Pulmonary Manifestations of the Antiphospholipid Antibody Syndrome

Pulmonary renal syndrome: a clinical review

The term "pulmonary renal syndrome" describes a clinical syndrome which is characterised by the presence of both diffuse alveolar haemorrhage and glomerulonephritis. It encompasses a group of diseases with distinctive clinical and radiological manifestations, as well as different pathophysiological processes. The most common diseases implicated are anti-neutrophil cytoplasm antibodies (ANCA)-positive small vessel vasculitis and anti-glomerular basement membrane (anti-GBM) disease. Prompt recognition is required as respiratory failure and end-stage renal failure can rapidly occur. Treatment includes a combination of glucocorticoids, immunosuppression, plasmapheresis and supportive measures. The use of targeted treatments has significantly reduced mortality. Thus, an understanding of pulmonary renal syndrome is essential for the respiratory physician.

Primary antiphospholipid syndrome in pediatrics: beyond thrombosis. Report of 32 cases and review of the evidence

OBJECTIVE

Describe the frequency of thrombotic and non-thrombotic clinical manifestations, laboratory, treatment and prognosis in patients with pediatric primary antiphospholipid syndrome.

MATERIAL AND METHODS

A retrospective study was carried out in patients with a diagnosis of primary antiphospholipid antibody syndrome, under 16 years of age, under follow-up by the pediatric rheumatology service of the General Hospital, National Medical Center, La Raza, from January 2013 to December 2020. The antiphospholipid syndrome was defined when it met the laboratory criteria of the Sidney criteria and the presence of thrombosis or non-criteria manifestations of the disease (hematological, neurological, cutaneous, renal, cardiac or pulmonary). Demographic, clinical, laboratory, treatment, and prognosis data were collected.

RESULTS

We report 32 patients, 21 female (65%) and 11 male (35%), mean age 11.75 years, evolution time 16 weeks. Thrombosis 9 patients (28%), 1 arterial and 8 venous. Non-thrombotic manifestations; Hematologic: thrombocytopenia 22 patients (69%), autoimmune hemolytic anemia 13 (40%), Fisher-Evans syndrome 6 (19%), lupus anticoagulant with hypoprothrombinemia syndrome 2 (6%). Dermatological: livedo reticularis 20 (62%), skin ulcers 2 (6%), Raynaud's phenomenon 8 (25%). Neurological: epilepsy 1 (3%), migraine 3 (9%), chorea 1 (3%) and cognitive impairment 3 (9%). Renal in 4 (13%). Laboratory: prolonged aPTT 30 (93%), lupus anticoagulant 32 (100%), positive IgG anticardiolipin 20 (62%), positive IgM anticardiolipin 19 (60%). AntiB2GPI was performed in only 3 patients, being positive in all.

TREATMENT

anticoagulation in patients with thrombosis, antiplatelet in 23 (72%), steroid 30 (94%), immunosuppressant 30 (94%) and rituximab 4 (12.5%). No deaths were reported.

CONCLUSIONS

The clinical characteristics of patients with pediatric primary antiphospholipid syndrome differ from those presented in adults, since non-thrombotic manifestations are more frequent in children, for which classification criteria that include these manifestations are necessary for a better characterization of the disease in pediatric population.

Pulmonary manifestations of antiphospholipid syndrome: a retrospective analysis of 67 patients

Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by arterial and/ or venous thrombosis accompanied by persistently elevated levels of antiphospholipid antibodies (aPLs). The aim of this study is to evaluate the pulmonary manifestations of APS and compare the levels of aPLs in patients with and without pulmonary involvement. We retrospectively reviewed the files of patients with the diagnosis of APS between October 2010 and May 2017. Demographic data, clinical, radiological and laboratory findings were recorded. The study included 67 patients (56 female/11 male) with a mean age of 39 ± 13 years. Pulmonary manifestations such as parenchymal and/or vascular involvement were seen in 12 (17.9%) patients. The patients with and without pulmonary manifestations were not significantly different in terms of age (p = 0.46), comorbidities (p = 0.48) and APS duration (p = 0.66). Acute pulmonary thromboembolism (PE) was determined in 11 (16.4%), alveolar hemorrhage in 2 (3%) patients. Four patients with acute PE (36%) developed chronic thromboembolic pulmonary hypertension (CTEPH). One patient developed both CTEPH and diffuse alveolar hemorrhage after acute PE during follow up. Antiphosholipid antibody IgM was highly positive in patients with PE compared to patients without PE (p = 0.005). Other antibodies and lupus anticoagulant were not significantly different in patients with and without PE. None of the patients were deceased due to pulmonary manifestations of APS. PE was the most common pulmonary manifestation of APS. The development of CTEPH was high among APS patients. Patients with APS should be closely followed for the onset of PE and CTEPH.

Pulmonary hypertension associated with antiphospholipid antibody: Call for a screening tool?

Antiphospholipid (aPL) antibodies are antibodies specific for anionic phospholipids. They are immunoglobulins that attack phospholipids, phospholipid-binding proteins, or phospholipid-protein complexes and are detected in anticardiolipin and lupus anticoagulant assays. aPL antibodies are often associated with antiphospholipid syndrome (APS) which can be idiopathic or from secondary causes such as systemic lupus erythematosus (SLE), infection or drugs. They have also been shown to be associated with Pulmonary Hypertension. We conducted a review of the literature that included all articles on PubMed with keywords 'antiphospholipid antibody' and 'pulmonary hypertension' between January 1980 and July 2017 and identified 217 articles. A total of 47 articles were found to be relevant to the topic and included as references. We ascertained that aPL antibodies have been implicated in the development of both idiopathic pulmonary arterial hypertension (PAH) and PAH associated with connective tissue disease (CTD). aPL antibodies were also noted to be associated with left-sided valvular heart disease that can lead to pulmonary venous hypertension (PVH). Patients with anitiphospholipid antibody syndrome (Diagnostic criteria incudes +aPL antibodies) were noted to have a high risk of developing chronic thromboembolic pulmonary hypertension (CTEPH). A recent study also found a positive association of aPL antibodies with ILD and PH in patients with systemic sclerosis. While association between autoimmune thyroid disease and PH (Group V PH), and autoimmune thyroid disease and aPL antibodies is established, no studies linked these three phenomena together. Thus, aPL antibodies had an association with all WHO groups of Pulmonary hypertension (PH). In this review article, we study the association and discuss the need for screening for PH in patients with positive aPL antibodies.

Antiphospholipid Syndrome and the Lungs

Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterised by recurrent thromboembolic events (arterial or venous) and/or morbidity in pregnancy (fetal loss, premature birth, or recurrent embryonic losses) in the presence of laboratory evidence of antiphospholipid antibodies (aPL). APS is a multisystem disorder. Several lung manifestations may develop in patients with APS including pulmonary embolism (PE)/infarction; thromboembolic and non-thromboembolic pulmonary hypertension (PH) (pulmonary arterial hypertension); pulmonary microthrombosis; acute respiratory distress syndrome associated with catastrophic APS; diffuse alveolar haemorrhage; and pulmonary capillaritis. Postpartum syndrome and cryptogenic fibrosing alveolitis (CFA) can be associated with APS. Pulmonary manifestations are relatively rare but are more likely to be life-threatening compared with other complications of APS. Particularly in the presence of aPL, pulmonary manifestations should be suspected in any systemic lupus erythematosus patient with clinical findings such as chest pain, dyspnoea, tachypnoea, and haemoptysis. Early diagnosis and treatment of pulmonary manifestations in APS are essential for improving mortality rates in patients with this condition. The purpose of this review is to assess current evidence around the diagnosis, prognosis, and management of patients with common and rare pulmonary manifestations of APS.

Antiphospholipid Syndrome (APS) - An Update on Clinical Features and Treatment Options

Antiphospholipid syndrome (APS) is an autoantibody disorder characterized by the presence of antiphospholipid (APL) antibodies and heterogeneous clinical manifestations. Patients may present with recurrent thrombosis, obstetric morbidity, cardiac valvular lesions, thrombocytopenia, skin lesions, renal or neurologic abnormalities. We provide a comprehensive review of these diverse clinical features except renal and obstetric complications. Treatment of APS can be challenging as one tries to balance the benefit of anticoagulation therapy in this hypercoagulable state while minimizing the risk of bleeding. We discuss the various therapeutic options including the role of aspirin, warfarin, low molecular weight heparin, new direct thrombin inhibitors, hydroxychloroquine, intravenous gamma globulin, rituximab and others. Lower risk APS patients (i.e. first venous thrombosis) should receive warfarin with a target INR of 2.0-3.0. Higher risk patients (i.e. arterial thrombosis or recurrent venous events) have a target INR of >3.0. Currently, warfarin remains the mainstay in treatment of APS. Because of lack of adequate data, the newer oral direct inhibitors should be considered only when there is a known allergy/ intolerance or poor control with warfarin. Additional vascular and thrombotic risk factors should be aggressively reduced. Further studies involving large number of APS patients, diagnosed according to accepted criteria, are needed to better define the role of newer anticoagulants and other novel therapies.

Asthma-like symptoms as a presentation of antiphospholipid syndrome

We herein report a case of antiphospholipid syndrome (APS) primarily presenting with asthma-like symptoms that had been misdiagnosed as severe asthma. Patients presenting with severe asthma symptoms along with systemic thrombosis should be systematically evaluated for APS.

Alveolar Hemorrhage

Diffuse alveolar hemorrhage (DAH) is a clinical syndrome characterized by generalized intra-alveolar bleeding originating from the pulmonary microcirculation. The finding of DAH carries an extended differential diagnosis and may be associated with a number of histopathologic patterns. The prompt recognition and diagnosis of DAH is of critical importance to the practicing clinician as accurate diagnosis and prompt initiation of therapy may dramatically improve patient outcomes. This chapter reviews the diagnosis and management of diffuse alveolar hemorrhage.

Selective adsorption of antiphospholipid and anti-dsDNA autoantibodies on histidine based pseudobioaffinity adsorbent from sera of patients with systemic lupus erythematosus (SLE)

Systemic lupus erythematosus (SLE) is an autoimmune diseases characterized by the presence of antiphospholipid and anti-dsDNA autoantibodies in the sera of patients. These autoantibodies and their subclasses have received increasing attention by medical community due to their association with recurrent venous thrombosis, fetal loss and thrombocytopenia. In particular, attention has been paid to IgG subclasses in SLE. The biological and functional properties together with the subclass distribution might therefore influence the course of SLE. The separation and elimination of these autoantibodies from sera of patients can be effective in clinical therapy. In the present study, histidine based pseudobioaffinity adsorbents have been used for the selective adsorption and separation of anti-double stranded DNA (anti-dsDNA), anticardiolipin (aCL) and anti-β2-glycoprotein-I (anti-β2-GPI) antibodies from sera of patients with SLE. For this purpose histidine acting as a pseudobiospecific ligand has been coupled to bisoxirane activated sepharose CL-6B for the adsorption and separation of these autoantibodies. The removal of autoantibodies was carried out under gentle adsorption and elution chromatographic conditions at pH values 7.0 and 8.0. Autoantibodies isotypes and subclasses distribution in the separated fractions were studied by enzyme-linked immune-sorbent assay. The obtained results showed that the separated anticardiolipin and anti-β2-glycoprotein-I autoantibodies belong to IgG1, IgG2 and IgG3subclasses, while those of anti-dsDNA belong to IgM isotype and were shown to have a DNA hydrolyzing activity that hydrolyzes plasmid DNA. The results also indicate a total IgM and IgG recovery superior to 90% of the fraction loaded at pH 7.4 and pH 8.0 respectively.

A large and massive abdominal venous thrombosis associated with the presence of a big axillary mass, lupus-like syndrome and antiphospholipid antibodies

This case report concerns a 40-year-old patient with an unspecific abdominal pain, diarrhoea, a big axillary mass and a previous pulmonary infection. After biopsy of the axillary mass the diagnosis of lymphoma was excluded based on the presence of cells expressing polyclonal antibodies. Abdominal CT scans and angionuclear magnetic resonance showed an extensive intestinal venous thrombosis. The patient also presented positive results for C and S proteins, lupic anticoagulant factor and antiphospholipid antibodies (anticardiolipin antibodies - IgM and IgG). Treatment started with administration of recombinant tissue plasminogen activator and heparin which decreased the degree of thrombosis. Antibiotics were also administrated to treat pulmonary and abdominal infections. After 25 days, he was discharged with no signs of infection, no abdominal pain and reduction of the thrombosis. He was medicated with warfarin, hydroxichloroquine and clopidogrel. Forty-five days after discharge, abdominal CT scan showed a significant regression of thrombosis.

M pneumoniae infection, pulmonary thromboembolism and antiphospholipid antibodies

A 28-year-old, hypertensive and hypercholesterolaemic patient, was referred to our emergency unit with a mild thoracic pain, productive cough and a body temperature of 37.3°C. Laboratory examinations showed normal white cell count and moderate elevation of C reactive protein (CRP). Later, the thoracic pain increased accompanied by shortness of breath. High D-dimer was detected. Positive lupic anticoagulant factor and anticardiolipin and antibodies anti-Mycoplasma pneumoniae were present and high titres of antinuclear factor. Recombinant tissue-type plasminogen activator plus heparin and vancomycin were administered due the high possibility of mycoplasma pneumonia associated with pulmonary thromboembolism. CRP increased to very high levels with very mild modification of white blood cells during the evolution. Thoracic tomography and pulmonary scintigraphy of the lungs confirmed the diagnosis. The patient responded well and he was discharged after 25 days medicated with hydroxychloroquine sulphate, warfarin and aspirin. At present date he is well (150 days).