[Non-simultaneous malignant lymphoma and antiphospholipid syndrome: 4 cases]

Concomitant factor VIII inhibitor and lupus anticoagulant in an asymptomatic patient

Acquired hemophilia A, caused by autoantibodies that bind to and neutralize the activity of coagulation factor VIII (FVIII), almost universally presents as a severe bleeding diathesis. Lupus anticoagulants (LAs), autoantibodies directed against phospholipids or protein-phospholipid complexes, manifest clinically with an increased risk of thrombosis. While these autoantibodies are uncommon, the distinctive clinical presentation in conjunction with the typical laboratory findings often enable straightforward identification of the underlying autoantibody. However, the presence of a concomitant acquired FVIII inhibitor and LA is exceedingly rare with fewer than 20 documented cases. All prior patients presented with life-threatening hemorrhage, thrombosis, or both, prompting comprehensive hematologic evaluation and subsequent identification of the pathologic antibodies. We describe a novel case of a patient with no signs of hemorrhage or thrombosis who was incidentally found to have both a FVIII inhibitor and LA during evaluation of a prolonged partial thromboplastin time (PTT). This finding resulted in FVIII inhibitor-directed management, including immunosuppressive therapy. The unique presentation of an incidental FVIII inhibitor and LA in an asymptomatic patient without thrombotic or bleeding complications highlights the potential challenge in elucidating the etiology of a prolonged PTT, as LAs and FVIII inhibitors both prolong the PTT, and each entity can interfere with assays designed to detect the presence of the other autoantibody. This case underscores the importance of recognizing that patients with major underlying disturbances in their hematologic physiology, but in whom clinical symptoms have yet to manifest, may potentially be overlooked until such symptoms are evident.

Antiphospholipid antibodies associated with nodal marginal zone lymphoma and its progression to diffuse large B-cell lymphoma-A case report

An association between autoimmune events, as well as the development of antiphospholipid (aPL) antibodies and lymphoproliferative disorders is well recognized. We present the patient with coagulation abnormalities and non-Hodgkin lymphoma (NHL), primarily diagnosed as nodal marginal zone B-cell lymphoma (NMZL), and in relapse as diffuse large B-cell lymphoma (DLBCL). In the follow-up period, the patient simultaneously developed different aPL antibodies. The presence of aPL antibodies in NHL is frequent but it is not common in the NMZL. The aim of the present case report is to highlight the possible underlying increase of aPL antibodies in NMZL patients with coagulation tests abnormalities.

Clinical and serological follow-up of 71 patients with anti-mitochondrial type 5 antibodies

Antimitochondrial M5 type antibodies (AMA M5) have been described in patients with antiphospholipid syndrome (APS), thrombocytopenia and autoimmune hemolytic anemia. The aim of this study was to describe the clinical and immunological characteristics of a series of patients with AMA M5. We analyzed 71 patients with AMA M5 seen consecutively at our centres during the last 8 years. The clinical and immunological characteristics of diseases expression were compared with 70 consecutive disease control patients without AMA M5. Compared with the control group, AMA M5 positive patients presented higher prevalence of false positive VDRL test ( P < 0.001) and thrombocytopenia ( P = 0.002) with lower levels of anti-β2 glycoprotein I antibodies. In AMA M5 patients (56 female, 15 male) a heterogeneous group of disorders were found. Twenty-seven (38%) patients fulfilled the Sapporo criteria for the classification of the APS. Laboratory criteria were met in 55 (77.5%), and clinical criteria in 31 (43.7%) patients. Six patients initially presented with non-criteria features of APS during follow-up period developed APS. Younger patients with AMA M5 should be carefully observed for the development of APS, even in the absence of serological criteria, while elderly must be screened for monoclonal gammopathy and hematological disorders. Lupus (2007) 16, 788—793.

Prolonged Activated Partial Thromboplastin Time

To review the diagnostic difficulties of a prolonged activated partial thromboplastin time (aPTT) when 2 inhibitors with opposite clinical presentations coexist, we searched MEDLINE from January 1970 to November 2013 using acquired, factor VIII (FVIII), factor IX, hemophilia A and B, inhibitor, lupus anticoagulant (LA), antiphospholipid, anticardiolipin, anti-β2-glycoprotein I, antibodies, syndrome, bleeding, and thrombosis. We identified 13 articles for a total of 15 cases of possible coexistence of FVIII inhibitor and LA. The presenting clinical manifestation was thrombosis in 6 cases and bleeding in 9 cases. Activated partial thromboplastin time was the presenting laboratory abnormality in all cases, and first-line investigations suggested the coexistence of LA and acquired FVIII inhibitor. None of the articles addressed the diagnostic accuracy of the screening tests by performing “second line” assays. We reviewed the diagnostic pitfalls of the cases under study and provide some guidance for alternative tests when facing a prolonged aPTT that may have a double meaning.

The catastrophic antiphospholipid (Asherson's) syndrome and malignancies

The catastrophic antiphospholipid syndrome is characterised by the rapid chronological development of fulminant thrombotic complications that predominantly affect small vessels. It has been reported as frequently occurring in patients with underlying malignancies. We analysed the web site-based international registry of patients with catastrophic APS. The clinical characteristics of patients with CAPS and an underlying malignancy were evaluated. Of the 262 patients included in the CAPS registry, information on associated malignancies was available in 23 (9%) cases. Haematological malignancies were present in 6 (26%) patients. Four of the patients suffered from lung carcinoma (17%), and two patients (9%) from colon carcinoma. In most of the patients (61%), malignancy was the precipitating factor for CAPS. In 4 patients (17%), however, surgical procedures related to the carcinoma were noted as precipitating factors. In one patient CAPS occurred during allogenic stem cell transplantation after diagnosis of acute lymphoblastic leukemia (ALL). Cerebral manifestations were most common and consisted mainly of cerebral infarcts and encephalopathy. Recovery occurred in 9/23 (39%) patients. Malignancy may be an important risk factor for CAPS. 9% of patients with CAPS presented with an underlying malignancy. In most of these patients, the malignancy and/or surgical procedures were the precipitating factors for CAPS.

Antiphospholipid antibodies associated with malignancies: clinical and pathological characteristics of 120 patients

OBJECTIVE

To describe the different types of malignancies associated with antiphospholipid antibodies (aPL).

METHODS

We performed a computer-assisted (MEDLINE, National Library of Medicine, Bethesda, MD) search of the literature from 1966 to 2003 to identify all cases of malignancies having aPL.

RESULTS

One hundred twenty patients were found. The mean age was 56+/-17 years (range 5 to 88). Sixty-two (52%) patients were men and 58 (48%) were women. A heterogeneous group of malignancies were found. Regarding hematological malignancies, 10 (8%) patients suffered from B-cell lymphoma, 8 (7%) from spleen lymphoma, 7 (6%) from chronic myeloid leukemia, and 6 (5%) from non-Hodgkin's lymphoma (NHL). Regarding solid tumors, renal cell carcinoma was diagnosed in 7 (6%) patients, primary tumor with unknown origin in 7 (6%), lung adenocarcinoma in 6 (5%), breast carcinoma in 6 (5%), and melanoma in 6 (5%). The main aPL-related manifestations were thrombocytopenia (25%), cerebrovascular accidents (24%), deep vein thrombosis (19%), pulmonary embolism (15%), and heart valve lesions (9%). In 17 cases, catastrophic antiphospholipid syndrome was considered to be triggered by the malignancy. Seventy-one (63%) of 113 patients recovered or are still alive after cancer treatment. Twenty-three (35%) of 65 patients achieved aPL remission after proper treatment of the malignancy.

CONCLUSIONS

It is important to bear in mind, especially in elderly patients, that thrombotic events associated with aPL can be the first manifestation of malignancy. At the same time, the presence of aPL in patients with malignancies has important implications in their treatment and prognosis.

Thrombotic manifestations of the antiphospholipid syndrome in patients with malignancies

The presence of antiphospholipid antibodies has been reported in a large variety of patients with malignancies. Many case reports and reviews have appeared indicating that the presence of the antiphospholipid antibodies is related to thrombotic associations with the antiphospholipid syndrome (APS) in a proportion of these patients. We investigated the frequency of the thrombotic manifestations in 58 patients demonstrating antiphospholipid antibodies and with a history of neoplasia, including haematologic and lymphoproliferative malignancies. Antiphospholipid antibodies were detected by clotting assay [lupus anticoagulant (LAC)] or by enzyme-linked immunosorbent assay [anticardiolipin antibodies (aCL)] according to the Sapporo criteria. Patients, 39/58, suffered from solid tumours and 19/58 patients from malignant haematologic or lymphoproliferative diseases. One patient was suffering simultaneously from two solid tumours and a malignant lymphoma. Among the patients with solid tumours, 18/39 (46%) patients had thromboembolic complications of the antiphospholipid syndrome. Among the patients with haematologic and lymphoproliferative malignancies, only 6/19 (32%) suffered from thromboembolic complications. There was, however, no relation between the titres of aCL antibodies and the clinical manifestations. The presence, but not the titres, of antiphospholipid antibodies may identify a subset of cancer patients with a high risk of developing thrombotic complications. The frequency of thrombosis, however, is lower in aPL-positive patients with lymphoproliferative and haematological malignancies.

Paraneoplastic manifestations of lymphoma

Paraneoplastic syndromes are manifestations of malignancies that have produced effects that are distant from the primary tumor or metastases. Paraneoplastic syndromes are not caused by local effects of compression or infiltration into tissues, but are generally due to ectopic hormone production, autoimmune phenomena, or overproduction of cytokines. Paraneoplasia may be the presenting symptom of underlying malignancy and can affect almost any organ system, such as the neurologic syndromes associated with small-cell lung cancer or hypercalcemia associated with squamous cell carcinomas. Lymphoproliferative disorders are also associated with many paraneoplastic disorders; however, to date, most published information has been in the form of case reports and series of small numbers of patients. In this review, the most common paraneoplastic syndromes associated with non-Hodgkin's lymphoma and Hodgkin's disease will be discussed.