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Radin M, Cecchi I, Arbrile M, Montin D, Farinasso L, Cioffi M, Foddai SG, Barinotti A, Menegatti E, Baldovino S, Sciascia S, Roccatello D. Pediatric Presentation of Antiphospholipid Syndrome: A Review of Recent Literature With Estimation of Local Prevalence. Semin Thromb Hemost 2024; 50:182-187. [PMID: 36940717 DOI: 10.1055/s-0043-1764472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
We aimed to investigate the epidemiology, the clinical and laboratory characteristics of the pediatric involvement of antiphospholipid syndrome (APS), by performing a review of the current evidence and reviewing local experience in the Northwest Italy. To achieve this, we performed a detailed literature search to identify articles describing clinical and laboratory characteristics of pediatric APS. In concomitance, we conducted a registry-based study collecting data from the Piedmont and Aosta Valley Rare Disease Registry including pediatric patients diagnosed with APS in the last 11 years. The literature review led to inclusion of six articles with a total of 386 pediatric patients (65% females, 50% with systemic lupus erythematosus (SLE) as concomitant diagnosis). Rates of venous and arterial thrombosis were 57 and 35%, respectively. "Extra-criteria manifestations" included mostly hematologic and neurologic involvement. Almost one-quarter of patients (19%) reported recurrent events and 13% manifested as catastrophic APS. A total of 17 pediatric patients (mean age 15.1 ± 2.8, 76% female) developed APS in the Northwest of Italy. In 29% of cases, SLE was a concomitant diagnosis. Deep vein thrombosis was the most frequent manifestation (28%) followed by catastrophic APS (6%). The estimated prevalence of pediatric APS in Piedmont and Aosta Valley Region is 2.5/100,000 people, whereas the estimated annual incidence is 0.2/100,000 inhabitants. In conclusion, clinical manifestations of pediatric APS seem to be more severe and with a high prevalence of noncriteria manifestations. International efforts are needed to better characterize this condition and to develop new specific diagnostic criteria to avoid missed/delayed diagnosis in children with APS.
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Affiliation(s)
- Massimo Radin
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Italy
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Irene Cecchi
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Italy
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Marta Arbrile
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Davide Montin
- Department of Public Health and Pediatrics, University of Turin, Pediatria Specialistica U, "Regina Margherita" Children Hospital, Turin, Italy
| | - Loredana Farinasso
- Department of Public Health and Pediatrics, University of Turin, Pediatria Specialistica U, "Regina Margherita" Children Hospital, Turin, Italy
| | - Michele Cioffi
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
| | - Silvia Grazietta Foddai
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
| | - Alice Barinotti
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
| | - Elisa Menegatti
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Simone Baldovino
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Italy
- Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Italy
| | - Dario Roccatello
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, University of Turin, S. Giovanni Bosco Hospital, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Italy
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2
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Branch DW, Lim MY. How I diagnose and treat antiphospholipid syndrome in pregnancy. Blood 2024; 143:757-768. [PMID: 38145574 DOI: 10.1182/blood.2023020727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 12/27/2023] Open
Abstract
ABSTRACT Antiphospholipid syndrome (APS) is a rare autoimmune disease characterized by arterial, venous, or microvascular thrombosis, pregnancy morbidities, or nonthrombotic manifestations in patients with persistently positive antiphospholipid antibodies. These antibodies bind cellular phospholipids and phospholipid-protein complexes resulting in cellular activation and inflammation that lead to the clinical features of APS. Our evolving understanding of APS has resulted in more specific classification criteria. Patients meeting these criteria should be treated during pregnancy according to current guidelines. Yet, despite treatment, those positive for lupus anticoagulant have at least a 30% likelihood of adverse pregnancy outcomes. Patients with recurrent early miscarriage or fetal death in the absence of preeclampsia or placental insufficiency may not meet current classification criteria for APS. Patients with only low titer anticardiolipin or anti-β(2)-glycoprotein I antibodies or immunoglobulin M isotype antibodies will not meet current classification criteria. In such cases, clinicians should implement management plans that balance potential risks and benefits, some of which involve emotional concerns surrounding the patient's reproductive future. Finally, APS may present in pregnancy or postpartum as a thrombotic microangiopathy, a life-threatening condition that may initially mimic preeclampsia with severe features but requires a very different treatment approach.
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Affiliation(s)
- D Ware Branch
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, University of Utah Health, Salt Lake City, UT
| | - Ming Y Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah School of Medicine, University of Utah Health, Salt Lake City, UT
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3
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Windisch S, Ash JY, Frishman WH. Antiphospholipid Syndrome: Thrombotic and Vascular Complications. Cardiol Rev 2023:00045415-990000000-00143. [PMID: 37607079 DOI: 10.1097/crd.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Antiphospholipid syndrome is a rare, autoimmune thrombophilia defined by vascular thrombosis and pregnancy morbidity, in the setting of documented persistent antiphospholipid antibodies including the lupus anticoagulant, anticardiolipin antibodies, or anti-β2 glycoprotein I antibodies. The presence of antiphospholipid antibodies can be completely asymptomatic, or they can lead to clinical manifestations as severe as catastrophic antiphospholipid syndrome, which involves widespread coagulopathy over a very short period of time. The degree of risk associated with antiphospholipid syndrome depends on the characteristics of the antiphospholipid antibody profile and on the presence of additional thrombotic risk factors. The current standard treatment for unprovoked thrombosis is long-term warfarin. Treatment to prevent recurrent obstetric complications is low-dose aspirin and prophylactic heparin in pregnant patients. The use of direct oral anticoagulants in patients with antiphospholipid syndrome is still being debated. Their use is generally contraindicated, especially in high-risk patients, such as those with all 3 antiphospholipid antibodies present, but they may potentially be of some use in some low-risk patients.
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Affiliation(s)
- Stephen Windisch
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - Julia Y Ash
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - William H Frishman
- Departments of Medicine and Cardiology, New York Medical College/Westchester Medical Center, Valhalla, NY
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4
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Maheshwari M, Athiraman H. A Rare Rheumatologic Case of Catastrophic Antiphospholipid Syndrome. Cureus 2023; 15:e41972. [PMID: 37465086 PMCID: PMC10350343 DOI: 10.7759/cureus.41972] [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] [Accepted: 07/16/2023] [Indexed: 07/20/2023] Open
Abstract
A very rare and severe disease catastrophic antiphospholipid syndrome is defined by small vessel occlusions resulting in multi-organ involvement in the presence of antiphospholipid antibodies. This case report presents a case of catastrophic antiphospholipid syndrome in a young female without past medical history.
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5
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Grossi C, Capitani N, Benagiano M, Baldari CT, Della Bella C, Macor P, Tedesco F, Borghi MO, Maugeri N, D’Elios MM, Meroni PL. Beta 2 glycoprotein I and neutrophil extracellular traps: Potential bridge between innate and adaptive immunity in anti-phospholipid syndrome. Front Immunol 2023; 13:1076167. [PMID: 36700193 PMCID: PMC9868732 DOI: 10.3389/fimmu.2022.1076167] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/20/2022] [Indexed: 01/10/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by recurrent vascular thrombosis and miscarriages in the absence of known causes. Antibodies against phospholipid-binding proteins (aPL) are pathogenic players in both clotting and pregnancy APS manifestations. There is sound evidence that antibodies specific for beta2 glycoprotein I (β2GPI) trigger thrombotic and pregnancy complications by interacting with the molecule on the membranes of different cell types of the coagulation cascade, and in placenta tissues. In addition to the humoral response against β2GPI, both peripheral and tissue CD4+ β2GPI-specific T cells have been reported in primary APS as well as in systemic lupus erythematosus (SLE)-associated APS. While adaptive immunity plays a clear role in APS, it is still debated whether innate immunity is involved as well. Acute systemic inflammation does not seem to be present in the syndrome, however, there is sound evidence that complement activation is crucial in animal models and can be found also in patients. Furthermore, neutrophil extracellular traps (NETs) have been documented in arterial and venous thrombi with different etiology, including clots in APS models. Keeping in mind that β2GPI is a pleiotropic glycoprotein, acting as scavenger molecule for infectious agents and apoptotic/damaged body constituents and that self-molecules externalized through NETs formation may become immunogenic autoantigens, we demonstrated β2GPI on NETs, and its ability to stimulate CD4+β2GPI-specific T cells. The aim of this review is to elucidate the role of β2GPI in the cross-talk between the innate and adaptive immunity in APS.
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Affiliation(s)
- Claudia Grossi
- Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immuno-Rheumatology, Milan, Italy
| | - Nagaja Capitani
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy,Department of Life Sciences, University of Siena, Siena, Italy
| | - Marisa Benagiano
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Chiara Della Bella
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paolo Macor
- Department of Life Science, University of Trieste, Trieste, Italy
| | - Francesco Tedesco
- Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immuno-Rheumatology, Milan, Italy
| | - Maria Orietta Borghi
- Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immuno-Rheumatology, Milan, Italy,Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Norma Maugeri
- Autoimmunity and Vascular Inflammation Unit, Division of Immunology, Transplantation & Infectious Diseases, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Institute, Milan, Italy
| | - Mario Milco D’Elios
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy,*Correspondence: Pier Luigi Meroni, ; ; Mario Milco D’Elios,
| | - Pier Luigi Meroni
- Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immuno-Rheumatology, Milan, Italy,*Correspondence: Pier Luigi Meroni, ; ; Mario Milco D’Elios,
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Christopher N, Periaswamy G, Arunachalam VK, Mangalakumar V, Mehta P, Cherian M. Catastrophic Antiphospholipid Syndrome: A Case Series. Indian J Radiol Imaging 2022; 33:235-239. [PMID: 37123583 PMCID: PMC10132881 DOI: 10.1055/s-0042-1759857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AbstractCatastrophic antiphospholipid syndrome (CAPS) is the rare but most severe form of antiphospholipid syndrome with multiple organ ischemia developing over a short period of time. CAPS should be considered when imaging suggests an acute and concurrent multiorgan ischemia, associated with positive antiphospholipid antibodies. As CAPS can have fulminant irreversible complications, its early recognition is important to initiate the treatment promptly. We present three patients of CAPS who were managed at our institution.
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Affiliation(s)
- Navya Christopher
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
| | - Gopinath Periaswamy
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
| | | | - V. Mangalakumar
- Department of Nephrology, Kovai Medical Center and Hospital, Coimbatore, India
| | - Pankaj Mehta
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
| | - Mathew Cherian
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
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7
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Ruscitti P, Di Cola I, Di Muzio C, Italiano N, Ursini F, Giacomelli R, Cipriani P. Expanding the spectrum of the hyperferritinemic syndrome, from pathogenic mechanisms to clinical observations, and therapeutic implications. Autoimmun Rev 2022; 21:103114. [PMID: 35595050 DOI: 10.1016/j.autrev.2022.103114] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 05/15/2022] [Indexed: 01/19/2023]
Abstract
From the introduction of hyperferritinemic syndrome concept, a growing body of evidence has suggested the role of ferritin as a pathogenic mediator and a relevant clinical feature in the management of patients with inflammatory diseases. From a pathogenic point of view, ferritin may directly stimulate the aberrant immune response by triggering the production of pro-inflammatory mediators in inducing a vicious pathogenic loop and contributing to the occurrence of cytokine storm syndrome. The latter has been recently defined as a clinical picture characterised by elevated circulating cytokine levels, acute systemic inflammatory symptoms, and secondary organ dysfunction beyond that which could be attributed to a normal response to a pathogen It is noteworthy that the occurrence of hyperferritinemia may be correlated with the development of the cytokine storm syndrome in the context of an inflammatory disease. In addition to adult onset Still's disease, macrophage activation syndrome, catastrophic anti-phospholipids syndrome, and septic shock, recent evidence has suggested this association between ferritin and life-threatening evolution in patients with systemic lupus erythematosus, with anti-MDA5 antibodies in the context of poly-dermatomyositis, with severe COVID-19, and with multisystem inflammatory syndrome. The possible underlying common inflammatory mechanisms, associated with hyperferritinemia, may led to the similar clinical picture observed in these patients. Furthermore, similar therapeutic strategies could be suggested inhibiting pro-inflammatory cytokines and improving long-term outcomes in these disorders. Thus, it could be possible to expand the spectrum of the hyperferritinemic syndrome to those diseases burdened by a dreadful clinical picture correlated with hyperferritinemia and the occurrence of the cytokine storm syndrome. In addition, the assessment of ferritin may provide useful information to the physicians in clinical practice to manage these patients. Therefore, ferritin may be considered a relevant clinical feature to be used as biomarker in dissecting the unmet needs in the management of these disorders. Novel evidence may thus support an expansion of the spectrum of the hyperferritinemic syndrome to these diseases burdened by a life-threatening clinical picture correlated with hyperferritinemia and the occurrence of the cytokine storm syndrome.
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Affiliation(s)
- Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
| | - Ilenia Di Cola
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Claudia Di Muzio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Noemi Italiano
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Francesco Ursini
- Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Roberto Giacomelli
- Rheumatology and Immunology Unit, Department of Medicine, University of Rome Campus Biomedico, Rome, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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8
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Scheen M, Adedjouma A, Esteve E, Buob D, Abisror N, Planche V, Fain O, Boffa JJ, De Seigneux S, Mekinian A, Haidar F. Kidney disease in antiphospholipid antibody syndrome: Risk factors, pathophysiology and management. Autoimmun Rev 2022; 21:103072. [PMID: 35217200 DOI: 10.1016/j.autrev.2022.103072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/19/2022] [Indexed: 11/02/2022]
Abstract
Antiphospholipid antibody syndrome (APLS) is a rare autoimmune disease characterized by recurrent arterial and venous thromboembolic events, pregnancy related complications as well as the persistent detection of antiphospholipid antibodies at a 12 week interval. Renal complications tend to occur in 3% of APLS patients, with renal artery stenosis being the most common kidney related complication. Renal pathology may be subdivided into macro as well as microvascular thrombotic complications with stenosis, thrombosis and infarction representing the principle macrovascular events and APLS nephropathy representing the predominant microvascular complication. APLS related kidney disease may present with an array of heterogenous manifestations ranging from hematuria and non-nephrotic range proteinuria to hypertension or as part of a severe, life threatening and fulminant multiorgan failure disorder known as catastrophic antiphospholipid antibody syndrome (CAPS). Management of APLS related renal complications depends on the site of vascular injury, the thromboembolic risk profile based on the subtype, isotype and titer of the autoantibodies as well as the severity of the injury. Primary prophylaxis in these patients primarily revolves around the use of low dose aspirin, with prophylactic anticoagulation during events that increase thromboembolic like surgery and hospitalization. Anticoagulation is the cornerstone of treatment of APLS related kidney disease with INR targets varying depending on the associated venous or arterial thrombosis. Immunosuppression with the likes of rituximab, mTOR inhibitors, eculizumab and belimumab have been used with some success, but lack randomized control trial validation for their use. Pulsed corticosteroids with Plasmapheresis and intravenous immunoglobulins is the recommended treatment for CAPS.
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Affiliation(s)
- Marc Scheen
- Hôpitaux universitaires de Genève, Service de Néphrologie, Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland.
| | - Amir Adedjouma
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne, 75012 Paris, France
| | - Emmanuel Esteve
- Sorbonne Université, AP-HP, Hôpital Tenon, Service de Néphrologie, 75020 Paris, France
| | - David Buob
- Sorbonne Université, AP-HP, Hôpital Tenon, Service de Anatomopathologie, 75020 Paris, France
| | - Noémie Abisror
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne, 75012 Paris, France
| | - Virginie Planche
- Sorbonne Université, Service de Hématologie biologique, APHP, Hôpital Saint Antoine, 75012, Paris, France
| | - Olivier Fain
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne, 75012 Paris, France
| | - Jean Jacques Boffa
- Sorbonne Université, AP-HP, Hôpital Tenon, Service de Néphrologie, 75020 Paris, France
| | - Sophie De Seigneux
- Hôpitaux universitaires de Genève, Service de Néphrologie, Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland
| | - Arsène Mekinian
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne, 75012 Paris, France
| | - Fadi Haidar
- Hôpitaux universitaires de Genève, Service de Néphrologie, Rue Gabrielle-Perret-Gentil 4, 1205 Genève, Switzerland
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9
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McRae HL, Yang AH, Kruzer K, Scott GA, Refaai MA. A rare case of catastrophic antiphospholipid syndrome triggered by estrogen-containing oral contraceptives in a patient with double heterozygous factor V Leiden and prothrombin G20210A mutations. Am J Hematol 2022; 97:239-242. [PMID: 33621390 DOI: 10.1002/ajh.26138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Hannah L. McRae
- Department of Pathology and Laboratory Medicine University of Rochester Medical Center Rochester New York USA
- Transfusion Medicine Division, Hemostasis and Thrombosis Unit University of Rochester Medical Center Rochester New York USA
| | - Annie H. Yang
- Department of Medicine University of Rochester Medical Center Rochester New York USA
- Division of Allergy, Immunology, and Rheumatology University of Rochester Medical Center Rochester New York USA
| | - Karen Kruzer
- Department of Medicine University of Rochester Medical Center Rochester New York USA
| | - Glynis A. Scott
- Department of Pathology and Laboratory Medicine University of Rochester Medical Center Rochester New York USA
- Department of Dermatology University of Rochester Medical Center Rochester New York USA
| | - Majed A. Refaai
- Department of Pathology and Laboratory Medicine University of Rochester Medical Center Rochester New York USA
- Transfusion Medicine Division, Hemostasis and Thrombosis Unit University of Rochester Medical Center Rochester New York USA
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10
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Abstract
Purpose of the Review Elevated levels of anti-phospholipid (aPL) antibodies are the most important criterion in the diagnosis of anti-phospholipid syndrome (APS) and are usually responsible for promoting the risk of thrombotic complications. Now, in the course of the global coronavirus disease 2019 (COVID-19) pandemic, measurable aPL antibodies have also been detected in a noticeable number of patients showing a variety ranging from studies with only isolated positive tests to cohorts with very high positivity. Thus, the question arises as to whether these two different clinical pictures may be linked. Recent Findings The ambivalent results showed a frequent occurrence of the investigated aPL antibodies in COVID-19 patients to an individually varying degree. While some question a substantial correlation according to their results, a number of studies raise questions about the significance of a correlation of aPL antibodies in COVID-19 patients. Within the scope of this review, these have now been described and compared with each other. Summary Ultimately, it is necessary to conduct further studies that specifically test aPL antibodies in a larger context in order to make subsequent important statements about the role of APS in COVID-19 and to further strengthen the significance of the described comparisons.
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Affiliation(s)
| | - Jörg Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II (Oncology, Hematology, Immunology, Rheumatology, Pulmology), University Hospital Tuebingen, Otfried-Mueller-Str. 10, DE 72076, Tuebingen, Germany
| | - Sebastian Saur
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II (Oncology, Hematology, Immunology, Rheumatology, Pulmology), University Hospital Tuebingen, Otfried-Mueller-Str. 10, DE 72076, Tuebingen, Germany.
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11
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Lee HA, Kim SE, Jung DW, Byeon JR, Choe AR, Tae CH, Moon CM, Jung HK, Shim KN, Jung SA. Small Bowel Necrosis Associated with Catastrophic Antiphospholipid Syndrome: A Case Report. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2021; 77:294-299. [PMID: 34158449 DOI: 10.4166/kjg.2021.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/17/2021] [Accepted: 04/12/2021] [Indexed: 11/03/2022]
Abstract
Catastrophic antiphospholipid syndrome is a highly fatal condition characterized by widespread thromboembolism subsequent to a triggering factor (e.g., infection, trauma, and neoplasia) in antiphospholipid antibody-positive patients. This paper reports a case of a 29-year-old male without the underlying disease who developed extensive mesenteric thromboembolism and jejunal necrosis during the treatment for acute enteritis. The patient's condition was improved with low-molecular-weight heparin and an intravenous Ig treatment with emergency surgery. The serum antiphospholipid (anticardiolipin IgM) and lupus anticoagulant antibody tests showed positive results. Acute infectious enterocolitis is generally considered a mild disease. On the other hand, aggressive evaluation and treatment should be considered if the clinical conditions do not improve and deteriorate rapidly despite appropriate antibiotic treatment because of the possibility of acute immunological complications, such as catastrophic antiphospholipid syndrome.
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Affiliation(s)
- Hyun Ae Lee
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, Korea
| | - Do Woung Jung
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, Korea
| | - Ju Ran Byeon
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, Korea
| | - A Reum Choe
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, Korea
| | - Chang Mo Moon
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, Korea
| | - Hye Kyung Jung
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, Korea
| | - Ki Nam Shim
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, Korea
| | - Sung Ae Jung
- Department of Internal Medicine, Ewha Womans University, College of Medicine, Seoul, Korea
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12
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Banerji D, Mendoza D, Ghoshhajra BB, Hedgire SS. The Role of Contrast-Enhanced Cardiac Magnetic Resonance in the Assessment of Patients with Malignant Ventricular Arrhythmias. Magn Reson Imaging Clin N Am 2019; 27:475-490. [PMID: 31279451 DOI: 10.1016/j.mric.2019.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cardiac magnetic resonance (CMR) imaging has gained significant traction as an imaging modality of choice in the evaluation of individuals with, or at risk for, heart failure. Ventricular arrhythmias, often malignant, may be sequelae of heart failure and arise from fibrosis. Late gadolinium enhancement evaluation by CMR has become a preferred modality to assess individuals at risk for malignant ventricular arrhythmias. A spectrum of various pathologies that predispose individuals to malignant ventricular arrhythmias, as well as the usefulness of CMR in their identification and prognostication, are reviewed.
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Affiliation(s)
- Dahlia Banerji
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging), Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Dexter Mendoza
- Thoracic Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders 202, Boston, MA 02114, USA
| | - Brian B Ghoshhajra
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging), Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
| | - Sandeep S Hedgire
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging), Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA.
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13
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Tucker SA, Choi J, Khullar D. A probable case of catastrophic antiphospholipid syndrome: Should high-dose steroids be given in the setting of polymicrobial sepsis? SAGE Open Med Case Rep 2019; 7:2050313X19839531. [PMID: 30967955 PMCID: PMC6444769 DOI: 10.1177/2050313x19839531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/25/2019] [Indexed: 11/15/2022] Open
Abstract
In this clinical vignette, we present a case of a 59-year-old woman with catastrophic antiphospholipid syndrome likely triggered by polymicrobial sepsis. The diagnostic criteria and clinical manifestations of catastrophic antiphospholipid syndrome are reviewed. We also compare diagnostic criteria and clinical manifestations with other clinical entities in the differential diagnosis, including thrombotic thrombocytopenic purpura-hemolytic-uremic syndrome, disseminated intravascular coagulation, sepsis, and inflammatory bowel disease. Catastrophic antiphospholipid syndrome is a rare, but lethal condition, and treatment recommendations are based on expert consensus and analyses of the international Catastrophic Antiphospholipid Syndrome Registry. Current management guidelines recommend triple therapy, with anticoagulation, glucocorticoids, and plasma exchange or intravenous immunoglobulins. This case brings this rare clinical entity to the attention of clinicians and emphasizes the need for more research to understand the best management. It also raises the question of whether high-dose steroids should be continued for treatment of catastrophic antiphospholipid syndrome in the setting of a severe sepsis.
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Affiliation(s)
- Shanna Ariane Tucker
- Department of Medicine, Weill Cornell
Medicine/New York-Presbyterian Hospital, New York, NY, USA
- Shanna Ariane Tucker, Department of
Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, 505 East 70th
Street, Floor 4, Weill Cornell Internal Medicine Associates, New York, NY
10021-4872, USA.
| | - Justin Choi
- Department of Medicine, Weill Cornell
Medicine/New York-Presbyterian Hospital, New York, NY, USA
| | - Dhruv Khullar
- Department of Medicine, Weill Cornell
Medicine/New York-Presbyterian Hospital, New York, NY, USA
- Department of Healthcare Policy &
Research, Weill Cornell Medicine, New York, NY, USA
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14
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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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15
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Immunomodulation in the Treatment of Refractory Catastrophic Antiphospholipid Syndrome. Case Rep Hematol 2018; 2018:1041396. [PMID: 29805821 PMCID: PMC5902127 DOI: 10.1155/2018/1041396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/05/2018] [Indexed: 11/18/2022] Open
Abstract
Catastrophic antiphospholipid syndrome is a rare condition with high morbidity and mortality. We present a refractory case of catastrophic antiphospholipid syndrome with a view to highlight the importance of early identification and aggressive treatment of this condition. A 36-year-old female presented with clinical manifestations of multiorgan vascular occlusion with a known history of primary antiphospholipid syndrome. The presentation was on a background of a recent change of her long-term anticoagulation from warfarin to therapeutic low-molecular-weight heparin. Given that multiorgan involvement with 3 organ systems occurred nearly simultaneously, a diagnosis of probable catastrophic antiphospholipid syndrome was made. Prompt therapeutic anticoagulation, antiplatelet, and glucocorticoid therapy was commenced. Despite this, the patient continued to demonstrate clinical features concerning for ongoing small vessel occlusion necessitating aggressive immunomodulatory therapy in the form of intravenous immunoglobulin, plasma exchange, and rituximab.
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16
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Gracia-Tello B, Isenberg D. Kidney disease in primary anti-phospholipid antibody syndrome. Rheumatology (Oxford) 2017; 56:1069-1080. [PMID: 27550302 DOI: 10.1093/rheumatology/kew307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Indexed: 12/19/2022] Open
Abstract
APS is an autoimmune disease defined by the presence of arterial or venous thrombotic events and/or pregnancy morbidity in patients who test positive for aPL. APS can be isolated (primary APS) or associated with other autoimmune diseases. The kidney is a major target organ in APS, and renal thrombosis can occur at any level within the vasculature of the kidney (renal arteries, intrarenal vasculature and renal veins). Histological findings vary widely, including ischaemic glomeruli and thrombotic lesions without glomerular or arterial immune deposits on immunofluorescence. Renal involvement in patients with definite APS is treated with long-term anticoagulants as warfarin, but new treatments are being tried. The aim of this article is to review the links between primary APS and kidney disease.
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Affiliation(s)
| | - David Isenberg
- Centre for Rheumatology, University College London Hospitals, London, UK
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17
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Catastrophic antiphospholipid antibody syndrome presenting as severe ischaemic colitis. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 40:684-687. [PMID: 27939948 DOI: 10.1016/j.gastrohep.2016.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/03/2016] [Accepted: 10/05/2016] [Indexed: 11/22/2022]
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18
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Arachchillage DRJ, Mackie IJ, Efthymiou M, Chitolie A, Hunt BJ, Isenberg DA, Khamashta M, Machin SJ, Cohen H. Rivaroxaban limits complement activation compared with warfarin in antiphospholipid syndrome patients with venous thromboembolism. J Thromb Haemost 2016; 14:2177-2186. [PMID: 27541499 DOI: 10.1111/jth.13475] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Indexed: 12/19/2022]
Abstract
Essentials Complement activation has a pathogenic role in thrombotic antiphospholipid syndrome (APS). Coagulation proteases such as factor Xa can activate complement proteins. Complement activation markers were elevated in anticoagulated thrombotic APS patients. Complement activation decreased in APS patients switching from warfarin to rivaroxaban. SUMMARY Background Complement activation may play a major role in the pathogenesis of thrombotic antiphospholipid syndrome (APS). Coagulation proteases such as factor Xa can activate complement proteins. Aims To establish whether rivaroxaban, a direct factor Xa inhibitor, limits complement activation compared with warfarin in APS patients with previous venous thromboembolism (VTE). Methods A total of 111 APS patients with previous VTE, on warfarin target INR 2.5, had blood samples taken at baseline and at day 42 after randomization in the RAPS (Rivaroxaban in Antiphospholipid Syndrome) trial. Fifty-six patients remained on warfarin and 55 switched to rivaroxaban. Fifty-five normal controls (NC) were also studied. Markers of complement activation (C3a, C5a, terminal complement complex [SC5b-9] and Bb fragment) were assessed. Results APS patients had significantly higher complement activation markers compared with NC at both time-points irrespective of the anticoagulant. There were no differences between the two patient groups at baseline, or patients remaining on warfarin at day 42. In 55 patients randomized to rivaroxaban, C3a, C5a and SC5b-9 were lower at day 42 (median (ng mL-1 ) [confidence interval] 64 [29-125] vs. 83 [35-147], 9 [2-15] vs. 12 [4-18] and 171 [56-245] vs. 201 [66-350], respectively) but levels of Bb fragment were unchanged. There were no correlations between rivaroxaban levels and complement activation markers. Conclusions APS patients with previous VTE on warfarin exhibit increased complement activation, which is likely to occur via the classical pathway and is decreased by rivaroxaban administration. Rivaroxaban may therefore potentially provide an additional benefit to its anticoagulant effect in this patient group by limiting complement activation.
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Affiliation(s)
- D R J Arachchillage
- Department of Haematology, Haemostasis Research Unit, University College London, London, UK
| | - I J Mackie
- Department of Haematology, Haemostasis Research Unit, University College London, London, UK
| | - M Efthymiou
- Department of Haematology, Haemostasis Research Unit, University College London, London, UK
| | - A Chitolie
- Department of Haematology, Haemostasis Research Unit, University College London, London, UK
| | - B J Hunt
- Thrombosis and Haemophilia, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Haematology, Kings College London, London, UK
| | - D A Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - M Khamashta
- Lupus Research Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Department of Rheumatology, Kings College London, London, UK
| | - S J Machin
- Department of Haematology, Haemostasis Research Unit, University College London, London, UK
| | - H Cohen
- Department of Haematology, Haemostasis Research Unit, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
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Catastrophic Antiphospholipid Syndrome. Case Rep Rheumatol 2016; 2016:4161439. [PMID: 27375916 PMCID: PMC4914728 DOI: 10.1155/2016/4161439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 05/05/2016] [Accepted: 05/12/2016] [Indexed: 11/18/2022] Open
Abstract
This paper reports one case of successfully treated patients suffering from a rare entity, the catastrophic antiphospholipid syndrome (CAPS). Management of this patient is discussed in detail.
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20
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Wan T, Tsang P. Catastrophic antiphospholipid syndrome presenting with pulmonary hemorrhage: case report. J Thromb Thrombolysis 2015; 39:68-70. [PMID: 24894406 DOI: 10.1007/s11239-014-1089-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This is a case report of catastrophic antiphospholipid syndrome (APLS) involving the rare manifestation of pulmonary hemorrhage. This rare variant of APLS is frequently life threatening despite medical therapy. The pathogenesis of pulmonary hemorrhage in catastrophic APLS remains incompletely understood. The optimal approach to managing pulmonary hemorrhage in the setting of catastrophic APLS is still unclear, however this case report demonstrates the success of combination therapy with anticoagulation, corticosteroids and plasma exchange.
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Affiliation(s)
- Tony Wan
- The University of British Columbia, Vancouver, BC, Canada,
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21
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Forastiero R, Martinuzzo M. The emerging role of multiple antiphospholipid antibodies positivity in patients with antiphospholipid syndrome. Expert Rev Clin Immunol 2015; 11:1255-63. [DOI: 10.1586/1744666x.2015.1080121] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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22
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Suryadevara S, Ferrara J, Gore J, Smith C. Severe cardiomyopathy in the setting of relapsing catastrophic antiphospholipid antibody syndrome. Am J Med 2015; 128:e13-4. [PMID: 25555546 DOI: 10.1016/j.amjmed.2014.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 12/05/2014] [Accepted: 12/05/2014] [Indexed: 10/24/2022]
Affiliation(s)
| | - Jarrod Ferrara
- Department of Medicine, University of Massachusetts, Worcester
| | - Joel Gore
- Department of Medicine, University of Massachusetts, Worcester
| | - Craig Smith
- Department of Medicine, University of Massachusetts, Worcester.
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23
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Bazzan M, Vaccarino A, Marletto F. Systemic lupus erythematosus and thrombosis. Thromb J 2015; 13:16. [PMID: 25908929 PMCID: PMC4407320 DOI: 10.1186/s12959-015-0043-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 02/26/2015] [Indexed: 12/30/2022] Open
Abstract
Systemic Lupus Erythematosus (SLE) is an acquired, multiorgan, autoimmune disease. Clinical presentation is extremely variable and heterogeneous. It has been shown that SLE itself is an independent risk factor for developing both arterial and venous thrombotic events since SLE patients have an Odds Ratio (OR) for thrombosis that varies depending on the clinical and laboratory characteristics of each study cohort. The risk of developing a thrombotic event is higher in this setting than in the general population and may further increase when associated with other risk factors, or in the presence of inherited or acquired pro-thrombotic abnormalities, or trigger events. In particular, a striking increase in the number of thrombotic events was observed when SLE was associated with antiphospholipid antibodies (aPL). The presence of aPLs has been described in about 50% of SLE patients, while about 20% of antiphospholipid syndrome (APS) patients have SLE. While APS patients (with or without an autoimmune disease) have been widely studied in the last years, fewer studies are available for SLE patients and thrombosis in the absence of APS. Although the available literature undoubtedly shows that SLE patients have a greater prevalence of thrombotic events as compared to healthy subjects, it is difficult to obtain a definite result from these studies because in some cases the study cohort was too small, in others it is due to the varied characteristics of the study population, or because of the different (and very copious) laboratory assays and methods that were used. When an SLE patient develops a thrombotic event, it is of great clinical relevance since it is potentially life-threatening. Moreover, it worsens the quality of life and is a clinical challenge for the clinician.
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Affiliation(s)
- Mario Bazzan
- Haematology and Thrombosis Unit, CMID Department, San Giovanni Bosco Hospital, Piazza Donatore di Sangue 3, 10154 Turin, Italy
| | - Antonella Vaccarino
- Haematology and Thrombosis Unit, CMID Department, San Giovanni Bosco Hospital, Piazza Donatore di Sangue 3, 10154 Turin, Italy
| | - Fabio Marletto
- Haematology and Thrombosis Unit, CMID Department, San Giovanni Bosco Hospital, Piazza Donatore di Sangue 3, 10154 Turin, Italy
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24
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Mira-Avendano IC, Abril A. Pulmonary manifestations of Sjögren syndrome, systemic lupus erythematosus, and mixed connective tissue disease. Rheum Dis Clin North Am 2015; 41:263-77. [PMID: 25836642 DOI: 10.1016/j.rdc.2015.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Interstitial lung disease is a common and often life-threatening manifestation of different connective tissue disorders, often affecting its overall prognosis. Systemic lupus erythematosus, Sjögren syndrome, and mixed connective tissue disease, although all unique diseases, can have lung manifestations as an important part of these conditions. This article reviews the different pulmonary manifestations seen in these 3 systemic rheumatologic conditions.
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Affiliation(s)
- Isabel C Mira-Avendano
- Department of Pulmonary Medicine, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Andy Abril
- Department of Rheumatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 33224, USA
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25
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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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26
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Raso S, Sciascia S, Kuzenko A, Castagno I, Marozio L, Bertero MT. Bridging therapy in antiphospholipid syndrome and antiphospholipid antibodies carriers: case series and review of the literature. Autoimmun Rev 2014; 14:36-42. [PMID: 25242343 DOI: 10.1016/j.autrev.2014.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 09/02/2014] [Indexed: 11/29/2022]
Abstract
Peri-operative management of patients on warfarin involves assessing and balancing individual risks for thromboembolism and bleeding. The timing of warfarin withdrawal and a tailored pre/postoperative management (including the substitution of heparin in place of warfarin, the so-called bridging therapy) is critical in patients with prothrombotic conditions. The antiphospholipid syndrome (APS) is the most common cause of acquired thrombophilia. In this particular subset of patients, as the risk of thrombosis is higher than in general population, bridging therapy can represent a real challenge for treating physicians. Only few studies have been designed to address this topic. We aim to report our experience and to review the available literature in the peri-procedural management of APS and antiphospholipid antibody-positive patients, reporting adverse events and attempting to identify potential risk factor associated with thrombosis or bleeding complications.
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Affiliation(s)
- Samuele Raso
- Clinical Immunology, AO Ordine Mauriziano, Torino, Italy
| | - Savino Sciascia
- Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare and Università di Torino, Torino, Italy; Graham Hughes Lupus Research Laboratory, King's College London, London, UK.
| | - Anna Kuzenko
- Clinical Immunology, AO Ordine Mauriziano, Torino, Italy
| | - Irene Castagno
- Clinical Immunology, AO Ordine Mauriziano, Torino, Italy
| | - Luca Marozio
- Department of Obstetrics and Gynaecology, Università di Torino, Torino, Italy
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27
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Hucker WJ, Chatzizisis YS, Steigner ML, Winters GL, Kirshenbaum JM. Myocardial catastrophe: a case of sudden, severe myocardial dysfunction. Circulation 2014; 130:854-62. [PMID: 25210096 DOI: 10.1161/circulationaha.113.007417] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- William J Hucker
- From the Cardiovascular Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (W.J.H.); and Departments of Radiology (M.L.S.) and Pathology (G.L.W.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yiannis S Chatzizisis
- From the Cardiovascular Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (W.J.H.); and Departments of Radiology (M.L.S.) and Pathology (G.L.W.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael L Steigner
- From the Cardiovascular Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (W.J.H.); and Departments of Radiology (M.L.S.) and Pathology (G.L.W.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gayle L Winters
- From the Cardiovascular Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (W.J.H.); and Departments of Radiology (M.L.S.) and Pathology (G.L.W.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James M Kirshenbaum
- From the Cardiovascular Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (W.J.H.); and Departments of Radiology (M.L.S.) and Pathology (G.L.W.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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28
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Sciascia S, Cuadrado MJ, Khamashta M, Roccatello D. Renal involvement in antiphospholipid syndrome. Nat Rev Nephrol 2014; 10:279-89. [PMID: 24642799 DOI: 10.1038/nrneph.2014.38] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease defined by the presence of arterial or venous thrombotic events and/or pregnancy morbidity in patients who test positive for antiphospholipid antibodies (aPLs). APS can be isolated (known as primary APS) or associated with other autoimmune diseases, such as systemic lupus erythematosus (SLE; known as secondary APS). The kidney is a major target organ in APS and renal thrombosis can occur at any level within the vasculature of the kidney (renal arteries, intrarenal arteries, glomerular capillaries and renal veins); events reflect the site and size of the involved vessels. Histological findings vary widely, including ischaemic glomeruli and thrombotic lesions without glomerular or arterial immune deposits on immunofluorescence. Renal prognosis is affected by the presence of aPLs in patients with lupus nephritis and can be poor. In patients with SLE and aPLs, biopsy should be performed because inflammatory and thrombotic lesions require different therapeutic approaches. Renal involvement in patients with definite APS is treated by anticoagulation with long-term warfarin. The range of renal manifestations associated with APS is broadening and, therefore, aPLs have increasing relevance in end-stage renal disease, transplantation and pregnancy.
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Affiliation(s)
- Savino Sciascia
- Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare and Università di Torino, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
| | - Maria José Cuadrado
- Louise Coote Lupus Unit, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, King's College London, Westminster Bridge Road, London SE1 7EH, UK
| | - Munther Khamashta
- Graham Hughes Lupus Research Laboratory, The Rayne Institute, Division of Women's Health, King's College London, Westminster Bridge Road, London SE1 7EH, UK
| | - Dario Roccatello
- Centro di Ricerche di Immunopatologia e Documentazione su Malattie Rare and Università di Torino, Piazza del Donatore di Sangue 3, 10154 Turin, Italy
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29
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Reggia R, Andreoli L, Tincani A, Shoenfeld Y. Current treatment strategies for management of antiphospholipid syndrome. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.881734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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30
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Schofield JR, Blitshteyn S, Shoenfeld Y, Hughes GRV. Postural tachycardia syndrome (POTS) and other autonomic disorders in antiphospholipid (Hughes) syndrome (APS). Lupus 2014; 23:697-702. [DOI: 10.1177/0961203314524468] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/28/2014] [Indexed: 12/29/2022]
Abstract
Background Antiphospholipid syndrome (APS) is an autoimmune hypercoagulable disorder that has been shown to cause a large number of cardiac and neurological manifestations. Two recent studies have demonstrated abnormalities in cardiovascular autonomic function testing in APS patients without other cardiovascular or autoimmune disease. However, an association between autonomic disorders such as postural tachycardia syndrome and APS has not previously been described. Methods and results Data were obtained by retrospective chart review. We identified 15 patients who have been diagnosed with APS and an autonomic disorder. The median age of the patients at the time of data analysis was 39 years. The autonomic disorders seen in these patients included postural tachycardia syndrome, neurocardiogenic syncope and orthostatic hypotension. The majority of patients (14/15) were female and the majority (14/15) had non-thrombotic neurological manifestations of APS, most commonly migraine, memory loss and balance disorder. Many also had livedo reticularis (11/15) and Raynaud’s phenomenon (nine of 15). In some patients, the autonomic manifestations improved with anticoagulation and/or anti-platelet therapy; in others they did not. Two patients with postural tachycardia syndrome who failed to improve with the usual treatment of APS have been treated with intravenous immunoglobulin with significant improvement in their autonomic symptoms. Conclusion We believe that autonomic disorders in APS may represent an important clinical association with significant implications for treatment.
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Affiliation(s)
- JR Schofield
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - S Blitshteyn
- Department of Neurology, State University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Y Shoenfeld
- Sackler Faculty in Medicine, Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Tel-Aviv University, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - GRV Hughes
- The London Lupus Centre, London Bridge Hospital, London, UK
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31
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Nyo MTL, Kalla AA. Thrombocytopenia and thrombosis: a double-edged sword. Clin Rheumatol 2013; 33:587-90. [PMID: 24196990 DOI: 10.1007/s10067-013-2416-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/18/2013] [Indexed: 01/08/2023]
Abstract
Severe thrombocytopenia with bleeding associated with a life-threatening thrombotic manifestation in the setting of antiphospholipid syndrome is a major diagnostic and therapeutic challenge for the clinician. Hemorrhage is a less common complication than thrombosis in patients with APS, although severe thrombocytopenia can sometimes result in bleeding. There are no evidence-based guidelines regarding the management of a patient with severe thrombocytopenia associated with a major thrombotic manifestation. In this case report, we review the literature reporting the difficulties in management of such patient.
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Affiliation(s)
- Myat Tun Lin Nyo
- Department of Medicine, Division of Rheumatology, Medical University of Southern Africa, MEDUNSA 0204, P O Box 625, Pretoria, South Africa,
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Rosário C, Zandman-Goddard G, Meyron-Holtz EG, D'Cruz DP, Shoenfeld Y. The hyperferritinemic syndrome: macrophage activation syndrome, Still's disease, septic shock and catastrophic antiphospholipid syndrome. BMC Med 2013; 11:185. [PMID: 23968282 PMCID: PMC3751883 DOI: 10.1186/1741-7015-11-185] [Citation(s) in RCA: 313] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 07/29/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Over the last few years, accumulating data have implicated a role for ferritin as a signaling molecule and direct mediator of the immune system. Hyperferritinemia is associated with a multitude of clinical conditions and with worse prognosis in critically ill patients. DISCUSSION There are four uncommon medical conditions characterized by high levels of ferritin, namely the macrophage activation syndrome (MAS), adult onset Still's disease (AOSD), catastrophic antiphospholipid syndrome (cAPS) and septic shock, that share a similar clinical and laboratory features, and also respond to similar treatments, suggesting a common pathogenic mechanism. Ferritin is known to be a pro-inflammatory mediator inducing expression of pro-inflammatory molecules, yet it has opposing actions as a pro-inflammatory and as an immunosuppressant. We propose that the exceptionally high ferritin levels observed in these uncommon clinical conditions are not just the product of the inflammation but rather may contribute to the development of a cytokine storm. SUMMARY Here we review and compare four clinical conditions and the role of ferritin as an immunomodulator. We would like to propose including these four conditions under a common syndrome entity termed "Hyperferritinemic Syndrome".
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Affiliation(s)
- Cristina Rosário
- Center for Autoimmune Diseases, Sheba Medical Center affiliated with the Tel-Aviv University, Tel-Hashomer 52621, Israel
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Punnialingam S, Khamashta MA. Duration of anticoagulation treatment for thrombosis in APS: is it ever safe to stop? Curr Rheumatol Rep 2013; 15:318. [PMID: 23494857 DOI: 10.1007/s11926-013-0318-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Antiphospholipid syndrome (APS) is an auto-immune thrombophilia for which anti-thrombotic medication is necessary for long-term management to reduce thrombotic risk or pregnancy morbidity. Choosing the type of pharmacological treatment, i.e. the intensity and duration of anticoagulation, depends on the severity of an individual's APS and the risk of bleeding. This article reviews the current literature on anticoagulation therapy, provides recommendations on when to initiate therapy, and suggests possible alternatives for optimisation of management.
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Affiliation(s)
- Sinthiya Punnialingam
- Department of General Medicine, Guy's and St Thomas' Hospital, Westminster Bridge Rd, London, UK.
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Vascular endothelial cell function in catastrophic antiphospholipid syndrome: a case report and review of the literature. Case Rep Hematol 2013; 2013:710365. [PMID: 23762673 PMCID: PMC3671306 DOI: 10.1155/2013/710365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 04/23/2013] [Indexed: 01/13/2023] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare autoimmune condition, which has been associated with a high mortality rate. However, with current management that includes a combination of anticoagulation, glucocorticoid administration, and plasma exchange, mortality rate has declined. Despite survival improvement with new generation immunosuppressive agents, their mechanisms of action are poorly defined, and CAPS is still considered a high-risk complication in patients known with antiphospholipid antibody syndrome. Herein, we present a case of a 79-year-old male who presented with a myocardial infarct and renal failure secondary to CAPS following a splenectomy for immune thrombocytopenia. Regardless of rapid combination of first-line treatment and rituximab therapy, the patient developed lethal cardiogenic shock secondary to mitral valve papillary muscle necrosis. Discussion of the pathophysiology and avenues of future therapies in CAPS are reported.
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