review of the literature. Semin Arthritis Rheum 2014; 44:241-5. [DOI: 10.1016/j.semarthrit.2014.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 03/10/2014] [Accepted: 04/04/2014] [Indexed: 11/29/2022]
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Clinical, laboratory, and therapeutic analyses of 21 patients with neonatal thrombosis and antiphospholipid antibodies: a literature review. J Immunol Res 2014; 2014:672603. [PMID: 25133197 PMCID: PMC4124841 DOI: 10.1155/2014/672603] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 07/01/2014] [Accepted: 07/07/2014] [Indexed: 11/19/2022] Open
Abstract
Objectives. A review of the literature reports neonatal thrombosis and antiphospholipid antibodies cases through a retrospective study that focuses on the pathogenesis and main clinical and laboratory manifestations of this disease. Methods. The case reports were selected from PubMed. The keywords used to search were neonatal, antiphospholipid syndrome, thrombosis, and antiphospholipid antibodies. References that were published from 1987 to 2013 were reviewed. Results. Twenty-one cases of neonatal thrombosis and antiphospholipid antibodies were identified. Ten children were born preterm (before 37 weeks). Arterial involvement (17/21) was predominant, of which stroke (12/17) was the most prevalent clinical manifestation. Anti-cardiolipin antibodies were predominant (13/21) in the antiphospholipid antibody profiles. Treatments were based on the use of symptomatics such as antiepileptics (8/21), and 6/21 patients received heparin. There were 4 deaths (4/21); otherwise, the children recovered well, especially the neonates who suffered from strokes (9/12). Conclusion. Neonatal thrombosis and antiphospholipid antibodies are rare. The development of thrombotic manifestations in neonates seems not to be associated exclusively with the aPL, but their etiology may be linked to pre- and perinatal events. We noted good therapeutic responses, especially in stroke patients, who presented with favorable outcomes in 82% of the cases.
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Berkun Y, Simchen MJ, Strauss T, Menashcu S, Padeh S, Kenet G. Antiphospholipid antibodies in neonates with stroke--a unique entity or variant of antiphospholipid syndrome? Lupus 2014; 23:986-93. [PMID: 24729280 DOI: 10.1177/0961203314531842] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE YB current affiliation: Department of Pediatrics, Hadassah-Hebrew University Medical Center, Mount Scopus, Israel YB and MJS contributed equally to the study and should be regarded as joint first authors on this manuscript. Antiphospholipid syndrome (APS) may present with thrombosis and persistently elevated titers of antiphospholipid antibodies (aPL) in the neonatal period. Our aim was to investigate the course and impact of elevated titers of aPL in a cohort of infants presenting with either perinatal arterial ischemic stroke (PAS) or cerebral sinus vein thrombosis (CSVT) during the perinatal period. STUDY DESIGN Sixty-two infants with clinically and radiologically confirmed PAS or CSVT presenting in the neonatal period underwent thrombophilia workup that included Factor V Leiden (FVL), PII20210A mutation, MTHFR 677T polymorphism, protein C, protein S, aPL namely either circulating lupus anticoagulant (CLA), anticardiolipin antibodies (aCL) or anti-β2-glycoprotein-1 (β2GP1). Mothers also underwent thrombophilia workup. RESULTS Twelve infants with persistently elevated aPL were prospectively followed. Infants with positive aPL showed no concordance with presence of maternal aPL. All children were followed for a median of 3.5 years (range: nine months to 19 years) with repeated aPL testing every three to six months. Anticoagulant therapy initiation and therapy duration varied at the physician's discretion. In 10/12 cases aPL decreased to normal range within 2.5 years; one female with complex thrombophilia risk factors required indefinite prolonged anticoagulation. None of the infants showed recurrent thrombosis or any other APS manifestations, despite lack of prolonged anticoagulation. CONCLUSIONS The presence of aPL may be important in the pathogenesis of cerebral thrombosis in neonates. Nevertheless, the nature of thrombophilia interactions in this period and their therapeutic impact warrants further investigation.
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Affiliation(s)
- Y Berkun
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - M J Simchen
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - T Strauss
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - S Menashcu
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - S Padeh
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - G Kenet
- Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel Departments of Pediatrics; Obstetrics and Gynecology; Neonatology; Pediatric Neurology; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
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Shindo A, Wada H, Ishikawa H, Ito A, Asahi M, Ii Y, Ikejiri M, Tomimoto H. Clinical features and underlying causes of cerebral venous thrombosis in Japanese patients. Int J Hematol 2014; 99:437-40. [PMID: 24599415 DOI: 10.1007/s12185-014-1550-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 02/12/2014] [Accepted: 02/13/2014] [Indexed: 01/08/2023]
Abstract
The clinical symptoms, causative factors, and prognosis in Japanese patients with cerebral venous thrombosis have not been adequately characterized. The present study describes these features in patients in Japan. Twenty-two patients with cerebral venous thrombosis were retrospectively identified. Diagnosis was confirmed by either digital subtraction angiography, magnetic resonance venography, or contrast-enhanced computed tomography. Demographic data and clinical and radiological features were recorded and analyzed for each patient. Prognosis was evaluated by the modified Rankin scale (mRS) at the time of hospital discharge. The most frequent symptom of cerebral venous thrombosis was headache (59.1 %). Causative factors included congenital thrombophilia (31.8 %), acquired thrombophilia (27.3 %), and iron-deficiency anemia (13.6 %). Of seven patients with congenital thrombophilia, four had mutations in the protein S gene, two had mutations in the protein C gene, and one had mutations in the antithrombin gene. All patients were alive at discharge from hospital. Nineteen of the 22 patients (86.4 %) recovered completely or exhibited only mild residual symptoms (mRS 0-2). However, three patients (13.6 %) had a poor prognosis (mRS 3-5). Cerebral venous thrombosis in Japanese patients is frequently associated with congenital thrombophilia and protein S gene mutation.
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Affiliation(s)
- Akihiro Shindo
- Department of Neurology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan,
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Abstract
Compared to adults, venous thromboembolism in the pediatric population is a rare event. Cancer, cardiac disease, antiphospholipid antibodies, and indwelling catheters are established risk factors for thromboembolism in children. We examined the literature related to thrombophilia in children, childhood cancer and thrombosis, cardiac disease and thrombosis, and antiphospholipid antibody syndrome in children. Citations in identified articles yielded additional articles for review. We found that studies of acquired thrombophilia in children are limited. Current treatment for thromboembolism in children is based on adult data therefore optimal treatment in this population remains unclear.
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Affiliation(s)
- Jaszianne Tolbert
- Division of Pediatric Hematology/Oncology/BMT, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
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Familial antiphospholipid syndrome presenting as bivessel arterial occlusion in a 17-year-old girl. Rheumatol Int 2013; 33:1359-62. [DOI: 10.1007/s00296-011-2300-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 12/10/2011] [Indexed: 10/14/2022]
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Abstract
Abstract
The incidence of venous thromboembolism (VTE) in the pediatric population is increasing. Technological advances in medicine and imaging techniques, improved awareness of the disease, and longer survival of life-threatening or chronic medical conditions all contribute to the increase in VTE rates. There is a paucity of data on management of VTE based on properly designed clinical trials, but there is significant advancement in the last 2 decades. This review summarizes the progress made in pediatric thrombosis, including epidemiological changes, advances in anticoagulant agents, and outcomes of VTE.
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Rego Sousa P, Figueira R, Vasconcellos R. Neonatal stroke associated with de novo antiphospholipid antibody and homozygous 1298C/C methylenetetrahydrofolate reductase mutation. BMJ Case Rep 2012; 2012:bcr-2012-006451. [PMID: 23162020 DOI: 10.1136/bcr-2012-006451] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Antiphospholipid antibodies are a recognised prothrombotic risk factor associated with acute ischaemic infarction. Most autoimmune diseases are rare in infants, and in the neonatal period, autoimmunity is related to transplacental passage of maternal immunoglobulin G autoantibodies. Distinguishing between de novo and acquired autoimmunity has important therapeutic implications and is crucial for determining the prognosis. We present a case of a neonatal thrombotic stroke associated with de novo synthesis of antiphospholipid antibodies, a homozygous 1298C/C methylene-tetrahydrofolate reductase mutation and a double-homozygous plasminogen activator inhibitor 1 polymorphism (PAI-1 844A/A and 675 4G/4G), which may have increased the final thrombotic risk. Her mother was not positive for antiphospholipid antibodies. The authors highlight an unequivocal evidence of a de novo case of paediatric antiphospholipid antibody syndrome and emphasise the need for a thorough investigation in cases of neonatal stroke including molecular thrombophilia study.
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Affiliation(s)
- Paulo Rego Sousa
- Department of Paediatrics, Paediatric Neurology Unit, Hospital Central do Funchal, Funchal, Portugal.
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Merlin E, Doré E, Chabrier S, Biard M, Marques-Verdier A, Stéphan JL. A case of infantile de novo primary antiphospholipid syndrome revealed by a neonatal arterial ischemic stroke. J Child Neurol 2012; 27:1340-2. [PMID: 23007300 DOI: 10.1177/0883073811435238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The few cases of antiphospholipid syndrome that have been reported in neonates are believed to have resulted from a transplacental transfer of antiphospholipid antibodies. Here we report on a boy with a neonatal stroke revealing a de novo primary antiphospholipid, the mother being free of antiphospholipid antibodies. Other thrombosis risk factors included primiparity, gestational diabetes, macrosomia, polyglobulia, and lipoprotein(a) >30 mg/dL. Anti-cardiolipin and anti-β(2)-glycoprotein I persisted more than 2 years. Under aspirin therapy, the child did not exhibit recurrence of thrombotic events or symptoms of autoimmunity after a follow-up of 3 years. Our case indicates that clinicians should consider a second retesting for anticardiolipin antibodies and anti-β(2)-glycoprotein I antibodies, even when children and mother neonatal tests are negative.
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Estepp JH, Smeltzer M, Reiss UM. The impact of quality and duration of enoxaparin therapy on recurrent venous thrombosis in children. Pediatr Blood Cancer 2012; 59:105-9. [PMID: 22106013 DOI: 10.1002/pbc.23396] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 09/20/2011] [Indexed: 01/06/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) and recurrent venous thromboembolism (rVTE) are rare, but significant problems in pediatrics. Current recommendations for anticoagulant therapy arise from adult literature, and there is little data on clinical outcomes following therapeutic low-molecular-weight heparin in children. METHOD All patients <19 years of age that were diagnosed with a VTE or right atrial thrombus via standard imaging methods at St. Jude Children's Research Hospital were retrospectively identified from January 2004 through August 2008. Demographic characteristics, coexisting clinic conditions, description of anticoagulant therapy, and record of rVTE were chronicled following a comprehensive chart review. Descriptive statistics of clinical characteristics and anticoagulation are presented. RESULTS Venous thrombosis was identified in 149 children with 21% (31/149) developing a rVTE. Coexisting clinical conditions were identified in 93% of children at initial diagnosis with 48% (71/149) of patients having a coexisting malignancy. Seventy-seven percent (114/149) of children received anticoagulant therapy with UFH (10/114) or enoxaparin (104/114). Neither duration of enoxaparin therapy (>6, 3-6, <3 months) (P = 0.61), nor quality of therapy (≥75% of time on anticoagulation spent with an anti-FXa of 0.5-1.0 U/ml) (P = 1.0) were found to be protective against rVTE. CONCLUSION Anticoagulation with enoxaparin based on adult literature may be suboptimal in preventing rVTE in pediatric populations. Future prospective randomized controlled trials in pediatrics using clinical outcomes with anticoagulant therapy are urgently needed.
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Affiliation(s)
- Jeremie H Estepp
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee 38105-3678, USA.
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Frequent association of thrombophilia in cerebral venous sinus thrombosis. Int J Hematol 2012; 95:257-62. [DOI: 10.1007/s12185-012-1006-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 01/05/2012] [Accepted: 01/10/2012] [Indexed: 10/14/2022]
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Nowak-Göttl U, Kurnik K, Manner D, Kenet G. Thrombophilia testing in neonates and infants with thrombosis. Semin Fetal Neonatal Med 2011; 16:345-8. [PMID: 21835708 DOI: 10.1016/j.siny.2011.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
In neonates and infants with idiopathic venous thrombosis (VTE) and in pediatric populations in which thromboses were associated with medical diseases, inherited thrombophilia (IT) have been described as risk factors. Follow-up data for VTE recurrence in neonates suggest a recurrence rate between 3% in provoked and 21% in idiopathic VTE. Apart from underlying medical conditions, recently reported systematic reviews on pediatric VTE have shown significant associations between factor V G1691A, factor II G20210A, and deficiencies of protein C, protein S and antithrombin, even more pronounced when combined IT were involved. Independent from the age at first VTE onset, the pooled odds ratios (OR: single IT) for VTE ranged from 2.4 for the factor II G20210A mutation to 9.4 in neonates and infants with antithrombin deficiency. The pooled OR for persistent antiphospholipid antibodies/lupus anticoagulants was 4.9 for pediatric patients with venous VTE. The factor II G20210A mutation (OR: 2.1), and deficiencies of protein C (OR: 2.4), S (OR: 3.1) and antithrombin (OR: 3.0) also played a significant role at recurrence. Based on these data, screening and treatment algorithms must be discussed.
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Affiliation(s)
- Ulrike Nowak-Göttl
- Department of Coagulation and Hemostasis, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, Building 17, Campus Kiel, D-24105 Kiel, Germany.
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Chaturvedi S, Brandao L, Geary D, Licht C. Primary antiphospholipid syndrome presenting as renal vein thrombosis and membranous nephropathy. Pediatr Nephrol 2011; 26:979-85. [PMID: 21431428 DOI: 10.1007/s00467-011-1787-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 01/12/2011] [Accepted: 01/17/2011] [Indexed: 10/18/2022]
Abstract
Antiphospholipid syndrome is a multisystem auto-immune disorder characterized by thrombotic events and the presence of circulating antiphospholipid antibodies. Large vessel involvement in the form of thrombosis/stenosis and thrombotic microangiopathy is a commonly described renal finding. However, non-thrombotic glomerulopathies are increasingly being recognized in patients with antiphospholipid syndrome. We report a rare occurrence of both renal vein thrombosis and membranous nephropathy in a previously healthy adolescent male. Investigations revealed persistently positive antiphospholipid antibodies in the absence of an underlying systemic autoimmune disorder or malignancy. Our patient responded favourably to anti-proteinuric therapy and anticoagulation with complete resolution of proteinuria and a nearly occlusive thrombus.
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Affiliation(s)
- Swasti Chaturvedi
- Division of Nephrology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Spalice A, Del Balzo F, Perla FM, Papetti L, Nicita F, Ursitti F, Properzi E. Pediatric cerebellar stroke associated with elevated titer of antibodies to β2-glycoprotein. Med Hypotheses 2011; 76:831-3. [PMID: 21388749 DOI: 10.1016/j.mehy.2011.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 02/04/2011] [Accepted: 02/14/2011] [Indexed: 10/18/2022]
Abstract
Antibodies to 2-glycoprotein I (anti-2GPI) have been associated with recurrent thrombosis and pregnancy morbidity. However, the prevalence of anti-2GPI in children suffering from cerebral and cerebellar infarction is unknown. We report on a 10-month-old boy who had an ischemic cerebellar stroke, secondary to antiphospholipid syndrome with high titers of immunoglobulin G anti-2GPI (first titer: 132U) anticardiolipin antibodies and lupus anticoagulant tests were negative. All other causes of infarction were excluded. To our knowledge, this is the first reported case of childhood cerebellar ischemic stroke with only anti-2GPI but no antibodies detectable in standard antiphospholipid assays.
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Affiliation(s)
- Alberto Spalice
- Department of Pediatrics, Division of Child Neurology, University La Sapienza, Roma, Italy.
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Bernard TJ, Manco-Johnson MJ, Goldenberg NA. The roles of anatomic factors, thrombophilia, and antithrombotic therapies in childhood-onset arterial ischemic stroke. Thromb Res 2011; 127:6-12. [PMID: 20947137 PMCID: PMC3204859 DOI: 10.1016/j.thromres.2010.09.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 09/01/2010] [Accepted: 09/15/2010] [Indexed: 11/28/2022]
Abstract
Childhood-onset arterial ischemic stroke (AIS) is a rare disorder with high risks of both recurrent stroke and life-long neurological morbidity. Anatomic risk factors for primary and/or recurrent AIS include a venous thrombotic source for paradoxical embolism via a patent foramen ovale, primary cardioembolism, extracranial dissection, and intracranial arteriopathies, among others. Genetic and acquired thrombophilias are common, some of which have been shown to have prognostic influence on risk of recurrent AIS. While knowledge of childhood AIS risk factors has grown considerably in recent years, an evidence-based understanding of optimal antithrombotic therapy strategies has not yet been attained. Consensus-based guidelines have been developed, but future research must emphasize identification of additional prognostic factors and the initiation of cooperative randomized controlled clinical trials.
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Affiliation(s)
- Timothy J Bernard
- Department of Pediatrics, Section of Child Neurology, Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado Denver and The Children's Hospital, Aurora, Colorado, USA.
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Kim SH, Hwang H, Chae JH, Kim KJ, Hwang YS, Lim BC. Ischemic stroke in a 7-month-old infant with antiphospholipid antibody and homozygous C677T methylenetetrahydrofolate reductase (MTHFR) polymorphism. J Child Neurol 2010; 25:1047-50. [PMID: 20110213 DOI: 10.1177/0883073809356710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Prothrombotic risk factors in children with ischemic stroke have been increasingly recognized with recent developments in technology. Extensive evaluation including a detailed family history is required to identify various inherited or acquired prothrombotic conditions. We report a 7-month-old male who presented with right hemiparesis. Acute cerebral infarction in the area supplied by the left lenticulostriate artery was confirmed through magnetic resonance imaging. De novo synthesis of antiphospholipid antibodies and homozygous methylenetetrahydrofolate reductase (MTHFR) polymorphism were identified as presumed prothrombotic risk factors. His twin sister and mother were also positive for antiphospholipid antibodies. Multiple risk factors for ischemic stroke should be considered, particularly in the perinatal and infancy period. This case also underlines the rare familial occurrence of antiphospholipid antibodies and its relationship to ischemic stroke in infancy.
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Affiliation(s)
- Se Hee Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Papadimitraki ED, Isenberg DA. Childhood- and adult-onset lupus: an update of similarities and differences. Expert Rev Clin Immunol 2010; 5:391-403. [PMID: 20477036 DOI: 10.1586/eci.09.29] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multifactorial autoimmune rheumatic disease. Although its highest prevalence is among women of childbearing age, the disease is not confined within this population. A total of 15-20% of cases of SLE are diagnosed in children younger than 16 years (childhood-onset lupus). Although there have been few studies directly comparing childhood- to adult-onset lupus, there is substantial evidence to suggest that pediatric lupus patients display some differences in their disease profile compared with adult-onset populations. Overall, an increased male-to-female ratio, a higher prevalence of nephritis and CNS involvement necessitating a more sustained need for steroids and immnosuppressive drugs, and a higher prevalence of progression to end-stage renal disease are distinguishing features of childhood-onset lupus. In contrast, a higher prevalence of pulmonary involvement, arthritis and discoid lupus are reported in adult-onset SLE patients. Furthermore, childhood-onset lupus patients may experience a serious negative impact on their psychosocial and physical development, issues that pose extra challenges to healthcare providers. Growth delay, osteoporosis, the psychological effect of steroid-induced alterations of the physical image, and often poor treatment compliance are the issues that need to be addressed in pediatric lupus populations. In this review, we compare the epidemiological, clinical and laboratory features, and treatment options of childhood- and adult-onset lupus, and comment on the applicability of the instruments that measure activity, severity and cumulative disease damage in childhood-onset disease. In addition, we highlight special issues of concern for pediatric lupus patients, discussing the significance in the transition from pediatric to adult rheumatology care.
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Affiliation(s)
- Eva D Papadimitraki
- Department of Rheumatology, 3rd floor, University College Hospital, 250 Euston Road, London NW1 2PG, UK
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Kenet G, Lütkhoff LK, Albisetti M, Bernard T, Bonduel M, Brandao L, Chabrier S, Chan A, deVeber G, Fiedler B, Fullerton HJ, Goldenberg NA, Grabowski E, Günther G, Heller C, Holzhauer S, Iorio A, Journeycake J, Junker R, Kirkham FJ, Kurnik K, Lynch JK, Male C, Manco-Johnson M, Mesters R, Monagle P, van Ommen CH, Raffini L, Rostásy K, Simioni P, Sträter RD, Young G, Nowak-Göttl U. Impact of Thrombophilia on Risk of Arterial Ischemic Stroke or Cerebral Sinovenous Thrombosis in Neonates and Children. Circulation 2010; 121:1838-47. [DOI: 10.1161/circulationaha.109.913673] [Citation(s) in RCA: 325] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Gili Kenet
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Lisa K. Lütkhoff
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Manuela Albisetti
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Timothy Bernard
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Mariana Bonduel
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Leonardo Brandao
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Stephane Chabrier
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Anthony Chan
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Gabrielle deVeber
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Barbara Fiedler
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Heather J. Fullerton
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Neil A. Goldenberg
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Eric Grabowski
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Gudrun Günther
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Christine Heller
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Susanne Holzhauer
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Alfonso Iorio
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Janna Journeycake
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Ralf Junker
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Fenella J. Kirkham
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Karin Kurnik
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - John K. Lynch
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Christoph Male
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Marilyn Manco-Johnson
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Rolf Mesters
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Paul Monagle
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - C. Heleen van Ommen
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Leslie Raffini
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Kevin Rostásy
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Paolo Simioni
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Ronald D. Sträter
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Guy Young
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
| | - Ulrike Nowak-Göttl
- From the Israel National Haemophilia Centre, Sheba Medical Centre, Tel-Hashomer, Israel (G.K.); Department of Pediatric Hematology/Oncology, University Hospital of Münster, Münster, Germany (L.K.L., R.D.S., U.N.-G.); Division of Hematology, University Children’s Hospital, Zurich, Switzerland (M.A.); Department of Pediatrics, Hematology/Oncology/BMT, and the Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, and Children’s Hospital, Denver/Aurora, Colo (T.B., N.A.G.,
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