|
1
|
Gaspar P, Sciascia S, Tektonidou MG. Epidemiology of antiphospholipid syndrome: macro- and microvascular manifestations. Rheumatology (Oxford) 2024; 63:SI24-SI36. [PMID: 38320589 PMCID: PMC10846913 DOI: 10.1093/rheumatology/kead571] [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: 08/16/2023] [Accepted: 10/08/2023] [Indexed: 02/08/2024] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by thrombotic and non-thrombotic macro- and microvascular manifestations and pregnancy complications in the setting of persistent antiphospholipid antibodies (aPL), namely anticardiolipin antibodies, anti-β2 glycoprotein-I antibodies and lupus anticoagulant. Four decades after its first description, APS prevalence and incidence are still not completely understood due to the limited number of well-designed, population-based multi-ethnic studies. Furthermore, despite decades of efforts to standardise aPL immunoassays, considerable intraassay and interlaboratory variances in aPL measures still exist. Large multicentre APS cohorts have shown a 10-year survival of ∼91% and the presence of catastrophic APS occurs in about 1% of the entire population, associated with a 50% mortality rate. Clinically, any organ can be affected in the context of large, medium or small vessel (artery and/or vein) thrombosis. Macrovascular thrombosis is the hallmark of the disease and veins are more frequently affected than arteries. Deep vein thrombosis/pulmonary embolism thromboembolic disease is the most common APS manifestation, while stroke and transient ischaemic attack are the most frequent arterial thrombosis events. Myocardial infarction can also occur and contributes to increased mortality in APS. A minority of patients present with thrombosis affecting the intraabdominal organs, including the liver, spleen, small and large bowel, and the kidneys. Microvascular thrombosis, including APS nephropathy, chronic skin ulcers and livedoid vasculopathy represent a diagnostic challenge requiring histologic confirmation. In this narrative review we summarize the available evidence on APS epidemiology, focusing on the description of the prevalence of macro- and microvascular manifestations of the disease.
Collapse
Affiliation(s)
- Pedro Gaspar
- Internal Medicine Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Centro Académico de Medicina de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-ReConnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), ASL Città Di Torino and University of Turin, Turin, Italy
| | - Maria G Tektonidou
- First Department of Propaedeutic and Internal Medicine, Joint Academic Rheumatology Program, EULAR Centre of Excellence, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| |
Collapse
|
|
2
|
Bitsadze V, Yakubova F, Khizroeva J, Lazarchuk A, Salnikova P, Vorobev A, Tretyakova M, Degtyareva N, Grigoreva K, Gashimova N, Kvaratskheliia M, Makatsariya N, Kudryavtseva E, Tomlenova A, Gris JC, Elalamy I, Ay C, Makatsariya A. Catastrophic Antiphospholipid Syndrome. Int J Mol Sci 2024; 25:668. [PMID: 38203837 PMCID: PMC10779422 DOI: 10.3390/ijms25010668] [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: 11/24/2023] [Revised: 12/26/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Unlike classic APS, CAPS causes multiple microthrombosis due to an increased inflammatory response, known as a "thrombotic storm". CAPS typically develops after infection, trauma, or surgery and begins with the following symptoms: fever, thrombocytopenia, muscle weakness, visual and cognitive disturbances, abdominal pain, renal failure, and disseminated intravascular coagulation. Although the presence of antiphospholipid antibodies in the blood is one of the diagnostic criteria, the level of these antibodies can fluctuate significantly, which complicates the diagnostic process and can lead to erroneous interpretation of rapidly developing symptoms. Triple therapy is often used to treat CAPS, which includes the use of anticoagulants, plasmapheresis, and high doses of glucocorticosteroids and, in some cases, additional intravenous immunoglobulins. The use of LMWH is recommended as the drug of choice due to its anti-inflammatory and anticoagulant properties. CAPS is a multifactorial disease that requires not only an interdisciplinary approach but also highly qualified medical care, adequate and timely diagnosis, and appropriate prevention in the context of relapse or occurrence of the disease. Improved new clinical protocols and education of medical personnel regarding CAPS can significantly improve the therapeutic approach and reduce mortality rates.
Collapse
Affiliation(s)
- Victoria Bitsadze
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Fidan Yakubova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Jamilya Khizroeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Arina Lazarchuk
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Polina Salnikova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Alexander Vorobev
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Maria Tretyakova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Natalia Degtyareva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Kristina Grigoreva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Nilufar Gashimova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Margaret Kvaratskheliia
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Nataliya Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Ekaterina Kudryavtseva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Anna Tomlenova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Jean-Christophe Gris
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Faculty of Pharmaceutical and Biological Sciences, Montpellier University, 34093 Montpellier, France
| | - Ismail Elalamy
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Department Hematology and Thrombosis Center, Medicine Sorbonne University, 75012 Paris, France
- Hospital Tenon, 4 Rue de la Chine, 75020 Paris, France
| | - Cihan Ay
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, 1080 Vienna, Austria
| | - Alexander Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| |
Collapse
|
|
3
|
Addison's Disease in the Course of Recurrent Microangiopathic Antiphospholipid Syndrome-A Clinical Presentation and Review of the Literature. Medicina (B Aires) 2022; 59:medicina59010004. [PMID: 36676628 PMCID: PMC9863237 DOI: 10.3390/medicina59010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
The article presents a male patient with adrenocortical insufficiency in the course of antiphospholipid syndrome (APS). It also describes recurrent exacerbations of his clinical status, characteristic of microangiopathic antiphospholipid syndrome (MAPS) which had been misdiagnosed as a disseminated intravascular coagulopathy (DIC) syndrome due to sepsis with multi-organ failure, including heart, kidneys, and liver. Issues related to pathogenesis, clinical symptoms, differential diagnosis, and treatment of APS in the context of presently distinguished subtypes of this syndrome have been addressed. The role of vascular endothelial cell activation and the influence of coagulation patterns on the development of APS continuum clinical symptoms have also been mentioned. In addition, this paper highlights that the diagnosis of APS should be considered in patients with adrenal insufficiency and abdominal pain, even without any prior history of thromboembolic diseases, as well as in the course of DIC, especially without predisposing factors.
Collapse
|
|
4
|
Komici K, Faris P, Negri S, Rosti V, García-Carrasco M, Mendoza-Pinto C, Berra-Romani R, Cervera R, Guerra G, Moccia F. Systemic lupus erythematosus, endothelial progenitor cells and intracellular Ca2+ signaling: A novel approach for an old disease. J Autoimmun 2020; 112:102486. [DOI: 10.1016/j.jaut.2020.102486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 02/07/2023]
|
|
5
|
Sun Y, Zhao J, Zhang P, Wu C, Jiang N, Zhou J, Zhang S, Wu Q, Wang Q, Li M, Zeng X. Clinical characteristics and risk factors of microvascular involvement in primary antiphospholipid syndrome: a longitudinal single-center study in China. Lupus 2019; 28:1558-1565. [PMID: 31635555 DOI: 10.1177/0961203319882506] [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: 12/30/2022]
Abstract
OBJECTIVES The objective of this study was to investigate risk factors of microvascular involvement and survival in Chinese patients with primary antiphospholipid syndrome. METHODS In this single-center, retrospective study, we enrolled 112 patients with a confirmed diagnosis of primary antiphospholipid syndrome who were admitted to Peking Union Medical College Hospital from January 2004 to December 2016. Demographic data, clinical characteristics, laboratory results, and follow-up records were collected. RESULTS A total of 112 patients with primary antiphospholipid syndrome were studied. Microvascular involvement was identified in 21 patients (18.75%). Patients with microvascular involvement experienced fewer episodes of arterial or venous thrombosis (28.6% vs. 84.6%) and a higher incidence of thrombocytopenia (85.7% vs. 54.9%), respectively. Low complement and elevated high-sensitivity CRP levels were observed more frequently in the microvascular group compared with the non-microvascular group (complement 38.1% vs. 18.7%; high-sensitivity CRP 71.4% vs. 31.9%, respectively). Anti-β2-glycoprotein I antibodies were more prevalent in patients with microvascular involvement than in patients without (66.7% vs. 33.0%, respectively). Multivariate logistic regression analysis revealed that thrombocytopenia (odds ratio = 4.523, 95% confidence interval 1.139-17.962), elevated high-sensitivity CRP levels (odds ratio = 6.385, 95% confidence interval 1.969-20.704), and anti-β2-glycoprotein I antibody positivity (odds ratio = 5.042, 95% confidence interval 1.555-16.352) were independent risk factors for microvascular involvement. A Kaplan-Meier analysis revealed that survival was significantly poorer in patients with microvascular involvement compared with patients without (p = 0.0278). CONCLUSIONS In addition to arterial and venous thrombosis, antiphospholipid syndrome can affect the microvasculature of select organs. It is thus important for clinicians to be aware that antiphospholipid syndrome-associated microvascular involvement has a unique pathogenesis and can be a life-threatening condition.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - X Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| |
Collapse
|
|
6
|
Pengo V, Denas G. Diagnostics and treatment of thrombotic antiphospholipid syndrome (APS): A personal perspective. Thromb Res 2018; 169:35-40. [PMID: 30007134 DOI: 10.1016/j.thromres.2018.07.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/02/2018] [Accepted: 07/05/2018] [Indexed: 01/25/2023]
Abstract
Antiphospholipid Syndrome (APS) is a condition characterized by the occurrence of thromboembolic events and/or pregnancy loss combined with one laboratory criterion among Lupus Anticoagulant- LAC, anticardiolipin -aCL, and anti β2-Glycoprotein I -aβ2GPI antibodies. Several hypotheses were put forward to explain the causal role of antibodies in the clinical events but none is fully convincing. Current laboratory diagnosis is based on three tests (LAC, IgG/IgM aβ2GPI and IgG/IgM aCL antibodies). The triple-positive profile (all the three tests positive, same isotype) is associated with a higher risk for thrombosis. The mainstay of therapy in thrombotic APS is anticoagulation, with VKAs being the cornerstone. Low dose aspirin in combination or alone may have a role in arterial thrombosis, and in primary thromboprophylaxis. The Non-Vitamin K Antagonists Oral Anticoagulants (NOACs) role in the therapy of APS is under investigation but not verified. Alternative treatment options including rituximab and eculizumab have been successfully reported in few cases of catastrophic APS.
Collapse
Affiliation(s)
- Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Italy.
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Italy
| |
Collapse
|
|
7
|
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]
|
|
8
|
Abstract
The association between antiphospholipid antibodies (aPL) and clinical problems goes beyond what is stated in the antiphospholipid syndrome (APS) classification criteria, namely thrombosis and pregnancy morbidity, and thrombocytopenia is the most common non-criteria hematologic manifestation of aPL with a frequency ranging from 20 to 50 %. Thrombocytopenia is rarely severe, and hemorrhage is far less common than thrombosis. However, when anticoagulation is considered, it may constitute a clinical problem with increased bleeding risk. Furthermore, thrombocytopenia represents a risk factor for thrombosis in aPL-positive patients. Therefore, it is important to understand the pathogenesis and the clinical associations of thrombocytopenia to build the right medical approach in aPL-positive patients. In this paper, we review the literature on aPL/APS-associated thrombocytopenia and briefly discuss the other conditions that can result in thrombocytopenia as they have commonalities with APS and their recognition is important to establish the most appropriate treatment strategy.
Collapse
|
|
9
|
Rodríguez-Pintó I, Espinosa G, Cervera R. Catastrophic APS in the context of other thrombotic microangiopathies. Curr Rheumatol Rep 2015; 17:482. [PMID: 25604575 DOI: 10.1007/s11926-014-0482-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The catastrophic antiphospholipid syndrome (CAPS) is a rare disease that affects 1 % of cases with antiphospholipid syndrome (APS). CAPS can mimic or overlap with different thrombotic diseases; many patients present with a microthrombotic storm or thrombotic microangiopathic hemolytic anemia (TMHA). Thus, the differential diagnosis of CAPS includes thrombotic thrombocytopenic purpura (TTP), typical and atypical hemolytic uremic syndrome (HUS), systemic infections, malignancies, pregnancy-related disorders, malignant hypertension, heparin-induced thrombocytopenia, and drug-induced thrombotic microangiopathies. Antiphospholipid antibody (aPL) positivity has been proposed as the clue in this differential diagnosis; however, aPL can also occur in healthy people and in those with infections or malignancies. Thus, the differential diagnosis of an aPL-positive patient presenting with a microthrombotic storm is broad; the workup should include a special attention to signs of infection and disseminated malignant disease, assessing the funduscopic signs of malignant hypertension, testing ADAMTS13 activity and anti-heparin-platelet factor 4 (HPF4) antibodies, and searching previous exposure to certain drugs. This article aims to review the main diseases included in the differential diagnosis of CAPS in the context of other thrombotic microangiopathies.
Collapse
Affiliation(s)
- Ignasi Rodríguez-Pintó
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, Catalonia, Spain
| | | | | |
Collapse
|
|
10
|
An approach to differential diagnosis of antiphospholipid antibody syndrome and related conditions. ScientificWorldJournal 2014; 2014:341342. [PMID: 25374937 PMCID: PMC4211159 DOI: 10.1155/2014/341342] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/01/2014] [Indexed: 01/17/2023] Open
Abstract
The antiphospholipid antibody syndrome is a systemic, acquired, immune-mediated disorder characterized by episodes of venous, arterial, or microcirculation thrombosis and/or pregnancy abnormalities, associated with the persistent presence of autoantibodies, confirmed at least in two occasions 12 weeks apart, directed to molecular complexes consisting of phospholipids and proteins. Antiphospholipid antibody syndrome should always be considered as a potential diagnosis especially for young patients presenting with a history of thrombotic events, in particular when they occur without any obvious external trigger or any inherited thrombophilic mutation (even if 2006 criteria do not exclude antiphospholipid antibody syndrome in patients with other inherited or acquired prothrombotic conditions), or for women with recurrent pregnancy losses or later fetal deaths. Many other disorders are able to mimic antiphospholipid antibody syndrome, so a broad range of alternative diagnoses should be investigated and ruled out during clinical workup.
Collapse
|
|
11
|
Szodoray P, Hajas A, Toth L, Szakall S, Nakken B, Soltesz P, Bodolay E. The beneficial effect of plasmapheresis in mixed connective tissue disease with coexisting antiphospholipid syndrome. Lupus 2014; 23:1079-84. [DOI: 10.1177/0961203314533602] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The authors report a rare case of a female patient with mixed connective tissue disease (MCTD) with coexisting antiphospholipid syndrome (APS). Five years after the diagnosis of MCTD high concentrations of anticardiolipin (anti-CL) and anti-β2-glycoprotein (anti-β2GPI) autoantibodies were present in the patient’s serum without thrombotic events. Epstein-Barr virus (EBV) reactivation provoked APS, with the clinical manifestations of livedo reticularis, digital gangrene and leg ulcers. Skin biopsy from the necrotic area showed multiple fibrin microthrombi in the superficial vessels. Corticosteroid pulse therapy, and plasma exchange in combination with synchronized cyclophosphamide was administered, which led to improvement of the digital gangrenes, while no new lesions developed. The number of CD27high plasma cells decreased, and the previous high levels of autoantibodies also normalized in the peripheral blood. In the case of MCTD with coexisting APS combination therapy, including plasmapheresis has beneficial effects.
Collapse
Affiliation(s)
- P Szodoray
- Institute of Immunology, Rikshospitalet, University of Oslo, Oslo, Norway
| | | | - L Toth
- Department of Pathology, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
| | - S Szakall
- Department of Pathology, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
| | - B Nakken
- Institute of Immunology, Rikshospitalet, University of Oslo, Oslo, Norway
| | | | | |
Collapse
|
|
12
|
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]
|
|
13
|
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.
Collapse
Affiliation(s)
- Cassyanne L Aguiar
- Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021, USA
| | | |
Collapse
|
|
14
|
Antiphospholipid syndrome nephropathy (APSN) in patients with lupus nephritis: a retrospective clinical and renal pathology study. Rheumatol Int 2013; 34:535-41. [DOI: 10.1007/s00296-013-2900-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 11/06/2013] [Indexed: 10/26/2022]
|
|
15
|
Kwak-Kim J, Agcaoili MSL, Aleta L, Liao A, Ota K, Dambaeva S, Beaman K, Kim JW, Gilman-Sachs A. Management of women with recurrent pregnancy losses and antiphospholipid antibody syndrome. Am J Reprod Immunol 2013; 69:596-607. [PMID: 23521391 DOI: 10.1111/aji.12114] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 02/20/2013] [Indexed: 02/06/2023] Open
Abstract
Antiphospholipid antibodies (aPL) have been associated with recurrent pregnancy losses (RPL) and other obstetrical complications. The diagnostic criteria for the classical antiphospholipid antibody syndrome (APS) have been utilized for the detection of obstetrical APS in women with RPL. However, laboratory findings and immunopathology of obstetrical APS are significantly different from those of classical APS. In addition, many women with RPL who have positive aPL do not have symptoms consistent with the current APS criteria. The induction of a proinflammatory immune response from trophoblasts and complement activation by aPL rather than thromboembolic changes has been reported as a major immunopathological feature of obstetrical APS. Heparin treatment has been reported to be effective in prevention of early pregnancy loss with APS but not for the late pregnancy loss or complications. The complex effects of heparin may explain the limited efficacy of heparin treatment in RPL. New diagnostic criteria for obstetrical APS are needed urgently, and new therapeutic approaches should be explored further.
Collapse
Affiliation(s)
- Joanne Kwak-Kim
- Reproductive Medicine, Department of Obstetrics and Gynecology, The Chicago Medical School at Rosalind Franklin University of Medicine and Science, Vernon Hills, IL 60061, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
|
16
|
Current management and therapeutical perspectives in thrombotic thrombocytopenic purpura. Presse Med 2012; 41:e163-76. [DOI: 10.1016/j.lpm.2011.10.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Revised: 10/26/2011] [Accepted: 10/28/2011] [Indexed: 12/26/2022] Open
|
|
17
|
Much more than thrombosis and pregnancy loss: The antiphospholipid syndrome as a ‘systemic disease’. Best Pract Res Clin Rheumatol 2012; 26:79-90. [DOI: 10.1016/j.berh.2012.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 01/04/2012] [Indexed: 11/19/2022]
|
|
18
|
van Os GMA, Meijers JCM, Agar Ç, Seron MV, Marquart JA, Åkesson P, Urbanus RT, Derksen RHWM, Herwald H, Mörgelin M, D E Groot PG. Induction of anti-β2 -glycoprotein I autoantibodies in mice by protein H of Streptococcus pyogenes. J Thromb Haemost 2011; 9:2447-56. [PMID: 21985124 DOI: 10.1111/j.1538-7836.2011.04532.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The antiphospholipid syndrome (APS) is characterized by the persistent presence of anti-β(2) -glycoprotein I (β(2) -GPI) autoantibodies. β(2) -GPI can exist in two conformations. In plasma it is a circular protein, whereas it adopts a fish-hook conformation after binding to phospholipids. Only the latter conformation is recognized by patient antibodies. β(2) -GPI has been shown to interact with Streptococcus pyogenes. OBJECTIVE To evaluate the potential of S. pyogenes-derived proteins to induce anti-β(2) -GPI autoantibodies. METHODS AND RESULTS Four S. pyogenes surface proteins (M1 protein, protein H, streptococcal collagen-like protein A [SclA], and streptococcal collagen-like protein B [SclB]) were found to interact with β(2) -GPI. Only binding to protein H induces a conformational change in β(2) -GPI, thereby exposing a cryptic epitope for APS-related autoantibodies. Mice were injected with the four proteins. Only mice injected with protein H developed antibodies against the patient antibody-related epitope in domain I of β(2) -GPI. Patients with pharyngotonsillitis caused by S. pyogenes who developed anti-protein H antibodies also generated anti-β(2) -GPI antibodies. CONCLUSIONS Our study has demonstrated that a bacterial protein can induce a conformational change in β(2) -GPI, resulting in the formation of antiβ(2) -GPI autoantibodies. This constitutes a novel mechanism for the formation of anti-β(2) -GPI autoantibodies.
Collapse
Affiliation(s)
- G M A van Os
- Department of Clinical Chemistry and Hematology, University Medical Center, CX, Utrecht, the Netherlands
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
19
|
Abstract
Background: Cardiomyopathy in systemic lupus erythematosus (SLE) may be secondary to myocardial inflammation (i.e. myocarditis) or to systemic complications such as hypertension. Symptomatic left ventricular dysfunction is the most common clinical presentation of cardiomyopathy and is potentially life threatening. Identifying the cause is critical as it dictates therapy. Methods: We present three cases of left ventricular failure suggestive of myocarditis in SLE patients followed in the Lupus Clinic of the Montreal General Hospital over a 5-year period. Results: The most frequent presentation is acute onset of a marked reduction of the left ventricular ejection fraction (LVEF). All patients were treated with cardiac support, prednisone, and additional immunosuppressive medications. Improvement of symptoms and LVEF was observed in two of three patients. Conclusion: Myocarditis is a rare, but life-threatening, manifestation of SLE. With immunosuppressive medications and cardiovascular support, the long-term outcome is usually favorable.
Collapse
Affiliation(s)
- S Appenzeller
- Divisions of Clinical Immunology/Allergy and Clinical Epidemiology, McGill University Health Centre, Canada
- Faculty of Medical Science-State University of Campinas (UNICAMP)
| | - CA Pineau
- Division of Rheumatology, McGill University Health Centre, Canada
| | - AE Clarke
- Divisions of Clinical Immunology/Allergy and Clinical Epidemiology, McGill University Health Centre, Canada
| |
Collapse
|
|
20
|
Cervera R, Tektonidou MG, Espinosa G, Cabral AR, González EB, Erkan D, Vadya S, Adrogué HE, Solomon M, Zandman-Goddard G, Shoenfeld Y. Task Force on Catastrophic Antiphospholipid Syndrome (APS) and Non-criteria APS Manifestations (II): thrombocytopenia and skin manifestations. Lupus 2011; 20:174-81. [DOI: 10.1177/0961203310395052] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The objectives of the ‘Task Force on Catastrophic Antiphospholipid Syndrome (APS) and Non-criteria APS Manifestations’ were to assess the clinical utility of the international consensus statement on classification criteria and treatment guidelines for the catastrophic APS, to identify and grade the studies that analyze the relationship between the antiphospholipid antibodies and the non-criteria APS manifestations, and to present the current evidence regarding the accuracy of these non-criteria APS manifestations for the detection of patients with APS. This article summarizes the studies analyzed on thrombocytopenia and skin manifestations, and presents the recommendations elaborated by the Task Force after this analysis.
Collapse
Affiliation(s)
- R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
| | - MG Tektonidou
- First Department of Internal Medicine, Medical School, National University of Athens, Athens, Greece
| | - G Espinosa
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
| | - AR Cabral
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - EB González
- Division of Rheumatology, Department of Medicine, The University of Texas Medical Branch (UTMB), Galveston, Texas, USA
| | - D Erkan
- The Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
| | - S Vadya
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, USA
| | - HE Adrogué
- The Methodist Hospital Transplant Center, Fannin, Houston, Texas, USA
| | - M Solomon
- Department of Dermatology, Chaim Sheba Medical Center, Tel Hashomer, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Zandman-Goddard
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine C, Wolfson Medical Center, Tel Hashomer, Israel
| | - Y Shoenfeld
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Zublodovitz Center for Autoimmune Diseases and Department of Medicine B, Chaim Sheba Medical Center, Tel Hashomer, Israel
| |
Collapse
|
|
21
|
Médecine interne et réanimation — Le syndrome catastrophique des antiphospholipides. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0108-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
|
22
|
|
|
23
|
Bhatnagar H, Kala S, Sharma L, Jain S, Kim KS, Pal R. Serum and organ-associated anti-hemoglobin humoral autoreactivity: association with anti-Sm responses and inflammation. Eur J Immunol 2010; 41:537-48. [PMID: 21268022 DOI: 10.1002/eji.201040989] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 10/25/2010] [Accepted: 11/19/2010] [Indexed: 11/08/2022]
Abstract
The release of hemoglobin (Hb) occurs in some infectious and autoimmune diseases characterized by inflammation. As levels of haptoglobin (Hp) fall, free Hb can cause pathology. Humoral autoreactivity to human Hb was demonstrated in the sera of systemic lupus erythematosus (SLE), leishmania and malaria patients. Serum anti-murine Hb antibody levels in lupus-prone mice also exhibited an age-dependent increase, with progressive organ sequestration; significant isotypic correlation was observed with anti-dsDNA antibodies. A suggestive link between anti-Hb and anti-Sm responses was observed: Human lupus sera expressing anti-Sm antibody reactivity preferentially contained heightened levels of anti-Hb autoantibodies, and immunization of lupus-prone mice with Sm led to enhanced anti-murine Hb reactivity. Human and murine anti-Hb monoclonal antibodies were generated, some of which were preferentially reactive toward disease-associated methemoglobin. Epitope-mapping studies revealed evidence of intra-molecular cross-reactivity. One such autoantibody synergized with Hb to enhance the secretion of pro-inflammatory cytokines while eliciting the increased production of monocyte migratory signals from endothelial cells. Preferential usage of specific variable region gene segments was not observed, although somatic mutations were documented. These studies reveal that, while the etiology, specificity and sequences of anti-Hb autoreactive antibodies can vary, they occur quite frequently and can have inflammatory consequences.
Collapse
Affiliation(s)
- Harshita Bhatnagar
- National Institute of Immunology, Aruna Asaf Ali Marg, JNU Complex, New Delhi, India
| | | | | | | | | | | |
Collapse
|
|
24
|
Cervera R. Update on the diagnosis, treatment, and prognosis of the catastrophic antiphospholipid syndrome. Curr Rheumatol Rep 2010; 12:70-6. [PMID: 20425537 DOI: 10.1007/s11926-009-0073-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The catastrophic antiphospholipid syndrome (APS) is a potentially life-threatening condition, the diagnosis of which requires a high degree of clinical awareness on the part of attending physicians. Patients with APS present with 1) clinical evidence of multiple organ involvement developed over a very short time; 2) histopathologic evidence of multiple small-vessel occlusions; and 3) laboratory confirmation of the presence of antiphospholipid antibodies, usually in high titer. A combination of anticoagulants, corticosteroids, intravenous immunoglobulins, and plasma exchanges is the basic treatment for all patients with this severe condition. Unfortunately, despite current therapies, the mortality rate is still high (around 30%). However, once patients with catastrophic APS have recovered, they usually follow a stable course with continued anticoagulation and few patients present with a relapse of the catastrophic episode.
Collapse
Affiliation(s)
- Ricard Cervera
- Department of Autoimmune Diseases, Servei de Malalties Autoimmunes, Hospital Clínic, Villarroel 170, Barcelona, Catalonia, 08036, Spain.
| |
Collapse
|
|
25
|
Erkan D, Espinosa G, Cervera R. Catastrophic antiphospholipid syndrome: updated diagnostic algorithms. Autoimmun Rev 2010; 10:74-9. [PMID: 20696282 DOI: 10.1016/j.autrev.2010.08.005] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 08/03/2010] [Indexed: 11/30/2022]
Abstract
The catastrophic antiphospholipid syndrome (APS) is the most severe form of APS with acute multiple organ involvement and small vessel thrombosis. During the 13th International Congress on Antiphospholipid Antibodies (aPL) a "Catastrophic APS Task Force" was developed to discuss the challenges in the diagnosis and management of catastrophic APS. The purpose of this paper is to summarize the diagnostic challenges (false-positive/negative aPL results and overlap with other thrombotic microangiopathies) and propose updated diagnostic algorithms for catastrophic APS. Important steps of the diagnostic algorithms include: a) history of APS or persistent aPL-positivity; b) three or more organ new thrombosis developing in less than a week; c) biopsy diagnosis of microthrombosis; and d) other explanations for multiple organ thromboses and/or microthrombosis.
Collapse
Affiliation(s)
- Doruk Erkan
- The Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
| | | | | |
Collapse
|
|
26
|
Dierickx D, Monbaliu D, De Rycke A, Wisanto E, Lerut E, Devos T, Meers S, Darius T, Ferdinande P, Pirenne J. Thrombotic microangiopathy following intestinal transplantation: a single center experience. Transplant Proc 2010; 42:79-81. [PMID: 20172285 DOI: 10.1016/j.transproceed.2009.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transplant-related thrombotic microangiopathy (TMA) is a well-recognized complication of all types of transplantations. Despite its known relationship with immunosuppressive therapy, only a few cases have been reported following intestinal transplantation. METHODS We retrospectively reviewed the medical files of nine consecutive intestinal transplant patients between 2000 and 2008. RESULTS The diagnosis of TMA was established in 3 patients (33%). At diagnosis the immunosuppressive therapy consisted of tacrolimus (n = 3), combined with azathioprine (n = 1) or sirolimus (n = 2) and steroids (n = 2). The median time between transplantation and TMA was 104 days (range, 55-167 days). Levels of ADAMTS13, a von Willebrand protease, were within normal ranges in all 3 patients. Treatment consisted of stopping/tapering of tacrolimus, together with initiation of plasma therapy, leading to complete remission in all 3 patients. During further follow-up, all 3 patients showed severe graft rejection necessitating more profound immunosuppressive therapy, leading to graft loss in 1 patient and infection-related death in the 2 others. At a median follow-up of 52 months (range, 9-100 months) all remaining TMA-free patients (n = 6) were alive with functioning grafts under minimal immunosuppression. CONCLUSION Herein we have described 3 intestinal transplant patients who were diagnosed with transplantation-related TMA. Despite excellent disease control the final outcomes were dismal, which clearly contrasts with the outcome among TMA-free patients, who were all well with functioning grafts at last follow-up.
Collapse
Affiliation(s)
- D Dierickx
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
27
|
Coppo P, Schwarzinger M, Buffet M, Wynckel A, Clabault K, Presne C, Poullin P, Malot S, Vanhille P, Azoulay E, Galicier L, Lemiale V, Mira JP, Ridel C, Rondeau E, Pourrat J, Girault S, Bordessoule D, Saheb S, Ramakers M, Hamidou M, Vernant JP, Guidet B, Wolf M, Veyradier A. Predictive features of severe acquired ADAMTS13 deficiency in idiopathic thrombotic microangiopathies: the French TMA reference center experience. PLoS One 2010; 5:e10208. [PMID: 20436664 PMCID: PMC2859048 DOI: 10.1371/journal.pone.0010208] [Citation(s) in RCA: 233] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 03/12/2010] [Indexed: 11/19/2022] Open
Abstract
Severe ADAMTS13 deficiency occurs in 13% to 75% of thrombotic microangiopathies (TMA). In this context, the early identification of a severe, antibody-mediated, ADAMTS13 deficiency may allow to start targeted therapies such as B-lymphocytes-depleting monoclonal antibodies. To date, assays exploring ADAMTS13 activity require skill and are limited to only some specialized reference laboratories, given the very low incidence of the disease. To identify clinical features which may allow to predict rapidly an acquired ADAMTS13 deficiency, we performed a cross-sectional analysis of our national registry from 2000 to 2007. The clinical presentation of 160 patients with TMA and acquired ADAMTS13 deficiency was compared with that of 54 patients with detectable ADAMTS13 activity. ADAMTS13 deficiency was associated with more relapses during treatment and with a good renal prognosis. Patients with acquired ADAMTS13 deficiency had platelet count <30×109/L (adjusted odds ratio [OR] 9.1, 95% confidence interval [CI] 3.4–24.2, P<.001), serum creatinine level ≤200 µmol/L (OR 23.4, 95% CI 8.8–62.5, P<.001), and detectable antinuclear antibodies (OR 2.8, 95% CI 1.0–8.0, P<.05). When at least 1 criteria was met, patients with a severe acquired ADAMTS13 deficiency were identified with positive predictive value of 85%, negative predictive value of 93.3%, sensitivity of 98.8%, and specificity of 48.1%. Our criteria should be useful to identify rapidly newly diagnosed patients with an acquired ADAMTS13 deficiency to better tailor treatment for different pathophysiological groups.
Collapse
Affiliation(s)
- Paul Coppo
- Service d'Hématologie et de Thérapie Cellulaire, AP-HP, Hôpital Saint-Antoine, Paris, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
28
|
Abstract
Sudden sensorineural hearing loss is usually unilateral and can be associated with tinnitus and vertigo. In most cases the cause is not identified, although various infective, vascular, and immune causes have been proposed. A careful examination is needed to exclude life threatening or treatable causes such as vascular events and malignant diseases, and patients should be referred urgently for further assessment. About half of patients completely recover, usually in about 2 weeks. Many treatments are used, including corticosteroids, antiviral drugs, and vasoactive and oxygen-based treatments. Although no treatment is proven, we recommend a short course of oral high-dose corticosteroids. There is much to learn about pathogenesis of sudden sensorineural hearing loss, and more clinical trials are needed to establish evidence-based management.
Collapse
|
|
29
|
|
|
30
|
Galindo M, Gonzalo E, Martinez-Vidal MP, Montes S, Redondo N, Santiago B, Loza E, Pablos JL. Immunohistochemical detection of intravascular platelet microthrombi in patients with lupus nephritis and anti-phospholipid antibodies. Rheumatology (Oxford) 2009; 48:1003-7. [PMID: 19542214 DOI: 10.1093/rheumatology/kep152] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate whether the use of platelet immunohistochemistry (IHC) markers improves the sensitivity of histological methods to detect microthrombosis in SLE nephritis and aPLs and to analyse the clinicopathological correlations of microthrombosis in this setting. METHODS Kidney biopsy specimens from 65 patients with SLE, including 36 with positive aPLs, were studied by IHC using antibodies against platelet glycoproteins CD41 and CD61. Clinical data at the time of kidney biopsy and during a mean follow-up of 7.5 years after biopsy were recorded and analysed with regard to histological or IHC data. RESULTS Histological lesions previously defined as APS nephropathy were found in 33% of the SLE kidney biopsies and were not associated with positive aPLs. Microthrombi detected as intravascular CD61(+) platelet deposits were present in 43% of the tissues and were significantly associated with positive aPLs, but not with histological APS nephropathy, nephritis manifestations nor with renal outcome. Histological APS lesions but not CD61(+) microthrombi correlated with an older age at nephritis presentation, previous cardiovascular risk factors and worse renal outcome. CONCLUSIONS Immunodetection of intravascular CD61(+) platelet aggregates is more sensitive than histological evaluation to detect acute microthrombosis and provides a better correlation with aPLs in SLE patients. In contrast, histological lesions consistent with APS nephropathy were not associated with aPLs but with cardiovascular risk factors and worse renal outcome.
Collapse
Affiliation(s)
- María Galindo
- Servicio de Reumatología, Hospital 12 de Octubre, Madrid, Spain.
| | | | | | | | | | | | | | | |
Collapse
|
|
31
|
Shoenfeld Y, Gershwin ME, Cervera R. Ronald A. Asherson—“In Memoriam”. Clin Rev Allergy Immunol 2009. [DOI: 10.1007/s12016-008-8111-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
|
32
|
Cervera R, Bucciarelli S, Plasín MA, Gómez-Puerta JA, Plaza J, Pons-Estel G, Shoenfeld Y, Ingelmo M, Espinos G. Catastrophic antiphospholipid syndrome (CAPS): Descriptive analysis of a series of 280 patients from the “CAPS Registry”. J Autoimmun 2009; 32:240-5. [PMID: 19324520 DOI: 10.1016/j.jaut.2009.02.008] [Citation(s) in RCA: 221] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Accepted: 02/11/2009] [Indexed: 02/08/2023]
|
|
33
|
Letchumanan P, Ng HJ, Lee LH, Thumboo J. A comparison of thrombotic thrombocytopenic purpura in an inception cohort of patients with and without systemic lupus erythematosus. Rheumatology (Oxford) 2009; 48:399-403. [PMID: 19202160 DOI: 10.1093/rheumatology/ken510] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To compare the clinical presentation, response to therapy and outcome of thrombotic thrombocytopenic purpura (TTP) in an inception cohort of patients with and without SLE. METHODS Medical records of patients diagnosed with TTP at Singapore General Hospital between January 2003 and December 2007 were reviewed. RESULTS Ten idiopathic TTP (iTTP) and eight SLE-associated TTP (sTTP) patients were identified, with iTTP patients being older (mean 50.4 vs 34.5 yrs). Five iTTP patients were ANA positive but did not have any features of SLE. All sTTP patients had active SLE at TTP diagnosis and had more renal involvement than iTTP (87.5% vs 50%). The mean duration from the first symptom suggestive of TTP to diagnosis was 7.7 days and 19.5 days in iTTP and sTTP patients. All patients received high-dose corticosteroids. Cytotoxic and immunosuppressive drugs were used more commonly (87.5% vs 50%) and earlier (Day 2/3 vs after Day 7) in sTTP patients. Vincristine was the drug of choice in iTTP and cyclophosphamide in sTTP. Three SLE patients received rituximab. Mortality for iTTP and sTTP was 50% (95% CI 19%, 81%) and 62.5% (95% CI 29%, 96%), respectively. The mean (s.d.) time to complete remission was 31.3 (+/- 26.4) days in sTTP (n = 3) and 16.8 (+/- 6.1) days in iTTP (n = 5). CONCLUSION Despite early and more aggressive therapy in sTTP, mortality was higher and the time to complete remission were longer, suggesting that sTTP is more severe. The tempo of development of TTP in SLE patients was slower.
Collapse
|
|
34
|
Affiliation(s)
- Savino Sciascia
- Allergy and Clinical Immunology Department, Umberto I Hospital, Turin, Italy.
| | | |
Collapse
|
|
35
|
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.
Collapse
Affiliation(s)
- Gerard Espinosa
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, Catalonia, Spain.
| | | |
Collapse
|
|
36
|
Praprotnik S, Ferluga D, Vizjak A, Hvala A, Avčin T, Rozman B. Microthrombotic/Microangiopathic Manifestations of the Antiphospholipid Syndrome. Clin Rev Allergy Immunol 2008; 36:109-25. [DOI: 10.1007/s12016-008-8104-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
|
37
|
The Catastrophic Antiphospholipid Syndrome in Serbia: Diagnostic and Management Problems. Clin Rev Allergy Immunol 2008; 36:98-103. [DOI: 10.1007/s12016-008-8102-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|