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Moyon Q, Mathian A, Papo M, Combes A, Amoura Z, Pineton de Chambrun M. Antiphospholipid Patients Admitted in the Intensive Care Unit: What Must The Rheumatologist Know? Curr Rheumatol Rep 2024; 26:269-277. [PMID: 38652403 DOI: 10.1007/s11926-024-01148-7] [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] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE OF THE REVIEW Antiphospholipid syndrome (APS) is a rare systemic autoimmune disorder that can escalate into a 'thrombotic storm' called the catastrophic antiphospholipid syndrome (CAPS), frequently requiring ICU admission for multiple organ failure. This review aims to offer insight and recent evidence on critically-ill APS patients. RECENT FINDINGS The CAPS classification criteria define this condition as the involvement of at least three organs/systems/tissues within less than a week, caused by small vessel thrombosis, in patients with elevated antiphospholipid antibodies levels. These criteria do not encompass the full spectrum of critically-ill thrombotic APS patients and they need to be cautiously used for the bedside diagnosis of CAPS. Thrombocytopenia is the laboratory hallmark of CAPS, sometimes dropping below 20G/L, but a complete thrombotic microangiopathy pattern is infrequent. Anticoagulation is the pivotal treatment for APS and CAPS, associated with improved outcome. Triple therapy - the combination of anticoagulation, high-dose corticosteroids, and either plasma exchange or intravenous immunoglobulins - remains the standard treatment for CAPS patients. Eculizumab, an anti-C5 monoclonal antibody, may be useful in refractory patients. Despite significant progress, CAPS mortality rate remains high. Its diagnosis and management are complex, requiring a close multidisciplinary cross talk between APS specialists and intensivists.
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Affiliation(s)
- Quentin Moyon
- Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- AP-HP, Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Paris, France
| | - Alexis Mathian
- AP-HP, Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Paris, France
- Inserm, Centre d'Immunologie Et Des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France
| | - Matthias Papo
- AP-HP, Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Paris, France
| | - Alain Combes
- Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Institut de Cardiométabolisme Et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
| | - Zahir Amoura
- AP-HP, Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Paris, France
- Inserm, Centre d'Immunologie Et Des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France
| | - Marc Pineton de Chambrun
- Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
- AP-HP, Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Paris, France.
- Inserm, Centre d'Immunologie Et Des Maladies Infectieuses (CIMI-Paris), Sorbonne Université, Paris, France.
- Institut de Cardiométabolisme Et Nutrition (ICAN), Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France.
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Lonati PA, Bodio C, Scavone M, Martini G, Pesce E, Bandera A, Lombardi A, Gerosa M, Franceschini F, Tincani A, Podda G, Abrignani S, Grifantini R, Cattaneo M, Borghi MO, Meroni PL. Production of anti-PF4 antibodies in antiphospholipid antibody-positive patients is not affected by COVID-19 vaccination. RMD Open 2022; 8:rmdopen-2021-001902. [PMID: 35131751 PMCID: PMC8822540 DOI: 10.1136/rmdopen-2021-001902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/08/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Antibodies against cationic platelet chemokine, platelet factor 4 (PF4/CXCL4), have been described in heparin-induced thrombocytopenia (HIT), but also in patients positive for antiphospholipid antibodies (aPL) even in the absence of heparin treatment and HIT-related clinical manifestations. Anti-PF4 antibodies have been recently described also in subjects who developed thrombosis with thrombocytopenia syndrome (TTS) in association with adenoviral vector-based, but not with mRNA-based, COVID-19 vaccines. OBJECTIVE To investigate whether COVID-19 vaccination affects the production of anti-PF4 antibodies in aPL-positive patients and in control groups. METHODS Anti-PF4 immunoglobulins were detected in patients' and controls' serum samples by ELISA and their ability to activate normal platelets was assessed by the platelet aggregation test. RESULTS Anti-PF4 were found in 9 of 126 aPL-positive patients, 4 of 50 patients with COVID-19, 9 of 49 with other infections, and 1 of 50 aPL-negative patients with systemic lupus erythematosus. Clinical manifestations of TTS were not observed in any aPL patient positive for anti-PF4, whose serum failed to cause platelet aggregation. The administration of COVID-19 vaccines did not affect the production of anti-PF4 immunoglobulins or their ability to cause platelet aggregation in 44 aPL-positive patients tested before and after vaccination. CONCLUSIONS Heparin treatment-independent anti-PF4 antibodies can be found in aPL-positive patients and asymptomatic carriers, but their presence, titre as well as in vitro effect on platelet activation are not affected by COVID-19 vaccination.
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Affiliation(s)
- Paola Adele Lonati
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Cusano Milanino, Italy
| | - Caterina Bodio
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Cusano Milanino, Italy
| | - Mariangela Scavone
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
| | - Giuliana Martini
- Hemostasis Central Laboratory, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Elisa Pesce
- Istituto Nazionale di Genetica Molecolare, Padiglione Romeo ed Enrica Invernizzi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Bandera
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Andrea Lombardi
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy.,Division of Rheumatology, ASST Gaetano Pini, Milano, Italy
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Gianmarco Podda
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
| | - Sergio Abrignani
- Istituto Nazionale di Genetica Molecolare, Padiglione Romeo ed Enrica Invernizzi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | - Renata Grifantini
- Istituto Nazionale di Genetica Molecolare, Padiglione Romeo ed Enrica Invernizzi, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Cattaneo
- Department of Health Sciences, Università degli Studi di Milano, Milano, Italy
| | - Maria Orietta Borghi
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Cusano Milanino, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy
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Markovic I, Debeljak Z, Bosnjak B, Marijanovic M. False positive immunoassay for heparin-induced thrombocytopenia in the presence of monoclonal gammopathy: a case report. Biochem Med (Zagreb) 2017; 27:030801. [PMID: 29180919 PMCID: PMC5696753 DOI: 10.11613/bm.2017.030801] [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] [Received: 05/18/2017] [Accepted: 09/19/2017] [Indexed: 11/09/2022] Open
Abstract
Heparin induced thrombocytopenia (HIT) is a life-threatening disorder which diagnosis depends on laboratory evaluation. The objective of this report is to present the impact of different laboratory methods for HIT detection on the diagnostic evaluation process. In this case, a 78-year old female patient previously diagnosed with monoclonal gammopathy of undetermined significance (MGUS) was administered with heparin for pulmonary embolism treatment. Patient’s initial diagnostic work-up (determination of platelet count and prothrombin time measurement for monitoring of pharmacotherapy) was followed by the clinical estimation of HIT likelihood by “4Ts” score, two immunoassays (ID-PaGIA Heparin/PF4 Antibody Test and ELISA PF4 IgG assay) and one functional test called high-performance liquid chromatography serotonin release assay (HPLC-SRA). The result of “4Ts” score indicated a low likelihood of HIT but persistent thrombocytopenia that appeared days after discontinuation of heparin therapy suggested delayed-onset HIT. Both immunoassays were positive for presence of HIT-autoantibodies, while the functional HPLC-SRA was negative. Since different methods gave opposing results, their interpretation required great attention. In comparison to the HPLC-SRA, immunoassays are prone to the analytical interferences associated with the presence of non-specific antibodies, which may lead to false positive results. In this case, where the patient is known to produce antibodies of undetermined significance, HIT was ruled out as the possible cause of persistent thrombocytopenia primarily due to the negative result of HPLC-SRA, which is not prone to this type of interferences, but also due to the low “4Ts” clinical score.
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Affiliation(s)
- Ivana Markovic
- Institute of Clinical Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Zeljko Debeljak
- Institute of Clinical Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Bojana Bosnjak
- Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia.,Institute of Transfusion Medicine, Osijek University Hospital, Osijek, Croatia
| | - Maja Marijanovic
- Institute of Transfusion Medicine, Osijek University Hospital, Osijek, Croatia
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Le Jeune C, Danin PE, Lega JC, Bohe J, Piriou V. [Anticoagulation and antiphospholipid syndrome: be careful to the catastrophe]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:806-809. [PMID: 22925943 DOI: 10.1016/j.annfar.2012.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 07/06/2012] [Indexed: 06/01/2023]
Abstract
Antiphospholipid syndrome associate thromboembolic events (arterial or venous), and presence of antiphospholipid antibodies, and require anticoagulation. A catastrophic variant may develop, resulting in multiorgan failure, with high mortality rate. This article presented a patient with antiphospholipid syndrome presenting a catastrophic antiphospholipide syndrome after anticoagulation suspending for gastrointestinal bleeding. Multidisciplinary management in intensive care unit and aggressive therapies (corticosteroids, anticoagulation, plasma exchange) were essential to rescue the patient.
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Affiliation(s)
- C Le Jeune
- Service de médecine interne - médecine vasculaire, CHU Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France.
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