1
|
Hu S, Zhou Y, Li M, Zeng X, Zhao J. Dancing with disorder: chorea - an unusual and neglected manifestation of antiphospholipid syndrome. Lupus Sci Med 2024; 11:e001332. [PMID: 39353714 PMCID: PMC11448224 DOI: 10.1136/lupus-2024-001332] [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: 07/31/2024] [Accepted: 09/17/2024] [Indexed: 10/04/2024]
Abstract
OBJECTIVES Chorea, characterised by involuntary, irregular movements, is a rare neurological manifestation of antiphospholipid syndrome (APS). The specific clinical features remain unclear. This study aimed to summarise the available evidence on antiphospholipid antibody (aPL)-associated chorea. METHODS We used a mixed-methods approach, combining data from patients with chorea with aPL positivity admitted to Peking Union Medical College Hospital (PUMCH) from 2014 to 2024, with cases identified in public databases since 1983. We collected and analysed clinical, laboratory, and imaging results, along with their treatments and outcomes. RESULTS A total of 180 patients with incident aPL-associated chorea were included (13 from PUMCH and 167 from the literature). The majority (81.7%) were female, with a mean age of chorea onset 22.8 years (SD=16.0). Chorea was the initial symptom in 87.9% of cases and often occurred as a single episode (67%), involving bilateral limbs (58.8%) and both upper and lower limbs (87.2%). 43.3% met the 2023 American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) APS classification criteria. Thrombocytopenia (30.0%) and arterial thrombosis (29.1%) were the most common manifestations. Lupus anticoagulant was positive in 84.2% of patients, anticardiolipin IgG in 70.8%, and anti-β2 glycoprotein I IgG in 52.9%. Among those who had results available for the three tests, 57.6% were triple-positive. ANAs were positive in 63.6%. MRI revealed basal ganglia lesions in only 14.8% of patients, whereas all positron emission tomography (PET) scans showed contralateral striatal hypermetabolism. Treatment varied, with most receiving combination therapies of neuroleptics, anticoagulants, antiplatelets, steroids and immunosuppressants. Chorea completely or partially improved in 95.5% of patients. CONCLUSION Chorea is a significant but under-recognised manifestation of APS, predominantly affecting young women and often presenting as the initial symptom. Characteristic PET findings of contralateral striatal hypermetabolism can assist in diagnosis. Treatments with glucocorticoids and immunosuppressive therapies appear beneficial. Further research is needed to understand the pathophysiology and optimise management strategies for aPL-associated chorea.
Collapse
Affiliation(s)
- Shikai Hu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- School of Medicine, Tsinghua Medicine, Tsinghua University, Beijing, China
| | - Yangzhong Zhou
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology of the People's Republic of China, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology of the People's Republic of China, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology of the People's Republic of China, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology of the People's Republic of China, Beijing, China
| |
Collapse
|
2
|
Sahu KK, Malhotra P, Khadwal A, Sachdeva MS, Sharma P, Varma N, Varma SC. Hypereosinophilia in Acute Lymphoblastic Leukemia: Two Cases with Review of Literature. Indian J Hematol Blood Transfus 2015; 31:460-5. [PMID: 26306071 PMCID: PMC4542759 DOI: 10.1007/s12288-014-0436-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 07/10/2014] [Indexed: 01/22/2023] Open
Abstract
Eosinophilia is rare in acute leukemia at presentation. Discrete reports and case studies in recent years have created significant interest in the field of "Acute leukemia with eosinophilia". We herein present two cases of eosinophilia in association with acute lymphoblastic leukemia with brief review of literature in this field. First case is about 21-year-old female who presented with mediastinal mass along with leukocytosis and hypereosinophilia. On evaluation, she was found to have T cell acute lymphoblastic leukemia. After ruling out benign causes of eosinophilia, she was treated with modified BFM-90 protocol. Her eosinophilia resolved after 4 weeks of induction therapy. Second case is about 32-year-old male who was diagnosed as a case of mixed phenotype leukemia (B cell/myeloid type) along with severe eosinophilia. His hypereosinophilia finally resolved by week 16 of modified BFM-90 protocol. Diagnosing ALL is challenging when eosinophilia is the initial presentation. These two cases emphasize on the importance of considering ALL amongst one of the etiological causes of eosinophilia as delay in diagnosis endangers patient's life at risk. Also eosinophilia per se is an independent poor risk factor, hence prompt diagnosis and early treatment is the key in all such cases.
Collapse
Affiliation(s)
- Kamal Kant Sahu
- />Department of Clinical Hematology, Internal Medicine, PGIMER, Chandigarh, India
| | - Pankaj Malhotra
- />Department of Clinical Hematology, Internal Medicine, PGIMER, Chandigarh, India
| | - Alka Khadwal
- />Department of Clinical Hematology, Internal Medicine, PGIMER, Chandigarh, India
| | | | | | - Neelam Varma
- />Department of Hepatopathology, PGIMER, Chandigarh, India
| | | |
Collapse
|
3
|
O'Toole O, Lennon VA, Ahlskog JE, Matsumoto JY, Pittock SJ, Bower J, Fealey R, Lachance DH, McKeon A. Autoimmune chorea in adults. Neurology 2013; 80:1133-44. [PMID: 23427325 DOI: 10.1212/wnl.0b013e3182886991] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES To determine the characteristics of adult-onset autoimmune chorea, and compare paraneoplastic and idiopathic subgroups. METHODS Thirty-six adults with autoimmune chorea were identified at Mayo Clinic (Rochester, MN) from 1997 to 2012. Medical record and laboratory data were recorded. Nonparaneoplastic (n = 22) and paraneoplastic cases (n = 14) were compared. RESULTS Women accounted for 21 patients (58%). Median age at symptom onset was 67 years (range 18-87 years). We estimated the incidence for Olmsted County was 1.5 per million person-years. Symptom onset was subacute in all. Chorea was focal (20 patients) or generalized (16 patients). Although chorea predominated, other neurologic disorders frequently coexisted (29 patients); abnormal eye movements were uncommon (4 patients). No patient had NMDA receptor antibody or any immunoglobulin (Ig)G yielding a detectable immunofluorescence binding pattern restricted to basal ganglia. Two had synaptic IgG antibodies novel to the context of chorea (GAD65, 1; CASPR2, 1). In the paraneoplastic group, 14 patients had evidence of cancer. Of 13 with a histopathologically confirmed neoplasm, small-cell carcinoma and adenocarcinoma were most common; 6 patients had a cancer-predictive paraneoplastic autoantibody, with CRMP-5-IgG and ANNA-1 being most common. In the idiopathic group, 19 of the 22 patients had a coexisting autoimmune disorder (most frequently systemic lupus erythematosus and antiphospholipid syndrome); autoantibodies were detected in 21 patients, most frequently lupus and phospholipid specificities (19 patients). The paraneoplastic group was older (p = 0.001), more frequently male (p = 0.006), had more frequent weight loss (p = 0.02), and frequently had peripheral neuropathy (p = 0.008). CONCLUSIONS Autoimmune chorea is a rare disorder with rapid onset. Male sex, older age, severe chorea, coexisting peripheral neuropathy, and weight loss increase the likelihood of cancer.
Collapse
Affiliation(s)
- Orna O'Toole
- Department of Neurology, Mayo Clinic, College of Medicine, Rochester, MN, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Gómez-Puerta JA, Cervera R, Espinosa G, Aguiló S, Bucciarelli S, Ramos-Casals M, Ingelmo M, Asherson RA, Font J. Antiphospholipid antibodies associated with malignancies: clinical and pathological characteristics of 120 patients. Semin Arthritis Rheum 2006; 35:322-32. [PMID: 16616155 DOI: 10.1016/j.semarthrit.2005.07.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To describe the different types of malignancies associated with antiphospholipid antibodies (aPL). METHODS We performed a computer-assisted (MEDLINE, National Library of Medicine, Bethesda, MD) search of the literature from 1966 to 2003 to identify all cases of malignancies having aPL. RESULTS One hundred twenty patients were found. The mean age was 56+/-17 years (range 5 to 88). Sixty-two (52%) patients were men and 58 (48%) were women. A heterogeneous group of malignancies were found. Regarding hematological malignancies, 10 (8%) patients suffered from B-cell lymphoma, 8 (7%) from spleen lymphoma, 7 (6%) from chronic myeloid leukemia, and 6 (5%) from non-Hodgkin's lymphoma (NHL). Regarding solid tumors, renal cell carcinoma was diagnosed in 7 (6%) patients, primary tumor with unknown origin in 7 (6%), lung adenocarcinoma in 6 (5%), breast carcinoma in 6 (5%), and melanoma in 6 (5%). The main aPL-related manifestations were thrombocytopenia (25%), cerebrovascular accidents (24%), deep vein thrombosis (19%), pulmonary embolism (15%), and heart valve lesions (9%). In 17 cases, catastrophic antiphospholipid syndrome was considered to be triggered by the malignancy. Seventy-one (63%) of 113 patients recovered or are still alive after cancer treatment. Twenty-three (35%) of 65 patients achieved aPL remission after proper treatment of the malignancy. CONCLUSIONS It is important to bear in mind, especially in elderly patients, that thrombotic events associated with aPL can be the first manifestation of malignancy. At the same time, the presence of aPL in patients with malignancies has important implications in their treatment and prognosis.
Collapse
Affiliation(s)
- José A Gómez-Puerta
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia (ICMiD), Hospital Clínic, Barcelona, Catalonia, Spain
| | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Chien AJ, Argenyi ZB, Colven RM, Kirby P. Acute lymphoblastic leukemia presenting with urticarial plaques and hypereosinophilia in a child. J Am Acad Dermatol 2005; 51:S151-5. [PMID: 15577757 DOI: 10.1016/j.jaad.2004.04.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Our report describes a previously healthy 10-year-old female who was seen for urticarial plaques and mild loss of appetite. An initial laboratory workup revealed an elevated leukocyte count of 30,000/microL and a peripheral eosinophil count of 22,500/microL. A skin biopsy showed a marked hypersensitivity tissue response with abundant eosinophils. Further investigation of her peripheral eosinophilia uncovered Giardia lamblia in a stool sample. Despite treatment with the anti-parasitic agent furazolidone, the patient's urticarial plaques, leukocyte count, and peripheral eosinophil count remained unchanged. A bone marrow biopsy confirmed a diagnosis of acute lymphoblastic leukemia (ALL). ALL with hypereosinophilia (ALL/Eo) represents a rare and distinct subset of ALL, with more than 30 cases documented in the literature. Our discussion summarizes the clinical aspects of this disease and reviews the reported dermatological manifestations of ALL/Eo.
Collapse
Affiliation(s)
- Andy J Chien
- University of Washington Department of Medicine, Division of Dermatology, Seattle, Washington 98195, USA
| | | | | | | |
Collapse
|
6
|
Orsino A, Schneider R, DeVeber G, Grant R, Massicotte P, Canning P, Carcao M. Childhood acute myelomonocytic leukemia (AML-M4) presenting as catastrophic antiphospholipid antibody syndrome. J Pediatr Hematol Oncol 2004; 26:327-30. [PMID: 15111789 DOI: 10.1097/00043426-200405000-00015] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
: The authors describe a 15-year-old girl presenting with a cerebral ischemic stroke as the first manifestation of catastrophic antiphospholipid antibody syndrome secondary to acute myeloid leukemia (AML). Despite treatment with anticoagulants, therapeutic plasma exchange, and chemotherapy, the patient developed multiorgan thromboses and failure, eventually culminating in death. This unusual presentation of AML has not been previously described in children. Clinical features of antiphospholipid antibody syndrome and current knowledge regarding its association with malignancies are reviewed.
Collapse
Affiliation(s)
- Angela Orsino
- Division of Rheumatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
7
|
Wynn TT, Heerema NA, Hammond S, Ranalli M, Kahwash SB. Acute lymphoblastic leukemia with hypereosinophilia: report of a case with 5q deletion and review of the literature. Pediatr Dev Pathol 2003; 6:558-63. [PMID: 15018456 DOI: 10.1007/s10024-003-2019-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Peripheral blood eosinophilia as a presentation of acute lymphoblastic leukemia (ALL) has only rarely been reported. The eosinophilia is thought to be a nonneoplastic reaction to the neoplastic lymphoblasts. We present the case of a 5-year-old girl who developed peripheral hypereosinophilia with no circulating blasts prior to her diagnosis of B-cell lineage ALL. Cytogenetic study showed a hyperdiploid blast population with 5q deletion. Persistent peripheral hypereosinophilia should always be fully investigated, the possibility of a malignancy including ALL needs to be excluded, even in the absence of peripheral cytopenias and circulating blasts.
Collapse
Affiliation(s)
- Tung T Wynn
- Section of Hematology/Oncology, Columbus Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
| | | | | | | | | |
Collapse
|
8
|
Affiliation(s)
- R A Asherson
- Rheumatic Diseases Unit, Department of Rheumatology, The Groote Schuur Hospital and The University of Cape Town School of Medicine, Cape Town, South Africa
| |
Collapse
|
9
|
|
10
|
Heckmann JG, Lang CJ, Neundörfer B. Comment on the paper: Batchelor TT, Platten M, Palmer-Toy DE, Hunter GJ, Lev MH, Dalmau J, Hochberg FH: Chorea as a paraneoplastic complication of Hodgkin's disease. Journal of Neuro-Oncology 36: 185-190, 1998. J Neurooncol 1999; 41:95-6. [PMID: 10222428 DOI: 10.1023/a:1006110127226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
11
|
Heckmann JG, Lang CJ, Druschky A, Claus D, Bartels O, Neundörfer B. Chorea resulting from paraneoplastic encephalitis. Mov Disord 1997; 12:464-6. [PMID: 9159752 DOI: 10.1002/mds.870120336] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- J G Heckmann
- Department of Neurology, University Erlangen-Nürnberg, Germany
| | | | | | | | | | | |
Collapse
|
12
|
Thoracic Aorta Thrombus With Systemic Embolization: A Rare Paraneoplastic Antiphospholipid Syndrome? Am J Med Sci 1996. [DOI: 10.1016/s0002-9629(15)41847-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
13
|
Messiaen T, Lefebvre C, Lambert M. Case report: thoracic aorta thrombus with systemic embolization: a rare paraneoplastic antiphospholipid syndrome? Am J Med Sci 1996; 312:303-5. [PMID: 8969621 DOI: 10.1097/00000441-199612000-00010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Antiphospholipid syndrome (APS) is characterized by venous and/or arterial thromboses in the presence of the lupus anticoagulant, anticardiolipin antibodies, or both. Antiphospholipid syndrome may occur as a primary disease or in patients with systemic lupus erythematosus or other autoimmune, infectious, or neoplastic disorders. This is a case of APS associated with chronic myelomonocytic leukemia and complicated by a large descending thoracic aorta thrombus responsible for lower limb and visceral emboli. The intraaortic clot was discovered by transesophageal echography (TEE). The association of APS with chronic leukemias has only rarely been described and, as far as can be ascertained, the location of a thrombus in the descending thoracic aorta has never been reported for this syndrome. This case illustrates the crucial role of TEE in the assessment of patients with systemic embolizations.
Collapse
Affiliation(s)
- T Messiaen
- Division of General Internal Medicine, Saint-Luc University Hospital, Brussels, Belgium
| | | | | |
Collapse
|
14
|
Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 26-1996. A seven-year-old boy with fever, lymphadenopathy, hepatosplenomegaly, and prominent eosinophilia. N Engl J Med 1996; 335:577-84. [PMID: 8684410 DOI: 10.1056/nejm199608223350808] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|
15
|
Mouas H, Lortholary O, Eclache V, Leroux G, Casassus P, Guillevin L, Raphäel M. Antiphospholipid syndrome during acute monocytic leukaemia. Eur J Haematol Suppl 1994; 53:59-60. [PMID: 8062901 DOI: 10.1111/j.1600-0609.1994.tb00183.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|