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Vélez-Páez JL, Carranza-Jara JM, Almeida-Posso DC, Witkin SS, de Almeida-Neto C. Oligosymptomatic infection by SARS-Cov-2 in catastrophic antiphospholipid syndrome, a singular coincidence: a case report in an Ecuadorian hospital. Hematol Transfus Cell Ther 2024; 46:316-320. [PMID: 37455218 PMCID: PMC11221254 DOI: 10.1016/j.htct.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/17/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023] Open
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2
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Rahman A, Nathani M, Malekan M. The Relentless Recurrence of Diffuse Alveolar Hemorrhage in Catastrophic Antiphospholipid Syndrome and Lupus: A Therapeutic Challenge. Cureus 2024; 16:e62635. [PMID: 38898898 PMCID: PMC11186662 DOI: 10.7759/cureus.62635] [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: 06/18/2024] [Indexed: 06/21/2024] Open
Abstract
Diffuse alveolar hemorrhage (DAH), a rare complication of coexisting antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE), poses significant diagnostic and therapeutic challenges, especially with recurrent episodes. We present a 27-year-old male with catastrophic APS and SLE who experienced acute respiratory failure and hemoptysis due to DAH. Despite aggressive therapy with immunosuppressants, plasma exchange, and anticoagulation, he had recurrent DAH episodes requiring repeated admissions. Early recognition, multidisciplinary management, and utilization of effective targeted therapies, such as intravenous immunoglobulin, in refractory cases are crucial for improving outcomes in this challenging complication.
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Affiliation(s)
- Aruni Rahman
- Internal Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
| | - Mashal Nathani
- Internal Medicine, Medical University of the Americas, Charlestown, KNA
| | - Michael Malekan
- Rheumatology, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
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3
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Park JH, Siddiqui N, Hrebec WK, Szymanski TJ, Uribe-Marquez S, Miletic KG, Krishnan S. Management of Anticoagulation and Antifibrinolytics in Catastrophic Antiphospholipid Syndrome. Semin Cardiothorac Vasc Anesth 2024:10892532241249782. [PMID: 38705843 DOI: 10.1177/10892532241249782] [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: 05/07/2024]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder that presents with hypercoagulability and results in a lab artifact of prolonged PTT. The most severe form is catastrophic antiphospholipid antibody syndrome (CAPS), which manifests as rapidly progressing thromboses in multiple organ systems leading to multi-organ ischemia. The mainstay management CAPS is anticoagulation and systemic corticosteroids. Antifibrinolytic agents have previously been thought to be relatively contraindicated in CAPS due to the pro-thrombotic nature of the disease; the complex coagulation profile of CAPS can make it difficult to assess the risks and benefits of antifibrinolytic therapy. Also, should a patient with CAPS require cardiopulmonary bypass (CPB) for surgery, it poses a unique challenge in providing appropriate anticoagulation in the setting of prolonged ACT. We present a case of a 32-year-old postpartum female with CAPS requiring heart transplant who safely received intraoperative antifibrinolytic therapy and was successfully anticoagulated during CPB after perioperative plasmapheresis.
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Affiliation(s)
- Jee Ha Park
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nazia Siddiqui
- Department of Anesthesiology, Trinity Health Oakland Hospital, Pontiac, MI, USA
- Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, USA
| | - William K Hrebec
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
| | | | | | - Kyle G Miletic
- Department of Cardiothoracic Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Sandeep Krishnan
- Department of Anesthesiology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Anesthesiology, Trinity Health Oakland Hospital, Pontiac, MI, USA
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4
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Desai SB, Ahdoot R, Malik F, Obert M, Hanna R. New guidelines and therapeutic updates for the management of lupus nephritis. Curr Opin Nephrol Hypertens 2024; 33:344-353. [PMID: 38334499 DOI: 10.1097/mnh.0000000000000969] [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: 02/10/2024]
Abstract
PURPOSE OF REVIEW Systemic lupus erythematosus (SLE) can be a devastating condition, striking young patients often in their prime reproductive years. Lupus nephritis is a common and serious complication occurring in roughly 50% of SLE cases, indicating a high likelihood of disease progression, morbidity, and mortality. As the early trials of steroid therapy, and later cyclophosphamide (CYC), therapeutic changes had been stagnant. Then came the introduction of mycophenolate mofetil (MMF) in the 2000s. After the Aspreva Lupus Management Study, there had been a dearth of trials showing positive therapy results. Since 2020, new studies have emerged for lupus nephritis involving the use of anti-BLYS agents, novel calcineurin inhibitors, CD20 blockade, and antiinterferon agents. Nephrology and rheumatology society guidelines in the United States and across the world are still catching up. RECENT FINDINGS Although therapeutic guidelines are being developed, updates that have come through have focused on improved diagnostic and monitoring guidelines. One theme is the recommendation of increasingly tight proteinuria control and firmer guidelines for the rapid induction of remission. The reality of multitarget therapy and the expectation of rapid induction for a more complete remission are being widely recognized. SUMMARY The need for more complete and more rapid induction and control of lupus nephritis is undisputed according to the evidence and guidelines, and the medications to achieve this are growing at a rate not seen over the prior two decades. What remains is a stepwise approach to recognize how to best optimize therapy. Based on available evidence, an algorithm for induction and maintenance treatment of lupus nephritis used by the University of California Irvine Lupus Nephritis clinic, is recommended.
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Affiliation(s)
| | - Rebecca Ahdoot
- Division of Nephrology, Department of Medicine, University of California Irvine, Orange, California, USA
| | - Fatima Malik
- Division of Nephrology, Department of Medicine, University of California Irvine, Orange, California, USA
| | | | - Ramy Hanna
- Division of Nephrology, Department of Medicine, University of California Irvine, Orange, California, USA
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5
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Wiegley N, Arora S, Norouzi S, Rovin B. A Comprehensive and Practical Approach to the Management of Lupus Nephritis in the Current Era. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:234-245. [PMID: 39004463 DOI: 10.1053/j.akdh.2023.11.003] [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: 07/16/2023] [Revised: 09/27/2023] [Accepted: 11/29/2023] [Indexed: 07/16/2024]
Abstract
Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE) and is one of the leading causes of morbidity and mortality in patients with SLE. It is estimated that up to 60% of individuals with SLE will develop LN, which can manifest at any stage of a patient's life; however, it commonly emerges early in the course of SLE and tends to exhibit a more aggressive phenotype in men compared to women. Black and Hispanic patients are more likely to progress to kidney failure than white patients. LN is characterized by kidney inflammation and chronic parenchymal damage, leading to impaired kidney function and potential progression to kidney failure. This article provides a comprehensive overview of the epidemiology, pathogenesis, clinical presentation, diagnosis, and management of LN, highlighting the importance of early recognition and treatment of LN to prevent progressive, irreversible kidney damage and improve patient outcomes. Additionally, the article discusses current and emerging therapies for LN, including traditional immunosuppressive agents, biological agents, and novel therapies targeting specific pathways involved in LN pathogenesis, to provide a practical guide for clinicians in properly diagnosing LN and determining a patient-centered treatment plan.
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Affiliation(s)
- Nasim Wiegley
- Division of Nephrology, University of California, Davis School of Medicine, Sacramento, CA.
| | - Swati Arora
- Division of Nephrology, Allegheny Health Network, Pittsburgh, PA
| | - Sayna Norouzi
- Division of Nephrology, Loma Linda University Medical Center, Loma Linda, CA
| | - Brad Rovin
- Division of Nephrology, Ohio State University, Columbus, OH
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6
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Dong Q, Yin J, Su H, Ni Q. Primary catastrophic antiphospholipid syndrome in children with midbrain infarction: a case report. Front Pediatr 2024; 12:1370843. [PMID: 38650992 PMCID: PMC11033311 DOI: 10.3389/fped.2024.1370843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024] Open
Abstract
Background Catastrophic antiphospholipid syndrome (CAPS) is a multi-system autoimmune disease characterized by extensive thrombosis. Pediatric CAPS is extremely rare and associated with a high mortality rate, especially when midbrain infarction is involved. Hence, early diagnosis and prompt initiation of appropriate treatment for CAPS complicated by midbrain infarction are of utmost importance in achieving favorable outcomes. Case presentation In this report, we present the case of a 14-year-old girl who presented with neurological symptoms and digestive system infection and was initially diagnosed with an "intracranial infection". After a series of rigorous diagnostic procedures, the patient was ultimately diagnosed with primary CAPS and was immediately transferred to the intensive care unit where she was treated with anticoagulation, glucocorticoids, intravenous immunoglobulin (IVIG) therapy, and multiple plasma infusions. Twenty-seven days after admission, the patient's condition improved with standardized treatment, and she was discharged and followed up regularly. Conclusion This case report provides a description of the clinical features observed in a pediatric patient with CAPS and concurrent midbrain infarction, highlighting the crucial role of early diagnosis and timely treatment in influencing patient prognosis.
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Affiliation(s)
- Qinghua Dong
- The Second Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Jianyun Yin
- The Second Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Hang Su
- The Second Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Qian Ni
- Pediatric Respiratory Medicine, Lanzhou University Second Hospital, Lanzhou, China
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Jacobs L, Wauters N, Lablad Y, Morelle J, Taghavi M. Diagnosis and Management of Catastrophic Antiphospholipid Syndrome and the Potential Impact of the 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria. Antibodies (Basel) 2024; 13:21. [PMID: 38534211 DOI: 10.3390/antib13010021] [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: 12/31/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/28/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare and life-threatening condition characterized by the persistence of antiphospholipid antibodies and occurrence of multiple vascular occlusive events. CAPS currently remains a diagnostic challenge and requires urgent treatment. The diagnosis of CAPS is made difficult by classification criteria used as diagnostic criteria in clinical practice, knowledge derived from retrospective data and case reports, confounding clinical and biological features, and its rapid onset and mortality. The absence of prospective studies of CAPS limits the strength of evidence for guideline treatment protocols. This comprehensive review summarizes the current understanding of the disease, and discusses how the 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria impact the definition and therapeutic management of CAPS, which is considered the most severe form of APS. The correct integration of 2023 ACR/EULAR APS classification criteria is poised to facilitate CAPS diagnosis, particularly in critical situations, offering a promising avenue for improved outcomes.
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Affiliation(s)
- Lucas Jacobs
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Nephrology and Dialysis Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Internal Medicine Department, Tivoli University Hospital, Université Libre de Bruxelles, 7100 La Louvière, Belgium
| | - Nader Wauters
- Internal Medicine Department, Tivoli University Hospital, Université Libre de Bruxelles, 7100 La Louvière, Belgium
| | - Yahya Lablad
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
| | - Johann Morelle
- Division of Nephrology, Namur University Hospitals (CHU UCL Namur), 5000 Namur, Belgium
| | - Maxime Taghavi
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Nephrology and Dialysis Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
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8
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Wei LK, Sule AA. Challenges in Treating Extensive Deep Vein Thrombosis with Severe Thrombocytopenia in Patients with Antiphospholipid Syndrome-A Follow-up of 2 Years. Int J Angiol 2024; 33:66-69. [PMID: 38352633 PMCID: PMC10861292 DOI: 10.1055/s-0039-1693996] [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] Open
Abstract
Thrombocytopenia is one of the most common manifestations of antiphospholipid syndrome (APS). There is little evidence or definitive guidelines regarding the treatment of APS with thrombocytopenia. We describe a patient with APS and moderate-to-severe thrombocytopenia and the challenges of balancing anticoagulation with thrombocytopenia. A 19-year-old male patient presented with right lower limb swelling to the emergency department with a history of gradually worsening right leg swelling for 1 week and was diagnosed with right leg proximal deep vein thrombosis. Ultrasound Doppler of the right lower limb revealed complete venous thrombosis from the level of the popliteal vein to the distal superficial femoral vein. Subsequently, he was found to have triple-positive APS and moderate-to-severe immune thrombocytopenia, with a platelet count nadir of 31 × 10 to the ninth power/L. He was started on anticoagulation with warfarin. The severe thrombocytopenia was not treated with immunosuppressants and the platelets fluctuated in the range of moderate-to-severe thrombocytopenia but did not develop any rethrombotic or bleeding events. His platelets varied from 31 × 10 to the ninth power/L to 106 × 10 to the ninth power/L. This case report demonstrates that it may be safe to hold off treatment for thrombocytopenia in APS, even in cases of severe thrombocytopenia. Treatment with immunosuppressants may be instituted only when platelet levels fall below 20 × 10 to the ninth power/L or when there is clinically significant bleeding, as in primary immune thrombocytopenia.
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Affiliation(s)
- Lee Kai Wei
- Student Assistantship Programme, Lee Kong Chian School of Medicine, Singapore
| | - Ashish Anil Sule
- Department of General Medicine, Subspecialty of Vascular Medicine and Hypertension, Tan Tock Seng Hospital, Singapore
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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10
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Hussein G, Liu B, Yadav SK, Warsame M, Jamil R, Surani SR, Khan SA. Plasmapheresis in the ICU. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2152. [PMID: 38138254 PMCID: PMC10744423 DOI: 10.3390/medicina59122152] [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: 10/19/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023]
Abstract
Therapeutic plasma exchange (TPE) is a treatment paradigm used to remove harmful molecules from the body. In short, it is a technique that employs a process that functions partially outside the body and involves the replacement of the patient's plasma. It has been used in the ICU for a number of different disease states, for some as a first-line treatment modality and for others as a type of salvage therapy. This paper provides a brief review of the principles, current applications, and potential future directions of TPE in critical care settings.
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Affiliation(s)
- Guleid Hussein
- Mayo Clinic Health System, Mankato, MN 56001, USA; (B.L.); (S.K.Y.); (M.W.)
| | - Bolun Liu
- Mayo Clinic Health System, Mankato, MN 56001, USA; (B.L.); (S.K.Y.); (M.W.)
| | - Sumeet K. Yadav
- Mayo Clinic Health System, Mankato, MN 56001, USA; (B.L.); (S.K.Y.); (M.W.)
| | - Mohamed Warsame
- Mayo Clinic Health System, Mankato, MN 56001, USA; (B.L.); (S.K.Y.); (M.W.)
| | - Ramsha Jamil
- Sindh Medical College, Jinnah Sindh Medical University, Karachi 75510, Pakistan;
| | - Salim R. Surani
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Medicine and Pharmacology, Texas A&M University, College Station, TX 77843, USA
| | - Syed A. Khan
- Mayo Clinic Health System, Mankato, MN 56001, USA; (B.L.); (S.K.Y.); (M.W.)
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11
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Krittanawong C, Khawaja M, Tamis‐Holland JE, Girotra S, Rao SV. Acute Myocardial Infarction: Etiologies and Mimickers in Young Patients. J Am Heart Assoc 2023; 12:e029971. [PMID: 37724944 PMCID: PMC10547302 DOI: 10.1161/jaha.123.029971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Acute myocardial infarction is an important cause of death worldwide. While it often affects patients of older age, acute myocardial infarction is garnering more attention as a significant cause of morbidity and mortality among young patients (<45 years of age). More specifically, there is a focus on recognizing the unique etiologies for myocardial infarction in these younger patients as nonatherosclerotic etiologies occur more frequently in this population. As such, there is a potential for delayed and inaccurate diagnoses and treatments that can carry serious clinical implications. The understanding of acute myocardial infarction manifestations in young patients is evolving, but there remains a significant need for better strategies to rapidly diagnose, risk stratify, and manage such patients. This comprehensive review explores the various etiologies for acute myocardial infarction in young adults and outlines the approach to efficient diagnosis and management for these unique patient phenotypes.
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Affiliation(s)
| | - Muzamil Khawaja
- Cardiology DivisionEmory University School of MedicineAtlantaGAUSA
| | | | - Saket Girotra
- Division of Cardiovascular MedicineUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Sunil V. Rao
- New York University Langone Health SystemNew YorkNYUSA
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12
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Bangolo A, Sagireddy S, Mahamadeen S, Hasta F, Reddy SA, Naz A, Ranganatha R, Ricketts C, Muppalla P, Veliginti S, Arana G, Sathyarajan DT, Singh S, Shetty T, Bhardwaj K, Hashemy S, Duran RL, Kim SH, Hipolito CM, Yoon K, Patel V, Alshimari A, Inban P, Yasmeen S, Weissman S. A Rare Case of Refractory Catastrophic Antiphospholipid Syndrome Successfully Treated With Rituximab and Plasma Exchange. J Community Hosp Intern Med Perspect 2023; 13:79-82. [PMID: 37877050 PMCID: PMC10593160 DOI: 10.55729/2000-9666.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 10/26/2023] Open
Abstract
A small subset of patients with antiphospholipid syndrome (APS) may develop widespread thrombotic disease with organ damage, referred to as catastrophic APS (CAPS) that is associated with a high mortality. Medical therapy typically involves a combination of anticoagulation, systemic glucocorticoids, plasmapheresis, and intravenous immune globulin (IVIG). There is currently no consensus for the management of refractory cases of CAPS. However, monoclonal antibodies such as rituximab and eculizumab have shown some benefits. Herein, we present a 29-year-old female with previous pulmonary embolism who presented with necrotic left toes and was eventually diagnosed with refractory CAPS, successfully treated with Plasmapheresis and Rituximab. With this case report, we hope to encourage the usage of Rituximab in the management of CAPS.
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Affiliation(s)
- Ayrton Bangolo
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sowmya Sagireddy
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sarah Mahamadeen
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Felicia Hasta
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sadhu A. Reddy
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Afshan Naz
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Ravishankar Ranganatha
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Cleveland Ricketts
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Padmavathi Muppalla
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Swathi Veliginti
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Georgemar Arana
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Dily T. Sathyarajan
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sachin Singh
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Tanvi Shetty
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Kshitij Bhardwaj
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sayed Hashemy
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Roberto L. Duran
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Sung H. Kim
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Candice M. Hipolito
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Kibo Yoon
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Vrusha Patel
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Aseel Alshimari
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Pugazhendi Inban
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Saaniya Yasmeen
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
| | - Simcha Weissman
- Department of Internal Medicine, Hackensack University Medical Center/Palisades Medical Center, North Bergen, NJ,
USA
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Abstract
Antiphospholipid syndrome (APS) is a thrombo-inflammatory disease propelled by circulating autoantibodies that recognize cell surface phospholipids and phospholipid binding proteins. The result is an increased risk of thrombotic events, pregnancy morbidity, and various other autoimmune and inflammatory complications. Although antiphospholipid syndrome was first recognized in patients with lupus, the stand alone presentation of antiphospholipid syndrome is at least equally common. Overall, the diagnosis appears to affect at least one in 2000 people. Studies of antiphospholipid syndrome pathogenesis have long focused on logical candidates such as coagulation factors, endothelial cells, and platelets. Recent work has shed light on additional potential therapeutic targets within the innate immune system, including the complement system and neutrophil extracellular traps. Vitamin K antagonists remain the mainstay of treatment for most patients with thrombotic antiphospholipid syndrome and, based on current data, appear superior to the more targeted direct oral anticoagulants. The potential role of immunomodulatory treatments in antiphospholipid syndrome management is receiving increased attention. As for many systemic autoimmune diseases, the most important future direction is to more precisely identify mechanistic drivers of disease heterogeneity in pursuit of unlocking personalized and proactive treatments for patients.
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Affiliation(s)
- Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas L Ortel
- Division of Hematology, Departments of Medicine and Pathology, Duke University, Durham, North Carolina, USA
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Lam K, Selim M. An Unusual Case of Catastrophic Antiphospholipid Syndrome in an Elderly Man. Cureus 2023; 15:e34810. [PMID: 36915843 PMCID: PMC10008068 DOI: 10.7759/cureus.34810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/11/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a condition in which the body produces antiphospholipid antibodies, resulting in arterial and venous thrombosis. Catastrophic antiphospholipid syndrome (CAPS) is a rare APS subtype characterized by acute thrombotic microangiography. Antiphospholipid antibodies cause thrombosis through activating and inhibiting properties. CAPS is caused by conditions or factors that trigger the production of antiphospholipid antibodies: genetics that increases the risk of antiphospholipid antibody-associated thrombosis, infection, surgery, medications, and malignancy. We present a unique case of CAPS in a 63-year-old male patient.
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Affiliation(s)
- Kayla Lam
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
| | - Mohammad Selim
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
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15
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Furmańczyk-Zawiska A, Bułło-Piontecka B, Komorniczak M, Dębska-Ślizień A, Augustyniak-Bartosik H, Durlik M. Antiphospholipid Syndrome in Renal Allograft Recipients-A Long-Term Multicenter Analysis. J Clin Med 2023; 12:jcm12020667. [PMID: 36675596 PMCID: PMC9864673 DOI: 10.3390/jcm12020667] [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] [Received: 10/31/2022] [Revised: 01/03/2023] [Accepted: 01/07/2023] [Indexed: 01/18/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a devastating autoimmune disease and in renal transplant recipients may result in allograft thrombosis or in extra-renal manifestation, mostly venous thromboembolism. There are many non- and immune risk factors affecting renal allograft in recipients with APS. However, renal allograft outcome in recipients with APS without APS nephropathy remains unknown. Aim: The aim of the study was to assess renal allograft function and survival in recipients with APS. Methods: Retrospective, multicenter study included 19 adult renal recipients with definite APS (primary or lupus-related) from three Polish transplant centers. Renal allograft function was assessed using serum creatinine concentration (SCr1) at 3rd month post-transplant and at the end of the observation (SCr2) and glomerular filtration rate (GFR) was estimated based on modification of diet in renal disease (MDRD) formula. General linear model was used to assess 12 month GFR change over time. Kaplan-Meier curves and restricted mean survival time were used for allograft survival. Matched control group consisted of 21 stable renal recipients without history of thrombosis and without anticoagulation/antiplatelet treatment. Results: The study group differs in induction therapy (p = 0.019), high-urgency procedure (p = 0.04), proteinuria (p = 0.0058), primary disease (lupus) (p < 0.0001), re-transplantation in primary APS (p = 0.0046) and shorter time since engraftment to SCr2 (p = 0.016). Primary APS was more often diagnosed post-transplant (p = 0.0005). Allograft biopsy revealed thrombotic microangiopathy (TMA) with acute rejection (AR) or isolated AR vs AR or chronic rejection in controls but did not reach significance (p = 0.054). Renal allograft function was inferior in the study group but did not reach significance: mean SCr2 (mg/dL) was 2.18 ± 1.41 and 1.5 ± 0.68 in controls, respectively, p = 0.27; mean GFR2 (ml/min/1.73m2) was 39.9 ± 20.83 and 51.23 ± 19.03, respectively, p = 0.102. Renal allograft duration was inferior in patients with APS and was (in years) 11.22 ± 1.44 vs. 14.36 ± 0.42, respectively, p = 0.037, in patients with primary APS (p = 0.021), in patients with APS diagnosed post-transplant (p = 0.012) but not in lupus-related APS (p = ns). Fifteen year renal allograft survival was inferior in APS vs. controls (73,86% vs. 90.48%, respectively, p = 0.049). Conclusions: Recipients with APS are at higher risk for allograft loss due to immune and non-immune causes. Renal allograft survival was inferior in recipients with APS and renal function remains impaired but stable.
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Affiliation(s)
- Agnieszka Furmańczyk-Zawiska
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
- Correspondence:
| | - Barbara Bułło-Piontecka
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Dębinki 7, 80-952 Gdańsk, Poland
| | - Michał Komorniczak
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Dębinki 7, 80-952 Gdańsk, Poland
| | - Alicja Dębska-Ślizień
- Department of Nephrology, Transplantology and Internal Diseases, Medical University of Gdańsk, Dębinki 7, 80-952 Gdańsk, Poland
| | - Hanna Augustyniak-Bartosik
- Department of Nephrology and Transplant Medicine, Medical University of Wrocław, Borowska 213, 50-556 Wrocław, Poland
| | - Magdalena Durlik
- Department of Transplant Medicine, Nephrology and Internal Diseases, Medical University of Warsaw, Nowogrodzka 59, 02-006 Warsaw, Poland
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Marinho A, Delgado Alves J, Fortuna J, Faria R, Almeida I, Alves G, Araújo Correia J, Campar A, Brandão M, Crespo J, Marado D, Matos-Costa J, Oliveira S, Salvador F, Santos L, Silva F, Fernandes M, Vasconcelos C. Biological therapy in systemic lupus erythematosus, antiphospholipid syndrome, and Sjögren's syndrome: evidence- and practice-based guidance. Front Immunol 2023; 14:1117699. [PMID: 37138867 PMCID: PMC10150407 DOI: 10.3389/fimmu.2023.1117699] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
Systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and Sjögren's syndrome (SS) are heterogeneous autoimmune diseases. Severe manifestations and refractory/intolerance to conventional immunosuppressants demand other options, namely biological drugs, and small molecules. We aimed to define evidence and practice-based guidance for the off-label use of biologics in SLE, APS, and SS. Recommendations were made by an independent expert panel, following a comprehensive literature review and two consensus rounds. The panel included 17 internal medicine experts with recognized practice in autoimmune disease management. The literature review was systematic from 2014 until 2019 and later updated by cross-reference checking and experts' input until 2021. Preliminary recommendations were drafted by working groups for each disease. A revision meeting with all experts anticipated the consensus meeting held in June 2021. All experts voted (agree, disagree, neither agree nor disagree) during two rounds, and recommendations with at least 75% agreement were approved. A total of 32 final recommendations (20 for SLE treatment, 5 for APS, and 7 for SS) were approved by the experts. These recommendations consider organ involvement, manifestations, severity, and response to previous treatments. In these three autoimmune diseases, most recommendations refer to rituximab, which aligns with the higher number of studies and clinical experience with this biological agent. Belimumab sequential treatment after rituximab may also be used in severe cases of SLE and SS. Second-line therapy with baricitinib, bortezomib, eculizumab, secukinumab, or tocilizumab can be considered in SLE-specific manifestations. These evidence and practice-based recommendations may support treatment decision and, ultimately, improve the outcome of patients living with SLE, APS, or SS.
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Affiliation(s)
- António Marinho
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- *Correspondence: António Marinho,
| | - José Delgado Alves
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
- Immune Response and Vascular Disease Unit - iNOVA4Health, NOVA Medical School, Lisboa, Portugal
| | - Jorge Fortuna
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Raquel Faria
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Isabel Almeida
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Glória Alves
- Serviço de Medicina Interna, Hospital da Senhora da Oliveira - Centro Hospitalar Alto Ave, Guimarães, Portugal
| | - João Araújo Correia
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
- Serviço de Medicina Interna, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Campar
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Mariana Brandão
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Jorge Crespo
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Daniela Marado
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - João Matos-Costa
- Serviço de Medicina Interna, Hospital Distrital de Santarém, Santarém, Portugal
| | - Susana Oliveira
- Systemic Autoimmune Diseases Unit, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Fernando Salvador
- Unidade de Doenças Autoimunes, Serviço de Medicina Interna, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Lelita Santos
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
- Linha de Investigação Clínica e Interdisciplinar em Meio Ambiente, Genética e Oncobiologia (CIMAGO), Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal
| | - Fátima Silva
- Serviço de Medicina Interna, Departamento de Medicina, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Milene Fernandes
- Real-World Evidence & Late Phase, CTI Clinical Trial & Consulting Services Unipessoal Lda, Lisboa, Portugal
| | - Carlos Vasconcelos
- Unidade de Imunologia Clínica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- UMIB - Unidade Multidisciplinar de Investigação Biomédica, ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
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Oredegbe AA, Robledo FMS, Hongalgi K, Faddoul G, Mehta S. Bilateral adrenal hemorrhage: A rare presentation of catastrophic anti-phospholipid syndrome. Am J Med Sci 2023; 365:104-108. [PMID: 36030897 DOI: 10.1016/j.amjms.2022.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/06/2022] [Accepted: 08/19/2022] [Indexed: 01/04/2023]
Abstract
Catastrophic anti-phospholipid syndrome (CAPS) is characterized by microvascular thrombosis in multiple sites leading to multi-organ damage. It is a rare and fatal complication of antiphospholipid syndrome (APS). We present a rare case of CAPS that presented with bilateral (b/l) adrenal hemorrhage making the diagnosis challenging in this otherwise rare disease. A 51-year-old female was initially admitted with abdominal pain and found to have bilateral adrenal hemorrhage. Patient had a fulminant disease course in which she had thrombotic manifestations involving multiple organ systems. This case was especially challenging as the patient's bilateral adrenal hemorrhage was the first manifestation of CAPS; the diagnosis of APS had to be made while treatment for presumed CAPS was emergently commenced for this life-threatening disease. Key to managing this condition is having a high index of suspicion for the diagnosis in patients presenting with multi-organ failure and multiple thromboses and hemorrhage.
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Affiliation(s)
| | | | | | | | - Swati Mehta
- Albany Medical Center, Albany, New York, USA.
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18
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The Presence of Antineutrophil Cytoplasmic Antibodies and Antiphospholipid Antibodies in Patients with Severe Acute Respiratory Syndrome Coronavirus 2: A Case-Control Study among Sudanese Patients. Interdiscip Perspect Infect Dis 2022; 2022:6511198. [PMID: 36570594 PMCID: PMC9780010 DOI: 10.1155/2022/6511198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/31/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022] Open
Abstract
Patients infected with COVID-19 are at an increased risk for thrombosis, suggesting a possible role of COVID-19 in the induction of coagulopathy. This study aimed to investigate the presence of prothrombotic antineutrophil cytoplasmic antibodies (ANCA) and antiphospholipid antibodies (aPLs) in the course of COVID-19 infection and to correlate these markers with severity and fatality, suggesting that COVID-19-induced autoimmune thrombosis is a possible axis in the inflammatory circuit of this infection. To investigate this, we conducted a case-control study which included patients with a positive reverse transcription-polymerase chain reaction (RT-PCR) test of COVID-19 and a control group with negative COVID-19 PCR and antibody (IgG-IgM and IgA nucleoprotein) ELISA results. An indirect immunofluorescence assay using granulocyte biochips (Aesku slides from AESKU DIAGNOSTICS, Germany) was used to detect ANCA (IgG), as well as multiplex ELISA for the detection of antiphospholipid antibodies for all patients with COVID-19 and for the control group. The results revealed the detection of antiphospholipid antibodies (IgG) in one patient out of the 45 patients in the case group. 1/45(2.2%) and 7/45(15.6%) tested positive for ANCA. Five were men and two were females, with one case revealed to be positive for both aPL and ANCA. A cytoplasmic reaction on the eosinophil granulocytes was observed in 2 cases; both were positive for ANCA. Other markers (CRP, APTT, PT, INR, ESR, and neutrophil and lymphocyte counts) were included in the study, along with demographic data. No aPL or ANCA reactions were detected for any of the control groups. These findings suggest that aPL and ANCA may be induced during the course of inflammation in COVID-19 and possibly contribute to the disease's severity and mortality.
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19
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Mengeot L, Marot L, Baeck M. Rapidly evolving necrotic skin lesions of the face. JAAD Case Rep 2022; 28:149-151. [PMID: 36274788 PMCID: PMC9579697 DOI: 10.1016/j.jdcr.2022.01.043] [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: 11/18/2022] Open
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20
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Initial presentation of Systemic Lupus Erythematosus coinciding with Thrombotic Thrombocytopenic Purpura. THROMBOSIS UPDATE 2022. [DOI: 10.1016/j.tru.2022.100118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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21
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Singal M, Kouides P. All catastrophes are not catastrophic antiphospholipid syndrome. Am J Hematol 2022; 97:968-974. [PMID: 35253923 DOI: 10.1002/ajh.26516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/24/2022] [Accepted: 03/01/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Mukul Singal
- Rochester General Hospital Hematology and Oncology Rochester New York USA
- Rochester General Hospital Department of Internal Medicine Rochester New York USA
| | - Peter Kouides
- Rochester General Hospital Hematology and Oncology Rochester New York USA
- University of Rochester School of Medicine and Dentistry Hematology and Oncology Rochester New York USA
- Mary M Gooley Hemophilia Center Rochester New York USA
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22
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Catastrophic Antiphospholipid Syndrome Presenting as a Stroke in an 11-Year-Old with Lupus. Case Rep Pediatr 2022; 2022:7890566. [PMID: 35600982 PMCID: PMC9122718 DOI: 10.1155/2022/7890566] [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: 02/20/2022] [Accepted: 05/05/2022] [Indexed: 11/26/2022] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is an infrequent but feared life-threatening complication of antiphospholipid syndrome (APS). CAPS is characterized by the rapid development of numerous thromboses across multiple organs resulting in multiorgan failure. It is rare but well-documented in the adult population. In contrast, it is exceedingly uncommon in pediatric patients and therefore not yet well described in the pediatric literature. Early recognition of APS is of the utmost importance to provide timely and effective management for a positive outcome. We present the case of an 11-year-old girl with history of systemic lupus erythematosus (SLE) and hypertension (HTN) who presented with acute onset altered mental status, found to have a large ischemic middle cerebral artery (MCA) and anterior cerebral artery (ACA) stroke as well as multiple, diffuse, and smaller ischemic lesions in the frontal lobe and cerebellum. Her presentation was further complicated by thrombocytopenia and renal and splenic infarction, as well as thrombosis of the right brachial vein consistent with a diagnosis of CAPS.
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23
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Catastrophic Antiphospholipid Syndrome after Orthotopic Liver Transplant. Case Rep Transplant 2022; 2022:6209300. [PMID: 35573422 PMCID: PMC9098363 DOI: 10.1155/2022/6209300] [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: 01/30/2022] [Accepted: 04/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background. Catastrophic antiphospholipid syndrome (CAPS) is an autoimmune thrombogenic disorder of small and large vessels caused by autoantibodies against phospholipids and phospholipid-binding proteins. This severe form of antiphospholipid syndrome (APS) presents clinically with simultaneous life-threatening multiorgan thrombosis and the presence of two or more persistent antiphospholipid antibodies (APL) confirmed on testing 12 weeks apart. Case Presentation. We describe a case report of a 66-year-old woman with detected antinuclear antibodies (ANA) pretransplant diagnosed with CAPS following orthotopic liver transplant. The patient had acute respiratory failure; Doppler ultrasound and CT angiogram confirmed thrombosis in the hepatic artery, subsequent occlusion of the jump graft, and a splenic infarct. Hypercoagulability workup showed elevated levels of anticardiolipin IgG and beta-2-glycoprotein IgG/IgM and positive lupus anticoagulant, treated with steroids and anticoagulation. The patient was discharged after one month and was transitioned from heparin to life-long warfarin. Conclusion. Our patient provided a standard presentation of CAPS with abnormal pretransplant levels of antinuclear antibodies (ANA). Although there have been studies investigating the relationship between anticardiolipin antibodies and lupus anticoagulants and APS, the relationship between pretransplant positive ANA or antimitochondrial antibodies (AMA) and CAPS has yet to be explored. Further studies will be needed to determine the significance of these antibodies. We recommend preoperative APL testing for patients with positive ANA and AMA at preliver transplant presentation.
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24
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Spring J, Munshi L. Hematology Emergencies in Critically Ill Adults. Chest 2022; 161:1285-1296. [DOI: 10.1016/j.chest.2021.12.650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/14/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022] Open
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25
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Association between COVID-19 Diagnosis and Coronary Artery Thrombosis: A Narrative Review. Biomedicines 2022; 10:biomedicines10030702. [PMID: 35327504 PMCID: PMC8945192 DOI: 10.3390/biomedicines10030702] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/13/2022] [Accepted: 03/16/2022] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 2019 is characterized by its severe respiratory effects. Data early on indicated an increased risk of mortality in patients with cardiovascular comorbidities. Early reports highlighted the multisystem inflammatory syndrome, cytokine storm, and thromboembolic events as part of the disease processes. The aim of this review is to assess the association between COVID-19 and its thrombotic complications, specifically related to the cardiovascular system. The role of neutrophil extracellular traps (NETs) is explored in the pathogenesis of the disease. The structure and anatomy of the virus are pivotal to its virulence in comparison to other α and β Coronaviridae (HCoV-229E, HCoV-OC43, HCoV-229E, HCoV-NL63, HCoV-OC43, and HCoV-HKU1). In particular, the host interaction and response may explain the variability of severity in patients. Angio tensin-converting enzyme 2 (ACE2) activation may be implicated in the cardiovascular and throm bogenic potential of the disease. The virus may also have direct effects on the endothelial lining affecting hemostasis and resulting in thrombosis through several mechanisms. Dipyridamole may have a therapeutic benefit in NET suppression. Therapeutic avenues should be concentrated on the different pathophysiological steps involving the virus and the host.
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Hegde A, Dorji T, Asturkar V, Yangzom S, Bhanu KU. Cases of catastrophic anti-phospholipid syndrome in systemic lupus erythematosus: An experience. SAGE Open Med Case Rep 2022; 10:2050313X221085099. [PMID: 35308057 PMCID: PMC8928371 DOI: 10.1177/2050313x221085099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 02/15/2022] [Indexed: 11/25/2022] Open
Abstract
Anti-phospholipid syndrome is an autoimmune disorder characterized by episodes of arterial and/or venous thrombosis and/or pregnancy morbidity in the presence of anti-phospholipid antibodies. Catastrophic anti-phospholipid syndrome is an accelerated form of the disease with rapid involvement of multiple organ systems often posing a diagnostic challenge. There is a paucity of literature on the myriad presentations of catastrophic anti-phospholipid syndrome owing to the orphan nature of the disease. We present three cases of catastrophic anti-phospholipid syndrome in patients with systemic lupus erythematosus that presented with episodes of thrombosis involving both arterial and venous systems and multisystem organ failure. Timely diagnoses were made based on a high index of suspicion and were managed with a combination of systemic glucocorticoids, cyclophosphamide, plasmapheresis, intravenous immunoglobulin and other supportive measures. However, despite providing the standard of care, we encountered a poor outcome in two of these patients, highlighting the high mortality associated with catastrophic anti-phospholipid syndrome.
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Affiliation(s)
- Arun Hegde
- Department of Rheumatology, Command Hospital (Southern Command), Pune, India
| | - Thinley Dorji
- Department of Internal Medicine, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
- Department of Internal Medicine, Armed Forces Medical College, Pune, India
| | - Vikram Asturkar
- Department of Neurology, Command Hospital (Southern Command), Pune, India
| | - Sonam Yangzom
- Department of Radiodiagnosis and Imaging, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
- Department of Radiodiagnosis and Imaging, Armed Forces Medical College, Pune, India
| | - Kovilapu Uday Bhanu
- Department of Radiodiagnosis and Imaging, Armed Forces Medical College, Pune, India
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Knight JS, Kanthi Y. Mechanisms of immunothrombosis and vasculopathy in antiphospholipid syndrome. Semin Immunopathol 2022; 44:347-362. [PMID: 35122116 PMCID: PMC8816310 DOI: 10.1007/s00281-022-00916-w] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/19/2022] [Indexed: 12/14/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune thrombophilia propelled by circulating antiphospholipid antibodies that herald vascular thrombosis and obstetrical complications. Antiphospholipid antibodies recognize phospholipids and phospholipid-binding proteins and are not only markers of disease but also key drivers of APS pathophysiology. Thrombotic events in APS can be attributed to various conspirators including activated endothelial cells, platelets, and myeloid-lineage cells, as well as derangements in coagulation and fibrinolytic systems. Furthermore, recent work has especially highlighted the role of neutrophil extracellular traps (NETs) and the complement system in APS thrombosis. Beyond acute thrombosis, patients with APS can also develop an occlusive vasculopathy, a long-term consequence of APS characterized by cell proliferation and infiltration that progressively expands the intima and leads to organ damage. This review will highlight known pathogenic factors in APS and will also briefly discuss similarities between APS and the thrombophilic coagulopathy of COVID-19.
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Affiliation(s)
- Jason S Knight
- Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Yogendra Kanthi
- Division of Intramural Research National Heart, Lung, and Blood Institute, Bethesda, MD, USA
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Alijotas-Reig J, Esteve-Valverde E, Anunciación-Llunell A, Marques-Soares J, Pardos-Gea J, Miró-Mur F. Pathogenesis, Diagnosis and Management of Obstetric Antiphospholipid Syndrome: A Comprehensive Review. J Clin Med 2022; 11:jcm11030675. [PMID: 35160128 PMCID: PMC8836886 DOI: 10.3390/jcm11030675] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Antiphospholipid syndrome is an autoimmune disorder characterized by vascular thrombosis and/or pregnancy morbidity associated with persistent antiphospholipid antibody positivity. Cases fulfilling the Sydney criteria for obstetric morbidity with no previous thrombosis are known as obstetric antiphospholipid syndrome (OAPS). OAPS is the most identified cause of recurrent pregnancy loss and late-pregnancy morbidity related to placental injury. Cases with incomplete clinical or laboratory data are classified as obstetric morbidity APS (OMAPS) and non-criteria OAPS (NC-OAPS), respectively. Inflammatory and thrombotic mechanisms are involved in the pathophysiology of OAPS. Trophoblasts, endothelium, platelets and innate immune cells are key cellular players. Complement activation plays a crucial pathogenic role. Secondary placental thrombosis appears by clot formation in response to tissue factor activation. New risk assessment tools could improve the prediction of obstetric complication recurrences or thromboses. The standard-of-care treatment consists of low-dose aspirin and prophylactic low molecular weight heparin. In refractory cases, the addition of hydroxychloroquine, low-dose prednisone or IVIG improve pregnancy outcomes. Statins and eculizumab are currently being tested for treating selected OAPS women. Finally, we revisited recent insights and concerns about the pathophysiology, diagnosis and management of OAPS.
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Affiliation(s)
- Jaume Alijotas-Reig
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
- Department of Medicine, Faculty of Medicine, Universitat Autònoma de Barcelona (UAB), 08193 Barcelona, Spain
- Correspondence: (J.A.-R.); (F.M.-M.); Tel.: +34-93-489-4194 (J.A.-R.); +34-93-489-4047 (F.M.-M.); Fax: +34-93-489-4047 (J.A.-R.)
| | - Enrique Esteve-Valverde
- Department of Internal Medicine, Althaia Xarxa Assistencial, Carrer Dr Joan Soler 1-3, 08243 Manresa, Spain;
| | - Ariadna Anunciación-Llunell
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
| | - Joana Marques-Soares
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Josep Pardos-Gea
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Vall d’Hebron Hospital Campus, Hospital Universitari Vall d’Hebron (HUVH), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain
| | - Francesc Miró-Mur
- Systemic Autoimmune Diseases Research Unit, Vall d’Hebron Hospital Campus, Vall d’Hebron Institut de Recerca (VHIR), Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; (A.A.-L.); (J.M.-S.); (J.P.-G.)
- Correspondence: (J.A.-R.); (F.M.-M.); Tel.: +34-93-489-4194 (J.A.-R.); +34-93-489-4047 (F.M.-M.); Fax: +34-93-489-4047 (J.A.-R.)
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Kim C, Kim HS. Catastrophic antiphospholipid syndrome presented with coronary thrombosis, renal impairment, and suspected diffuse alveolar hemorrhage treated with rituximab biosimilar (CT-P10). EUR J INFLAMM 2022. [DOI: 10.1177/20587392211050805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a lethal disease that occurs suddenly and progresses to multi-organ failure. We present a case of CAPS successfully treated with the rituximab biosimilar CT-P10. A 38-year-old man was referred with a sustained fever and unexplained elevated creatinine levels. Cardiac arrest by ventricular fibrillation occurred upon arrival at the hospital. We diagnosed probable CAPS because of coronary thrombus, renal impairment, suspected diffuse alveolar hemorrhage, and positive anticardiolipin antibody immunoglobulin G. We performed percutaneous coronary intervention for the cardiac arrest, and treated him with extracorporeal membrane oxygenation, mechanical ventilation, and continuous renal replacement therapy. When CAPS was diagnosed, we administered CT-P10 after administering high-dose glucocorticoid. Our case suggests that the use of a rituximab biosimilar is economically efficient in the treatment of CAPS, as in other rheumatic diseases. The patient was cured without recurrence at the 2-year follow-up.
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Affiliation(s)
- Changgon Kim
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Yongsan-gu, Republic of Korea
| | - Hyun-Sook Kim
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Yongsan-gu, Republic of Korea
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Liu LW, Tsai HH, Lafian A, Sadeghi-Najafabadi E. A Case of Probable Catastrophic Antiphospholipid Syndrome Treated With Rituximab and Without Anticoagulation. J Clin Rheumatol 2021; 27:S541-S542. [PMID: 31124923 DOI: 10.1097/rhu.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Chidharla A, Syed SB, Chatterjee T, Tarantino MD. A Case Report of COVID-Associated Catastrophic Antiphospholipid Syndrome Successfully Treated with Eculizumab. J Blood Med 2021; 12:929-933. [PMID: 34744467 PMCID: PMC8566005 DOI: 10.2147/jbm.s324873] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/28/2021] [Indexed: 12/16/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by multiple episodes of venous and arterial thromboses or recurrent fetal losses in the presence of antiphospholipid antibodies against β2GP1, frequently accompanied by moderate thrombocytopenia. Catastrophic APS (CAPS) is a severe manifestation of APS. COVID-19 may have an intense hypercoagulable state in critically ill patients. SARS-CoV2 may potentiate pathogenic APS effects, including the activation of endothelial cells, monocytes, platelets, and complement, resulting in a proinflammatory state and prothrombotic events. The endothelial tropism of SARS-CoV2 may also modify the clinical presentation of COVID-19 in susceptible individuals and trigger flares of underlying vascular diseases. We report a case of a 64-year-old woman with a history of triple-positive APS who had multiple thrombotic and bleeding episodes after being found to have a COVID-19 infection temporally associated with CAPS development that was successfully treated with eculizumab, preventing further macro- and microvascular thrombotic events at 1 month follow-up. Our case highlights the need for more research regarding the mechanism by which COVID-19 may potentiate APS and lead to the development of CAPS.
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Affiliation(s)
- Anusha Chidharla
- Department of Medical Oncology, Kansas University Cancer Center, Kansas, KS, USA
| | - Salman B Syed
- Department of Internal Medicine, University of Illinois College of Medicine, Peoria, IL, USA
| | - Tulika Chatterjee
- Department of Internal Medicine, University of Illinois College of Medicine, Peoria, IL, USA
| | - Michael D Tarantino
- Department of Hematology, Bleeding and Clotting Disorders Institute, Peoria, IL, USA
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Pongphitcha P, Okuno Y, Vilaiyuk S, Tunlayadechanont P, Sasanakul W, Kadegasem P, Songdej D, Sirachainan N. Report on effective treatment and genetic predisposition in two children with refractory probable catastrophic antiphospholipid syndrome. Thromb Res 2021; 208:117-120. [PMID: 34749043 DOI: 10.1016/j.thromres.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Pongpak Pongphitcha
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Yusuke Okuno
- Department of Virology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan; Medical Genomics Center, Nagoya University Hospital, Nagoya, Japan
| | - Soamarat Vilaiyuk
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Padcha Tunlayadechanont
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Werasak Sasanakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Praguywan Kadegasem
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Duantida Songdej
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 693] [Impact Index Per Article: 231.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Stanescu C, Andronesi AG, Jurcut C, Gherghiceanu M, Vornicu A, Burcea FA, Andronesi TD, Lupusoru GE, Iliuta L, Sorohan BM, Obrisca B, Ismail G. Successful Treatment of Catastrophic Antiphospholipid Syndrome Using Rituximab: Case Report and Review of the Literature. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:912. [PMID: 34577835 PMCID: PMC8470109 DOI: 10.3390/medicina57090912] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Kidney involvement is a frequent complication of systemic lupus erythematosus (SLE) and kidney biopsy is essential in differentiating lupus nephritis (LN) from thrombotic microangiopathy (TMA) secondary to antiphospholipid autoantibodies (aPL). Association between antiphospholipid syndrome (APS) and acquired hemophilia due to inhibitors was very rarely described in SLE patients. CASE PRESENTATION We present the case of a 61-year-old male diagnosed with SLE who acquired deficiency of clotting factor VIII due to circulating inhibitors, admitted for acute kidney injury (AKI), microangiopathic hemolytic anemia, thrombocytopenia, and diplopia. Kidney biopsy showed TMA due to APS, but no signs of LN. Head computed tomography identified low dense areas in the white matter, suggesting small blood vessels' involvement. A diagnosis of probable catastrophic antiphospholipid syndrome (CAPS) was established and treatment with low molecular weight heparin, intravenous methylprednisolone, plasmapheresis, and rituximab was initiated, followed by resolution of AKI, diplopia, and TMA with complete depletion of CD19+B-lymphocytes (CD19+B-Ly) after one month. We further review the current knowledge regarding pathogenesis and management of CAPS in SLE patients. CONCLUSIONS Targeted therapy was possible after kidney biopsy, improving renal and general prognosis. CD19+B-Ly repopulation preceded biological relapse, so monitoring of CD19+B-Ly may serve as a tool to predict relapses and guide rituximab therapy.
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Affiliation(s)
- Cristina Stanescu
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
| | - Andreea Gabriella Andronesi
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania; (B.M.S.); (B.O.)
| | - Ciprian Jurcut
- Internal Medicine Department, “Carol Davila” Military Emergency Hospital, 010225 Bucharest, Romania;
| | - Mihaela Gherghiceanu
- “Victor Babes” National Institute for Research and Development in Pathology and Biomedical Sciences, 050097 Bucharest, Romania;
| | - Alexandra Vornicu
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
| | - Florentina Andreea Burcea
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
| | - Toader Danut Andronesi
- Department of General Surgery and Liver Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania;
| | - Gabriela Elena Lupusoru
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania; (B.M.S.); (B.O.)
| | - Luminita Iliuta
- Department of Biostatistics, Marketing and Medical Technology, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania;
| | - Bogdan Marian Sorohan
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania; (B.M.S.); (B.O.)
| | - Bogdan Obrisca
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania; (B.M.S.); (B.O.)
| | - Gener Ismail
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania; (C.S.); (A.V.); (F.A.B.); (G.E.L.); (G.I.)
- Nephrology Department, “Carol Davila” University of Medicine and Pharmacy, 050471 Bucharest, Romania; (B.M.S.); (B.O.)
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Complement and the prothrombotic state. Blood 2021; 139:1954-1972. [PMID: 34415298 DOI: 10.1182/blood.2020007206] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 06/08/2021] [Indexed: 11/20/2022] Open
Abstract
In 2007 and 2009 the regulatory approval of the first-in-class complement inhibitor Eculizumab has revolutionized the clinical management of two rare, life-threatening clinical conditions: paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS). While being completely distinct diseases affecting blood cells and the glomerulus, PNH and aHUS remarkably share several features in their etiology and clinical presentation. An imbalance between complement activation and regulation at host surfaces underlies both diseases precipitating in severe thrombotic events that are largely resistant to anti-coagulant and/or anti-platelet therapies. Inhibition of the common terminal complement pathway by Eculizumab prevents the frequently occurring thrombotic events responsible for the high mortality and morbidity observed in patients not treated with anti-complement therapy. While many in vitro and ex vivo studies elaborate numerous different molecular interactions between complement activation products and hemostasis, this review focuses on the clinical evidence that links these two fields in humans. Several non-infectious conditions with known complement involvement are scrutinized for common patterns concerning a prothrombotic statues and the occurrence of certain complement activation levels. Next to PNH and aHUS, germline encoded CD59 or CD55 deficiency (the latter causing the disease Complement Hyperactivation, Angiopathic thrombosis, and Protein-Losing Enteropathy; CHAPLE), autoimmune hemolytic anemia (AIHA), (catastrophic) anti-phospholipid syndrome (APS, CAPS) and C3 glomerulopathy are considered. Parallels and distinct features among these conditions are discussed against the background of thrombosis, complement activation, and potential complement diagnostic and therapeutic avenues.
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Tannous T, Rosso C, Iannuccilli J, Tannous K, Keating M. Primary Refractory Catastrophic Antiphospholipid Syndrome Masquerading as Buerger's Disease. Cureus 2021; 13:e14350. [PMID: 33972907 PMCID: PMC8104915 DOI: 10.7759/cureus.14350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a lethal disease with up to 30% mortality rate. It can occur as a primary disease or secondary to an underlying autoimmune disease. Current treatment focuses on disease control with anticoagulation and steroids. Plasma exchange and intravenous immunoglobulin (IVIG) have shown some benefit when added. Monoclonal drugs such as rituximab have shown some benefit in refractory cases, and eculizumab, a drug approved for use in atypical hemolytic uremic syndrome, has demonstrated disease control in a few case reports. We describe a unique case of primary refractory CAPS with an unusual presentation that was treated with five lines of therapy before disease control was established.
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Affiliation(s)
- Toufic Tannous
- Internal Medicine, Roger Williams Medical Center/Boston University, Providence, USA
| | - Claudia Rosso
- School of Medicine, University of California - Irvine, Irvine, USA
| | | | - Karim Tannous
- School of Medicine, University of Balamand, Tripoli, LBN
| | - Matthew Keating
- Division of Hematology and Oncology, University of California - Irvine, Irvine, USA.,School of Medicine, University of California - Irvine, Irvine, USA
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Understanding the Pathophysiology of Thrombotic APS through Animal Models. Int J Mol Sci 2021; 22:ijms22052588. [PMID: 33806694 PMCID: PMC7961365 DOI: 10.3390/ijms22052588] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/01/2021] [Accepted: 03/01/2021] [Indexed: 12/12/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a leading acquired cause of thrombotic events, with a notable tendency to promote thrombosis in vascular beds of all sizes, including both arterial and venous circuits. While pathogenic antiphospholipid antibodies circulate at relatively stable levels in blood, thrombosis tends to manifest as discrete and acute events, suggesting the requirement for a “second hit.” While this two-hit model is generally accepted, much remains to be learned about exactly how antiphospholipid antibodies predispose to thrombosis in vivo and exactly how this predisposition interacts with the second hit. To this end, investigators have turned to animal models. Numerous approaches for modeling APS in animals have been described to date, each with potential advantages and disadvantages. This review will attempt to describe the most common APS models employed so far while discussing some pros and cons of each. Mechanisms of thrombotic APS that have thus far been explored in animal models will also be briefly addressed.
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Reddy RL. Therapeutic Apheresis. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
PURPOSE OF REVIEW Antiphospholipid syndrome (APS), more common than once believed, is an autoimmune disease best known for its high risk of incident and recurrent thrombotic events. The approach to treatment potentially differs from treatment of thrombosis in the general population, and this article endeavors to review the latest updates on this topic. RECENT FINDINGS The epidemiology of APS is being increasingly elucidated by large population-based studies, with APS perhaps affecting as many as 1 in 2000 individuals. Vitamin K antagonists, aspirin, and heparinoids continue to have obvious roles in the management of patients with APS. There has recently been intensive study of direct oral anticoagulants in APS, with the most recent randomized studies raising concerns about their inferiority to vitamin K antagonists, at least in some subgroups. Other approaches to treating APS beyond anticoagulants and antiaggregants are also receiving increased attention in mechanistic and preclinical studies with an eye toward future roles in patients with refractory and/or microvascular disease. Pediatric APS is identified as an area in desperate need of additional prospective research. SUMMARY Progress continues to be made in pursuit of improving the lives of individuals afflicted with APS. The most important future directions would seem to involve leveraging modern molecular technologies in order to improve subphenotyping of antiphospholipid antibody-positive individuals. This will help personalize risk profiles and ideally define the optimal approach to therapy based on future risk, rather than past morbid events.
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In Yun Y, Kim JH, Lim SH, Ahn YH, Kang HG, Ha IS, Oh BL. Case of catastrophic antiphospholipid syndrome presenting as neuroretinitis and vaso-occlusive retinopathy. BMC Ophthalmol 2020; 20:482. [PMID: 33298003 PMCID: PMC7727181 DOI: 10.1186/s12886-020-01755-9] [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: 09/18/2020] [Accepted: 12/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ocular involvement in catastrophic antiphospholipid syndrome (CAPS), a rare, life-threatening form of antiphospholipid syndrome (APS) that results in multiorgan failure and a high mortality rate, has rarely been reported. CASE PRESENTATION A 15-year-old girl presented with sudden vision blurring in both eyes. She had marked optic disc swelling and macular exudates in the right eye and intra-arterial white plaques, a few retinal blot hemorrhages, and a white ischemic retina in the left eye. Systemic examination revealed she had acute kidney injury with thrombotic microangiopathy (TMA), multiple cerebral infarcts, valvular dysfunction, and a high titer of triple aPL. Thus, she was diagnosed with CAPS involving the brain, eyes, heart, and kidneys. Plasma exchange and the administration of glucocorticoids, immunoglobulin, warfarin, and rituximab brought a sustained recovery of the TMA, visual symptoms, and echocardiographic findings. CONCLUSIONS Ocular involvement of both vaso-occlusive retinopathy, an APS-related thrombotic microangiopathy, and neuroretinitis, a non-thrombotic microangiopathy, can occur as an initial presentation of CAPS.
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Affiliation(s)
- Young In Yun
- Department of Ophthalmology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Ji Hyun Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seon Hee Lim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Baek-Lok Oh
- Department of Ophthalmology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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Hematologic Chaos in Lupus Flare: A Case of Fulminant and Simultaneous Antiphospholipid, Anti-ADAMTS13, and Red Blood Cell Autoantibodies. Case Rep Rheumatol 2020; 2020:8812550. [PMID: 33274103 PMCID: PMC7683143 DOI: 10.1155/2020/8812550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 11/25/2022] Open
Abstract
Systemic lupus erythematosus may present with several distinct autoimmune phenomena simultaneously. We report a patient presenting with three serious hematologic disorders: thrombotic thrombocytopenic purpura, catastrophic antiphospholipid syndrome, and warm-type IgG red cell autoantibodies. The case is an example of the complex clinical nature of lupus and the importance of accurately identifying individual complications in order to optimize management.
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Piedrafita A, Ribes D, Cointault O, Chauveau D, Faguer S, Huart A. Plasma exchange and thrombotic microangiopathies: From pathophysiology to clinical practice. Transfus Apher Sci 2020; 59:102990. [PMID: 33272850 DOI: 10.1016/j.transci.2020.102990] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thrombotic microangiopathy (TMA) brings together many diseases that have a commonality in the apparition of mechanical hemolysis with consuming thrombopenia. In all cases, these diseases can be life threatening, thereby justifying the implementation of treatment as an emergency. First-line treatment represents plasma exchange. This treatment has proven efficiency in improving the vital patient's and functional prognosis. However, the administration methods of plasma exchange can be redefined in light of the understanding of the pathophysiology of TMA. The aim of this review is to try to define, from pathophysiology, the place of plasma exchanges in the modern therapeutic arsenal of TMA.
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Affiliation(s)
- Alexis Piedrafita
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - David Ribes
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Olivier Cointault
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Dominique Chauveau
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Institut National de la Santé et de la Recherche Médicale, UMR1048, Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Antoine Huart
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
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Zuo Y, Estes SK, Ali RA, Gandhi AA, Yalavarthi S, Shi H, Sule G, Gockman K, Madison JA, Zuo M, Yadav V, Wang J, Woodard W, Lezak SP, Lugogo NL, Smith SA, Morrissey JH, Kanthi Y, Knight JS. Prothrombotic autoantibodies in serum from patients hospitalized with COVID-19. Sci Transl Med 2020; 12:eabd3876. [PMID: 33139519 PMCID: PMC7724273 DOI: 10.1126/scitranslmed.abd3876] [Citation(s) in RCA: 409] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/14/2020] [Accepted: 10/30/2020] [Indexed: 01/08/2023]
Abstract
Patients with COVID-19 are at high risk for thrombotic arterial and venous occlusions. Lung histopathology often reveals fibrin-based blockages in the small blood vessels of patients who succumb to the disease. Antiphospholipid syndrome is an acquired and potentially life-threatening thrombophilia in which patients develop pathogenic autoantibodies targeting phospholipids and phospholipid-binding proteins (aPL antibodies). Case series have recently detected aPL antibodies in patients with COVID-19. Here, we measured eight types of aPL antibodies in serum samples from 172 patients hospitalized with COVID-19. These aPL antibodies included anticardiolipin IgG, IgM, and IgA; anti-β2 glycoprotein I IgG, IgM, and IgA; and anti-phosphatidylserine/prothrombin (aPS/PT) IgG and IgM. We detected aPS/PT IgG in 24% of serum samples, anticardiolipin IgM in 23% of samples, and aPS/PT IgM in 18% of samples. Antiphospholipid autoantibodies were present in 52% of serum samples using the manufacturer's threshold and in 30% using a more stringent cutoff (≥40 ELISA-specific units). Higher titers of aPL antibodies were associated with neutrophil hyperactivity, including the release of neutrophil extracellular traps (NETs), higher platelet counts, more severe respiratory disease, and lower clinical estimated glomerular filtration rate. Similar to IgG from patients with antiphospholipid syndrome, IgG fractions isolated from patients with COVID-19 promoted NET release from neutrophils isolated from healthy individuals. Furthermore, injection of IgG purified from COVID-19 patient serum into mice accelerated venous thrombosis in two mouse models. These findings suggest that half of patients hospitalized with COVID-19 become at least transiently positive for aPL antibodies and that these autoantibodies are potentially pathogenic.
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Affiliation(s)
- Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Shanea K Estes
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ramadan A Ali
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alex A Gandhi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Srilakshmi Yalavarthi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Hui Shi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
- Division of Rheumatology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gautam Sule
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kelsey Gockman
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jacqueline A Madison
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Melanie Zuo
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Vinita Yadav
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jintao Wang
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD 20892, USA
| | - Wrenn Woodard
- Michigan Clinical Research Unit, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sean P Lezak
- Michigan Clinical Research Unit, University of Michigan, Ann Arbor, MI 48109, USA
| | - Njira L Lugogo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Stephanie A Smith
- Department of Biological Chemistry, University of Michigan, Ann Arbor, MI 48109, USA
| | - James H Morrissey
- Department of Biological Chemistry, University of Michigan, Ann Arbor, MI 48109, USA
| | - Yogendra Kanthi
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD 20892, USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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Konstantinov NK, Pearson DR. Systemic Lupus Erythematosus: Considerations in Diagnosis and Management for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00312-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the diagnosis and management of the antiphospholipid syndrome (APS) in children. RECENT FINDINGS APS is a rare, acquired autoimmune systemic disease that can result in significant morbidity in children related to vascular thrombosis. The diagnosis and management of APS in children can be challenging due to a lack of validated diagnostic criteria and the rarity of the disease. In addition, many healthy children have transient circulating antiphospholipid antibodies without thrombotic complications. Nevertheless, epidemiological studies suggest that APS represents a greater relative proportion of thrombotic disease in children than it does in adults. Management of pediatric APS is largely inferred from adult data despite unique characteristics of pediatric APS. The current recommendations include long-term anticoagulation, which can be problematic in young, active individuals. There is little data on potential benefits of nonantithrombotic therapy in the management of pediatric APS. SUMMARY Data on pediatric APS are limited, but evidence suggests that using current available diagnostic testing is valuable and, until further evidence is available, treating thrombotic complications with heparins or warfarin should be standard of care.
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Zuo Y, Estes SK, Ali RA, Gandhi AA, Yalavarthi S, Shi H, Sule G, Gockman K, Madison JA, Zuo M, Yadav V, Wang J, Woodard W, Lezak SP, Lugogo NL, Smith SA, Morrissey JH, Kanthi Y, Knight JS. Prothrombotic antiphospholipid antibodies in COVID-19. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2020. [PMID: 32587992 DOI: 10.1101/2020.06.15.20131607] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients with coronavirus disease 19 (COVID-19) are at high risk for thrombotic arterial and venous occlusions. At the same time, lung histopathology often reveals fibrin-based occlusion in the small vessels of patients who succumb to the disease. Antiphospholipid syndrome (APS) is an acquired and potentially life-threatening thrombophilia in which patients develop pathogenic autoantibodies (aPL) targeting phospholipids and phospholipid-binding proteins. Case series have recently detected aPL in patients with COVID-19. Here, we measured eight types of aPL [anticardiolipin IgG/IgM/IgA, anti-beta-2 glycoprotein I IgG/IgM/IgA, and anti- phosphatidylserine/prothrombin (aPS/PT) IgG/IgM] in the sera of 172 patients hospitalized with COVID-19. We detected aPS/PT IgG in 24%, anticardiolipin IgM in 23%, and aPS/PT IgM in 18%. Any aPL was present in 52% of patients using the manufacturer's threshold and in 30% using a more stringent cutoff (≥40 units). Higher levels of aPL were associated with neutrophil hyperactivity (including the release of neutrophil extracellular traps/NETs), higher platelet count, more severe respiratory disease, and lower glomerular filtration rate. Similar to patients with longstanding APS, IgG fractions isolated from patients with COVID-19 promoted NET release from control neutrophils. Furthermore, injection of these COVID-19 IgG fractions into mice accelerated venous thrombosis. Taken together, these studies suggest that a significant percentage of patients with COVID-19 become at least transiently positive for aPL and that these aPL are potentially pathogenic.
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KARAGÜN E, ÖNEÇ B, AKBAŞ T, GAMSIZKAN M. Sjögren sendromu ve şiddetli cilt tutulumu mevcut olan katastrofik antifosfolipid sendromu. CUKUROVA MEDICAL JOURNAL 2020. [DOI: 10.17826/cumj.679449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Abstract
Purpose of review Although antiphospholipid syndrome (APS) is best known for conveying increased risk of thrombotic events and pregnancy morbidity, thrombocytopenia is also recognized as a common association. In this review, we will explore the relationship between thrombocytopenia and APS, highlighting our evolving understanding – and persistent knowledge gaps – through clinically oriented questions and answers. Recent findings A history of thrombocytopenia likely portends a more severe APS phenotype (including increased risk of thrombosis). Although the pathophysiology underlying thrombocytopenia in APS has yet to be definitively revealed, mechanisms that play a role (at least in subsets of patients) include: immune thrombocytopenic purpura/ITP-like autoantibodies against platelet glycoproteins; antiphospholipid antibody (aPL)-mediated platelet activation and consumption; and potentially life threatening thrombotic microangiopathy. Although thrombocytopenia is often ‘mild’ in APS (and therefore, may not require specific therapy), there are causes of acute-onset thrombocytopenia that mandate emergent work-up and treatment. When APS-related thrombocytopenia does require therapy, the approach must be individualized (requiring an understanding of pathophysiology in the particular APS patient). For patients with ITP-like disease, rituximab is emerging as a popular approach to treatment; in contrast, there are hints that thrombopoietin mimetics may be associated with elevated thrombotic risk. Summary Thrombocytopenia is common in APS, and is likely associated with more severe disease. Improved understanding of thrombocytopenia in APS has the potential to improve risk stratification, reveal novel aspects of APS pathophysiology, and lead to treatments that are more individualized and holistic.
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Song JC, Liu SY, Zhu F, Wen AQ, Ma LH, Li WQ, Wu J. Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China. Mil Med Res 2020; 7:15. [PMID: 32241296 PMCID: PMC7118900 DOI: 10.1186/s40779-020-00244-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/20/2020] [Indexed: 01/14/2023] Open
Abstract
Thrombocytopenia is a common complication of critical care patients. The rates of bleeding events and mortality are also significantly increased in critical care patients with thrombocytopenia. Therefore, the Critical Care Medicine Committee of Chinese People's Liberation Army (PLA) worked with Chinese Society of Laboratory Medicine, Chinese Medical Association to develop this consensus to provide guidance for clinical practice. The consensus includes five sections and 27 items: the definition of thrombocytopenia, etiology and pathophysiology, diagnosis and differential diagnosis, treatment and prevention.
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Affiliation(s)
- Jing-Chun Song
- Department of Critical Care Medicine, the 908th Hospital of Joint Logistics Support Forces of Chinese PLA, Nanchang, 360104, China.
| | - Shu-Yuan Liu
- Emergency Department, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Feng Zhu
- Burns and Trauma ICU, Changhai Hospital, Naval Medical University, Shanghai, 200003, China
| | - Ai-Qing Wen
- Department of Blood Transfusion, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Lin-Hao Ma
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Wei-Qin Li
- Surgery Intensive Care Unit, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China.
| | - Jun Wu
- Department of Clinical Laboratory, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, 100035, China.
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Cáliz Cáliz R, Díaz Del Campo Fontecha P, Galindo Izquierdo M, López Longo FJ, Martínez Zamora MÁ, Santamaria Ortiz A, Amengual Pliego O, Cuadrado Lozano MJ, Delgado Beltrán MP, Ortells LC, Pérez ECC, Rego GDC, Corral SG, Varela CF, López MM, Nishishinya B, Navarro MN, Testa CP, Pérez HS, Silva-Fernández L, Taboada VMM. Recommendations of the Spanish Rheumatology Society for Primary Antiphospholipid Syndrome. Part II: Obstetric Antiphospholipid Syndrome and Special Situations. REUMATOLOGIA CLINICA 2020; 16:133-148. [PMID: 30686569 DOI: 10.1016/j.reuma.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 10/31/2018] [Accepted: 11/09/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. METHODS A panel of 4rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for the document elaboration, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network, SIGN levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). RESULTS Forty-six recommendations were drawn up, addressing 5main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the last 25, referring to the areas of: obstetric APS and special situations. The document provides a table of recommendations and treatment algorithms. CONCLUSIONS Update of SER recommendations on APS is presented. This document corresponds to part II, related to obstetric SAF and special situations. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A part I has also been prepared, which addresses aspects related to diagnosis, evaluation and treatment.
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Affiliation(s)
- Rafael Cáliz Cáliz
- Servicio de Reumatología, Hospital Universitario Virgen de las Nieves, Facultad de Medicina, Universidad de Granada, España.
| | | | | | | | - María Ángeles Martínez Zamora
- Unidad de Ginecología y Obstetricia, Hospital Clinic, Barcelona, España; Representante de la Sociedad Española de Ginecología y Obstetricia (SEGO), Madrid, España
| | - Amparo Santamaria Ortiz
- Unidad de Hemostasia y Trombosis, Servicio de Hematología. Hospital Vall d́Hebron, Barcelona, España; Representante de la Sociedad Española de Trombosis y Hemostasia (SETH), Madrid, España
| | - Olga Amengual Pliego
- Departamento de Reumatología, Endocrinología y Nefrología. Facultad de Medicina. Universidad de Hokkaido, Sapporo, Japón
| | | | | | | | | | | | | | - Clara Fuego Varela
- Servicio de Reumatología. Hospital Regional Universitario de Málaga. Hospital Civil, Málaga, España
| | - María Martín López
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Betina Nishishinya
- Servicio de Reumatología y Medicina del deporte. Medicina del Deporte. Clínica Quirón, Barcelona, España
| | | | | | - Hiurma Sánchez Pérez
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - Lucia Silva-Fernández
- Servicio de Reumatología. Complexo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, España
| | - Víctor Manuel Martínez Taboada
- Facultad de Medicina, Universidad de Cantabria, Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
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