[What criteria for the diagnosis of antiphospholipid syndrome?]

Antiphospholipid syndrome: the need for new international classification criteria

Introduction: As soon as the association of lupus anticoagulant (LAC) and anticardiolipin antibodies (aCL) with thrombosis and miscarriages was described in the 1980s, the definition of the antiphospholipid syndrome (APS) became a need. Early descriptions of the disease by members of the Graham Hughes team included broad categories and unexplained laboratory inclusions. Over time, new clinical and experimental data refined the criteria, especially the obstetric manifestations, as well as the laboratory criteria.Areas covered: The authors performed a review of the literature using the PubMed database, and the following keywords were used: 'antiphospholipid antibody', 'antiphospholipid syndrome', and 'criteria of antiphospholipid'. The history of antiphospholipid criteria, clinical and experimental advancements, and other expert opinions were included in this paper.Expert opinion: It has been 14 years since an international congress on antiphospholipid antibodies has generated new classification based on the recent extensive research performed in the field. Currently, there is a need to update the international APS classification taking into consideration the inclusion of new clinical criteria such as aPL-related nephropathy as well as new standardized antibody specificities (e.g., anti-phosphatidylserine/prothrombin antibodies) with the adoption of a standardized scoring system that can stratify APS patients.

Histological appearance of the intra-osseous vessels of the femoral head in aseptic osteonecrosis of the hip, with or without antiphospholipid antibodies

It has been suggested that in some patients non-traumatic aseptic osteonecrosis of the hip (AOH) could be the result of the intra-osseous thrombosis. Antiphospholipid antibodies (APL) have been associated with venous and arterial occlusive events and the association between AOH and APL syndrome has been reported.

OBJECTIVES

To compare bone vessels of the femoral head in patients operated on for AOH with or without APL.

PATIENTS

Twenty patients (mean age 47 yrs) with AOH were included: in eight patients APL (IgG-ELISA) were negative (< 8 GPL units), in nine patients APL were doubtful (8-15 GPL units), and in three patients APL were positive (> 15 GPL units).

METHODS

Bone vessels were examined: arteriosclerotic lesions, i.e. fibrosis or thickening of the media and rupture of the internal elastic lamina, thrombosis or vasculitis were sought in the femoral heads after total hip replacement or core decompression.

RESULTS

Bone vessel lesions were the same in the three groups.

Recurrent fetal loss and antiphospholipid antibodies: clinical and therapeutic aspects

Recurrent fetal losses indicate screening for antiphospholipid antibodies, especially after the third consecutive fetal loss, or when they occur after 12 weeks gestation or when the mother presents with thrombosis or other ailments of antiphospholipid syndrome. Fetal loss may be caused by thromboses of placental vasculature. There is no agreement concerning the mechanism of thromboses: protein C pathway and/or annexin V are the best candidates. When fetal loss occurs early during gestation, murine models suggest that antiphospholipid antibodies can also act on trophoblasts by inhibiting syncytia formation. Among the high risk patients with more than two fetal losses, an association of aspirin and heparin given early during gestation is successful in 70–80% of cases.

[Obstetrical complications of antiphospholipid syndrome]

Spontaneous miscarriages and fetal deaths take part of the definition of the antiphospholipid syndrome. Preeclampsia, fetal distress, preterm delivery, intrauterine growth retardation, mother's or newborn's vascular thrombosis are also included in the spectrum of clinical events linked to the antiphospholipid antibodies in pregnant women. The pathogenesis is not fully understood, but involves interactions between antibodies and phospholipidic molecules that are complexed to plasmatic proteins of the coagulation, or present on endothelial cell and platelet surfaces. The poor spontaneous prognosis of pregnancy in the context of the antiphospholipid syndrome is dramatically improved by preventive treatment. Therapeutic options are not codified and are various combinations of low-dose aspirin, heparin, steroids, intravenous immunoglobulins, and fish-oil derivatives. Excellent obstetrical care is mandatory in every case.

1996 diagnostic and classification criteria for the antiphospholipid/cofactors syndrome: a "mission impossible'?

Due to recent acquisitions, diagnostic criteria for the antiphospholipid/cofactors syndrome need to be improved. In the absence of a "common biological denominator", the best approach should be based on a scoring system mixing clinical and immunological items. APS might be composed of different biological subsets characterized by antibodies directed to various cofactors. Among clinical subsets, the categorization between "primary" and SLE-related APS may be difficult to achieve. Contrasting with the innumerable conditions associated with the presence of aPL, the diversity of "true" secondary APS should probably be restrained. Attempts at establishing correlations between clinical and biological APS subsets will require further studies.

[Thyroid disease and multiple autoimmune syndromes. Clinical and immunogenetic aspects apropos of 11 cases]

The authors report eleven cases of multiple auto-immune syndrome, concerning a total of 15 different auto-immune diseases. This study suggests that auto-immune thyroid disorders (Graves' disease or hypothyroidism resulting from Hashimoto's thyroiditis) are a common feature of multiple auto-immune syndromes, while antithyroid antibodies are constant among our patients. Sjögren's syndrome is also very prevalent, and seems to be non-randomly associated with auto-immune thyroid disorders, a fact which suggests common aetiological factors. Among other auto-immune disorders, the antiphospholipid syndrome has been diagnosed twice. A genetic predisposition to multiple auto-immune syndrome is obvious, as shown by a familial history of auto-immune disorders (found in more than half of the cases), and a predominant HLA phenotype, B8 and/or DR3. The authors plead for a systematic enquiry for multiple auto-immune syndrome in patients with auto-immune thyroid disorders and a family history of auto-immune disorders.