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Pons I, Jeréz A, Espinosa G, Rodríguez-Pintó I, Erkan D, Shoenfeld Y, Cervera R. Cardiac involvement in the catastrophic antiphospholipid syndrome (CAPS): Lessons from the "CAPS registry". Semin Arthritis Rheum 2024; 66:152439. [PMID: 38552300 DOI: 10.1016/j.semarthrit.2024.152439] [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: 12/19/2023] [Revised: 02/28/2024] [Accepted: 03/25/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE To analyze the demographic, clinical, and laboratory characteristics of catastrophic antiphospholipid syndrome (CAPS) patients with cardiac involvement, and to identify the factors associated with this cardiac involvement. MATERIAL AND METHODS Based on the analysis of the "CAPS Registry", the demographic, clinical, and serological characteristics of patients with cardiac involvement were analyzed. Cardiac involvement was defined as heart failure, valvular disease, acute myocardial infarction, pericardial effusion, pulmonary arterial hypertension, systolic dysfunction, intracardiac thrombosis, and microvascular disease. Univariate and multivariate analysis was used for multiple comparisons. RESULTS 749 patients (293 [39 %] women and mean age 38.1 ± 16.2 years) accounting for 778 CAPS events were included, of them 404 (52 %) had cardiac involvement. The main cardiac manifestations were heart failure in 185/377 (55 %), valve disease in 116/377 (31 %), and acute myocardial infarction in 104/378 (28 %). Of 58 patients with autopsy/biopsy, 48 (83 %) had cardiac thrombotic microangiopathy, Stroke (29% vs. 21 %, p = 0.012), transient cerebral vascular accident (2% vs. 1 %, p = 0.005), pulmonary infarction (26% vs. 3 %, p = 0.017), renal infarction (46% vs. 35 %, p = 0.006), acute kidney injury (70% vs. 53 %, p < 0.001), and livedo reticularis (24% vs. 17 %, p = 0.016) were significantly more frequent during CAPS events with versus without heart involvement. Multivariate analysis identified acute kidney injury (OR 1.068, IC 95 % 1.8-4.8, p < 0.001) as the only clinical characteristics that were, independently, associated with cardiac involvement in CAPS events. Cardiac involvement was not related to higher mortality. CONCLUSIONS Cardiac involvement is frequent in CAPS, with association with kidney involvement, and it is not related to higher mortality. The presence of cardiac microthrombosis was demonstrated in most biopsies/autopsies performed.
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Affiliation(s)
- Isaac Pons
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Department of Internal Medicine, Althaia Xarxa Assistencial Universitària de Manresa, Facultat de Medicina, Universitat de Vic-Universitat Central de Catalunya (uVic-UCC), Manresa, Catalonia, Spain
| | - Alba Jeréz
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Department of Internal Medicine, Systemic Autoimmune Diseases Unit, Hospital Mútua de Terrassa, Terrassa, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
| | - Ignasi Rodríguez-Pintó
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Reichman University, Herzelya, Israel
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
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Hoxha A, Perin N, Lovisotto M, Calligaro A, Del Ross T, Favaro M, Tonello M, Doria A, Simioni P. Risk factors for damage accrual in primary antiphospholipid syndrome: A retrospective single-center cohort study. J Autoimmun 2024; 144:103180. [PMID: 38368768 DOI: 10.1016/j.jaut.2024.103180] [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: 12/29/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Despite anticoagulant therapy, a antiphospholipid syndrome (APS) has a higher rate of recurrent events, which can lead to damage accrual and a negative impact on life quality. OBJECTIVES To evaluate the risk factors and APS subsets associated with damage accrual. PATIENTS/METHODS We conducted a retrospective single-center study. We reviewed the medical records of 282 APS patients, with a median age of 36 (IQR 30-46) years and a median of 195 (IQR 137-272) months. The primary endpoint was damage accrual during follow-up, defined as organ/tissue impairment present for at least six months or causing permanent loss. The secondary endpoints were early organ damage within six months of disease onset and death. RESULTS Eighty (28.4%) patients presented damage accrual; 52.5% developed damage within six months of APS onset, and 41.3% had more than one organ involved. Neuropsychiatric involvement, affecting 38.8% of the patients, was the most frequent, followed by peripheral vasculopathy and renal involvement, 35% either. Death happened in 7 (2.5 %) patients; damage accrual was associated with a 6-fold risk of death [OR 6.7 (95% CI 1.3-35.1), p = 0.03]. Microangiopathy and non-criteria manifestations were independent risk factors for damage accrual with 5-fold and 4-fold higher risk, respectively [(OR 4.9 (95% CI 2.1-11.7), p < 0.0001 and (OR 3.8 (95% CI 1.5-10.1), p = 0.007]. The cumulative incidence of damage accrual increased by 5.7-fold and 3.6-fold in patients with microangiopathy and non-criteria manifestations. CONCLUSIONS APS patients had a higher frequency of damage accrual. Microangiopathy and non-criteria manifestations were independent risk factors for damage accrual.
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Affiliation(s)
- Ariela Hoxha
- Internal Medicine Unit, Thrombotic and Hemorrhagic Center, Department of Medicine, University of Padua, Italy.
| | - Nicola Perin
- Internal Medicine Unit, Thrombotic and Hemorrhagic Center, Department of Medicine, University of Padua, Italy
| | - Marco Lovisotto
- Internal Medicine Unit, Thrombotic and Hemorrhagic Center, Department of Medicine, University of Padua, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Teresa Del Ross
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Maria Favaro
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Marta Tonello
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Simioni
- Internal Medicine Unit, Thrombotic and Hemorrhagic Center, Department of Medicine, University of Padua, Italy
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de Oliveira Gomes J, Gagliardi AM, Andriolo BN, Torloni MR, Andriolo RB, Puga MEDS, Canteiro Cruz E. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev 2023; 10:CD008858. [PMID: 37781954 PMCID: PMC10542961 DOI: 10.1002/14651858.cd008858.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND Herpes zoster, commonly known as shingles, is a neurocutaneous disease caused by the reactivation of the virus that causes varicella (chickenpox). After resolution of the varicella episode, the virus can remain latent in the sensitive dorsal ganglia of the spine. Years later, with declining immunity, the varicella zoster virus (VZV) can reactivate and cause herpes zoster, an extremely painful condition that can last many weeks or months and significantly compromise the quality of life of the affected person. The natural process of ageing is associated with a reduction in cellular immunity, and this predisposes older adults to herpes zoster. Vaccination with an attenuated form of the VZV activates specific T-cell production avoiding viral reactivation. Two types of herpes zoster vaccines are currently available. One of them is the single-dose live attenuated zoster vaccine (LZV), which contains the same live attenuated virus used in the chickenpox vaccine, but it has over 14-fold more plaque-forming units of the attenuated virus per dose. The other is the recombinant zoster vaccine (RZV) which does not contain the live attenuated virus, but rather a small fraction of the virus that cannot replicate but can boost immunogenicity. The recommended schedule for the RZV is two doses two months apart. This is an update of a Cochrane Review first published in 2010, and updated in 2012, 2016, and 2019. OBJECTIVES To evaluate the effectiveness and safety of vaccination for preventing herpes zoster in older adults. SEARCH METHODS For this 2022 update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2022, Issue 10), MEDLINE (1948 to October 2022), Embase (2010 to October 2022), CINAHL (1981 to October 2022), LILACS (1982 to October 2022), and three trial registries. SELECTION CRITERIA We included studies involving healthy older adults (mean age 60 years or older). We included randomised controlled trials (RCTs) or quasi-RCTs comparing zoster vaccine (any dose and potency) versus any other type of intervention (e.g. varicella vaccine, antiviral medication), placebo, or no intervention (no vaccine). Outcomes were cumulative incidence of herpes zoster, adverse events (death, serious adverse events, systemic reactions, or local reaction occurring at any time after vaccination), and dropouts. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We included two new studies involving 1736 participants in this update. The review now includes a total of 26 studies involving 90,259 healthy older adults with a mean age of 63.7 years. Only three studies assessed the cumulative incidence of herpes zoster in groups that received vaccines versus placebo. Most studies were conducted in high-income countries in Europe and North America and included healthy Caucasians (understood to be white participants) aged 60 years or over with no immunosuppressive comorbidities. Two studies were conducted in Japan and one study was conducted in the Republic of Korea. Sixteen studies used LZV. Ten studies tested an RZV. The overall certainty of the evidence was moderate, which indicates that the intervention probably works. Most data for the primary outcome (cumulative incidence of herpes zoster) and secondary outcomes (adverse events and dropouts) came from studies that had a low risk of bias and included a large number of participants. The cumulative incidence of herpes zoster at up to three years of follow-up was lower in participants who received the LZV (one dose subcutaneously) than in those who received placebo (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.43 to 0.56; risk difference (RD) 2%; number needed to treat for an additional beneficial outcome (NNTB) 50; moderate-certainty evidence) in the largest study, which included 38,546 participants. There were no differences between the vaccinated and placebo groups for serious adverse events (RR 1.08, 95% CI 0.95 to 1.21) or deaths (RR 1.01, 95% CI 0.92 to 1.11; moderate-certainty evidence). The vaccinated group had a higher cumulative incidence of one or more adverse events (RR 1.71, 95% CI 1.38 to 2.11; RD 23%; number needed to treat for an additional harmful outcome (NNTH) 4.3) and injection site adverse events (RR 3.73, 95% CI 1.93 to 7.21; RD 28%; NNTH 3.6; moderate-certainty evidence) of mild to moderate intensity. These data came from four studies with 6980 participants aged 60 years or older. Two studies (29,311 participants for safety evaluation and 22,022 participants for efficacy evaluation) compared RZV (two doses intramuscularly, two months apart) versus placebo. Participants who received the new vaccine had a lower cumulative incidence of herpes zoster at 3.2 years follow-up (RR 0.08, 95% CI 0.03 to 0.23; RD 3%; NNTB 33; moderate-certainty evidence), probably indicating a favourable profile of the intervention. There were no differences between the vaccinated and placebo groups in cumulative incidence of serious adverse events (RR 0.97, 95% CI 0.91 to 1.03) or deaths (RR 0.94, 95% CI 0.84 to 1.04; moderate-certainty evidence). The vaccinated group had a higher cumulative incidence of adverse events, any systemic symptom (RR 2.23, 95% CI 2.12 to 2.34; RD 33%; NNTH 3.0), and any local symptom (RR 6.89, 95% CI 6.37 to 7.45; RD 67%; NNTH 1.5). Although most participants reported that their symptoms were of mild to moderate intensity, the risk of dropouts (participants not returning for the second dose, two months after the first dose) was higher in the vaccine group than in the placebo group (RR 1.25, 95% CI 1.13 to 1.39; RD 1%; NNTH 100, moderate-certainty evidence). Only one study reported funding from a non-commercial source (a university research foundation). All other included studies received funding from pharmaceutical companies. We did not conduct subgroup and sensitivity analyses AUTHORS' CONCLUSIONS: LZV (single dose) and RZV (two doses) are probably effective in preventing shingles disease for at least three years. To date, there are no data to recommend revaccination after receiving the basic schedule for each type of vaccine. Both vaccines produce systemic and injection site adverse events of mild to moderate intensity. The conclusions did not change in relation to the previous version of the systematic review.
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Affiliation(s)
| | - Anna Mz Gagliardi
- Department of Geriatrics and Gerontology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Brenda Ng Andriolo
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | - Maria Regina Torloni
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | - Regis B Andriolo
- Department of Public Health, Universidade do Estado do Pará, Belém, Brazil
| | - Maria Eduarda Dos Santos Puga
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | - Eduardo Canteiro Cruz
- Department of Geriatrics and Gerontology, Universidade Federal de São Paulo, São Paulo, Brazil
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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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5
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Wind M, Gaasbeek AGA, Oosten LEM, Rabelink TJ, van Lith JMM, Sueters M, Teng YKO. Therapeutic plasma exchange in pregnancy: A literature review. Eur J Obstet Gynecol Reprod Biol 2021; 260:29-36. [PMID: 33713886 DOI: 10.1016/j.ejogrb.2021.02.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/24/2021] [Accepted: 02/25/2021] [Indexed: 01/13/2023]
Abstract
Therapeutic plasma exchange (TPE) is indicated as a treatment for a wide array of diseases, extensively addressed in the Guidelines of the American Society for Apheresis. In pregnancy, TPE is an uncommon event and application is largely based on extrapolation of efficacy and safety in a non-pregnant population. This review intends to describe the currently available experience of TPE in pregnancy to help clinicians recognise indications during pregnancy and to support current guideline recommendations with literature-based experiences. In order to identify the clinical indications for which TPE is applied in pregnant women, we performed a literature search including studies till November 2019, without a start date restriction. Data extraction included medical indication for TPE and safety of TPE in pregnant women. 279 studies were included for analysis. Nowadays, TPE is predominantly applied for thrombotic microangiopathies, lipid disorders and a variety of autoimmune diseases. The application of TPE during pregnancy remains largely empiric and relies on individual case reports in the absence of high-quality studies and definitive evidence-based guidelines. Safety profile of TPE during pregnancy appears to be comparable to application of TPE in non-pregnant patients. In conclusion, based on the limited evidence that we found in literature with a high risk of publication bias, TPE procedures can be used safely during pregnancy with the appropriate preparation and experience of a multidisciplinary team.
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Affiliation(s)
- M Wind
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands.
| | - A G A Gaasbeek
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - L E M Oosten
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - T J Rabelink
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - J M M van Lith
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - M Sueters
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Y K O Teng
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
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Gagliardi AMZ, Andriolo BNG, Torloni MR, Soares BGO, de Oliveira Gomes J, Andriolo RB, Canteiro Cruz E. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev 2019; 2019:CD008858. [PMID: 31696946 PMCID: PMC6836378 DOI: 10.1002/14651858.cd008858.pub4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Herpes zoster, commonly known as shingles, is a neurocutaneous disease caused by the reactivation of the virus that causes varicella (chickenpox). After resolution of the varicella episode, the virus can remain latent in the sensitive dorsal ganglia of the spine. Years later, with declining immunity, the varicella zoster virus (VZV) can reactivate and cause herpes zoster, an extremely painful condition that can last many weeks or months and significantly compromise the quality of life of the affected person. The natural process of aging is associated with a reduction in cellular immunity, and this predisposes older people to herpes zoster. Vaccination with an attenuated form of the VZV activates specific T-cell production avoiding viral reactivation. The USA Food and Drug Administration has approved a herpes zoster vaccine with an attenuated active virus, live zoster vaccine (LZV), for clinical use amongst older adults, which has been tested in large populations. A new adjuvanted recombinant VZV subunit zoster vaccine, recombinant zoster vaccine (RZV), has also been approved. It consists of recombinant VZV glycoprotein E and a liposome-based AS01B adjuvant system. This is an update of a Cochrane Review last updated in 2016. OBJECTIVES To evaluate the effectiveness and safety of vaccination for preventing herpes zoster in older adults. SEARCH METHODS For this 2019 update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, January 2019), MEDLINE (1948 to January 2019), Embase (2010 to January 2019), CINAHL (1981 to January 2019), LILACS (1982 to January 2019), WHO ICTRP (on 31 January 2019) and ClinicalTrials.gov (on 31 January 2019). SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs comparing zoster vaccine (any dose and potency) versus any other type of intervention (e.g. varicella vaccine, antiviral medication), placebo, or no intervention (no vaccine). Outcomes were incidence of herpes zoster, adverse events (death, serious adverse events, systemic reactions, or local reaction occurring at any time after vaccination), and dropouts. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 11 new studies involving 18,615 participants in this update. The review now includes a total of 24 studies involving 88,531 participants. Only three studies assessed the incidence of herpes zoster in groups that received vaccines versus placebo. Most studies were conducted in high-income countries in Europe and North America and included healthy Caucasians (understood to be white participants) aged 60 years or over with no immunosuppressive comorbidities. Two studies were conducted in Japan. Fifteen studies used LZV. Nine studies tested an RZV. The overall quality of the evidence was moderate. Most data for the primary outcome (incidence of herpes zoster) and secondary outcomes (adverse events and dropouts) came from studies that had a low risk of bias and included a large number of participants. The incidence of herpes zoster at up to three years follow-up was lower in participants who received the LZV (one dose subcutaneously) than in those who received placebo (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.43 to 0.56; risk difference (RD) 2%; number needed to treat for an additional beneficial outcome (NNTB) 50; moderate-quality evidence) in the largest study, which included 38,546 participants. There were no differences between the vaccinated and placebo groups for serious adverse events (RR 1.08, 95% CI 0.95 to 1.21) or deaths (RR 1.01, 95% CI 0.92 to 1.11; moderate-quality evidence). The vaccinated group had a higher incidence of one or more adverse events (RR 1.71, 95% CI 1.38 to 2.11; RD 23%; number needed to treat for an additional harmful outcome (NNTH) 4.3) and injection site adverse events (RR 3.73, 95% CI 1.93 to 7.21; RD 28%; NNTH 3.6) of mild to moderate intensity (moderate-quality evidence). These data came from four studies with 6980 participants aged 60 years or over. Two studies (29,311 participants for safety evaluation and 22,022 participants for efficacy evaluation) compared RZV (two doses intramuscularly, two months apart) versus placebo. Participants who received the new vaccine had a lower incidence of herpes zoster at 3.2 years follow-up (RR 0.08, 95% CI 0.03 to 0.23; RD 3%; NNTB 33; moderate-quality evidence). There were no differences between the vaccinated and placebo groups in incidence of serious adverse events (RR 0.97, 95% CI 0.91 to 1.03) or deaths (RR 0.94, 95% CI 0.84 to 1.04; moderate-quality evidence). The vaccinated group had a higher incidence of adverse events, any systemic symptom (RR 2.23, 95% CI 2.12 to 2.34; RD 33%; NNTH 3.0), and any local symptom (RR 6.89, 95% CI 6.37 to 7.45; RD 67%; NNTH 1.5). Although most participants reported that there symptoms were of mild to moderate intensity, the risk of dropouts (participants not returning for the second dose, two months after the first dose) was higher in the vaccine group than in the placebo group (RR 1.25, 95% CI 1.13 to 1.39; RD 1%; NNTH 100, moderate-quality evidence). Only one study reported funding from a non-commercial source (a university research foundation). All of the other included studies received funding from pharmaceutical companies. We did not conduct subgroup and sensitivity analyses AUTHORS' CONCLUSIONS: LZV and RZV are effective in preventing herpes zoster disease for up to three years (the main studies did not follow participants for more than three years). To date, there are no data to recommend revaccination after receiving the basic schedule for each type of vaccine. Both vaccines produce systemic and injection site adverse events of mild to moderate intensity.
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Affiliation(s)
- Anna MZ Gagliardi
- Universidade Federal de São PauloDepartment of Geriatrics and GerontologyRua Professor Francisco de Castro 105São PauloSão PauloBrazil04020‐050
| | - Brenda NG Andriolo
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Maria Regina Torloni
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilRua Borges Lagoa, 564 cj 63São PauloSão PauloBrazil04038‐000
| | - Bernardo GO Soares
- Brazilian Cochrane CentreAlameda Itu 1025/ 42São PauloSão PauloBrazil01421‐001
| | - Juliana de Oliveira Gomes
- Universidade Federal de São PauloDepartment of Geriatrics and GerontologyRua Professor Francisco de Castro 105São PauloSão PauloBrazil04020‐050
| | - Regis B Andriolo
- Universidade do Estado do ParáDepartment of Public HealthTravessa Perebebuí, 2623BelémParáBrazil66087‐670
| | - Eduardo Canteiro Cruz
- Universidade Federal de São PauloDepartment of Geriatrics and GerontologyRua Professor Francisco de Castro 105São PauloSão PauloBrazil04020‐050
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Viner M, Murakhovskaya I. A rare combination of thrombotic thrombocytopenic purpura and antiphospholipid syndrome. Blood Coagul Fibrinolysis 2018; 28:411-415. [PMID: 27898514 DOI: 10.1097/mbc.0000000000000608] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Thrombocytopenia, in the setting of microangiopathic hemolytic anemia and thrombotic events, is characteristic of both thrombotic thrombocytopenic purpura and primary antiphospholipid syndrome. Clinically, it is difficult to distinguish between these two syndromes. We present a 41-year-old woman with chronic, relapsing thrombotic thrombocytopenic purpura in the presence of antiphospholipid antibodies. She had clinical manifestations of antiphospholipid syndrome without meeting laboratory criteria of the Sydney classification system. In the literature, there have only been nine cases of thrombotic thrombocytopenic purpura associated with primary antiphospholipid syndrome. Seven of the nine cases suffered from one or multiple strokes, a common feature in antiphospholipid syndrome, but an uncommon finding in thrombotic thrombocytopenic purpura. We introduce the possibility of an association between thrombotic thrombocytopenic purpura and the presence of antiphospholipid antibodies. Systematic testing of ADAMTS13 activity and anti-ADAMTS13 antibodies in patients who present with neurological symptoms and thrombocytopenia, in the presence of antiphospholipid antibodies, may help with the diagnosis of the rare thrombotic thrombocytopenic purpura-antiphospholipid syndrome combination.
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Affiliation(s)
- Maya Viner
- aUniversity of Illinois at Chicago, Chicago, Illinois bAlbert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
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Mohamed-Hussein AR, Makhlouf H, Hashem S. Catastrophic antiphospholipid lung syndrome in young female with repeated abortions. Lung India 2018; 35:85-87. [PMID: 29319044 PMCID: PMC5760878 DOI: 10.4103/lungindia.lungindia_254_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Vassalo J, Spector N, Meis ED, Soares M, Salluh JIF. Antiphospholipid antibodies in critically ill patients. Rev Bras Ter Intensiva 2015; 26:176-82. [PMID: 25028953 PMCID: PMC4103945 DOI: 10.5935/0103-507x.20140026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 04/18/2014] [Indexed: 12/14/2022] Open
Abstract
Antiphospholipid antibodies are responsible for a wide spectrum of clinical
manifestations. Venous, arterial and microvascular thrombosis and severe catastrophic
cases account for a large morbidly/mortality. Through the connection between the
immune, inflammatory and hemostatic systems, it is possible that these antibodies may
contribute to the development of organ dysfunction and are associated with poor short
and long-term prognoses in critically ill patients. We performed a search of the
PubMed/MedLine database for articles written during the period from January 2000 to
February 2013 to evaluate the frequency of antiphospholipid antibodies in critically
ill patients and their impact on the outcomes of these patients. Only eight original
studies involving critically ill patients were found. However, the development of
antiphospholipid antibodies in critically ill patients seems to be frequent, but more
studies are necessary to clarify their pathogenic role and implications for clinical
practice.
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Affiliation(s)
- Juliana Vassalo
- Programa de Pós-Graduação, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Nelson Spector
- Programa de Pós-Graduação, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Ernesto de Meis
- Hospital do Câncer, Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brasil
| | - Márcio Soares
- Programa de Pós-Graduação, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
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10
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Abstract
Catastrophic antiphospholipid syndrome (CAPS), also called "Asherson syndrome", is a variant of the antiphospholipid syndrome (APS) that occurs in less than 1% of APS cases. The etiology of CAPS is uncertain; however, several triggering factors have been recognized. The most common of these are infectious diseases, particularly those of the respiratory tract. CAPS pathogenesis is incompletely understood, but several theories have been proposed, such as the molecular mimicry theory, which describes the production of anti-β2-glycoprotein I (GP1) antibody in response to infection. The process is complex and involves the activation of Toll-like receptor 4 (TLR-4), which triggers a cytokine storm, followed by endothelial alterations that induce a procoagulant state.
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11
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Antiphospholipid syndrome and the heart: A case series and literature review. Autoimmun Rev 2015; 14:214-22. [DOI: 10.1016/j.autrev.2014.11.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 11/07/2014] [Indexed: 12/20/2022]
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12
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36-year-old female with catastrophic antiphospholipid syndrome treated with eculizumab: a case report and review of literature. Case Rep Hematol 2014; 2014:704371. [PMID: 25389502 PMCID: PMC4214168 DOI: 10.1155/2014/704371] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 09/08/2014] [Indexed: 12/16/2022] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare but potentially life-threatening condition characterized by diffuse vascular thrombosis, leading to multiple organ failure developing over a short period of time in the presence of positive antiphospholipid antibodies (aPL). CAPS is a severe form of antiphospholipid syndrome, developing in about 1% of cases of classic antiphospholipid syndrome, manifesting as microangiopathy, affecting small vessels of multiple organs. It is acute in onset, with majority of cases developing thrombocytopenia and less frequently hemolytic anemia and disseminated intravascular coagulation. Lupus anticoagulant and anticardiolipin antibodies have been reported as predominant antibodies associated with CAPS. Treatment options often utilized in CAPS include anticoagulation, steroids, plasma exchange, cyclophosphamide therapy, and intravenous immunoglobulin therapy. Even though the reported incidence of this condition is considered to be low, the mortality rate is approaching 50%. The high rate of mortality should warrant greater awareness among clinicians for timely diagnosis and treatment of this life-threatening condition. Studies have shown that complement activation plays a key role in the pathogenesis of aPL mediated thrombosis in CAPS. We report a case of a 36-year-old female admitted with clinical and laboratory findings consistent with CAPS successfully treated with eculizumab, a terminal complement inhibitor.
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13
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de Carvalho JF, Pereira RMR, Shoenfeld Y. Current knowledge regarding Asherson’s syndrome. Expert Rev Clin Immunol 2014; 5:587-91. [DOI: 10.1586/eci.09.34] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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Regunath H, Shortridge J, Raza S, Nistala P, Huffman BM, Wang MX, Xiang D. Occult pulmonary mucosa-associated lymphoid tissue lymphoma presenting as catastrophic antiphospholipid antibody syndrome. Oncol Lett 2013; 6:1261-1264. [PMID: 24179505 PMCID: PMC3813804 DOI: 10.3892/ol.2013.1585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 06/12/2013] [Indexed: 11/29/2022] Open
Abstract
Catastrophic antiphospholipid antibody syndrome (CAPS) is characterized by fulminant thrombosis of the arterial and venous beds of multiple organ systems over a relatively short period of time and with a high mortality rate. Mucosa-associated lymphoid tissue (MALT) lymphoma of the lung has never been reported as a causative or precipitating factor for CAPS in the CAPS registry database. The present study describes a rare case of pulmonary MALT lymphoma of the lung that presented as CAPS. A 19-year-old Hispanic female presented with shortness of breath and abdominal pain. Computed tomography (CT) scans of the chest and abdomen revealed multiple portal vein thromboses and bilateral pulmonary nodules. Within one week of presentation, the patient developed a straight sinus thrombosis and upper extremity deep vein thrombosis, which led to shortness of breath. A biopsy of the lung nodule revealed MALT lymphoma. The present case illustrates a rarely reported pulmonary MALT lymphoma presenting as CAPS in a young female. The patient was successfully treated with 90 mg/m2 bendamustine on days one and two and rituximab 375 mg/m2 on day one of each 28-day cycle. Complete remission of the lung nodules was observed following three cycles of treatment, as visualized by positron emission tomography (PET)/CT scan. Fondaparinux was identified as a feasible anticoagulation drug of choice for this case. At seven months post-treatment, the patient continues to be stable with no further evidence of thrombosis and is currently undergoing rituximab maintenance therapy every six months for two years. A repeat lupus anticoagulant antibody assay turned and remained negative during the clinical follow-up period. A prompt diagnosis and early aggressive treatment is potentially curative and may dramatically decrease the mortality risk. Future studies should explore the role of rituximab in the management of CAPS-associated B-cell lymphoid malignancies.
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Affiliation(s)
- Hariharan Regunath
- Department of Internal Medicine, University of Missouri, Columbia, MO 65203, USA
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15
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Abdul Haium AA, Sheppard M, Rubens M, Daubeney P. Catastrophic antiphospholipid syndrome in childhood: presentation with an inferior caval vein mass. BMJ Case Rep 2013; 2013:bcr-2013-010043. [PMID: 23861282 DOI: 10.1136/bcr-2013-010043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Venous thromboembolism remains one of the important causes of pulmonary hypertension in children. The causes of venous thromboembolism are varied and include antiphospholipid antibody syndrome (APS). Catastrophic APS (CAPS) is a severe variant of APS characterised by disseminated thrombosis and microangiopathy resulting in multiorgan failure. CAPS can occur independently (primary APS) but mainly occurs in association with systemic lupus erythematosus including the paediatric population. We report a young girl with primary CAPS who presented with pulmonary hypertension and an inferior vena cava mass masquerading as a tumour.
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16
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Lechner K, Simonitsch I, Haselböck J, Jäger U, Pabinger I. Acquired immune-mediated thrombophilia in lymphoproliferative disorders. Leuk Lymphoma 2011; 52:1836-43. [DOI: 10.3109/10428194.2011.580474] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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17
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Smythe MA, Warkentin TE, Woodhouse AL, Zakalik D. Venous limb gangrene and fatal hemorrhage: adverse consequences of HIT "overdiagnosis" in a patient with antiphospholipid syndrome. Am J Hematol 2011; 86:188-91. [PMID: 21264902 DOI: 10.1002/ajh.21916] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This unfortunate patient case highlights the problems with "overdiagnosis" of HIT. Despite "positive" tests for HIT antibodies, the low pretest probability for HIT and the known propensity of patients with APS to yield false-positive HIT antibody results suggests that the patient did not have a true diagnosis of HIT. Moreover, the early administration of warfarin and the choice of argatroban for parenteral anticoagulation when monitoring was hindered by a prolonged baseline aPTT likely play a key factor in the progression of UE DVT to VLG. Ironically, the problems of anticoagulant monitoring posed by the prolonged baseline aPTT likely contributed to the subsequent overanticoagulation and fatal pulmonary hemorrhage. With benefit of hindsight, avoiding the temptation to test for HIT in a low pretest probability situation, and treatment with either heparin using anti-factor Xa monitoring or with non-aPTT-monitored therapy such as LMWH or fondaparinux would likely have resulted in a more favorable clinical course.
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Affiliation(s)
- Maureen A. Smythe
- Department of Pharmaceutical Services, Beaumont Hospitals, Royal Oak, Michigan
- Department of Pharmacy Practice, Wayne State University, Detroit, Michigan
| | - Theodore E. Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Dana Zakalik
- Division of Hematology and Oncology and Beaumont Cancer Institute, Beaumont Hospitals, Royal Oak, Michigan
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18
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Lansigan F, Isufi I, Tagoe CE. Microangiopathic haemolytic anaemia resembling thrombotic thrombocytopenic purpura in systemic lupus erythematosus: the role of ADAMTS13. Rheumatology (Oxford) 2010; 50:824-9. [PMID: 21149242 DOI: 10.1093/rheumatology/keq395] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare but frequently fatal complication of SLE. It occurs in the context of both active and inactive lupus and carries a worse overall prognosis than idiopathic acquired TTP. Recent advances in the knowledge and treatment of TTP do not seem to have brought similar improvements in the management and outcome of TTP in SLE. The illumination of the role of the von Willebrand factor multimer protease, ADAMTS13 in idiopathic TTP continues to enhance our comprehension of the pathogenesis of the disease and has contributed to improvements in diagnosis and management. We explore the overlap of TTP and SLE, and discuss the current understanding of the involvement of ADAMTS13 and its implications for patients with this uncommon form of microangiopathic haemolytic anaemia.
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Affiliation(s)
- Frederick Lansigan
- Department of Medicine, Division of Rheumatology, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467-2490, USA
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19
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Owaidah TM, Maghrabi K, Elkarouri MA, Al Mohareeb F, Al Harthi A, Al Zahrani H. Successful treatment of a case of catastrophic antiphospholipid syndrome with autologous BMT: case report and review of literature. Bone Marrow Transplant 2010; 46:597-600. [PMID: 20661234 DOI: 10.1038/bmt.2010.148] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- T M Owaidah
- Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
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20
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Vlachoyiannopoulos PG, Routsias JG. A novel mechanism of thrombosis in antiphospholipid antibody syndrome. J Autoimmun 2010; 35:248-55. [PMID: 20638238 DOI: 10.1016/j.jaut.2010.06.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Antiphospholipid antibody syndrome (APS) is an autoimmune thrombophilia mediated by autoantibodies directed against phospholipid-binding plasma proteins, mainly β2 Glycoprotein I (β2GPI)-a plasma apolipoprotein and prothrombin (PT). A subgroup of these antibodies termed "Lupus Anticoagulant" (LA) elongate in vitro the clotting times, this elongation not corrected by adding normal plasma in the detection system. The exact mechanism by which these autoantibodies induce thrombosis is not well understood. Resistance to natural anticoagulants such as protein C, impaired fibrinolysis, activation of endothelial cells to a pro-coagulant phenotype and activation of platelets, are among the mechanisms partially supported by experimental evidence. Artificially dimerized β2GPI binds tightly to platelet membrane activating them. We search for mechanisms of natural dimerization of β2GPI by proteins of the platelet membranes and found that platelet factor 4 (PF4) assembled in homotetramers binds two molecules of β2GPI and this complex is recognized by anti-β2GPI antibodies, the whole complexes being thrombogenic in terms of activating platelets as confirmed by p38MAP kinase phosphorylation and thromboxane B2 production. Of note PF4/heparin complexes are also immunogenic triggering the production of anti-PF4/heparin antibodies which activate also platelets (the so-called "heparin-induced thrombocytopenia and thrombosis syndrome", HITT). The anti-β2GPI antibodies activate platelets by their F(ab)2, while the anti-PF4/heparin by their Fc fragments. Thus PF4 is a common denominator in the pathogenesis of APS and HITT which share also clinical characteristics such as thrombocytopenia and thrombosis.
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21
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Rafik R, Hachimi MA, Hommadi A, Rouimi A. [Ischaemic stroke and multi-organ failures during catastrophic antiphospholipid syndrome]. ACTA ACUST UNITED AC 2010; 29:595-6. [PMID: 20621433 DOI: 10.1016/j.annfar.2010.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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22
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Vibert J, Gelsi E, Vanbiervliet G, Dellamonica J, Tieulie N, Dahman M, Hastier P, Bernardin G, Tran A, Hebuterne X. [Severe acute pancreatitis revealing an antiphospholipid syndrome]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2010; 34:233-236. [PMID: 20219307 DOI: 10.1016/j.gcb.2009.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 10/31/2009] [Accepted: 11/27/2009] [Indexed: 05/28/2023]
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23
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Medina G, Calleja C, Morán M, Vera-Lastra O, Jara LJ. Catastrophic antiphospholipid syndrome in a patient with Down syndrome. Lupus 2010; 18:1104-7. [PMID: 19762387 DOI: 10.1177/0961203309105878] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a patient with Down syndrome, under treatment with carbamazepine, levopromazine and clonazepam. After urinary infection he developed glans necrosis requiring excision of prepuce. Six hours post surgery he presented right-hand ischemia followed by arterial and venous thrombosis of the right thoracic extremity. Later, he progressed to a compartment syndrome and presented ischemia of toes. All the clinical manifestations developed over a week. Anticardiolipin (aCL) antibodies, lupus anticoagulant and perinuclear antineutrophil antibodies were positive. Anticoagulant and immunosuppressive treatment were initiated. Owing to the failure of both treatments, the patient underwent amputation of right hand and a toe. Histopathology revealed recent and old thrombosis of medium- and small-sized vessels without vasculitis. Diagnosis of catastrophic antiphospholipid syndrome (CAPS) was made. At present, the patient continues on oral anticoagulants, IgG aCL remains positive, and no further episodes of thromboses have been observed after 4 years of follow-up. To our knowledge, this is the first case of CAPS in a patient with Down syndrome.
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Affiliation(s)
- Gabriela Medina
- Clinical Research Unit, Hospital de Especialidades Centro Médico La Raza, IMSS, CP 02990 Mexico City, México
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24
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Shoenfeld Y, Gershwin ME. Whither autoimmunity: the lessons of anti-CCP and B cell depletion. Clin Rev Allergy Immunol 2009; 34:1-3. [PMID: 18270849 DOI: 10.1007/s12016-007-8014-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The most difficult component to understand in autoimmune disease has been the issue of causation. In contrast, there have been enormous gains in improved diagnostics as well as improved therapy. Indeed, the use of biologics have changed the profile of numerous autoimmune diseases. In this issue, we discuss two such aspects. Firstly, we place in perspective the use of anti-citrullinated protein antibodies in rheumatoid arthritis. Second, we discuss the increasing use of B cell depletion in the treatment of autoimmunity. Clinical Reviews in Allergy and Immunology is a unique venue for these themes because it covers the spectrum of allergy through autoimmunity. Indeed, we also present a special paper on the relationships of the hepatitis B virus and autoimmunity. Although the Th1 to Th2 dichotomy is well known to both murine and human immunologists, it is really in the study of specific inflammatory responses that they are correctly placed in the perspective of the continuum of immunopathology.
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Affiliation(s)
- Yehuda Shoenfeld
- Department of Medicine B and Center for Autoimmune Diseases, Sheba Medical Center, Affiliated to Tel-Aviv University, Tel-Hashomer, 52621, Israel.
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25
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de Meis E, Monteiro RQ, Levy RA. Lung adenocarcinoma and antiphospholipid antibodies. Autoimmun Rev 2009; 8:529-32. [PMID: 19185619 DOI: 10.1016/j.autrev.2009.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2009] [Accepted: 01/15/2009] [Indexed: 12/27/2022]
Abstract
Thrombosis is a frequent finding in cancer patients, being referred to as a poor prognostic factor. The mechanisms underlying the thrombophilic state in malignancy are not well elucidated but involve a complex interaction between tumor and host cells as well as the hemostatic system. A number of studies have demonstrated the presence of antiphospholipid antibodies (aPL) in cancer patients, suggesting a potential role in tumor-associated thrombosis. A prospective analysis has been performed in a group of lung adenocarcinoma patients in respect to the presence of aPL and thrombotic manifestations. Lupus anticoagulant (LAC) was identified in 61 out of 105 patients and it correlated highly with thrombosis (22/61, LAC positive vs 2/44, LAC negative RR=7.93; p<0.001). On the other hand, patients that displayed IgM anti-beta2-glycoprotein I (abeta2GPI) (22/80) showed an unexpected decrease in thrombosis risk (2/22, with IgM abeta2GPI vs 18/58, without IgM abeta2GPI RR=0.29; p=0.04). Considerations on the mechanisms that link cancer, thrombosis and aPL are discussed in this article.
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Affiliation(s)
- Ernesto de Meis
- Clinical Pathology, Instituto Nacional do Câncer, Rio de Janeiro, Brazil.
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26
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Abstract
Antiphospholipid syndrome is diagnosed when arterial or venous thrombosis or recurrent miscarriages occur in a person in whom laboratory tests for antiphospholipid antibodies (anticardiolipin antibodies and/or lupus anticoagulant and/or anti-beta 2-glycoprotein I) are positive. Despite the strong association between antiphospho-lipid antibodies and thrombosis, their pathogenic role in the development of thrombosis has not been fully elucidated. Novel mechanisms involving both the complement pathway and micro-particles have been described. The knowledge of these new pathogenic approaches might identify novel therapeutic targets and therefore may improve the management of these patients.
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Affiliation(s)
- Gerard Espinosa
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, Catalonia, Spain.
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27
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Pers YM, Puygrenier M, Borlot F, Simorre B, Barazer I, Oziol E, Reny JL. [Acute Q fever, antiphopholipid antibodies and renal artery thrombosis: case report and literature review]. Rev Med Interne 2008; 30:250-4. [PMID: 19026472 DOI: 10.1016/j.revmed.2008.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 08/29/2008] [Accepted: 10/08/2008] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Antiphospholipid antibodies (aPL) can be associated with numerous infectious and particularly Q fever. Data on the pathogenicity of aPL in the course of acute Q fever are scarce. CASE REPORT We report the case an acute Coxiella burnetii infection associated with clinical and biological manifestations of the aPL syndrome, including a renal infarction. Along with antibiotic treatment, anticoagulation and intravenous immunoglobulins, the clinical outcome was favourable. Antiphospholipid antibodies and Q fever antibody titers had a closely related evolution. CONCLUSION Arterial thrombosis associated with Q fever and aPL is exceptional. The nosology and potential mechanisms are discussed.
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Affiliation(s)
- Y-M Pers
- Département de médecine interne, Centre hospitalier de Béziers, 34525 Béziers cedex, France
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28
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Pasquali JL, Poindron V, Korganow AS, Martin T. The antiphospholipid syndrome. Best Pract Res Clin Rheumatol 2008; 22:831-45. [DOI: 10.1016/j.berh.2008.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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29
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Vasculitis: Current Status and Future Directions. Clin Rev Allergy Immunol 2008; 35:1-4. [DOI: 10.1007/s12016-007-8061-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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30
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Sherer Y, Matthias T, Shoenfeld Y. Cutting Edge Issues in Autoimmunity. Clin Rev Allergy Immunol 2008; 34:275-8. [DOI: 10.1007/s12016-007-8047-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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31
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van Wissen S, Bastiaansen BAJ, Stroobants AK, van den Dool EJ, Idu MM, Levi M, Stroes ESG. Catastrophic antiphospholipid syndrome mimicking a malignant pancreatic tumour – a case report. Lupus 2008; 17:586-90. [DOI: 10.1177/0961203307087406] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Abstract The catastrophic antiphospholipid syndrome is characterised by rapid onset thromboses, often resistant to conventional anticoagulant treatment, and resulting in life threatening multiple organ dysfunction. The diagnosis of catastrophic antiphospholipid syndrome may be difficult, predominantly due to its frequently atypical presentation. We report a case of a 35-year-old female who presented with a pancreatic tumour and extensive thromboses. Following a storm of ischemic events due to thrombotic occlusions in spite of therapeutic heparin dose, the suspicion of catastrophic antiphospholipid syndrome emerged. The patient was successfully treated with anticoagulants, immunuglobulins, plasmapheresis and rituximab. The present report shows that the use of the diluted Russell’s viper venom time can be helpful in providing additional information on the lupus anticoagulans antibody status, allowing careful monitoring of lupus anticoagulans conversion and hence response to therapy.
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Affiliation(s)
- S van Wissen
- Department of Internal Medicine and Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - BAJ Bastiaansen
- Department of Gastroenterology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - AK Stroobants
- Department of Clinical Chemistry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - EJ van den Dool
- Department of Clinical Chemistry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - MM Idu
- Department of Vascular Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M Levi
- Department of Internal Medicine and Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - ESG Stroes
- Department of Internal Medicine and Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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32
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Austin SK, Starke RD, Lawrie AS, Cohen H, Machin SJ, Mackie IJ. The VWF/ADAMTS13 axis in the antiphospholipid syndrome: ADAMTS13 antibodies and ADAMTS13 dysfunction. Br J Haematol 2008; 141:536-44. [DOI: 10.1111/j.1365-2141.2008.07074.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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33
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Antinucleosome antibodies in primary antiphospholipid syndrome: a hint at systemic autoimmunity? J Autoimmun 2008; 30:51-7. [PMID: 18191541 DOI: 10.1016/j.jaut.2007.11.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Antinucleosome antibodies (anti-NCS) are reported to be highly sensitive and specific for systemic lupus erythematosus (SLE) and to correlate with disease activity. They may appear in early stages of the disease, in particular before anti-dsDNA antibodies, being a potential marker for identifying patients susceptible to SLE. Patients with primary antiphospholipid syndrome (PAPS) may develop full-blown SLE but there is no evidence for markers predictive for that. AIM To evaluate whether anti-NCS may be predictors for full-blown or lupus like disease (LL) in a cohort of PAPS patients. METHODS A multicentric cohort of 105 PAPS patients was tested for IgG/IgM anti-NCS by using a home made assay with H1-stripped chromatin as antigen. RESULTS Eighty-one out of 105 (77%) of the patients were positive for anti-NCS; medium-high titre results were present only in 49/105 (46%). Anti-NCS were more frequently detected in PAPS+LL, but no relationship with clinical/serological features was found, except for a weak correlation with anti-dsDNA antibodies. Two PAPS patients evolved into full-blown SLE during the follow-up and displayed high titre anti-NCS many years before. CONCLUSIONS Our findings suggest that anti-NCS might be added to the mosaic of autoimmune phenomena characterizing PAPS patients and in particular those with more chance to evolve to SLE.
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Fernando MMA, Isenberg DA. Conversion of discoid lupus to antiphospholipid syndrome and SLE. ACTA ACUST UNITED AC 2008; 4:106-10. [PMID: 18235540 DOI: 10.1038/ncprheum0704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Accepted: 10/30/2007] [Indexed: 11/09/2022]
Abstract
BACKGROUND A 64-year-old man was admitted to hospital with increasing seizure frequency, lethargy and confusion. He had a history of discoid lupus erythematosus, complex partial seizures, cerebral thromboses associated with antiphospholipid syndrome (APS) and hypertension. After admission to hospital, he developed autoimmune hemolytic anemia, thrombocytopenia, severe hypertension, proteinuria and a fluctuating level of consciousness. INVESTIGATIONS Physical examination, biochemical and hematological indices, urine dipstick, electrocardiography and chest radiography on admission, with subsequent electroencephalography, lumbar puncture, septic screen, autoimmune screen, CT of the head, MRI of the brain and renal biopsy. DIAGNOSIS Conversion of discoid lupus erythematosus with APS to systemic lupus erythematosus with APS. MANAGEMENT Pulsed intravenous methylprednisolone and a single infusion of intravenous cyclophosphamide, followed by oral prednisolone, were initially administered for presumed cerebral lupus. When renal biopsy revealed dual pathology, another dose of intravenous cyclophosphamide was administered with intravenous heparin therapy to treat systemic lupus erythematosus and APS, respectively. Intravenous immunoglobulin was used to treat thrombocytopenia, which was unresponsive to immunosuppression and anticoagulation. Gradual improvement occurred with maximal antihypertensive therapy and supportive treatment. The patient was discharged after 9 months of hospital treatment. His medication at this stage included warfarin, clopidogrel, prednisolone, carbamazepine, ramipril, atenolol, calcium and vitamin D supplements, and alendronate.
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Affiliation(s)
- Michelle M A Fernando
- Section of Molecular Genetics and Rheumatology, Faculty of Medicine, Imperial College, London, UK
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Crispín JC, Tsokos GC. Novel molecular targets in the treatment of systemic lupus erythematosus. Autoimmun Rev 2007; 7:256-61. [PMID: 18190888 DOI: 10.1016/j.autrev.2007.11.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
T cells from patients with systemic lupus erythematosus (SLE) display a number of biochemical abnormalities which include altered expression of key signaling molecules, heightened calcium responses, and skewed expression of transcription factors. These defects are involved in the altered behavior of SLE T cells and are probably central in the disease pathogenesis. The aim of this communication is to review the defects that have been consistently documented in SLE T cells, highlighting molecules and pathways that represent therapeutic targets.
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Affiliation(s)
- José C Crispín
- Division of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, 4 Blackfan Circle, HIM-244, Boston, MA 02115, USA
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Sène D, Piette JC, Cacoub P. Antiphospholipid antibodies, antiphospholipid syndrome and infections. Autoimmun Rev 2007; 7:272-7. [PMID: 18295729 DOI: 10.1016/j.autrev.2007.10.001] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Accepted: 10/01/2007] [Indexed: 12/13/2022]
Abstract
Since the association between antiphospholipid antibodies (aPL) and syphilis was first described, many other viral, bacterial and parasitic infections have been shown to induce antiphospholipid antibodies, notably anticardiolipin antibodies (aCL). A review of the literature shows that while aCL occur frequently in viral infections, particularly in HIV (49.75%), HBV (24%) and HCV (20%), it is very rarely associated with anti-beta2 glycoprotein I antibodies (anti-beta2GPI) and is not correlated with thrombosis risk or hematological manifestations of the antiphospholipid syndrome (APS). Concerning bacterial infections, aCL is often present in leprosy (42.7%), where it is frequently associated with the presence of anti-beta2GPI (44.8%), and in syphilis infections (8 to 67%), though without correlation with thrombotic events. Though few individual patients with unequivocal infection-induced aPL satisfy criteria for APS, the lack of statistical association with thrombotic events strongly argues against the identification of a true APS subset in this context. However, physicians should keep in mind the fact that an infection, generally bacterial, in patients with confirmed APS, may lead to catastrophic antiphospholipid syndrome with a possible fatal outcome.
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Affiliation(s)
- Damien Sène
- Université Pierre et Marie Curie-Paris 6, CNRS, UMR 7087, Paris, F-75013 France
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Uppal SS, Bammigatti C. Antiphospholipid syndrome: recent advances. INDIAN JOURNAL OF RHEUMATOLOGY 2007. [DOI: 10.1016/s0973-3698(10)60094-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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