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Chen WH, Yang DH. Spontaneous Retroperitoneal Bleeding in a Patient with Systemic Lupus Erythematosus. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:78. [PMID: 38256339 PMCID: PMC10820223 DOI: 10.3390/medicina60010078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Systemic lupus erythematosus (SLE) is a disease with multiple organ involvement, and spontaneous hemorrhage, especially perirenal hemorrhage, is rare. Case Presentation: We report the case of a 19-year-old teenager with SLE who experienced left flank pain and hypovolemic shock. Abdominal computed tomography revealed a large left retroperitoneal hematoma. Recurrent hypovolemic shock occurred despite the transcatheter arterial embolization of the left renal artery. Repetitive abdominal computed tomography results showed active hemorrhage. Result: An exploratory laparotomy was used to confirm descending colonic mesenteric artery bleeding, which was resolved. The patient needed temporary regular kidney replacement therapy for active lupus nephritis, which terminated one month after discharge. Conclusions: When patients with SLE experience acute abdominal pain, flank pain, or back pain combined with hypovolemia, there is a higher risk of bleeding due to spontaneous hemorrhage, which should be included in the differential diagnosis. Therefore, early diagnosis and adequate emergency intervention are necessary.
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Affiliation(s)
- Wei-Hung Chen
- Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Taichung Armed-Forces General Hospital, Taichung 411, Taiwan;
- Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Deng-Ho Yang
- Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Taichung Armed-Forces General Hospital, Taichung 411, Taiwan;
- Division of Rheumatology/Immunology/Allergy, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
- Department of Medical Laboratory Science and Biotechnology, Central Taiwan University of Science and Technology, Taichung 406, Taiwan
- Institute of Biomedical Science, National Chung-Hsing University, Taichung 402, Taiwan
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2
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Sun YH, Nie WJ, Tian DD, Ye Q. Lupus anticoagulant-hypoprothrombinemia syndrome in children: Three case reports and systematic review of the literature. Lupus 2023; 32:1211-1221. [PMID: 37480550 DOI: 10.1177/09612033231191153] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
OBJECTIVE Children with lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) are characterized by prolonged activated partial thromboplastin time (APTT) and prothrombin time (PT), lupus anticoagulant positivity and low prothrombin (factor II, FII) levels. Bleeding or thrombosis tendencies related to LAHPS in children can occur due to the development of anti-prothrombin antibodies that are usually linked to autoimmune or infectious diseases. METHODS We report three pediatric cases of LAHPS and describe details on their clinical symptoms, laboratory characteristics, treatment. PubMed, Medline, and Web of Science searches were conducted on LAHPS in children between 1960 and 2023; articles in English were included. RESULTS The coagulation profile revealed prolonged PT and APTT, with low prothrombin levels (19.4%, 21.0% and 12.9%, respectively) and positive lupus anticoagulant in 3 pediatric cases. Fifty-nine relevant articles reported 93 pediatric LAHPS cases (mean age: 9 years (0.8-17 years)); 63 females and 30 males, 87 patients presented with minor to severe bleeding diathesis, and 3 patients presented with thrombosis events. Among 48 patients ≥9 years old, 36 had SLE; among 45 patients <9 years, 29 had viral infection. When all patients were divided into two groups based on age, associated disease, and factor II level, Pearson's χ2 tests were performed, p =.00, and there was clinical significance between autoimmune and infectious disease in patients ≥9 years old and <9 years old, and in patients FII level ≤10% and >10%. LAHPS patients with autoimmune disease had a protracted course and needed prolonged treatment with immune-modulating therapy, while those patients with infectious disease resolved spontaneously or needed short-term immune-modulating therapy. CONCLUSION LAHPS caused by autoimmune disease are common in patients ≥9 years old, especially SLE, and FII level ≤10% is often reported in patients caused by autoimmune disease, suggesting that children ≥9 years old diagnosed with LAHPS-related autoimmune disease should pay special attention to the FII level. While LAHPS caused by infectious disease is more frequently observed in patients <9 years, especially viral infection. Early diagnostic investigations are critical to differentiating LAHPS caused by autoimmune or infectious disease, as the prognosis, treatment and outcome are distinct.
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Affiliation(s)
- Yan-Hong Sun
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wen-Jian Nie
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dan-Dan Tian
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qing Ye
- Department of clinical laboratory, National Clinical Research Center for Child Health, National Children's Regional Medical Center, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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3
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Kocheril AP, Vettiyil GI, George AS, Shah S, Geevar T, Dave RG, T SK. Pediatric systemic lupus erythematosus with lupus anticoagulant hypoprothrombinemia syndrome-A case series with review of literature. Lupus 2021; 30:641-648. [PMID: 33509039 DOI: 10.1177/0961203321988934] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) is a rare phenomenon that leads to concomitant thrombosis and hemorrhage in children with SLE. LAHPS in pediatric SLE (pSLE) has a protracted course requiring long-term immunosuppressive therapy. Due to the rarity of this syndrome and paucity of reported cases, there is lack of standardized management. We herewith report 5 children with pSLE with LAHPS.Methodology: We retrospectively reviewed clinical features, laboratory features, treatment and outcome for 5 children with lupus anticoagulant hypoprothrombinemia syndrome with SLE and a review of literature of similar cases published. RESULTS Mean age of presentation was 10.2 ± 2.38 years (mean ± SD) and female to male ratio was 4:1. All children presented with mild to severe bleeding manifestations like gum bleed, epistaxis, hematuria, menorrhagia and subarachnoid bleed. Coagulation profile revealed prolonged PT and aPTT, with low prothrombin levels and positive Lupus anticoagulant in all children. Mixing studies were characteristic in these children. On comparing laboratory parameters majority had low C3, C4 levels, ANA and anti-DsDNA antibody positivity and three children had anticardiolipin positivity. One child had lupus nephritis along with LAHPS at presentation. All responded well to steroids and supportive measures. CONCLUSION High index of suspicion is needed when child with lupus presents with bleeding manifestations for early diagnosis and treatment.
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Affiliation(s)
- Anu Punnen Kocheril
- Pediatric Rheumatology, Department of Pediatrics, Christian Medical College, Vellore, India
| | - George Ipe Vettiyil
- Pediatric Rheumatology, Department of Pediatrics, Christian Medical College, Vellore, India
| | - Anish Sam George
- Pediatric Rheumatology, Department of Pediatrics, Christian Medical College, Vellore, India
| | - Sonam Shah
- Pediatric Rheumatology, Department of Pediatrics, Christian Medical College, Vellore, India
| | - Tulasi Geevar
- Department of Transfusion Medicine and Immuno-Hematology, Christian Medical College, Vellore, India
| | - Rutvi Gautam Dave
- Department of Transfusion Medicine and Immuno-Hematology, Christian Medical College, Vellore, India
| | - Sathish Kumar T
- Pediatric Rheumatology, Department of Pediatrics, Christian Medical College, Vellore, India
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4
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Libra F, Falsaperla D, Desiderio CM, Signorelli SS, Palmucci S, Basile A. Spontaneous bleeding in systemic lupus erythematosus: Endovascular treatment of two rare cases. Radiol Case Rep 2020; 15:992-998. [PMID: 32426083 PMCID: PMC7226670 DOI: 10.1016/j.radcr.2020.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 11/17/2022] Open
Abstract
Among the multiple clinical manifestations of systemic lupus erythematosus, spontaneous bleedings are rare but clinically important events. They could be potentially fatal, if not promptly treated. The appropriate diagnosis, followed by the timely treatment of these rare clinical presentations, is essential to prevent their lethal consequences. The purpose of this paper is to describe the diagnostic features and the endovascular treatment of 2 cases of spontaneous bleeding-respectively occurred in a 42-year-old woman with abdominal pain and melena, and in a 33-year-old woman with an extensive and painful hematoma in the left axillary region. The timely endovascular treatment-performed by a minimally invasive approach of super-selective percutaneous embolization-has allowed an immediate clinical improvement, avoiding major surgery.
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Affiliation(s)
- Federica Libra
- Department of Medical Surgical Sciences and Advanced Technologies – Radiology I Unit, University Hospital “Policlinico-Vittorio Emanuele”, Via Santa Sofia 78, Catania, 95123, Italy
- Corresponding author.
| | - Daniele Falsaperla
- Department of Medical Surgical Sciences and Advanced Technologies – Radiology I Unit, University Hospital “Policlinico-Vittorio Emanuele”, Via Santa Sofia 78, Catania, 95123, Italy
| | - Carla Maria Desiderio
- Department of Medical Surgical Sciences and Advanced Technologies – Radiology I Unit, University Hospital “Policlinico-Vittorio Emanuele”, Via Santa Sofia 78, Catania, 95123, Italy
| | - Salvatore Santo Signorelli
- Department of Clinical and Experimental Medicine, University of Catania, University Hospital “Policlinico-Vittorio Emanuele”, Catania, 95123, Italy
| | - Stefano Palmucci
- Department of Medical Surgical Sciences and Advanced Technologies – Radiology I Unit, University Hospital “Policlinico-Vittorio Emanuele”, Via Santa Sofia 78, Catania, 95123, Italy
| | - Antonio Basile
- Department of Medical Surgical Sciences and Advanced Technologies – Radiology I Unit, University Hospital “Policlinico-Vittorio Emanuele”, Via Santa Sofia 78, Catania, 95123, Italy
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5
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Madison JA, Zuo Y, Knight JS. Pediatric antiphospholipid syndrome. Eur J Rheumatol 2020; 7:S3-S12. [PMID: 31804173 PMCID: PMC7004270 DOI: 10.5152/eurjrheum.2019.19160] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022] Open
Abstract
Despite its potential to cause significant morbidity in children, pediatric antiphospholipid syndrome (APS) is an understudied condition. In this review, we will cover what is known about pediatric APS epidemiology and how the clinician might approach the diagnosis of pediatric APS. We will highlight similarities and differences with the adult disease, both for primary APS and in the context of lupus. Clinical manifestations beyond thrombosis, especially neurologic and hematologic in nature, will be discussed. We will also consider what unique implications antiphospholipid antibody-positivity may have for children with lupus and for neonates born to mothers with APS. The approach to treatment will be covered, including the unique impact of APS medications on children as compared with adults. Finally, the importance of future mechanistic research is emphasized as physicians endeavor to provide the personalized care that children with APS clearly deserve.
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Affiliation(s)
- Jacqueline A. Madison
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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6
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Fujiwara K, Shimizu J, Tsukahara H, Shimada A. Lupus anticoagulant-hypoprothrombinemia syndrome and immunoglobulin-A vasculitis: a report of Japanese sibling cases and review of the literature. Rheumatol Int 2019; 39:1811-1819. [PMID: 31392497 DOI: 10.1007/s00296-019-04404-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
Lupus anticoagulant-hypoprothrombinemia syndrome (LAHPS) is a rare bleeding disorder caused by antiprothrombin antibodies. LAHPS is associated with systemic lupus erythematosus (SLE) or infections. We describe two Japanese brothers with immunoglobulin-A vasculitis (IgAV) who met the diagnostic criteria of LAHPS. They presented with palpable purpura and abdominal pain, and had a prolonged activated partial thromboplastin time (APTT) and prothrombin deficiency with the presence of lupus anticoagulant. Pediatric LAHPS was reviewed in abstracts from the Japan Medical Abstracts Society that were written in Japanese and PubMed or Web of Science-listed articles in English between 1996 and 2019. Including our cases, pediatric LAHPS has been reported in 40 Japanese and 46 non-Japanese patients. We summarized the clinical and laboratory characteristics of all 86 cases, and found only one Japanese LAHPS case with IgAV, except for our cases. Of the 86 cases, most were associated with infections followed by SLE. The presence of SLE, older age, lower prothrombin levels, severe bleeding symptoms, and positivity of immunoglobulin G anticardiolipin antibodies and anticardiolipin/β2-glycoprotein I antibodies and/or β2-glycoprotein I-dependent anticardiolipin antibodies had higher odds of requiring treatment. Measuring the APTT and prothrombin time (PT) might be required in patients with IgAV when they do not have a typical clinical course or distinctive symptoms. LAHPS should be considered with prolongation of the APTT and/or PT. Additionally, it is important to maintain a balance between the risk of thrombosis and hemorrhage when normalization of the PT and FII levels occurs in LAHPS cases under treatment.
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Affiliation(s)
- Kaori Fujiwara
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Junya Shimizu
- Department of Pediatrics, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | | | - Akira Shimada
- Department of Pediatric Hematology/Oncology, Okayama University Hospital, 2-5-1, Shikatacho, Kitaku, Okayama, 700-8558, Japan.
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Pilania RK, Suri D, Jindal AK, Kumar N, Sharma A, Sharma P, Guleria S, Rawat A, Ahluwalia J, Singh S. Lupus anticoagulant hypoprothrombinemia syndrome associated with systemic lupus erythematosus in children: report of two cases and systematic review of the literature. Rheumatol Int 2018; 38:1933-1940. [PMID: 30099593 DOI: 10.1007/s00296-018-4127-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022]
Abstract
We report two children with systemic lupus erythematosus (SLE) having severe bleeding manifestations and lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) along with a review of published cases of childhood SLE and LAHPS. We report clinical and laboratory profile of two children diagnosed with childhood SLE and LAHPS. We also conducted literature search to identify similar published cases and a review was performed. An 8-year-old girl had presented with fever, arthralgia, alopecia, anasarca and bleeding from multiple sites. She was diagnosed to have SLE based on laboratory investigations which showed anemia, thrombocytopenia, low complements, positive anti-nuclear antibody (ANA) and double standard DNA (dsDNA) antibodies. She was also found to have prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), positive lupus anticoagulant (LA) and low factor II levels. She was diagnosed to have SLE with LAHPS and treated with intravenous methylprednisolone, intravenous immunoglobulin and cyclophosphamide with good outcome. Patient 2 was a 7-year-old-boy who was diagnosed to have SLE when he presented with fever, anasarca, malar rash, arthritis and bleeding from skin and mucosa. Laboratory investigations revealed anemia, proteinuria, low complements, positive ANA and anti-dsDNA titre. Coagulation studies showed deranged PT and aPTT, positive LA and low factor II levels. He was diagnosed to have SLE with LAHPS and was treated with intravenous methylprednisolone and oral mycophenolate mofetil. Review of literature of cases with childhood SLE and LAHPS showed that there are 32 cases have been reported till date which have been summarized. LAHPS is an uncommonly identified cause of bleeding in patients with SLE and must be suspected while evaluating these children.
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Affiliation(s)
- Rakesh Kumar Pilania
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Deepti Suri
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Ankur Kumar Jindal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Narender Kumar
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Avinash Sharma
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Praveen Sharma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandesh Guleria
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Amit Rawat
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jasmina Ahluwalia
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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8
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Cetin Gedik K, Siddique S, Aguiar CL. Rituximab use in pediatric lupus anticoagulant hypoprothrombinemia syndrome - report of three cases and review of the literature. Lupus 2018; 27:1190-1197. [PMID: 29320972 DOI: 10.1177/0961203317751853] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lupus anticoagulant hypoprothrombinemia syndrome (LA-HPS) is a rare condition that may predispose both to thrombosis and bleeding due to positive lupus anticoagulant (LA) and factor II (FII) deficiency. It can be seen in association with infections or systemic lupus erythematosus (SLE) and may require glucocorticoids (GCs) and/or immunosuppressive medications. Pediatric LA-HPS cases in the literature and three cases that received only rituximab (RTX) for LA-HPS (in addition to GCs) at two institutions between January 2010 and June 2017 were analyzed descriptively. Pediatric LA-HPS cases (≤18 years) with bleeding or thrombotic events were included. Information obtained included demographics, presenting symptoms, diagnoses, treatments, pre-/post-treatment prothrombin time (PT)/partial thromboplastin time (PTT)/LA/FII levels, and outcomes. In addition to three LA-HPS cases identified at our institutions, as of June 2017, 37 articles reported 54 pediatric LA-HPS cases (mean age: 8 years (0.9-17 years); female/male: (2:1); viral illness 27 (50%), SLE 20 (37%), and other six (11%)). All cases had a positive LA and FII deficiency (range: 0%-40%). All cases presented with bleeding diathesis and were treated with various regimens, but there was no reported use of RTX. The purpose of this report is to describe the novel use of RTX as a steroid-sparing agent in three pediatric SLE cases and to systematically review the literature on pediatric cases of LA-HPS.
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Affiliation(s)
- K Cetin Gedik
- 1 Department of Pediatric Rheumatology, 25050 Steven and Alexandra Cohen Children's Medical Center , Lake Success, NY, USA
| | - S Siddique
- 2 Department of Pediatric Rheumatology, 25062 Hospital for Special Surgery -Weill Cornell Medical Center, New York, NY, USA
| | - C L Aguiar
- 3 Department of Pediatric Rheumatology, 20666 Children's Hospital of The King's Daughters , Norfolk, VA, USA
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9
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Lupus Anticoagulant-hypoprothrombinemia Syndrome (LAC-HPS) in Children With Systemic Lupus Erythematosus: Report of 3 Cases. J Pediatr Hematol Oncol 2017; 39:e521-e524. [PMID: 28787393 DOI: 10.1097/mph.0000000000000891] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lupus anticoagulant, also known as lupus antibody, is generally associated with thrombosis rather than bleeding events. Lupus anticoagulant-hypoprothrombinemia syndrome in children is rather rare but can lead to mild to life-threatening bleeding. Here, we report 3 cases of lupus anticoagulant-hypoprothrombinemia syndrome associated with systemic lupus erythematosus. They initially presented with mucocutaneous bleedings, and subsequently developed other symptoms fulfilling the laboratory criteria for systemic lupus erythematosus. Case 2 and 3 had significant epistaxis and intracerebral hemorrhage responded to systemic corticosteroid along with fresh frozen plasma. Three cases demonstrated acquired hypoprothrombinemia with no correction of mixing studies. Case 1 had low factor X level, which has never been reported previously. In all 3 cases, their coagulogram returned to normal level after corticosteroid treatment.
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10
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Foord A, Baca N, Buchbinder D, Mahajerin A. Lupus anticoagulant hypoprothrombinemia syndrome associated with severe thrombocytopenia in a child. Pediatr Blood Cancer 2017; 64. [PMID: 27862892 DOI: 10.1002/pbc.26357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/07/2016] [Accepted: 10/12/2016] [Indexed: 01/19/2023]
Abstract
Lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) comprises lupus anticoagulant, acquired hypoprothrombinemia, and often mild thrombocytopenia or normal platelets. It is usually associated with autoimmunity or postviral illness. We describe a case of a 10-year-old boy with oral bleeding and severe thrombocytopenia initially suggestive of immune thrombocytopenia. Secondary to bleeding, evaluation demonstrated prolonged coagulation tests and subsequently revealed the presence of lupus anticoagulant and hypoprothrombinemia, along with marked autoimmunity, suggestive of LAHPS. He was treated with intravenous immunoglobulin and hydroxychloroquine. This case report and discussion highlight the diagnostic and therapeutic challenges associated with LAHPS and coincident severe thrombocytopenia.
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Affiliation(s)
- Aimee Foord
- Hematology-Oncology Hospitalist Service, Division of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Nicole Baca
- Division of Hematology/Oncology, CHOC Children's Hospital, Orange, California
| | - David Buchbinder
- Division of Hematology/Bone Marrow Transplant, CHOC Children's Hospital, Orange, California
| | - Arash Mahajerin
- Division of Hematology, CHOC Children's Hospital, Orange, California
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11
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Abstract
Antiphospholipid syndrome (APS) is a multisystem autoimmune condition characterized by vascular thromboses associated with persistently positive antiphospholipid antibodies. There is currently a paucity of data (incidence, prevalence, thrombosis risk, and effective treatment) in pediatric APS. The purpose of this report is to review the current literature on APS in children and neonates, identify the gaps in current knowledge, and suggest avenues for studies to fill those gaps.
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12
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Sarker T, Roy S, Hollon W, Rajpurkar M. Lupus anticoagulant acquired hypoprothrombinemia syndrome in childhood: two distinct patterns and review of the literature. Haemophilia 2015; 21:754-60. [PMID: 25929557 DOI: 10.1111/hae.12669] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Lupus anticoagulant associated with acquired prothrombin deficiency also known as 'lupus anticoagulant hypoprothrombinemia syndrome' (LAHS) is an entity that is well described in adults and is usually associated with autoimmune conditions (LAHS-AI). However, in children, LAHS has unique features that are distinct from the adult type. AIMS We report two paediatric cases of LAHS, describe their distinct patterns and review the paediatric literature on LAHS. METHODS Case studies on two patients with LAHS were reviewed, details on their presentation, work up and management were extracted. A Medline search was conducted on LAHS in children between 1960 and 2014; Articles in languages other than English were excluded. RESULTS The case studies highlight the differences in the two patterns of childhood LAHS. Additionally the review of the literature reveals that there are 15 case reports and 5 case series that report 25 children with LAHS-AI, 9 case reports and 6 case series report 26 children of LAHS associated with viral infections (LAHS-VI). At presentation, all patients with LAHS-AI had positive laboratory tests for autoimmune diseases, most commonly for systemic lupus erythematosus while these tests were negative in LAHS-VI. All patients with LAHS-AI had a protracted course and needed prolonged treatment with immune-suppressive therapy while patients with LAHS-VI resolved spontaneously or needed short-term immune-modulating therapy. CONCLUSION In childhood, two distinct patterns of LAHS are observed, either associated with infection or autoimmune disease. Initial diagnostic investigations are critical to differentiating these two patterns as the prognosis and outcome for each is distinct.
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Affiliation(s)
- T Sarker
- Division of Hematology/Oncology, Carman and Ann Adams, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.,Wayne State University, Detroit, MI, USA
| | - S Roy
- Division of Hematology/Oncology, Carman and Ann Adams, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.,Wayne State University, Detroit, MI, USA
| | - W Hollon
- Wayne State University, Detroit, MI, USA
| | - M Rajpurkar
- Division of Hematology/Oncology, Carman and Ann Adams, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.,Wayne State University, Detroit, MI, USA
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13
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Mulliez SMN, De Keyser F, Verbist C, Vantilborgh A, Wijns W, Beukinga I, Devreese KMJ. Lupus anticoagulant-hypoprothrombinemia syndrome: report of two cases and review of the literature. Lupus 2014; 24:736-45. [PMID: 25391540 DOI: 10.1177/0961203314558859] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 10/10/2014] [Indexed: 11/16/2022]
Abstract
Lupus anticoagulant-hypoprothrombinemia syndrome (LA-HPS) is a rare acquired disorder caused by prothrombin antibodies. The disease is most common in the pediatric age group (<16 years), and more prevalent in women. There are well-established clinical diseases associated with LA-HPS, most notably systemic lupus erythematosus (SLE) and viral infections. The clinical manifestation of LA-HPS varies greatly in severity and it may cause severe life-threatening bleeding diathesis. LA-HPS is to be suspected when a patient presents with bleeding and a prolonged activated partial thromboplastin and prothrombin time, in combination with a lupus anticoagulant. The diagnosis is confirmed in the laboratory by identification of reduced prothrombin levels. There are no standardized recommendations for treatment of the hemorrhage associated with the syndrome; corticosteroids are used as first-line treatment. This review summarizes what is currently known about the pathogenesis, clinical features, diagnosis, treatment and prognosis of LA-HPS, and presents two case reports.
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Affiliation(s)
- S M N Mulliez
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
| | - F De Keyser
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - C Verbist
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - A Vantilborgh
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - W Wijns
- Department of Hematobiology, Erasme Hospital, Brussels, Belgium
| | - I Beukinga
- Department of Hematobiology, Erasme Hospital, Brussels, Belgium
| | - K M J Devreese
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
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Paschal RD, Neff AT. Resolution of Hypoprothrombinemia-Lupus Anticoagulant Syndrome (HLAS) after multidrug therapy with rituximab: a case report and review of the literature. Haemophilia 2012; 19:e62-5. [DOI: 10.1111/hae.12027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2012] [Indexed: 12/25/2022]
Affiliation(s)
- R. D. Paschal
- Division of Hematology and Oncology, Department of Internal Medicine; Vanderbilt University Medical Center; Nashville; TN; USA
| | - A. T. Neff
- Division of Hematology and Oncology, Department of Internal Medicine; Vanderbilt University Medical Center; Nashville; TN; USA
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15
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Mazodier K, Arnaud L, Mathian A, Costedoat-Chalumeau N, Haroche J, Frances C, Harlé JR, Pernod G, Lespessailles E, Gaudin P, Charlanne H, Hachulla E, Niaudet P, Piette JC, Amoura Z. Lupus anticoagulant-hypoprothrombinemia syndrome: report of 8 cases and review of the literature. Medicine (Baltimore) 2012; 91:251-260. [PMID: 22932789 DOI: 10.1097/md.0b013e31826b971f] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The lupus anticoagulant-hypoprothrombinemia syndrome (LAHS)--the association of acquired factor II deficiency and lupus anticoagulant--is a rare disease drastically different from antiphospholipid syndrome in that it may cause predisposition not only to thrombosis but also to severe bleeding. We performed a retrospective study of 8 patients with LAHS referred to 6 French tertiary care centers between January 2003 and February 2011, and a literature review retrieving all related articles published between 1960 and April 2011. Including our 8 new cases, LAHS has been reported in 74 cases. The disease mostly occurs in young adults, with a female to male sex ratio of 1.4. Associated conditions mostly include autoimmune diseases such as systemic lupus erythematosus and infectious diseases. Bleeding is a frequent feature (89% of cases), while arterial and/or venous thrombosis is less common (13%). Factor II level is severely decreased at diagnosis (median value, 11%; range, 1%-40%). LAHS associated with autoimmune diseases is more persistent than LAHS associated with infection, and hemorrhagic complications are more common. Corticosteroids should be considered the first-line treatment, but the thrombotic risk strongly increases during treatment because of the improvement of factor II level. Despite the fact that 50% of patients develop severe bleeding, the mortality rate is <5%, after a median follow-up of 13 months (range, 0.5-252 mo). LAHS associated with autoimmune diseases should be diagnosed and managed carefully because the disease is persistent and severe hemorrhagic complications are common.
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Affiliation(s)
- Karin Mazodier
- From the Service de Médecine Interne (KM, JRH), Hôpital La Conception, Marseille; Service de Médecine Interne (LA, AM, NCC, JH, CF, JCP, ZA), Hôpital Pitié-Salpêtrière and Université Pierre et Marie Curie, Paris; Laboratoire d'Hématologie (GP), CHU de Grenoble, Grenoble; Service de Rhumatologie (EL), CHR d'Orléans, Orléans; Service de Rhumatologie (PG), CHUG Hôpital Sud, Grenoble; Service de Médecine Interne (HC, EH), Hôpital Claude Huriez, Lille; and Service de Néphro-Pédiatrie (PN), Hôpital Necker, Paris; France
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16
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Avcin T, Silverman ED. Antiphospholipid antibodies in pediatric systemic lupus erythematosus and the antiphospholipid syndrome. Lupus 2008; 16:627-33. [PMID: 17711899 DOI: 10.1177/0961203307079036] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The antiphospholipid syndrome (APS) is recognized increasingly as the most common acquired hypercoagulation state of autoimmune etiology and may occur as an isolated clinical entity (primary APS) or in association with an underlying systemic disease, particularly systemic lupus erythematosus (SLE). The major differences between pediatric and adult APS include absence of common acquired risk factors for thrombosis, absence of pregnancy-related morbidity, increased incidence of infection-induced antibodies, differences in cut-off values for determination of aPL and specific factors regarding long-term therapy in children. APS in children has been largely reported in patients with arterial or venous thromboses and less frequently in association with neurological or hematological manifestations. The presence of aPL in pediatric SLE can modify the disease expression and may be an important predictor of the development of irreversible organ damage. Two recently established international registries of neonates and children with APS provide a good opportunity to conduct large, prospective studies on the clinical significance of aPL and long-term outcome of pediatric APS.
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Affiliation(s)
- T Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Center Ljubljana, Ljubljana, Slovenia.
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17
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Mizumoto H, Maihara T, Hiejima E, Shiota M, Hata A, Seto S, Atsumi T, Koike T, Hata D. Transient antiphospholipid antibodies associated with acute infections in children: a report of three cases and a review of the literature. Eur J Pediatr 2006; 165:484-8. [PMID: 16552544 DOI: 10.1007/s00431-006-0117-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Revised: 02/13/2006] [Accepted: 02/14/2006] [Indexed: 10/24/2022]
Abstract
We describe two previously healthy children who had multiple ecchymoses several days after acute infection. In both cases, the prothrombin time (PT) and the activated partial thromboplastin time (APTT) were prolonged. Further examinations revealed the presence of lupus anticoagulant (LA), phosphatidylserine-dependent antiprothrombin antibodies (aPS/PT), and low serum complement. In both cases, we confirmed the presence of a serum immune complex. The patients' symptoms improved spontaneously within 1 week, and all laboratory data normalized within several months. We also describe another asymptomatic case positive for LA and aPS/PT presumably associated with cytomegalovirus infection. The prevalence of transient antiphospholipid antibodies associated with viral infections in children must be much higher than we expected. We have to take it into consideration when we see abnormal coagulation results, but the occurrence of significant bleeding symptoms is rare.
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Affiliation(s)
- H Mizumoto
- Department of Pediatrics, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan
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18
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Rodriguez V, Reed AM, Kuntz NL, Anderson PM, Smithson WA, Nichols WL. Antiphospholipid syndrome with catastrophic bleeding and recurrent ischemic strokes as initial presentation of systemic lupus erythematosus. J Pediatr Hematol Oncol 2005; 27:403-7. [PMID: 16012334 DOI: 10.1097/01.mph.0000174565.91343.43] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bleeding is a rare manifestation of lupus anticoagulant-antiphospholipid syndrome unless associated with coagulation factor deficiency, thrombocytopenia, or intrinsic vascular defect. The authors report the clinical and laboratory findings in a 16-year-old boy with potent lupus anticoagulant who initially presented with recurrent epistaxis, hematuria, and gastrointestinal bleeding. Lupus anticoagulant potently inhibited assay systems for coagulation factors, but levels of factors II, IX, and XI appeared to be decreased (2-5% of mean normal levels). Within 2 weeks after diagnosis, spontaneous subdural hematomas developed. During hemostatic therapy, including plasmapheresis and infusions of recombinant activated factor VII and activated prothrombin complex concentrate, an ischemic stroke developed. Subsequent multifocal recurrent ischemic strokes developed despite immunosuppression. This case shows that lupus anticoagulant or antiphospholipid antibodies can cause both hemorrhagic and thrombotic complications in the same patient and may, in some patients, have multiple target antigens (eg, coagulation factors II, IX, XI).
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Affiliation(s)
- Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, MN 55905, USA.
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Reus S, Abad S, Bustos S, Concepción L. Trombosis y hemorragia muscular espontánea secuenciales en el síndrome antifosfolipídico primario. Med Clin (Barc) 2004; 122:677. [PMID: 15153350 DOI: 10.1016/s0025-7753(04)74348-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Baca V, Montiel G, Meillón L, Pizzuto J, Catalán T, Juan-Shum L, Nieva B. Diagnosis of lupus anticoagulant in the lupus anticoagulant-hypoprothrombinemia syndrome: report of two cases and review of the literature. Am J Hematol 2002; 71:200-7. [PMID: 12410576 DOI: 10.1002/ajh.10194] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We report a severe hemorrhagic disorder in two pediatric patients with lupus anticoagulant (LA) associated to acquired factor II (prothrombin) deficiency. In both patients, hemorrhagic symptoms resolved after corticosteroid therapy. Serial coagulation studies showed that Staclot LA assay was more sensitive than DVVconfirm and Staclot PNP tests to confirm the presence of LA when associated with severe factor II deficiency. Both patients had non-neutralizing anti-prothrombin antibodies and their titers inversely correlated with factor II activity (r = -1.0, P < 0.0001). Associated findings in these patients included positive immunologic tests for systemic lupus erythematosus, a positive anti-cardiolipin antibody, and anti-beta(2) GPI antibodies in one case. Our findings point out the difficulty in diagnosing LA associated with acquired factor II deficiency and suggest that, in confirmation of its phospholipid dependency, the inclusion of a source of normal human plasma in the test sequence to correct for any factor deficiency and a confirmatory step utilizing hexagonal (II) phase phospholipids may be crucial to the diagnosis of LA in some patients with LA-hypoprothrombinemia syndrome.
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Affiliation(s)
- Vicente Baca
- Department of Immunology and Rheumatology, Hospital de Pediatría, Centro Medico Nacional Siglo XXI, IMSS, Av. Cuauhtémoc No. 330, Col. Doctores, 06720 México D.F., Mexico.
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