1
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Castro-Varela A, Martinez-Magallanes DM, Reyes-Chavez MF, Gonzalez-Rayas JM, Paredes-Vazquez JG, Vazquez-Garza E, Castillo-Perez M, Flores-Sayavedra YZ, Martinez A, Ramos Cazares RE, Guajardo J, Lopez-de la Garza H, Salinas-Casanova JA, Betancourt H, Molina-Rodriguez AM, Panneflek J, Fabiani MA, Jerjes-Sanchez C. Risk Factors, Clinical Presentation, Therapeutic Trends, and Outcomes in Arterial Thrombosis Complicating Unvaccinated COVID-19 Patients: A Systematic Review. Angiology 2024; 75:625-634. [PMID: 37005343 PMCID: PMC10083125 DOI: 10.1177/00033197231167055] [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] [Indexed: 04/04/2023]
Abstract
Data on characteristics and outcomes of coronavirus (COVID)-19 patients complicated with arterial thrombosis (AT) are scarce. Therefore, we carried out a systematic review (PRISMA, PROSPERO statements; PubMed, Scopus, and Web of Science) to identify risk factors, clinical presentation, treatment, and outcomes. We included publications from December 2019 to October 2020. Groups: (a) ischemic stroke, (b) thrombotic storm, (c) peripheral vascular thrombosis, (d) myocardial infarction, and (e) left cardiac thrombus or in-transit thrombus (venous system thrombus floating or attaching to the right heart). We considered 131 studies. The most frequent cardiovascular risk factors were: hypertension, diabetes, and dyslipidemia. A high proportion presented with asymptomatic, mild, or moderate COVID-19 (n = 91, 41.4%). We identified a high percentage of isolated ischemic stroke and thrombotic storm. Groups with higher mortality rate: intracardiac thrombus (1/2, 50.0%), thrombotic storm (18/49, 36.7%), and ischemic stroke (48/131, 36.6%). A small number received thromboprophylaxis. Most patients received antithrombotic treatment. The most frequent bleeding complication was intracranial hemorrhage, primarily with isolated stroke. Overall mortality was 33.6% (74/220). Despite a wide range of COVID-19 severity, a high proportion had AT as a complication of non-severe disease. AT can affect different vascular territories; mortality is associated with stroke, intensive care unit stay, and severe COVID-19.
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Affiliation(s)
- Alejandra Castro-Varela
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
| | | | - Maria Fernanda Reyes-Chavez
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
- Unidad Experimental de Terapias
Avanzadas del Hospital Zambrano Hellion, TecSalud, San Pedro Garza Garcia, Nuevo Leon, Mexico
| | | | - Jose Gildardo Paredes-Vazquez
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
- Instituto de Cardiologia y Medicina
Vascular, TecSalud, Escuela de Medicina y Ciencias de la Salud,
Tecnologico de Monterrey, San Pedro Garza Garcia, Nuevo Leon, Mexico
| | - Eduardo Vazquez-Garza
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
- Unidad Experimental de Terapias
Avanzadas del Hospital Zambrano Hellion, TecSalud, San Pedro Garza Garcia, Nuevo Leon, Mexico
| | - Mauricio Castillo-Perez
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
| | | | - Arturo Martinez
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
| | - Ray Erick Ramos Cazares
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
| | - Jaime Guajardo
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
| | - Hector Lopez-de la Garza
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
| | | | - Hector Betancourt
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
| | | | - Jathniel Panneflek
- Unidad Experimental de Terapias
Avanzadas del Hospital Zambrano Hellion, TecSalud, San Pedro Garza Garcia, Nuevo Leon, Mexico
| | - Mario Alejandro Fabiani
- Instituto de Cardiologia y Medicina
Vascular, TecSalud, Escuela de Medicina y Ciencias de la Salud,
Tecnologico de Monterrey, San Pedro Garza Garcia, Nuevo Leon, Mexico
| | - Carlos Jerjes-Sanchez
- Tecnologico de
Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey,
Nuevo Leon, Mexico
- Unidad Experimental de Terapias
Avanzadas del Hospital Zambrano Hellion, TecSalud, San Pedro Garza Garcia, Nuevo Leon, Mexico
- Instituto de Cardiologia y Medicina
Vascular, TecSalud, Escuela de Medicina y Ciencias de la Salud,
Tecnologico de Monterrey, San Pedro Garza Garcia, Nuevo Leon, Mexico
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2
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Mahroum N, Habra M, Alrifaai MA, Shoenfeld Y. Antiphospholipid syndrome in the era of COVID-19 - Two sides of a coin. Autoimmun Rev 2024:103543. [PMID: 38604461 DOI: 10.1016/j.autrev.2024.103543] [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: 01/31/2024] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 04/13/2024]
Abstract
In addition to the respiratory symptoms associated with COVID-19, the disease has consistently been linked to many autoimmune diseases such as systemic lupus erythematous and antiphospholipid syndrome (APS). APS in particular was of paramount significance due to its devastating clinical sequela. In fact, the hypercoagulable state seen in patients with acute COVID-19 and the critical role of anticoagulant treatment in affected individuals shed light on the possible relatedness between APS and COVID-19. Moreover, the role of autoimmunity in the assumed association is not less important especially with the accumulated data available regarding the autoimmunity-triggering effect of SARS-CoV-2 infection. This is furtherly strengthened at the time patients with COVID-19 manifested antiphospholipid antibodies of different types following infection. Additionally, the severe form of the APS spectrum, catastrophic APS (CAPS), was shown to have overlapping characteristics with severe COVID-19 such as cytokine storm and multi-organ failure. Interestingly, COVID vaccine-induced autoimmune phenomena described in the medical literature have pointed to an association with APS. Whether the antiphospholipid antibodies were present or de novo, COVID vaccine-induced vascular thrombosis in certain individuals necessitates further investigations regarding the possible mechanisms involved. In our current paper, we aimed to focus on the associations mentioned, their implications, importance, and consequences.
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Affiliation(s)
- Naim Mahroum
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey.
| | - Mona Habra
- International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | | | - Yehuda Shoenfeld
- Zabludowicz Center for autoimmune diseases, Sheba Medical Center, Ramat-Gan, Israel; Reichman University, Herzliya, Israel
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3
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Shankar T, Vempalli N, Bairwa A. An unusual case of thrombotic storm in an amateur cricketer-a case report. Int J Emerg Med 2023; 16:65. [PMID: 37784022 PMCID: PMC10544559 DOI: 10.1186/s12245-023-00539-4] [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: 03/03/2023] [Accepted: 09/19/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Thrombotic storm is a series of acute to subacute thrombotic events that evolve over a few days to weeks and result in progressive thromboses at multiple sites. There is often a predisposing event to thromboses, such as trauma or infections. Prompt initiation of anti-coagulation can prove life-saving in such patients. CASE REPORT We describe a previously healthy young male who developed thromboses of the right axillary, brachial, radial, and ulnar arteries while bowling in a cricket match. A few hours later, he developed a stroke involving the right anterior and middle cerebral arteries. His thrombophilia workup was significant for elevated homocysteine levels. Although he had a delayed presentation to our hospital, he was treated with anticoagulation and given a trial of thromboembolectomy, which failed and he had to ultimately undergo a right below-elbow guillotine amputation. CONCLUSION Thrombotic storm should be recognized promptly in the Emergency Department and timely anticoagulation should be initiated.
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Affiliation(s)
- Takshak Shankar
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, India
| | | | - Archana Bairwa
- Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, India
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4
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Alomair BM, Al-Kuraishy HM, Al-Gareeb AI, Al-Buhadily AK, Alexiou A, Papadakis M, Alshammari MA, Saad HM, Batiha GES. Mixed storm in SARS-CoV-2 infection: A narrative review and new term in the Covid-19 era. Immun Inflamm Dis 2023; 11:e838. [PMID: 37102645 PMCID: PMC10132185 DOI: 10.1002/iid3.838] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 04/28/2023] Open
Abstract
Coronavirus disease 2019 (Covid-19) is caused by a novel severe acute respiratory syndrome coronavirus virus type 2 (SARS-CoV-2) leading to the global pandemic worldwide. Systemic complications in Covid-19 are mainly related to the direct SARS-CoV-2 cytopathic effects, associated hyperinflammation, hypercytokinemia, and the development of cytokine storm (CS). As well, Covid-19 complications are developed due to the propagation of oxidative and thrombotic events which may progress to a severe state called oxidative storm and thrombotic storm (TS), respectively. In addition, inflammatory and lipid storms are also developed in Covid-19 due to the activation of inflammatory cells and the release of bioactive lipids correspondingly. Therefore, the present narrative review aimed to elucidate the interrelated relationship between different storm types in Covid-19 and the development of the mixed storm (MS). In conclusion, SARS-CoV-2 infection induces various storm types including CS, inflammatory storm, lipid storm, TS and oxidative storm. These storms are not developing alone since there is a close relationship between them. Therefore, the MS seems to be more appropriate to be related to severe Covid-19 than CS, since it develops in Covid-19 due to the intricate interface between reactive oxygen species, proinflammatory cytokines, complement activation, coagulation disorders, and activated inflammatory signaling pathway.
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Affiliation(s)
- Basil Mohammed Alomair
- Department of Medicine, College of Medicine, Internal Medicine and Endocrinology, Jouf University, Al-Jouf, Saudi Arabia
| | - Hayder M Al-Kuraishy
- Department of Clinical Pharmacology and Medicine, College of Medicine, Al-Mustansiriya University, Baghdad, Iraq
| | - Ali I Al-Gareeb
- Department of Clinical Pharmacology and Medicine, College of Medicine, Al-Mustansiriya University, Baghdad, Iraq
| | - Ali K Al-Buhadily
- Department of Clinical Pharmacology, Medicine, and Therapeutic, Medical Faculty, College of Medicine, Al-Mustansiriyah University, Baghdad, Iraq
| | - Athanasios Alexiou
- Department of Science and Engineering, Novel Global Community Educational Foundation, Hebersham, New South Wales, Australia
- AFNP Med, Wien, Austria
| | - Marios Papadakis
- Department of Surgery II, University Hospital Witten-Herdecke, University of Witten-Herdecke, Wuppertal, Germany
| | - Majed Ayed Alshammari
- Department of Medicine, Prince Mohammed Bin Abdulaziz Medical City, Sakaka, Al-Jouf, Saudi Arabia
| | - Hebatallah M Saad
- Department of Pathology, Faculty of Veterinary Medicine, Matrouh University, Marsa, Matruh, Egypt
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour, Egypt
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5
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Abu-Abaa M, Al-Qaysi G, Chadalawada S, Cole A. A Probable Catastrophic Antiphospholipid Antibody Syndrome/Thrombotic Storm Presenting As Rapidly Evolving Multifocal Ischemic and Hemorrhagic Strokes: A Case Report. Cureus 2023; 15:e35584. [PMID: 37007308 PMCID: PMC10062394 DOI: 10.7759/cureus.35584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/04/2023] Open
Abstract
Catastrophic antiphospholipid antibody syndrome (CAPS) is a life-threatening disorder. It is a rare and severe form of antiphospholipid antibody (APL) syndrome characterized by widespread multisystemic thrombosis. We present a 55-year-old male patient with acute cerebellar hemorrhagic stroke who developed widespread progressive microthrombosis and macrothrombosis manifesting as progressive bilateral ischemic strokes with lower extremities deep vein thrombosis (DVT) and acute renal failure within a week of presentation. The diagnosis and initiation of therapy were established after serological confirmation. This case adds to a limited number of cases of CAPS in literature and is interesting given the rarity of CAPS and thrombotic storm (TS) as well as the lack of inciting factor triggering CAPS/thrombotic syndrome. This case also helps to remind the clinicians of the importance to consider CAPS, even prior to serological confirmation, in those with rapidly progressive thrombotic events, as delayed diagnosis and therapy can yield poor clinical outcomes.
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6
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Zhang Y, Oye M, Omar M. COVID-19 Infection: A Sparked Ignition to a Thrombotic Storm. Cureus 2022; 14:e27038. [PMID: 35989812 PMCID: PMC9388329 DOI: 10.7759/cureus.27038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 11/28/2022] Open
Abstract
Thrombotic storm (TS) is a rare yet life-threatening condition that requires aggressive thrombolytic or anticoagulant therapy. Clinical manifestation of TS can be disastrous as it amplifies thrombotic pathways causing widespread organ ischemia. We present a patient who developed TS following a COVID-19 infection. He was simultaneously diagnosed with an ST-elevation myocardial infarction, multiple pulmonary emboli, aortic thrombi, and bilateral limb ischemia. Further workup was positive for a spindle cell neoplasm, which combined with the prothrombotic nature of COVID-19 infection likely produced an exaggerated response leading to a diffuse thrombotic event. Through this case, we would like to highlight the importance of having a collective field of expertise in making the most appropriate medical decision under critical situations.
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7
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Jindal AK, Ahluwalia J, Suku R, Suri D, Nuytemans K, Ortel TL, Pericak-Vance MA, Vance JM, Singh S. Successful Management of Catastrophic Thrombotic Storm in a Young Boy: A Case Report From Northern India. J Pediatr Hematol Oncol 2021; 43:e1132-e1135. [PMID: 33560088 DOI: 10.1097/mph.0000000000002069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/02/2020] [Indexed: 11/26/2022]
Abstract
Thrombotic storm is a rare clinical entity characterized by acute to subacute thrombosis developing at multiple sites over a few days to a few weeks. An 11-year-old boy presented with headache and facial nerve palsy. He was found to have cortical sinus venous thrombosis and was initiated on low molecular weight heparin, but rapidly progressed with thromboses involving the pulmonary arteries and deep veins of the legs. Thereafter managed on high-dose unfractionated heparin, he eventually stabilized after a hospital stay of 34 days. Genetic analysis showed potentially pathogenic variants in the factor V and stabilin-2 genes.
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Affiliation(s)
| | - Jasmina Ahluwalia
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajiv Suku
- Department of Paediatrics, Allergy Immunology Unit
| | - Deepti Suri
- Department of Paediatrics, Allergy Immunology Unit
| | - Karen Nuytemans
- John P. Hussman Institute for Human Genomics and Dr John T. Macdonald Foundation Department of Human Genomics, University of Miami Miller School of Medicine, Miami, FL
| | - Thomas L Ortel
- Division of Hematology, Duke University Medical Center, Duke Hemostasis and Thrombosis Center, Durham, NC
| | - Margaret A Pericak-Vance
- John P. Hussman Institute for Human Genomics and Dr John T. Macdonald Foundation Department of Human Genomics, University of Miami Miller School of Medicine, Miami, FL
| | - Jeffery M Vance
- John P. Hussman Institute for Human Genomics and Dr John T. Macdonald Foundation Department of Human Genomics, University of Miami Miller School of Medicine, Miami, FL
| | - Surjit Singh
- Department of Paediatrics, Allergy Immunology Unit
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8
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Thachil J. COVID-19 Vaccine-Induced Immune Thrombosis with Thrombocytopenia (VITT) and the Shades of Grey in Thrombus Formation. Semin Thromb Hemost 2021; 48:15-18. [PMID: 34624910 DOI: 10.1055/s-0041-1735453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford road, Manchester, United Kingdom
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9
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Santiago MB, Paz A. Acute Peripheral and/or Cutaneous Ischemic Syndrome: What Rheumatologists Should Know. J Clin Rheumatol 2021; 27:73-79. [PMID: 33315786 DOI: 10.1097/rhu.0000000000001609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT In daily practice, the frequent appearance of limb and/or skin necrosis, which we term "acute peripheral and/or cutaneous ischemic syndrome" (APCIS), can be a manifestation of numerous underlying diseases, or it can sometimes be a clinical phenomenon whose etiology is undefined even after a wide investigation. The mechanisms for the development of APCIS include vessel wall abnormalities (atherosclerosis, vasculitis, and calciphylaxis), embolic processes (infectious endocarditis, atrial myxoma, and cholesterol emboli), local thrombotic injuries (genetic or acquired thrombophilias and heparin- and warfarin-induced ischemia), dysproteinemias (cryoglobulinemia and cryofibrinogenemia), or venous limb gangrene. Here, we report 5 illustrative cases of APCIS with different pathogenetic mechanisms, thereby highlighting some clinical conditions that cause APCIS that may be of special interest for rheumatologists, such as antiphospholipid syndrome, primary and secondary vasculitis, and cryoproteinemias. Furthermore, we describe a large spectrum of other causes of APCIS beyond the scope of rheumatology. Because there are no validated guidelines for APCIS, we tentatively propose an initial diagnostic workup and a therapeutic approach based on full-dose anticoagulation and immunosuppressive therapy.
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Affiliation(s)
| | - Adriane Paz
- From the Hospital Universitário Professor Edgard Santos
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10
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Nielsen JJJ, Lillethorup TP, Glud AN, Sørensen JCH, Orlowski D. The application of iPSCs in Parkinson’s disease. Acta Neurobiol Exp (Wars) 2020. [DOI: 10.21307/ane-2020-024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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11
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Liu Z, Markham M, Mandernach MW. Marginal zone lymphoma-associated antiphospholipid antibodies successfully treated with bendamustine rituximab. BMJ Case Rep 2019; 12:12/3/e224636. [PMID: 30872333 DOI: 10.1136/bcr-2018-224636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 46-year-old man presented with splenomegaly, abdominal adenopathy and profoundly elevated prothrombin time and partial thromboplastin time. He was diagnosed with marginal zone lymphoma (MZL) and small lymphocytic lymphoma, and the abnormal coagulation studies were secondary to the presence of a lupus anticoagulant. Optimal upfront therapy for MZL has not been established, and the incidence of antiphospholipid antibodies (APLA) in this patient population is rare. Following treatment with six cycles of bendamustine and rituximab with 2 years of rituximab maintenance, our patient remained in remission and his coagulation studies normalised. This report describes a case of successful treatment of APLA associated with MZL that resolved after treatment of the lymphoma.
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Affiliation(s)
- Ziyang Liu
- Department of Medicine, Division of Hematology/Oncology, University of Florida, Gainesville, Florida, USA
| | - Merry Markham
- Department of Medicine, Division of Hematology/Oncology, University of Florida, Gainesville, Florida, USA
| | - Molly W Mandernach
- Department of Medicine, Division of Hematology/Oncology, University of Florida, Gainesville, Florida, USA
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12
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Firsov KV, Kotov AS, Bunak MS. [Genetic causes of stroke in young patients]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:102-109. [PMID: 30778040 DOI: 10.17116/jnevro2019119011102] [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
The paper addresses genetic causes of stroke: MELAS, antiphospholipid syndrome, CADASIL, Fabry disease. The etiology and pathogenesis, symptoms, diagnosis, treatment methods of these diseases are described.
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Affiliation(s)
- K V Firsov
- Vladimirsky Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - A S Kotov
- Vladimirsky Moscow Regional Research and Clinical Institute, Moscow, Russia
| | - M S Bunak
- Vladimirsky Moscow Regional Research and Clinical Institute, Moscow, Russia
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13
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Ma JY, Zhang X, Li XF, He LJ, Ma N, Wei YY, Wu RH, Wang FY. Thrombotic storm in a 4-year-old boy with a thrombus in the right atrium. Int J Immunopathol Pharmacol 2018; 32:2058738418778121. [PMID: 29798687 PMCID: PMC5971376 DOI: 10.1177/2058738418778121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Thrombotic storm (TS) is a rare disease, especially with thrombus in the heart of
pediatric patient. We present a case of a 4-year-old boy, who was diagnosed with
TS during his first hospitalization due to lower extremity deep venous
thrombosis, pulmonary embolism, and thrombosis of the inferior vena cava,
cerebral, left internal jugular, portal, renal, and iliac veins. He was
eventually prescribed with rivaroxaban to control thrombosis after 30 days of
successive use of low-molecular-weight heparin, unfractionated heparin, and
warfarin, which were demonstrating little effect on preventing thrombosis, and
the patient was intolerant to argatroban. While his lupus anticoagulant ratio
was slightly above the normal range and no other potential causes such as
congenital thrombophilia, severe infection, malignancy, and trauma were
confirmed, we suspected antiphospholipid antibody syndrome and prescribed
glucocorticoid and rituximab to control the disease. After 36 days of admission,
ultrasonography showed recanalization of the former thrombus. One month after
discharge, a tumor embolus resembling a mass emerged in his right atrium under
effective anticoagulant therapy. During his second admission, he underwent
surgical thrombectomy, and pathological examination confirmed the mass to be a
platelet-rich thrombus rather than tumor embolus or infection. Considering the
suspected antiphospholipid antibody syndrome as the cause of the TS, we
prescribed aspirin combined with rivaroxaban to prevent thrombosis. In this
case, surgery and pathology shed light on the type of thrombus that emerged from
the inferior vena cava and traveled to the heart, which is the possible
potential cause of TS. It also changed our therapeutic strategy to antiplatelet
therapy combined with anticoagulant therapy to control the disease.
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Affiliation(s)
- Jing-Yao Ma
- 1 Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Xin Zhang
- 2 Heart Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiao-Feng Li
- 2 Heart Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Le-Jian He
- 3 Department of Pathology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Ning Ma
- 2 Heart Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yun-Yun Wei
- 1 Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Run-Hui Wu
- 1 Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Fang-Yun Wang
- 2 Heart Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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14
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Burger E, Gou D, Vandergriff T, Dominguez A, Mauskar M. Acute syndrome of pan-epidermolysis and thrombotic storm arising in a patient with systemic lupus erythematosus. JAAD Case Rep 2018; 4:877-879. [PMID: 30306116 PMCID: PMC6172434 DOI: 10.1016/j.jdcr.2018.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Elise Burger
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Darlene Gou
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Melissa Mauskar
- University of Texas Southwestern Medical Center, Dallas, Texas
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15
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The diagnosis and clinical management of the catastrophic antiphospholipid syndrome: A comprehensive review. J Autoimmun 2018; 92:1-11. [DOI: 10.1016/j.jaut.2018.05.007] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/10/2018] [Indexed: 01/13/2023]
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16
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Lethal End of Spectrum of Clots-Thrombotic Storm. Case Rep Crit Care 2018; 2018:7273420. [PMID: 29977623 PMCID: PMC5994281 DOI: 10.1155/2018/7273420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 04/12/2018] [Accepted: 04/23/2018] [Indexed: 12/16/2022] Open
Abstract
Thrombotic storm (TS) is a rare, acute, hypercoagulable state characterized by multiple thromboembolic events affecting at least two different areas of the vascular system/organs over a short period of time. Typical triggers include inflammation, infections, minor trauma, surgery, pregnancy, and the puerperium. A single thrombotic event can set off a number of thromboembolic events, often including unusual locations like hepatic, portal, or renal veins, skin (purpura fulminans), adrenal glands, and cerebral sinus venous thrombosis. Usually, younger female patients are affected; in some patients, there is an association with an autoimmune disorder like lupus erythematosus, and they show evidence of antiphospholipid antibodies or other phenotypic expressions of anticoagulation disorders. The majority of patients have no previous history of thromboembolism. As the diagnosis of thrombotic storm relies solely on clinical symptoms with a lack of specific diagnostic tests, this can result in a delay of diagnosis. The treatment consists of uninterrupted lifelong anticoagulation. Sometimes immunomodulatory therapies have been used. The distinction between extensive thrombotic events like Heparin Induced Thrombosis (HIT), Thrombotic Thrombocytopenic Purpura (TTP), Antiphospholipids Syndrome (APS), and TS can sometimes be difficult, and the etiology of TS remains uncertain.
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Nuytemans K, Ortel TL, Gomez L, Hofmann N, Alves N, Dueker N, Beecham A, Whitehead P, Hahn Estabrooks S, Kitchens CS, Erkan D, Brandão LR, James AH, Kulkarni R, Manco-Johnson MJ, Pericak-Vance MA, Vance JM. Variants in chondroitin sulfate metabolism genes in thrombotic storm. Thromb Res 2017; 161:43-51. [PMID: 29178990 DOI: 10.1016/j.thromres.2017.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/24/2017] [Accepted: 11/19/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Thrombotic storm (TS) presents as a severe, acute thrombotic phenotype, characterized by multiple clotting events and frequently affecting younger adults. Understanding the extensive hypercoagulation of an extreme phenotype as TS will also provide insight into the pathogenesis of a wider spectrum of thrombotic disorders. MATERIAL AND METHODS We completed whole exome sequencing on 26 TS patients, including 1 multiplex family, 13 trios and 12 isolated TS patients. We examined both dominant and recessive inheritance models for known thrombotic factors as well as performed a genome-wide screen. Identified genes of interest in the family and trios were screened in the remaining TS patients. Variants were filtered on frequency (<5% in 1000 genomes), conservation and function in gene and were annotated for effect on protein and overall functionality. RESULTS We observed an accumulation of variants in genes linked to chondroitin sulfate (CS), but not heparan sulfate metabolism. Sixteen conserved, rare missense and nonsense variants in genes involved in CS metabolism (CHPF, CHPF2, CHST3, CHST12, CHST15, SLC26A2, PAPSS2, STAB2) were identified in over one-third of the TS patients. In contrast, we identified only seven variants in known thrombosis genes (including FV Leiden). CONCLUSIONS As CS has multiple functions in the glycocalyx protecting the endothelial cells, reduced availability of CS could diminish the normal control mechanisms for blood coagulation, making these CS metabolism genes strong potential risk factors for TS. Overall, no single gene was identified with strong evidence for TS causality; however, our data suggest TS is mediated by an accumulation of rare pro-thrombotic risk factors.
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Affiliation(s)
- Karen Nuytemans
- University of Miami, John P. Hussman Institute for Human Genomics, Miller School of Medicine, Biomedical Research Building, 1501 NW 10th Ave, Miami, FL 33136, United States.
| | - Thomas L Ortel
- Duke University Medical Center, Division of Hematology, Duke Hemostasis and Thrombosis Center, 40 Duke Medicine Circle, Durham, NC 27710, United States.
| | - Lissette Gomez
- University of Miami, John P. Hussman Institute for Human Genomics, Miller School of Medicine, Biomedical Research Building, 1501 NW 10th Ave, Miami, FL 33136, United States.
| | - Natalia Hofmann
- University of Miami, John P. Hussman Institute for Human Genomics, Miller School of Medicine, Biomedical Research Building, 1501 NW 10th Ave, Miami, FL 33136, United States.
| | - Natalie Alves
- University of Miami, John P. Hussman Institute for Human Genomics, Miller School of Medicine, Biomedical Research Building, 1501 NW 10th Ave, Miami, FL 33136, United States.
| | - Nicole Dueker
- University of Miami, John P. Hussman Institute for Human Genomics, Miller School of Medicine, Biomedical Research Building, 1501 NW 10th Ave, Miami, FL 33136, United States.
| | - Ashley Beecham
- University of Miami, John P. Hussman Institute for Human Genomics, Miller School of Medicine, Biomedical Research Building, 1501 NW 10th Ave, Miami, FL 33136, United States.
| | - Patrice Whitehead
- University of Miami, John P. Hussman Institute for Human Genomics, Miller School of Medicine, Biomedical Research Building, 1501 NW 10th Ave, Miami, FL 33136, United States.
| | - Susan Hahn Estabrooks
- University of Miami, John P. Hussman Institute for Human Genomics, Miller School of Medicine, Biomedical Research Building, 1501 NW 10th Ave, Miami, FL 33136, United States.
| | - Craig S Kitchens
- University of Florida, Division of Hematology and Oncology, 2000 SW Archer Rd, Gainesville, FL 32608, United States.
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, 535 East 70th Stm, New York, NY 10021, United States.
| | - Leonardo R Brandão
- The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Andra H James
- Duke University Medical Center, Division of Hematology, Duke Hemostasis and Thrombosis Center, 40 Duke Medicine Circle, Durham, NC 27710, United States.
| | - Roshni Kulkarni
- Michigan State University Centers for Bleeding and Clotting Disorders, 788 Service Rd B-216, East Lansing, MI 48824, United States.
| | - Marilyn J Manco-Johnson
- University of Colorado Hemophilia and Thrombosis Center, 13199 E. Montview Blvd Suite 100, Aurora, CO 80045, United States.
| | - Margaret A Pericak-Vance
- University of Miami, John P. Hussman Institute for Human Genomics, Miller School of Medicine, Biomedical Research Building, 1501 NW 10th Ave, Miami, FL 33136, United States.
| | - Jeffery M Vance
- University of Miami, John P. Hussman Institute for Human Genomics, Miller School of Medicine, Biomedical Research Building, 1501 NW 10th Ave, Miami, FL 33136, United States.
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Acquired thrombotic thrombocytopenic purpura and pregnancy: More light than shade but controversies remain. Thromb Res 2017; 156:195-197. [PMID: 28697902 DOI: 10.1016/j.thromres.2017.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
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19
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Treatment of Catastrophic Antiphospholipid Syndrome. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/b978-0-444-63655-3.00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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20
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El Hokayem J, Cukier HN, Dykxhoorn DM. Blood Derived Induced Pluripotent Stem Cells (iPSCs): Benefits, Challenges and the Road Ahead. ACTA ACUST UNITED AC 2016; 6. [PMID: 27882265 DOI: 10.4172/2161-0460.1000275] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Since the creation of induced Pluripotent Stem Cells (iPSCs) ten years ago, hundreds of publications have demonstrated their considerable impact on disease modeling and therapy. In this commentary, we will summarize key milestones, benefits and challenges in the iPSC field. Furthermore, we will highlight blood as an effective and easily accessible source for patient-specific iPSCs derivation in the context of work done in our laboratory and others.
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Affiliation(s)
- Jimmy El Hokayem
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, USA
| | - Holly N Cukier
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, USA.,Department of Neurology, University of Miami Miller School of Medicine, Miami, USA
| | - Derek M Dykxhoorn
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, USA.,John T. Macdonald Foundation Department of Human Genetics, University of Miami Miller School of Medicine, Miami, USA
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21
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Bester J, Pretorius E. Effects of IL-1β, IL-6 and IL-8 on erythrocytes, platelets and clot viscoelasticity. Sci Rep 2016; 6:32188. [PMID: 27561337 PMCID: PMC4999875 DOI: 10.1038/srep32188] [Citation(s) in RCA: 216] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/02/2016] [Indexed: 12/17/2022] Open
Abstract
Complex interactions exist between cytokines, and the interleukin family plays a fundamental role in inflammation. Particularly circulating IL-1β, IL-6 and IL-8 are unregulated in systemic and chronic inflammatory conditions. Hypercoagulability is an important hallmark of inflammation, and these cytokines are critically involved in abnormal clot formation, erythrocyte pathology and platelet hyper-activation, and these three cytokines have known receptors on platelets. Although these cytokines are always unregulated in inflammation, we do not know how the individual cytokines act upon the structure of erythrocytes and platelets, and which of the viscoelastic clot parameters are changed. Here we study the effects of IL-1β, IL-6 and IL-8 at low physiological levels, representative of chronic inflammation, by using scanning electron microscopy and thromboelastography. All three interleukins caused the viscoelastic properties to display an increased hypercoagulability of whole blood and pathology of both erythrocytes and platelets. The most pronounced changes were noted where all three cytokines caused platelet hyper-activation and spreading. Erythrocyte structure was notably affected in the presence of IL-8, where the morphological changes resembled that typically seen in eryptosis (programmed cell death). We suggest that erythrocytes and platelets are particularly sensitive to cytokine presence, and that they are excellent health indicators.
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Affiliation(s)
- Janette Bester
- Department of Physiology, University of Pretoria, South Africa
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22
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Raymond SB, Gee MS, Anupindi SA, Shailam R, Kaplan JL, Nimkin K. CT and MRI of Rare Extraintestinal Manifestations of Inflammatory Bowel Disease in Children and Adolescents. J Pediatr Gastroenterol Nutr 2016; 63:e1-9. [PMID: 27050046 DOI: 10.1097/mpg.0000000000001225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Inflammatory bowel disease (IBD) is associated with a spectrum of extraintestinal manifestations (EIMs) affecting many organ systems. EIMs can occur in more than 40% of patients with IBD and are associated with significant morbidity. They occur at any time point in the course of disease, often during an active phase of bowel inflammation, but sometimes preceding bowel disease. Prompt recognition of EIMs enables timely and more effective therapy. Physicians who image patients with IBD should be aware of the myriad extraintestinal conditions that may be detected on imaging studies, both within and outside of the abdomen, as they may predate the diagnosis of IBD. Cross-sectional imaging of unusual conditions associated with IBD will be presented, including pathology in the hepatobiliary, pancreatic, genitourinary, musculoskeletal, mucocutaneous, vascular, neurologic, and pulmonary systems.
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Affiliation(s)
- Scott B Raymond
- *Department of Radiology†Department of Radiology, Division of Pediatric Radiology, Massachusetts General Hospital, Boston, MA‡Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA§Department of Pediatrics, Division of Pediatric Gastroenterology, MassGeneral Hospital for Children, Boston, MA
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23
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Dhakal P, Gundabolu K, Bhatt VR. An Algorithmic Approach to Management of Venous Thromboembolism. Clin Appl Thromb Hemost 2016; 23:511-517. [PMID: 27268941 DOI: 10.1177/1076029616652727] [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] [Indexed: 12/12/2022] Open
Abstract
Venous thromboembolism (VTE) is associated with significant morbidity and mortality. Factors such as the presence of transient risk factors for VTE, risk of bleeding, and location of deep vein thrombosis (DVT) determine the duration of anticoagulation. Extended anticoagulation is offered to patients with unprovoked pulmonary embolism (PE) or proximal DVT and a low risk of bleeding. Anticoagulation for 3 months is advised in patients with provoked DVT or PE, high risk of bleeding, and isolated distal or upper extremity DVT. In patients with unprovoked PE or proximal DVT and a low risk of bleeding, who want to stop anticoagulation after 3 months, further risk stratification is necessary. Clinical scoring system, and thrombophilia testing otherwise not routinely performed, may be considered to measure risk of annual recurrence in such cases. Short-term anticoagulation may be considered in subsegmental PE and superficial vein thrombosis, particularly if patients are at low risk of bleeding and have persistent risk factors for recurrent VTE. In cases of catheter-associated thrombosis, the catheter need not be removed routinely, and the patient may be anticoagulated for 3 months or longer if the catheter is maintained in patients with cancer. Extensive screening for occult cancer in cases of unprovoked VTE is not beneficial. New oral anticoagulants such as apixaban, rivaroxaban, or dabigatran may be preferred to vitamin K antagonists in patients without cancer or renal failure, more so after the development of reversal agents such as idarucizumab and andexanet alfa.
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Affiliation(s)
- Prajwal Dhakal
- 1 Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | - Krishna Gundabolu
- 2 Division of Hematology and Oncology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vijaya R Bhatt
- 2 Division of Hematology and Oncology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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24
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Rodriguez-Pintó I, Espinosa G, Cervera R. Catastrophic antiphospholipid syndrome: The current management approach. Best Pract Res Clin Rheumatol 2016; 30:239-249. [DOI: 10.1016/j.berh.2016.07.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 07/28/2016] [Accepted: 07/28/2016] [Indexed: 02/08/2023]
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25
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Kell DB, Pretorius E. The simultaneous occurrence of both hypercoagulability and hypofibrinolysis in blood and serum during systemic inflammation, and the roles of iron and fibrin(ogen). Integr Biol (Camb) 2015; 7:24-52. [PMID: 25335120 DOI: 10.1039/c4ib00173g] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Although the two phenomena are usually studied separately, we summarise a considerable body of literature to the effect that a great many diseases involve (or are accompanied by) both an increased tendency for blood to clot (hypercoagulability) and the resistance of the clots so formed (hypofibrinolysis) to the typical, 'healthy' or physiological lysis. We concentrate here on the terminal stages of fibrin formation from fibrinogen, as catalysed by thrombin. Hypercoagulability goes hand in hand with inflammation, and is strongly influenced by the fibrinogen concentration (and vice versa); this can be mediated via interleukin-6. Poorly liganded iron is a significant feature of inflammatory diseases, and hypofibrinolysis may change as a result of changes in the structure and morphology of the clot, which may be mimicked in vitro, and may be caused in vivo, by the presence of unliganded iron interacting with fibrin(ogen) during clot formation. Many of these phenomena are probably caused by electrostatic changes in the iron-fibrinogen system, though hydroxyl radical (OH˙) formation can also contribute under both acute and (more especially) chronic conditions. Many substances are known to affect the nature of fibrin polymerised from fibrinogen, such that this might be seen as a kind of bellwether for human or plasma health. Overall, our analysis demonstrates the commonalities underpinning a variety of pathologies as seen in both hypercoagulability and hypofibrinolysis, and offers opportunities for both diagnostics and therapies.
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Affiliation(s)
- Douglas B Kell
- School of Chemistry and The Manchester Institute of Biotechnology, The University of Manchester, 131, Princess St, Manchester M1 7DN, Lancs, UK.
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26
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How I treat catastrophic thrombotic syndromes. Blood 2015; 126:1285-93. [DOI: 10.1182/blood-2014-09-551978] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 07/02/2015] [Indexed: 12/21/2022] Open
Abstract
Abstract
Catastrophic thrombotic syndromes are characterized by rapid onset of multiple thromboembolic occlusions affecting diverse vascular beds. Patients may have multiple events on presentation, or develop them rapidly over days to weeks. Several disorders can present with this extreme clinical phenotype, including catastrophic antiphospholipid syndrome (APS), atypical presentations of thrombotic thrombocytopenic purpura (TTP) or heparin-induced thrombocytopenia (HIT), and Trousseau syndrome, but some patients present with multiple thrombotic events in the absence of associated prothrombotic disorders. Diagnostic workup must rapidly determine which, if any, of these syndromes are present because therapeutic management is driven by the underlying disorder. With the exception of atypical presentations of TTP, which are treated with plasma exchange, anticoagulation is the most important therapeutic intervention in these patients. Effective anticoagulation may require laboratory confirmation with anti–factor Xa levels in patients treated with heparin, especially if the baseline (pretreatment) activated partial thromboplastin time is prolonged. Patients with catastrophic APS also benefit from immunosuppressive therapy and/or plasma exchange, whereas patients with HIT need an alternative anticoagulant to replace heparin. Progressive thrombotic events despite therapeutic anticoagulation may necessitate an alternative therapeutic strategy. If the thrombotic process can be controlled, these patients can recover, but indefinite anticoagulant therapy may be appropriate to prevent recurrent events.
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27
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Rodriguez-Pintó I, Santacreu I, Cervera R, Espinosa G. What is the best strategy in treating catastrophic antiphospholipid syndrome? ACTA ACUST UNITED AC 2015. [DOI: 10.2217/ijr.15.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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28
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Abstract
Persistently positive antiphospholipid antibodies (aPL) with thrombosis and/or pregnancy morbidity are a characteristic of antiphospholipid syndrome (APS). Although many challenges and controversies exist regarding APS diagnosis and management, there has been significant progress in APS clinical research in parallel with increased understanding of the pathogenesis. The purpose of this review is to discuss the "top ten" recent clinical developments in APS, including the magnitude of the problem, standardization of aPL tests, predictors of clinical events, diagnostic algorithms, new clinical research collaboration, and potential future treatments, e.g., new anticoagulants and immunosuppressive agents.
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29
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Aguiar CL, Erkan D. Catastrophic antiphospholipid syndrome: how to diagnose a rare but highly fatal disease. Ther Adv Musculoskelet Dis 2013; 5:305-14. [PMID: 24294304 DOI: 10.1177/1759720x13502919] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a multisystem autoimmune condition characterized by vascular thromboses and/or pregnancy loss associated with persistently positive antiphospholipid antibodies (aPL). Catastrophic APS (CAPS) is the most severe form of APS with multiple organ involvement developing over a short period of time, usually associated with microthrombosis. 'Definite' and 'probable' CAPS have been defined based on the preliminary classification criteria; however, in a real-world setting, aPL-positive patients with multiple organ thromboses and/or thrombotic microangiopathies exist who do not fulfill these criteria. Previous APS diagnosis and/or persistent clinically significant aPL positivity is of great importance for the CAPS diagnosis; however, almost half of the patients who develop CAPS do not have a history of aPL positivity. The purpose of this paper is to summarize the diagnostic challenges and the recently updated diagnostic algorithms for CAPS providing a 'step-by-step' approach for clinicians (and researchers) in the assessment of patients with multiple organ thromboses.
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Affiliation(s)
- Cassyanne L Aguiar
- Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021, USA
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30
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Aryal MR, Badal M, Bhandari N, Bhatt VR. Accelerated arterial and venous clots in a young pregnant woman: a saga of thrombotic storm. BMJ Case Rep 2013; 2013:bcr-2013-009776. [PMID: 23715841 DOI: 10.1136/bcr-2013-009776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Thrombotic storm is a rare condition, characterised by serial thrombotic events, which escalates rapidly within a few days to a few weeks involving multiple and unusual sites. Since it usually responds to anticoagulation and is often lethal if not treated promptly, early diagnosis is crucial. We describe a case of a young pregnant woman with multiple acute arterial and venous thrombotic events including stroke and myocardial infarction, who successfully recovered with continued anticoagulation therapy.
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Affiliation(s)
- Madan Raj Aryal
- Department of Internal Medicine, Reading Health System, Wyomissing, Pennsylvania, USA.
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31
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Ortel TL, Kitchens CS, Erkan D, Brandão LR, Hahn S, James AH, Kulkarni R, Manco-Johnson MJ, Pericak-Vance M, Vance J. Clinical causes and treatment of the thrombotic storm. Expert Rev Hematol 2013; 5:653-9. [PMID: 23216595 DOI: 10.1586/ehm.12.56] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Thrombotic storm represents an extreme prothrombotic phenotype, characterized by multiple thrombotic events affecting diverse vascular beds occurring over a brief period of time. Thrombotic events involve venous and arterial circulation, including unusual locations, such as cerebral sinus venous thrombosis, intra-abdominal thromboembolic occlusions and microvascular events. Some patients will have antiphospholipid antibodies, but a significant number have no identifiable hypercoagulable state. The mainstay of treatment consists of anticoagulant therapy, although some patients appear to benefit from the addition of immunomodulatory therapies. Other disorders that share this thrombotic storm phenotype include catastrophic antiphospholipid syndrome, spontaneous heparin-induced thrombocytopenia and similar aggressive clinical disorders. Ongoing studies are focused on identifying underlying genetic factors that may predispose patients to develop this extreme clinical phenotype.
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Affiliation(s)
- Thomas L Ortel
- Hemostasis and Thrombosis Center, Duke University Medical Center, Durham, NC 27710, USA.
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32
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Maggi U, Rossi G, Avesani EC, Artoni A, Caprioli F, Napolitano L, Martinelli I. Thrombotic storm in a teenager with previously undiagnosed ulcerative colitis. Pediatrics 2013; 131:e1288-91. [PMID: 23460680 DOI: 10.1542/peds.2012-2365] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Venous thrombosis can complicate inflammatory bowel diseases, both in adult and pediatric patients, and a few adult cases of thrombotic storm, ie, thrombosis at multiple sites occurring over a period of a few days to a few weeks, have been described. However, venous thrombosis as the first manifestation of an inflammatory bowel disease is extremely rare. We report the case of a 14-year-old girl presenting with ascites and marked hypertransaminasemia resulting from hepatic vein occlusion (Budd-Chiari syndrome). Despite anticoagulant therapy, in the following days she developed criteria suggestive of thrombotic storm to include cerebral vein, right atrial thrombosis, and bilateral pulmonary embolism. Thrombolytic treatment with recombinant-tissue plasminogen activator was started, with resolution of all venous thromboses and without bleeding complications. Additional examinations revealed a severely active ulcerative pancolitis, which did not respond to medical treatment and required surgery. No thrombophilia abnormality nor other risk factors for thrombosis were detected. We conclude that an underlying inflammatory state, such as ulcerative colitis, should be suspected in pediatric patients with venous thrombosis storm.
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Affiliation(s)
- Umberto Maggi
- UO Chirurgia Generale e Trapianti di Fegato Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy.
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Coagulopathies in orthopaedics: links to inflammation and the potential of individualizing treatment strategies. J Orthop Trauma 2013; 27:236-41. [PMID: 22874115 DOI: 10.1097/bot.0b013e318269b782] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Orthopaedic patients are at risk for developing pathologic imbalances of coagulation factors characterized by phases of both hypocoagulability and hypercoagulability. Complications from "hypocoagulability" include life-threatening hemorrhage, wound hematoma, and poor wound healing. Complications due to "hypercoagulability" include deep venous thrombosis, pulmonary embolus, and disseminated intravascular coagulation. In addition, coagulation imbalance that favors the production of procoagulant factors may lead to excessive inflammation and contribute to systemic inflammatory response syndrome, acute respiratory distress syndrome, multiple organ dysfunction syndrome, and death. Optimally, the goal of individualized treatment of coagulopathies in orthopaedic patients should be to achieve efficient healing while avoiding the morbidities associated with imbalance of coagulation and inflammation. Such individualized and time-sensitive measures of coagulation status require rapid, accurate, qualitative, and quantitative assessment of the critical balance of the coagulation system. Commonly used coagulation tests (prothrombin time and activated partial thromboplastin time) are incapable of determining this balance. An alternative to is to perform thrombin generation assays. The greatest advantage of thrombin generation assays over traditional coagulation tests is their ability to detect hypercoagulability, the balance of procoagulant and anticoagulant factors, and the effect of all pharmaceutical anticoagulants. Further clinical investigations are warranted to develop and refine the thrombin generation assays to help predict clinical complications related to coagulation imbalances. In addition, future testing will help define the prothrombotic period allowing for appropriate initiation and cessation of anticoagulant pharmaceuticals. These subsequent studies have the potential to allow the development of a real-time coagulation monitoring strategy that could have paramount implications in the management of postoperative patients.
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