[The heart and antiphospholipid antibodies. Personal experience and review of the literature]

Les anticorps antiphospholipides, signification et traitement

ANTIBODIES: The term antiphospholipid antibodies (APLA) regroups a family antibodies that recognise anionic and neutral phospholipids, which are the components of plasmatic cell membranes. These antibodies expose the patients to risk of venous and/or arterials thromboembolic accidents and obstetrical complications such as repeated early miscarriage or, more rarely foetal loss. A SYNDROME: The presence of such antibodies associated with this type of clinical events defines the antiphospholipid antibody syndrome (APS) that can be isolated and defined as primary or associated with systemic lupus erythematosus. The APS represents one of the most frequent thrombophilic states. The two APLA used in the diagnosis of APS are the circulating lupus anticoagulant and anticardiolipid antibodies. Indeed, these are the only APS for which research techniques have been standardised. PERSONALISED TREATMENT: Treatment relies on anticoagulants. Steroids are unnecessary except when APS is associated with lupus during the catastrophic syndrome of APS, characterised by multiorgan failure related to thrombotic microangiopathy lesions. The modalities of use of anticoagulants (indications, dose and duration) remain debated and underline the great risk of recurrent thrombosis on withdrawal of treatment.

Intracardiac thrombi in primary antiphospholipid syndrome: two case reports

We describe two patients who developed stroke and ischemia of the left lower limb, related to intracardiac thrombi, as the first manifestation of primary antiphospholipid syndrome (PAPS). Transesophageal echocardiography (TEE) revealed intracardiac thrombi as abnormal hyperechogenic, nonmobile masses, firmly attached to the left atrial appendage and the anterior part of the mitral annulus, respectively. Our patients received high-intensity oral anticoagulant therapy (INR 3.0-4.0), which resulted in the rapid disappearance of clinical symptoms, without subsequent recurrence of thromboembolic manifestations, and the disappearance of intracardiac thrombi on TEE. Our findings underscore that PAPS should be suspected in patients presenting with intracardiac thrombi, even if they have no previous history of thromboembolic disorders. Moreover, because intracardiac thrombi may precede other manifestations of PAPS, this finding in young patients without underlying heart disease should invoke a search for both antiphospholipid and anticardiolipin antibodies.

[Non-simultaneous malignant lymphoma and antiphospholipid syndrome: 4 cases]

OBJECTIVE

We report four cases of non-synchronous antiphospholipid syndrome (APS) and malignant lymphoma, which highlight the complex relationship that seems to exist between these illnesses.

METHODS

In a retrospective study conducted in two departments (internal medicine and clinical hematology) of a university hospital, we collected all observations of patients with both APS and malignant lymphoma diagnosed throughout the past decade.

RESULTS

An association of APS with malignant lymphoma was recorded in three female and one male patient, median age 42.5 years at the time of diagnosis of the first disease. In each case, the primary APS was diagnosed, with arterial thrombotic events in three cases and venous thrombotic events in one case. One patient had isolated IgG anticardiolipin antibody, whereas the others had a combination of IgG anticardiolipin antibody and lupus anticoagulant with or without IgG anti-beta 2 glycoprotein I antibody. One patient also had an acquired inhibitor to factor VIII:C and a chronic C virus hepatitis. The mean time apparently separating the two illnesses ranged from 18 months to 9 years, but in two cases the diagnosis of APS was delayed due to a progressive, atypical, neurological onset. In two instances, the APS took place at a distance from a cured malignant lymphoma (Hodgkin's disease and nodal large cell B-cell lymphoma), whilst in the others it preceded a B-cell lymphoma (nodal and cutaneous, small cells and primary hepatic, large cells). Treatment resulted in complete haematological response in both cases, with disappearance of anticardiolipin antibody and lupus anticoagulant in the latter following a double autologous peripheral blood stem cell transplantation. In addition, late carcinomas (breast, kidney, thyroid) were seen in two patients.

CONCLUSIONS

Our data indicate that the diagnosis of a malignant lymphoma should be considered in patients with a primary APS and peripheral lymph node enlargement or unexplained constitutional symptoms. Conversely, a late onset of arterial or venous thrombotic diathesis after a malignant lymphoma may indicate not only late relapse of malignant lymphoma but also a subsequent APS.