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Yoshino R, Nakatsubo M, Ujiie N, Yuzawa S, Ishida K, Kitada M. Granulocyte colony-stimulating factor-producing lung cancer complicated with antiphospholipid antibody syndrome: a case report. J Surg Case Rep 2024; 2024:rjae361. [PMID: 38817796 PMCID: PMC11138120 DOI: 10.1093/jscr/rjae361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 05/13/2024] [Indexed: 06/01/2024] Open
Abstract
No reports on granulocyte colony-stimulating factor-producing lung cancer associated with antiphospholipid antibody syndrome. A 73-year-old man was referred to our department to undergo surgery for lung cancer in the right upper lobe. His examination results suggested that his condition was caused by an elevated white blood cell count and an increased inflammatory response due to granulocyte colony-stimulating factor production. The presence of antiphospholipid antibody syndrome was suspected, and the decrease in coagulation factors was considered to be inhibited by the lupus anticoagulant. Perioperatively, the patient was treated with heparin and steroids, and a thoracoscopically assisted right upper lobectomy was performed. Postoperatively, histopathological examination revealed pleomorphic carcinoma, and the patient tested negative for anticardiolipin IgG antibodies. In lung cancer patients with elevated white blood cell counts, fever, and an inflammatory response, granulocyte colony-stimulating factor-producing lung cancer is an important differential diagnosis. Additionally, when coagulation abnormalities are observed preoperatively, a thorough examination is necessary to prepare for perioperative management.
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Affiliation(s)
- Ryusei Yoshino
- Department of Thoracic Surgery and Breast Surgery, Asahikawa Medical University Hospital, 2-1-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Masaki Nakatsubo
- Department of Thoracic Surgery and Breast Surgery, Asahikawa Medical University Hospital, 2-1-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Nanami Ujiie
- Department of Thoracic Surgery and Breast Surgery, Asahikawa Medical University Hospital, 2-1-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Sayaka Yuzawa
- Department of Diagnostic Pathology, Asahikawa Medical University Hospital, 2-1-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido 078-8510, Japan
| | - Kensuke Ishida
- Department of Respiratory Medicine, Nayoro City General Hospital, 1, West 7, South 8, Nayoro, Hokkaido 096-8511, Japan
| | - Masahiro Kitada
- Department of Thoracic Surgery and Breast Surgery, Asahikawa Medical University Hospital, 2-1-1-1 Midorigaoka Higashi, Asahikawa, Hokkaido 078-8510, Japan
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Ballif M, Vazquez SR, Saunders J, Witt DM. Prevalence of antiphospholipid antibody syndrome misclassification in an academic health system. Thromb Res 2023; 232:163-167. [PMID: 36446659 DOI: 10.1016/j.thromres.2022.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/12/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE Antiphospholipid Antibody Syndrome (APS) is a complex autoimmune disorder that includes a combination of laboratory criteria and clinical events (thrombosis, pregnancy complications). Accurate classification is essential, as APS patients may have limited oral anticoagulant options and requires indefinite anticoagulation. The prevalence of inaccurate APS misclassification is unknown. This study sought to determine the proportion of patients in an academic health-system who formally met APS criteria. METHODS This retrospective cohort study included any patient within the University of Utah Health system who had an International Classification of Diseases-10 code for APS, between January 1, 2016 and June 30, 2020. Manual chart review was performed to assess the appropriateness of the APS classification by laboratory and clinical criteria. RESULTS Of the 184 patients identified, 59 (32.1 %) formally met APS criteria, while 69 (37.5 %) did not meet criteria. The remaining 56 (30.4 %) patients lacked enough information in their medical records to decide on appropriateness of APS classification. The most prevalent reason for inappropriate APS classification in the 69 patients identified was incorrect interpretation of lab values as positive (62; 89.9 %), followed by lack of repeat confirmation testing (32; 46.4 %). CONCLUSION The results of this single-center study indicate that only one-third of patients with presumed APS met classification criteria. This was predominantly due to incorrect collection or interpretation of APS laboratory data. One-third had insufficient medical record data to determine APS classification, which impairs clinical decision-making. This suggests more education or implementation of anticoagulation stewardship is needed to ensure accurate APS classification and proper management of anticoagulation therapy.
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Affiliation(s)
- Madison Ballif
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America
| | - Sara R Vazquez
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America; University of Utah Health Thrombosis Service, 6056 Fashion Square Drive Suite 1200, Murray, UT 84107, United States of America.
| | - John Saunders
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America
| | - Daniel M Witt
- University of Utah College of Pharmacy, Department of Pharmacotherapy, University of Utah, 30 South 2000 East, Salt Lake City, UT 84112, United States of America; University of Utah Health Thrombosis Service, 6056 Fashion Square Drive Suite 1200, Murray, UT 84107, United States of America
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Neto AR, Mendonça FT, de Aviz MAB, Novas RGM, Freitas RDNB. Stroke with postoperative visual loss as the first clinical manifestation of antiphospholipid antibody syndrome: Case report. Int J Surg Case Rep 2023; 106:108231. [PMID: 37116282 PMCID: PMC10163633 DOI: 10.1016/j.ijscr.2023.108231] [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: 12/02/2022] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION Postoperative visual loss (POVL) is a rare and devastating complication. Its incidence in nonophthamologic surgeries varies from 0.056 % to 1.3 %. Autoimmune rheumatic diseases with a predisposition to thrombotic events, such as antiphospholipid antibody syndrome (APS), may constitute an important risk factor for this complication. PRESENTATION OF CASE A 34-year-old female patient, who was a former smoker and had no other comorbidities. She underwent orthopedic surgery and presented with bilateral POVL associated with the loss of secondary muscle strength and intraoperative venous and arterial cerebral thrombosis. She was thoroughly investigated regarding the etiology of her condition, and high levels of antiphospholipid antibodies were found. DISCUSSION APS is an autoimmune disease that predisposes the patient to thrombotic events. Among these, stroke is one of the main causes of POVL secondary to ischemia of the cortical territory, or also known as "cortical blindness." CONCLUSION The rare incidence of POVL in nonophthalmological surgeries and the consequence and preservation in the literature on the subject, explain the limitations of its pathophysiology, and especially the development of guidelines focused on the prevention of patients with risk factors for this condition. Thus, this case report warns about the risks and anesthetic care that patients with risk factors should have when undergoing nonophthalmological surgeries.
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Affiliation(s)
- Angelo Rossi Neto
- Department of Anesthesiology and Perioperative Medicine, Base Hospital of the Federal District, Brasília, Brazil.
| | - Fabricio Tavares Mendonça
- Department of Anesthesiology and Perioperative Medicine, Base Hospital of the Federal District, Brasília, Brazil
| | | | - Rodrigo Gomes Minas Novas
- Department of Anesthesiology and Perioperative Medicine, Base Hospital of the Federal District, Brasília, Brazil
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Eviatar T, Niznik S, Elkayam O, Ben-Gal Y, Shavit R, Raanani E, Agmon-Levin N, Paran D. Heart Valve Surgery in Antiphospholipid Syndrome Patients—Morbidity and Mortality. Life (Basel) 2023; 13:life13040891. [PMID: 37109420 PMCID: PMC10146753 DOI: 10.3390/life13040891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/23/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Objectives: To assess valve surgery outcomes in antiphospholipid syndrome (APS). Methods: A retrospective study assessing complications and mortality rate and possible factors associated with adverse outcomes of APS patients undergoing valve surgery in two tertiary medical centers. Results: Twenty-six APS patients (median age at surgery 47.5 years) who underwent valve surgery were detected, of whom 11 (42.3%) had secondary APS. The mitral valve was most commonly involved (n = 15, 57.7%). A valve replacement was performed in 24 operations (92.3%), 16 of which (66.7%) were mechanical valves. Fourteen (53.8%) patients sustained severe complications, and four of them died. The presence of mitral regurgitation (MR) was associated with severe complications and mortality (odds ratio (95% confidence interval) 12.5 (1.85–84.442), p = 0.008, for complications. All deceased patients had MR (p = 0.033). The presence of Libman-Sacks endocarditis (LSE) (7.333 (1.272–42.294), p = 0.045), low C3 (6.667 (1.047–42.431), p = 0.05) and higher perioperative prednisone doses (15 ± 21.89 vs. 1.36 ± 3.23 mg/day, p = 0.046) were also associated with complications. A lower glomerular filtration rate (GFR) was associated with mortality (30.75 ± 19.47 vs. 70.68 ± 34.44 mL/min, p = 0.038). Conclusions: Significant morbidity and mortality were observed among APS patients undergoing valve surgery. MR was associated with mortality and complications. LSE, low complement and higher doses of corticosteroids were associated with complications, while a low GFR was associated with mortality.
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Anderson M, Belmont M. Severe thrombotic events associated with pre-procedural interruption of anticoagulation in systemic lupus erythematosus with secondary antiphospholipid syndrome: Cases and literature review. Lupus 2022; 31:261-267. [PMID: 35041558 DOI: 10.1177/09612033221074920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American College of Chest Physicians (ACCP) and National Institutes for health and care Excellence in the United Kingdom (NICE) recommend that patients who are high risk for thrombotic events but require cessation of oral anticoagulation with warfarin, due to bleeding risk of a planned procedure, undergo bridging therapy with heparin. However, those conditions which are considered high risk are not universal, nor do guidelines differentiate between low molecular weight heparin (LMWH) and unfractionated heparin. Triple positive antiphospholipid syndrome (APS) is a thrombophilic state with a very high risk for thrombotic events during periods of anticoagulation cessation. Patients with secondary antiphospholipid syndrome in the setting of SLE may be at an even greater risk of thrombotic events during the perioperative period. PURPOSE Along with a review of the literature for perioperative management in APS we present three cases of triple positive secondary APS in systemic lupus erythematosus (SLE) patients who had severe thrombotic complications after cessation of their oral anticoagulation despite being bridged with LWMH. CONCLUSION Given the severity and rapidity of thrombotic complications with low molecular weight heparin bridging, we propose that all patients with triple positive APS, especially secondary APS with SLE should undergo bridging therapy with intravenous UFH to reduce time without anticoagulation and minimize risk of thrombotic complications. Furthermore, we propose that NICE include APS in the list of medical conditions which are high risk for thrombotic complications and require bridging therapy.
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Affiliation(s)
- Meghan Anderson
- 12297Department of Rheumatology at NYU Langone Health, New York, NY, USA.,12297Department of Rheumatology at NYU Langone Health and Hospital for Joint Disease, New York, NY, USA
| | - Michael Belmont
- 12297Department of Rheumatology at NYU Langone Health, New York, NY, USA.,12297Department of Rheumatology at NYU Langone Health and Hospital for Joint Disease, New York, NY, USA
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Kim JW, Kim TW, Ryu KH, Park SG, Jeong CY, Park DH. Anaesthetic considerations for patients with antiphospholipid syndrome undergoing non-cardiac surgery. J Int Med Res 2020; 48:300060519896889. [PMID: 31937174 PMCID: PMC7113712 DOI: 10.1177/0300060519896889] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/02/2019] [Indexed: 12/30/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an acquired thrombotic autoimmune disorder that is clinically characterized by the development of thrombosis and obstetric morbidities in patients with antiphospholipid antibodies. Due to hypercoagulability, the focus of management is anticoagulation for the prevention of thrombosis and its recurrence. When such patients undergo surgery, however, the underlying risk of thrombosis increases as a result of anticoagulant withdrawal, immobilization, and/or intimal injury. Conversely, there is also an increased risk of bleeding due to thrombocytopaenia, possible disseminated intravascular coagulation, or progression to catastrophic APS, as a result of excessive anticoagulation, surgery, and infection. Measures for appropriate perioperative anticoagulation are discussed in this review, as well as anaesthetic considerations for preventing perioperative complications in patients with APS undergoing non-cardiac surgery.
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Affiliation(s)
- Jae Won Kim
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Tae Woo Kim
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Keon Hee Ryu
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Sun Gyoo Park
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Chang Young Jeong
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Dong Ho Park
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
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Chen RX, Zhou YZ, Li PC, Yang HX, Fei YY, Hu XM, Wu W, Zhao LD, Chen H, Zhang X. The efficacy and safety of antithrombotic therapy in patients with positive antiphospholipid antibodies receiving invasive procedures: experience from a single tertiary center. Clin Rheumatol 2019; 38:1897-1904. [PMID: 30847686 DOI: 10.1007/s10067-019-04483-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/14/2019] [Accepted: 02/17/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of antithrombotic prophylaxis and to explore potential risk factors for thrombotic/bleeding events in patients with positive antiphospholipid (aPL) antibodies receiving invasive procedures. METHOD All aPL-positive patients who underwent invasive procedures in Peking Union Medical College Hospital, from January 2002 to April 2018, were retrospectively enrolled. Demographic features, clinical features, antiphospholipid antibody profiles, types of invasive procedures, and antithrombotic management, as well as complications and outcomes, were systematically reviewed and recorded. RESULTS A total of 111 aPL-positive patients with 130 invasive procedures were enrolled. One hundred nine (83.8%) cases were on regular antithrombotic therapy which started at least 1 month prior to the invasive procedures, with 58 (44.6%) receiving anticoagulation therapy, 27 (20.8%) receiving antiplatelet therapy, and 24 (18.5%) receiving both. During the periprocedural period, the median time free of antithrombotic therapy was 2.5 days (interquartile range 1.5-6.0 days). Two (1.5%) periprocedural thrombotic events and 18 (13.8%) bleeding events were identified. Large open/laparoscopic surgeries of the thorax and abdomen were associated with a higher risk of bleeding (OR 3.46, 95% CI 1.24-9.67, p = 0.014). All bleeding events were manageable and not life-threatening. CONCLUSIONS Aggressive antithrombotic therapy was associated with fewer thrombotic events in aPL-positive patients receiving invasive procedures, but might contribute to an increased bleeding rate, especially in large open surgeries. This study justifies more caution in prophylactic antithrombotic therapy in periprocedural aPL-positive patients.
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Affiliation(s)
- Ru-Xuan Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Yang-Zhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Peng-Chong Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Hua-Xia Yang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Yun-Yun Fei
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Xiao-Min Hu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China
| | - Wei Wu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Dan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China.
| | - Hua Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China.
| | - Xuan Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Clinical Immunology Center, Medical Epigenetics Research Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Ministry of Education Key Laboratory, 1# Shuai-Fu-Yuan, Dongcheng District, Beijing, 100730, China.
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Gualtierotti R, Parisi M, Ingegnoli F. Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview. Adv Ther 2018; 35:439-456. [PMID: 29556907 PMCID: PMC5910481 DOI: 10.1007/s12325-018-0686-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Indexed: 02/06/2023]
Abstract
Patients with inflammatory rheumatic diseases often need orthopaedic surgery due to joint involvement. Total hip replacement and total knee replacement are frequent surgical procedures in these patients. Due to the complexity of the inflammatory rheumatic diseases, the perioperative management of these patients must envisage a multidisciplinary approach. The frequent association with extraarticular comorbidities must be considered when evaluating perioperative risk of the patient and should guide the clinician in the decision-making process. However, guidelines of different medical societies may vary and are sometimes contradictory. Orthopaedics should collaborate with rheumatologists, anaesthesiologists and, when needed, cardiologists and haematologists with the common aim of minimising perioperative risk in patients with inflammatory rheumatic diseases. The aim of this review is to provide the reader with simple practical recommendations regarding perioperative management of drugs such as disease-modifying anti-rheumatic drugs, corticosteroids, non-steroidal anti-inflammatory drugs and tools for a risk stratification for cardiovascular and thromboembolic risk based on current evidence for patients with inflammatory rheumatic diseases.
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