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Davis JL. Defining Retinal Vasculitis. Am J Ophthalmol 2024:S0002-9394(24)00239-3. [PMID: 38925285 DOI: 10.1016/j.ajo.2024.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE To assess the validity of retinal vasculitis as the preferred diagnostic term for multiple conditions. DESIGN Perspective METHODS: Expert opinion and review of literature focused on the current nosology and pathology of retinal vasculitis. Interpretation of the subset of intraocular inflammation named retinal vasculitis based on fundamental knowledge of the blood-retinal barrier, the neurovascular unit and pathological and functional responses to a variety of stimuli. Correlation with multimodal imaging and known mechanisms of immunologically mediated disease. RESULTS A search of Medline in early 2024 for the phrase "retinal vasculitis" resulted in 2041 citations encompassing immunologic, genetic, neoplastic, infectious, drug- and ischemia-related disorders. Classification schemes and angiographic grading systems are descriptive and do not address pathologic mechanisms adequately, in part due to lack of histologic confirmation. Although OCT angiography holds promise for better imaging of retinal vascular changes, it does not reveal the key feature of leakage and only partially improves understanding of pathophysiology. Diagnosing catastrophic retinal vascular occlusion after intravitreal injections as a retinal vasculitis is the most recent example of speculative application of the term to complex and rare disorders. CONCLUSIONS Retinal vasculitis is a diagnostic term that is over-used and imprecise. Revised nosology should limit the term to primary inflammation of the retinal vasculature itself that results in opening of the blood-retinal barrier with or without retinal vascular occlusions. Pending new histologic or mechanistic evidence, the provisional term of retinal vascular inflammation or retinal vasculopathy should be used for leakage or occlusion occurring in the context of intraocular inflammation.
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Affiliation(s)
- Janet L Davis
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL, 33136.
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Bitsadze V, Yakubova F, Khizroeva J, Lazarchuk A, Salnikova P, Vorobev A, Tretyakova M, Degtyareva N, Grigoreva K, Gashimova N, Kvaratskheliia M, Makatsariya N, Kudryavtseva E, Tomlenova A, Gris JC, Elalamy I, Ay C, Makatsariya A. Catastrophic Antiphospholipid Syndrome. Int J Mol Sci 2024; 25:668. [PMID: 38203837 PMCID: PMC10779422 DOI: 10.3390/ijms25010668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/26/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Unlike classic APS, CAPS causes multiple microthrombosis due to an increased inflammatory response, known as a "thrombotic storm". CAPS typically develops after infection, trauma, or surgery and begins with the following symptoms: fever, thrombocytopenia, muscle weakness, visual and cognitive disturbances, abdominal pain, renal failure, and disseminated intravascular coagulation. Although the presence of antiphospholipid antibodies in the blood is one of the diagnostic criteria, the level of these antibodies can fluctuate significantly, which complicates the diagnostic process and can lead to erroneous interpretation of rapidly developing symptoms. Triple therapy is often used to treat CAPS, which includes the use of anticoagulants, plasmapheresis, and high doses of glucocorticosteroids and, in some cases, additional intravenous immunoglobulins. The use of LMWH is recommended as the drug of choice due to its anti-inflammatory and anticoagulant properties. CAPS is a multifactorial disease that requires not only an interdisciplinary approach but also highly qualified medical care, adequate and timely diagnosis, and appropriate prevention in the context of relapse or occurrence of the disease. Improved new clinical protocols and education of medical personnel regarding CAPS can significantly improve the therapeutic approach and reduce mortality rates.
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Affiliation(s)
- Victoria Bitsadze
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Fidan Yakubova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Jamilya Khizroeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Arina Lazarchuk
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Polina Salnikova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Alexander Vorobev
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Maria Tretyakova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Natalia Degtyareva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Kristina Grigoreva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Nilufar Gashimova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Margaret Kvaratskheliia
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Nataliya Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Ekaterina Kudryavtseva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Anna Tomlenova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Jean-Christophe Gris
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Faculty of Pharmaceutical and Biological Sciences, Montpellier University, 34093 Montpellier, France
| | - Ismail Elalamy
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Department Hematology and Thrombosis Center, Medicine Sorbonne University, 75012 Paris, France
- Hospital Tenon, 4 Rue de la Chine, 75020 Paris, France
| | - Cihan Ay
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, 1080 Vienna, Austria
| | - Alexander Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
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Zaafrane N, Fendouli I, Abdesslem NB, Mahjoub A, Chtioui H, Ghorbel M, Hachmi M. Choroidal involvement in patients with catastrophic anti-phospholipid syndrome: Two case reports. Eur J Ophthalmol 2024; 34:NP111-NP117. [PMID: 37365825 DOI: 10.1177/11206721231185813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
PURPOSE To describe choroidal involvement in catastrophic antiphospholipid syndrome (CAPS). METHODS We report here two cases of bilateral CAPS choroidopathy in two female patients. RESULTS Case report 1: A thirty-five-year-old female patient, with history of primary anti-phospholipid syndrome (APS), treated with anticoagulants, presented an acute renal failure following a salpingectomy. She complained of bilateral acute blurred vision. Ophthalmologic evaluation revealed visual acuity (VA) of 5/10, extensive serous retinal (SRD) detachment, areas of hypofluorescence on fluorescein angiography (FA), and non-perfusion areas in the choriocapillaris, on optical coherence tomography angiography (OCT-A), in both eyes. Considering the diagnosis of probable CAPS, the patient received intravenous pulse steroids, plasmapheresis, intravenous anticoagulation and haemodialysis, with favourable evolution. Case report 2: A thirty-three-year-old female patient, with history of systemic lupus erythematosus (SLE) and secondary APS, treated with corticosteroids, immunosuppressive agents and anti-coagulation, presented a myocardiac infarction. She complained of bilateral acute blurred vision. Ophthalmologic evaluation revealed VA of 1/10 in the RE and 6/10 in LE, bilateral extensive SRD, leakage points on FA and non-perfusion areas in the choriocapillaris on OCT-A. Criteria of probable CAPS were fulfilled. Treatment with intravenous pulse steroids, anticoagulation and reanimation modalities allowed VA improvement. Alveolar haemorrhage and cardiogenic shock led to fatal evolution. CONCLUSION Our case reports highlight the importance of early diagnosis and ophthalmic evaluation in CAPS. Multidisciplinary approach and rapid initiation of effective treatment, based on corticosteroids, anticoagulation and plasmapheresis, allow better vital and visual prognosis.
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Affiliation(s)
- Nesrine Zaafrane
- Ophtalmology Department, Farhat Hached Hospital, Sousse, Tunisia
- Faculty of Medicine Ibn Al Jazzar Sousse, Sousse, Tunisia
- University of Sousse, Tunis, Tunisia
| | - Ines Fendouli
- Ophtalmology Department, Farhat Hached Hospital, Sousse, Tunisia
| | - Nadia Ben Abdesslem
- Ophtalmology Department, Farhat Hached Hospital, Sousse, Tunisia
- Faculty of Medicine Ibn Al Jazzar Sousse, Sousse, Tunisia
- University of Sousse, Tunis, Tunisia
| | - Ahmed Mahjoub
- Ophtalmology Department, Farhat Hached Hospital, Sousse, Tunisia
- Faculty of Medicine Ibn Al Jazzar Sousse, Sousse, Tunisia
- University of Sousse, Tunis, Tunisia
| | - Hanin Chtioui
- Ophtalmology Department, Farhat Hached Hospital, Sousse, Tunisia
| | - Mohamed Ghorbel
- Ophtalmology Department, Farhat Hached Hospital, Sousse, Tunisia
- Faculty of Medicine Ibn Al Jazzar Sousse, Sousse, Tunisia
- University of Sousse, Tunis, Tunisia
| | - Mahjoub Hachmi
- Ophtalmology Department, Farhat Hached Hospital, Sousse, Tunisia
- Faculty of Medicine Ibn Al Jazzar Sousse, Sousse, Tunisia
- University of Sousse, Tunis, Tunisia
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Pelegrín L, Morató M, Araújo O, Figueras-Roca M, Zarranz-Ventura J, Adán A, Cervera R, Casaroli-Marano RP, Budi V, Barrera-López L, Ríos J, Hernández-Rodríguez J, Espinosa G. Preclinical ocular changes in systemic lupus erythematosus patients by optical coherence tomography. Rheumatology (Oxford) 2023; 62:2475-2482. [PMID: 36331348 DOI: 10.1093/rheumatology/keac626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/18/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE The aim of the present study was to detect preclinical changes in SLE patients in retinal microvascularization or retinal and optical nerve structure by optical coherence tomography. METHODS This cross-sectional, single-centre study aimed to describe structural changes [macular and retinal nerve fibre layer (RNFL) thickness] by structural spectral-domain optical coherence tomography (SD-OCT) and perifoveal vascular [vessel density (VD) and vascular perfusion (VP) and foveal avascular zone (FAZ) structural parameters] findings by OCT angiography (OCTA) in 78 SLE patients and 80 healthy volunteers. In addition, we analysed their association with clinical and laboratory parameters, medications received, disease duration, and SLE activity and damage. RESULTS Structural parameters by SD-OCT and perifoveal vascular parameters by OCTA were decreased in SLE patients compared with controls. OCTA parameters (VD, VP and FAZ circularity) and macular thickness were also decreased in patients with longer disease duration (>10 years). The presence of aPLs was associated with a decreased RNFL thickness, mainly in the inferior quadrants. Patients developing APS also showed decreased RNFL thickness and OCTA flow changes. SD-OCT and OCTA results were not associated with disease activity. Foveal structural parameters were lower in patients with higher damage score. CONCLUSION SD-OCT and OCTA can detect preclinical structural and microcirculatory changes in SLE patients. Structural and perifoveal vascular macular changes in SLE patients are related to disease duration. Macular structural parameters were impaired in patients with higher disease damage. APS seems to be associated with preclinical damage to the optic nerve and impairment of the perifoveal microvasculature.
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Affiliation(s)
- Laura Pelegrín
- Retina and Uveitis Unit, Department of Ophthalmology, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Montse Morató
- Retina and Uveitis Unit, Department of Ophthalmology, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Olga Araújo
- Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Marc Figueras-Roca
- Retina and Uveitis Unit, Department of Ophthalmology, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Javier Zarranz-Ventura
- Retina and Uveitis Unit, Department of Ophthalmology, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Alfredo Adán
- Retina and Uveitis Unit, Department of Ophthalmology, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Ricardo P Casaroli-Marano
- Retina and Uveitis Unit, Department of Ophthalmology, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Vanesa Budi
- Retina and Uveitis Unit, Department of Ophthalmology, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Lucía Barrera-López
- Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - José Ríos
- Department of Medical Statistics Platform, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - José Hernández-Rodríguez
- Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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Stammler R, Nguyen Y, Yelnik C, Le Guern V, Lambert M, Paule R, Hachulla E, Mouthon L, Dupré A, Ackermann F, Dufrost V, Wahl D, Godeau B, Leroux G, Benhamou Y, Lazaro E, Daugas E, Bezanahary H, Mekinian A, Piette JC, Morel N, Costedoat-Chalumeau N. Precipitating factors of catastrophic antiphospholipid syndrome: the role of anticoagulant treatment in a series of 112 patients. J Thromb Haemost 2023; 21:1258-1265. [PMID: 36792010 DOI: 10.1016/j.jtha.2023.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND The prevention of catastrophic antiphospholipid syndrome (CAPS), a rare complication of antiphospholipid syndrome (APS), is a major goal. OBJECTIVES We analyzed its precipitating factors, focusing on anticoagulation immediately before CAPS episodes. METHODS We retrospectively analyzed patients in the French multicenter APS/systemic lupus erythematosus database with at least 1 CAPS episode. Then we compared each patient with known APS before CAPS with 2 patients with non-CAPS APS matched for age, sex, center, and APS phenotype. RESULTS We included 112 patients with CAPS (70% women; mean age, 43 ± 15 years). At least 1 standard precipitating factor of CAPS was observed for 67 patients (64%), which were mainly infections (n = 28, 27%), pregnancy (n = 23, 22%), and surgery (n = 16, 15%). Before the CAPS episode, 67 (60%) patients already had a diagnosis of APS. Of the 61 treated with anticoagulants, 32 (48%) received vitamin K antagonists (VKAs), 23 (34%) heparin, and 2 (3%) a direct oral anticoagulant. They were less likely than their matched patients with APS without CAPS to receive VKA (48% vs 66%, p = .001). Among those treated with VKA, 72% had a subtherapeutic international normalized ratio (ie, <2) versus 28% in patients with APS without CAPS (p < .001). Finally, excluding pregnant patients (n = 14) for whom we could not differentiate the effect of treatment from that of pregnancy, we were left with 47 cases, 32 (68%) of whom had recently begun a direct oral anticoagulant, planned bridging therapy, or had VKA treatment with international normalized ratio <2. CONCLUSION These results strongly suggest that suboptimal anticoagulation management can trigger CAPS in patients with thrombotic APS.
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Affiliation(s)
- Romain Stammler
- Internal Medicine Department, AP-HP, Referral Center for Rare Autoimmune and Systemic Diseases of Ile de France, Cochin Hospital, Paris, France
| | - Yann Nguyen
- Internal Medicine Department, AP-HP, Referral Center for Rare Autoimmune and Systemic Diseases of Ile de France, Cochin Hospital, Paris, France
| | - Cécile Yelnik
- Univ. Lille, Inserm, CHU Lille, Service de Médecine Interne et d'Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du nord et Nord-Ouest de France (CeRAINO), U1167 RID-AGE, F-59000 Lille, France
| | - Véronique Le Guern
- Internal Medicine Department, AP-HP, Referral Center for Rare Autoimmune and Systemic Diseases of Ile de France, Cochin Hospital, Paris, France
| | - Marc Lambert
- Univ. Lille, Inserm, CHU Lille, Service de Médecine Interne et d'Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du nord et Nord-Ouest de France (CeRAINO), U1167 RID-AGE, F-59000 Lille, France
| | - Romain Paule
- Internal Medicine Department, AP-HP, Referral Center for Rare Autoimmune and Systemic Diseases of Ile de France, Cochin Hospital, Paris, France
| | - Eric Hachulla
- Univ. Lille, Inserm, CHU Lille, Service de Médecine Interne et d'Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du nord et Nord-Ouest de France (CeRAINO), U1167 RID-AGE, F-59000 Lille, France
| | - Luc Mouthon
- Internal Medicine Department, AP-HP, Referral Center for Rare Autoimmune and Systemic Diseases of Ile de France, Cochin Hospital, Paris, France
| | - Anastasia Dupré
- Internal Medicine Department, AP-HP, Referral Center for Rare Autoimmune and Systemic Diseases of Ile de France, Cochin Hospital, Paris, France
| | - Félix Ackermann
- Department of Internal Medicine and Clinical Immunology, Foch Hospital, Referral Center for Hypereosinophilic Syndromes, Suresnes, France
| | - Virginie Dufrost
- Vascular Medicine Division and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, CHRU Nancy, France
| | - Denis Wahl
- Vascular Medicine Division and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, CHRU Nancy, France
| | - Bertrand Godeau
- Department of Internal Medicine and Clinical Immunology, Mondor Hospital, Paris France
| | - Gaëlle Leroux
- Department of Internal Medicine and Clinical Immunology, AP-HP, La Pitié-Salpêtrière Hospital, Referral Center for Rare Autoimmune and Systemic Diseases, Paris, France; and Sorbonne University
| | - Ygal Benhamou
- Department of Internal Medicine and Clinical Immunology, Centre Hospitalier de Rouen, Rouen, France
| | - Estibaliz Lazaro
- Department of Internal Medicine and Clinical Immunology, Centre Hospitalier de Bordeaux, Bordeaux, France
| | - Eric Daugas
- Department of Nephrology, AP-HP, Bichat Hospital, Paris, France
| | - Holy Bezanahary
- Department of Internal Medicine and Clinical Immunology, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Arsène Mekinian
- Department of Internal Medicine and Clinical Immunology, APHP, Saint Antoine Hospital, Paris, France
| | - Jean-Charles Piette
- Department of Internal Medicine and Clinical Immunology, AP-HP, La Pitié-Salpêtrière Hospital, Referral Center for Rare Autoimmune and Systemic Diseases, Paris, France; and Sorbonne University
| | - Nathalie Morel
- Internal Medicine Department, AP-HP, Referral Center for Rare Autoimmune and Systemic Diseases of Ile de France, Cochin Hospital, Paris, France
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, AP-HP, Referral Center for Rare Autoimmune and Systemic Diseases of Ile de France, Cochin Hospital, Paris, France; Université Paris Cité, Center for Epidemiology and Statistics, Institut national de la santé et de la recherche médicale, French National Institute for Agricultural Research, Paris, France.
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Dupré A, Morel N, Yelnik C, Moguelet P, Le Guern V, Stammler R, Nguyen Y, Paule R, Dufrost V, Ackermann F, Benhamou Y, Godeau B, Lambert M, Duffau P, Mekinian A, Saadoun D, Mouthon L, Hachulla E, Maillard H, Levesque H, Morell-Dubois S, Leroux G, Piette JC, Chasset F, Costedoat-Chalumeau N. Cutaneous Involvement in Catastrophic Antiphospholipid Syndrome in a Multicenter Cohort of 65 Patients. JAMA Dermatol 2022; 159:62-67. [PMID: 36477813 PMCID: PMC9856595 DOI: 10.1001/jamadermatol.2022.5221] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Catastrophic antiphospholipid syndrome (CAPS) is a severe, rare complication of antiphospholipid syndrome (APS), but cutaneous involvement has not yet been adequately described. Objective To describe cutaneous involvement during CAPS, its clinical and pathological features, and outcomes. Design, Setting, and Participants This cohort study was a retrospective analysis of patients included in the French multicenter APS/systemic lupus erythematosus register (ClinicalTrials.gov: NCT02782039) by December 2020. All patients meeting the revised international classification criteria for CAPS were included, and patients with cutaneous manifestations were analyzed more specifically. Main Outcomes and Measures Clinical and pathological data as well as course and outcome in patients with cutaneous involvement during CAPS were collected and compared with those in the register without cutaneous involvement. Results Among 120 patients with at least 1 CAPS episode, the 65 (54%) with skin involvement (43 [66%] women; median [range] age, 31 [12-69] years) were analyzed. Catastrophic antiphospholipid syndrome was the first APS manifestation for 21 of 60 (35%) patients with available data. The main lesions were recent-onset or newly worsened livedo racemosa (n = 29, 45%), necrotic and/or ulcerated lesions (n = 27, 42%), subungual splinter hemorrhages (n = 19, 29%), apparent distal inflammatory edema (reddened and warm hands, feet, or face) (n = 15, 23%), and/or vascular purpura (n = 9, 14%). Sixteen biopsies performed during CAPS episodes were reviewed and showed microthrombi of dermal capillaries in 15 patients (94%). These lesions healed without sequelae in slightly more than 90% (58 of 64) of patients. Patients with cutaneous involvement showed a trend toward more frequent histologically proven CAPS (37% vs 24%, P = .16) than those without such involvement, while mortality did not differ significantly between the groups (respectively, 5% vs 9%, P = .47). Conclusions and Relevance In this cohort study, half the patients with CAPS showed cutaneous involvement, with a wide spectrum of clinical presentations, including distal inflammatory edema. Skin biopsies confirmed the diagnosis in all but 1 biopsied patient.
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Affiliation(s)
- Anastasia Dupré
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Nathalie Morel
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Cécile Yelnik
- Centre Hospitalo-Universitaire Claude Huriez, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Philippe Moguelet
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Tenon, Service d’Anatomopathologie, Paris, France
| | - Véronique Le Guern
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Romain Stammler
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Yann Nguyen
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Romain Paule
- Hôpital Foch, Service de Médecine Interne, Suresnes, France
| | - Virginie Dufrost
- Centre Hospitalier Régional et Universitaire de Nancy, Service de Médecine Vasculaire, Nancy, France
| | | | - Ygal Benhamou
- Normandie Université, UNIROUEN, U 1096, Centre Hospitalo-Universitaire, Service de Médecine Interne, Rouen, France
| | - Bertrand Godeau
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Mondor, Service de Médecine Interne, Créteil, France
| | - Marc Lambert
- Centre Hospitalo-Universitaire Claude Huriez, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Pierre Duffau
- Centre Hospitalo-Universitaire de Bordeaux, Service de Médecine Interne et Immunologie Clinique, Bordeaux, France
| | - Arsène Mekinian
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Centre Hospitalo-Universitaire Saint Antoine, service de médecine interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), Paris, France
| | - David Saadoun
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire La Pitié, Département de Médecine Interne et Immunologie Clinique, Paris, France
| | - Luc Mouthon
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Eric Hachulla
- Centre Hospitalo-Universitaire Claude Huriez, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Hélène Maillard
- Centre Hospitalo-Universitaire Claude Huriez, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Hervé Levesque
- Normandie Université, UNIROUEN, U 1096, Centre Hospitalo-Universitaire, Service de Médecine Interne, Rouen, France
| | - Sandrine Morell-Dubois
- Centre Hospitalo-Universitaire Claude Huriez, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Gaëlle Leroux
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire La Pitié, Département de Médecine Interne et Immunologie Clinique, Paris, France
| | - Jean-Charles Piette
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire La Pitié, Département de Médecine Interne et Immunologie Clinique, Paris, France
| | - François Chasset
- Sorbonne Université, Faculté de Médecine, Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Tenon, Service de Dermatologie, Paris, France
| | - Nathalie Costedoat-Chalumeau
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France,Université de Paris, Centre de Recherche Épidémiologie et Biostatistiques de Sorbonne Paris Cité, Paris, France
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