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Aguirre Del-Pino R, Monahan RC, Huizinga TWJ, Eikenboom J, Steup-Beekman GM. Risk Factors for Antiphospholipid Antibodies and Antiphospholipid Syndrome. Semin Thromb Hemost 2024; 50:817-828. [PMID: 38228166 DOI: 10.1055/s-0043-1776910] [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: 01/18/2024]
Abstract
Persistence of serum antiphospholipid antibodies (aPL) is associated with a high thrombotic risk, both arterial and venous, and with pregnancy complications. Due to the potential morbidity and mortality associated with the presence of aPL, identifying and recognizing risk factors for the development of aPL and thrombosis in aPL carriers may help to prevent and reduce the burden of disease. Multiple elements are involved in the pathomechanism of aPL development and aPL-related thrombosis such as genetics, malignancy, and infections. This review will address the role of both well-known risk factors and their evolution, and of emerging risk factors, including COVID-19, in the development of aPL and thrombosis in aPL carriers.
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Affiliation(s)
- Rodrigo Aguirre Del-Pino
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Division of Rheumatology, A Coruña University Hospital (CHUAC), Galicia, Spain
| | - Rory C Monahan
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Jeroen Eikenboom
- Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Department of Rheumatology, Haaglanden Medical Center, The Hague, The Netherlands
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2
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Bernardi M, Spadafora L, Andaloro S, Piscitelli A, Fornaci G, Intonti C, Fratta AE, Hsu CE, Kaziròd-Wolski K, Metsovitis T, Biondi-Zoccai G, Sabouret P, Marzetti E, Cacciatore S. Management of Cardiovascular Complications in Antiphospholipid Syndrome: A Narrative Review with a Focus on Older Adults. J Clin Med 2024; 13:3064. [PMID: 38892776 PMCID: PMC11173304 DOI: 10.3390/jcm13113064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 05/19/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Antiphospholipid syndrome (APS), also known as Hughes syndrome, is an acquired autoimmune and procoagulant condition that predisposes individuals to recurrent thrombotic events and obstetric complications. Central is the role of three types of antiphospholipid antibodies that target phospholipid-binding proteins: lupus anticoagulant (LAC), anti-β2-glycoprotein I (β2-GPI-Ab), and anti-cardiolipin (aCL). Together with clinical data, these antibodies are the diagnostic standard. However, the diagnosis of APS in older adults may be challenging and, in the diagnostic workup of thromboembolic complications, it is an underestimated etiology. The therapeutic management of APS requires distinguishing two groups with differential risks of thromboembolic complications. The standard therapy is based on low-dose aspirin in the low-risk group and vitamin K antagonists in the high-risk group. The value of direct oral anticoagulants is currently controversial. The potential role of monoclonal antibodies is investigated. For example, rituximab is currently recommended in catastrophic antiphospholipid antibody syndrome. Research is ongoing on other monoclonal antibodies, such as daratumumab and obinutuzumab. This narrative review illustrates the pathophysiological mechanisms of APS, with a particular emphasis on cardiovascular complications and their impact in older adults. This article also highlights advancements in the diagnosis, risk stratification, and management of APS.
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Affiliation(s)
- Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Piazzale A. Moro 5, 00185 Rome, Italy; (L.S.); (G.F.); (C.I.)
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Piazzale A. Moro 5, 00185 Rome, Italy; (L.S.); (G.F.); (C.I.)
| | - Silvia Andaloro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy;
| | - Alessandra Piscitelli
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy; (A.P.); (A.E.F.); (C.-E.H.); (T.M.)
| | - Giovanni Fornaci
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Piazzale A. Moro 5, 00185 Rome, Italy; (L.S.); (G.F.); (C.I.)
| | - Chiara Intonti
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Piazzale A. Moro 5, 00185 Rome, Italy; (L.S.); (G.F.); (C.I.)
| | - Alberto Emanuele Fratta
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy; (A.P.); (A.E.F.); (C.-E.H.); (T.M.)
| | - Chieh-En Hsu
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy; (A.P.); (A.E.F.); (C.-E.H.); (T.M.)
| | - Karol Kaziròd-Wolski
- Institute of Medical Sciences, Collegium Medicum, Jan Kochanowski University, Al. IX Wieków Kielc 19A, 25-317 Kielce, Poland;
| | - Theodora Metsovitis
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy; (A.P.); (A.E.F.); (C.-E.H.); (T.M.)
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Via XXIV Maggio 7, 04100 Latina, Italy;
- Cardiology Unit, Santa Maria Goretti Hospital, Via L. Scaravelli, 04100 Latina, Italy
| | - Pierre Sabouret
- Heart Institute, Pitié-Salpétrière Hospital, Sorbonne University, 47-83 Bd. de l’Hôpital, 75013 Paris, France;
- National College of French Cardiologists, 13 Niepce, 75014 Paris, France
| | - Emanuele Marzetti
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy;
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Stefano Cacciatore
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy;
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Anastasiadi A, Bott C, Kitterer D, Roser E, Henkes H, Bäzner H, Wolf ME. Primary antiphospholipid syndrome in the elderly: Four strokes and mechanical thrombectomies until the diagnosis - A case report. Brain Circ 2024; 10:184-187. [PMID: 39036303 PMCID: PMC11259320 DOI: 10.4103/bc.bc_67_23] [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: 08/18/2023] [Revised: 11/14/2023] [Accepted: 11/22/2023] [Indexed: 07/23/2024] Open
Abstract
Antiphospholipid syndrome (APS) is known as a rare etiology of embolic ischemic stroke. In individuals below 50 years, up to 20% of strokes are associated with APS, whereas in patients >50 years, it is considered a very seldom cause of stroke. We describe the course of a 66-year-old white woman, who experienced four embolic strokes with large vessel occlusion over a period of 2 years, which were repeatedly and successfully treated by mechanical thrombectomy. Initially attributed to atrial fibrillation and treated with direct oral anticoagulants, the patient was finally diagnosed with primary APS due to isolated anti-beta 2-glycoprotein antibodies and successfully treated after several stroke recurrences. After initiation of Vitamin K antagonist therapy, no further strokes occurred. For recurrent embolic stroke despite oral anticoagulation, late-onset APS might be considered a rare etiology also in the elderly.
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Affiliation(s)
- Anatoli Anastasiadi
- Department of Neurology, Klinikum Stuttgart, Katharinen Hospital, Stuttgart, Germany
| | - Chiara Bott
- Department of Neurology, Klinikum Stuttgart, Katharinen Hospital, Stuttgart, Germany
| | - Daniel Kitterer
- Department of Nephrology, Klinikum Stuttgart, Katharinen Hospital, Stuttgart, Germany
| | - Elke Roser
- Department of Cardiology, Klinikum Stuttgart, Katharinen Hospital, Stuttgart, Germany
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Katharinen Hospital, Stuttgart, Germany
| | - Hansjörg Bäzner
- Department of Neurology, Klinikum Stuttgart, Katharinen Hospital, Stuttgart, Germany
- Department of Neurologische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Germany
| | - Marc E. Wolf
- Department of Neurology, Klinikum Stuttgart, Katharinen Hospital, Stuttgart, Germany
- Department of Neurologische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Germany
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Masson C, An Nguyen TT, Dufrost V, Audrain M, Hémont C, Agard C, Artifoni M, Connault J, Fouassier M, Hamidou M, Guedon AF, Wahl D, Zuily S, Espitia O. Antiphospholipid syndrome in patients over 65 years: A comparative study of clinical and biological features and thrombotic relapses. Lupus 2022; 31:1816-1823. [PMID: 36177950 DOI: 10.1177/09612033221130975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of the study was to describe clinical and biological characteristics and thrombotic relapses of patients diagnosed with antiphospholipid syndrome (APS) after the age of 65 years, in comparison with patients diagnosed with APS before 65. METHODS This retrospective multicenter study was performed to 2005 from 2017 and included patients diagnosed with APS after the age of 65 years, in accordance with Sydney criteria. We compared these patients with APS patients diagnosed before the age of 65 years, and with control thrombotic patients older than 65 years. RESULTS Fifty-eight APS patients over the age of 65 years were compared to 127 APS patients aged less than 65 and to 58 controls. In elderly APS versus younger APS, there was a male predominance (58.6% vs 36.2% p = .001); myocardial infarction and lower limb deep vein thrombosis (LLDVT) were more frequent in elderly, respectively, 12.1% versus 1.6% (p = .005), and 44.8% versus 29.9% (p = .048). Anticardiolipin antibody (aCL) IgM was more frequently found in old patients compared to younger patients (33.9% vs 18.1%, p = .02), contrary to lupus anticoagulant (LAC) (52.8% vs 66.9%, p = .02). Older patients were more often diagnosed with single positive APS (82.8% vs 59.8% p = .002). The thrombotic relapse free survival was lower in elderly APS patients (p = .044) compared to younger APS. Elderly APS patients had more recurrent arterial and venous thrombosis (p = .03) and had poorer overall survival (p = .004) than elderly controls. CONCLUSION In this study, APS was different in patients aged more than 65 years, with a male predominance and more myocardial infarctions and LLDVT at diagnosis. Single antiphopholipid positivity and aCL IgM were more frequent in older patients. Older patient with APS had more thrombotic recurrence during follow-up. Compared to elderly controls, elderly APS patients had more thrombosis recurrences and poorer survival.
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Affiliation(s)
- Colombe Masson
- Department of Internal and Vascular Medicine, 26922CHU de Nantes, France
| | - Thi T An Nguyen
- 26907INSERM UMR-S1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | | | - Marie Audrain
- Department of Immunology, 26922CHU de Nantes, France
| | | | - Christian Agard
- Department of Internal and Vascular Medicine, 26922CHU de Nantes, France.,Nantes Université
| | - Mathieu Artifoni
- Department of Internal and Vascular Medicine, 26922CHU de Nantes, France
| | - Jérôme Connault
- Department of Internal and Vascular Medicine, 26922CHU de Nantes, France
| | | | - Mohamed Hamidou
- Department of Internal and Vascular Medicine, 26922CHU de Nantes, France
| | - Alexis F Guedon
- Department of Internal and Vascular Medicine, 26922CHU de Nantes, France
| | - Denis Wahl
- Department of Vascular Medicine, 26920CHRU de Nancy, France
| | - Stéphane Zuily
- Department of Vascular Medicine, 26920CHRU de Nancy, France
| | - Olivier Espitia
- Department of Internal and Vascular Medicine, 26922CHU de Nantes, France.,Nantes Université
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Shi M, Gao W, Jin Y, Zhu J, Liu Y, Wang T, Li C. Antiphospholipid Syndrome-Related Pulmonary Embolism: Clinical Characteristics and Early Recognition. Front Cardiovasc Med 2022; 9:872523. [PMID: 35898271 PMCID: PMC9309373 DOI: 10.3389/fcvm.2022.872523] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/03/2022] [Indexed: 11/29/2022] Open
Abstract
Background Pulmonary thromboembolism is a common disease frequently encountered in the emergency room and has a high mortality rate. Antiphospholipid syndrome (APS) is a high-risk factor for recurrent pulmonary embolism (PE). It is critical to effectively administer anticoagulants to avoid the recurrence of thrombotic events. This study aims to identify the clinical characteristics of APS patients with PE (APS-PE) and to develop a risk score for determining the presence of APS in PE patients in the emergency situations. Methods We retrospectively enrolled 76 PE patients in this study, with 46 patients in the APS-PE group and 30 patients in the non-APS-PE group. We compared differences in demographics, laboratory parameters, and early mortality risk between the two groups. Risk factors for APS-PE were screened using logistic regression analysis. We also developed an early risk score using multivariate analysis weighted points proportional to the β- regression coefficient values and calculated the sensitivity and specificity for APS in PE patients. Results In the APS-PE group, we observed a higher proportion of males (43.6 vs. 20%), a higher proportion of low-risk patients (58.7 vs. 10%), lower levels of white blood cells and platelets (PLT), longer activated partial thromboplastin time (APTT), and a slight increase in D-dimer levels. Patients who were triple positive for antiphospholipid antibodies (aPLs) were younger. The APTT gradually increased as the number of positive aPLs increased. The risk factors for APS included male (OR = 5.565, 95% CI 1.176–26.341), decreased PLT (OR = 0.029, 95% CI 0.003–0.330), slightly increased D-dimer (OR = 0.089, 95% CI 0.019–0.426), and prolonged APTT (OR = 4.870, 95% CI 1.189–19.951). The risk score was named MPDA and included male, PLT, D-dimer and APTT, which can predict APS in PE patients with the AUC at 0.888 (95% CI 0.811–0.965). Conclusion The risk factors for APS in PE patients are male, low PLT, prolonged APTT and slightly increased D-dimer. The MPDA is a quantitative scoring system which is highly suggestive of APS in PE patients.
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Affiliation(s)
- Maojing Shi
- Trauma Center, Peking University People's Hospital, Beijing, China
| | - Weibo Gao
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Yuebo Jin
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Jihong Zhu
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Yuansheng Liu
- Department of Emergency, Peking University People's Hospital, Beijing, China
- Yuansheng Liu
| | - Tianbing Wang
- Trauma Center, Peking University People's Hospital, Beijing, China
- Tianbing Wang
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- *Correspondence: Chun Li
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Grimaud F, Yelnik C, Pineton de Chambrun M, Amoura Z, Arnaud L, Costedoat Chalumeau N, Hachulla E, Lambert M, Roriz M, Sibilia J, Papo T, Sacre K. Clinical and immunological features of antiphospholipid syndrome in the elderly: a retrospective national multicentre study. Rheumatology (Oxford) 2019; 58:1006-1010. [DOI: 10.1093/rheumatology/key437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/07/2018] [Indexed: 12/24/2022] Open
Affiliation(s)
- Felix Grimaud
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Cecile Yelnik
- Centre de référence des maladies auto-immunes systémiques rares du Nord et Nord-Ouest de France, Département de Médecine Interne, Hôpital Huriez, Centre Hospitalier Universitaire, Lille, France
| | - Marc Pineton de Chambrun
- Centre de référence du lupus, syndrome des antiphospholipides et autres maladies auto-immunes rares, Département de Médecine Interne, Hôpital Pitie Salpetrière, Université Pierre et Marie Curie, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Zahir Amoura
- Centre de référence du lupus, syndrome des antiphospholipides et autres maladies auto-immunes rares, Département de Médecine Interne, Hôpital Pitie Salpetrière, Université Pierre et Marie Curie, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Laurent Arnaud
- Centre de référence des maladies auto-immunes systémiques rares de l’Est et Sud-Ouest de France, Département de Rhumatologie, Hôpital de Hautepierre, Centre Hospitalier Universitaire, Strasbourg, France
| | - Nathalie Costedoat Chalumeau
- Centre de référence des maladies auto-immunes systémiques rares Ile-de-France, Département de Médecine Interne, Hôpital Cochin, Université Paris Descartes, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Eric Hachulla
- Centre de référence des maladies auto-immunes systémiques rares du Nord et Nord-Ouest de France, Département de Médecine Interne, Hôpital Huriez, Centre Hospitalier Universitaire, Lille, France
| | - Marc Lambert
- Centre de référence des maladies auto-immunes systémiques rares du Nord et Nord-Ouest de France, Département de Médecine Interne, Hôpital Huriez, Centre Hospitalier Universitaire, Lille, France
| | - Mélanie Roriz
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jean Sibilia
- Centre de référence des maladies auto-immunes systémiques rares de l’Est et Sud-Ouest de France, Département de Rhumatologie, Hôpital de Hautepierre, Centre Hospitalier Universitaire, Strasbourg, France
| | - Thomas Papo
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
- INSERM U1149, Université Paris Diderot, Laboratoire d’excellence INFLAMEX, PRES Sorbonne Paris Cité, Paris, France
- Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Université Paris Diderot, PRES Sorbonne Paris Cité, Paris, France
| | - Karim Sacre
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
- INSERM U1149, Université Paris Diderot, Laboratoire d’excellence INFLAMEX, PRES Sorbonne Paris Cité, Paris, France
- Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Université Paris Diderot, PRES Sorbonne Paris Cité, Paris, France
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7
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Na YS, Jang S, Hong S, Oh YM, Lee SD, Lee JS. Clinical Phenotype of a First Unprovoked Acute Pulmonary Embolism Associated with Antiphospholipid Antibody Syndrome. Tuberc Respir Dis (Seoul) 2019; 82:53-61. [PMID: 30574689 PMCID: PMC6304333 DOI: 10.4046/trd.2018.0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/22/2018] [Accepted: 10/16/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Antiphospholipid antibody syndrome (APS), an important cause of acquired thrombophilia, is diagnosed when vascular thrombosis or pregnancy morbidity occurs with persistently positive antiphospholipid antibodies (aPL). APS is a risk factor for unprovoked recurrence of pulmonary embolism (PE). Performing laboratory testing for aPL after a first unprovoked acute PE is controversial. We investigated if a specific phenotype existed in patients with unprovoked with acute PE, suggesting the need to evaluate them for APS. METHODS We retrospectively reviewed patients with PE and APS (n=24) and those with unprovoked PE with aPL negative (n=44), evaluated 2006-2016 at the Asan Medical Center. We compared patient demographics, clinical manifestations, laboratory findings, and radiological findings between the groups. RESULTS On multivariate logistic regression analysis, two models of independent risk factors for APS-PE were suggested. Model I included hemoptysis (odds ratio [OR], 12.897; 95% confidence interval [CI], 1.025-162.343), low PE severity index (OR, 0.948; 95% CI, 0.917-0.979), and activated partial thromboplastin time (aPTT; OR, 1.166; 95% CI, 1.040-1.307). Model II included age (OR, 0.930; 95% CI, 0.893-0.969) and aPTT (OR, 1.104; 95% CI, 1.000-1.217). CONCLUSION We conclude that patients with first unprovoked PE with hemoptysis and are age <40; have a low pulmonary embolism severity index, especially in risk class I-II; and/or prolonged aPTT (above 75th percentile of the reference interval), should be suspected of having APS, and undergo laboratory testing for aPL.
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Affiliation(s)
- Yong Sub Na
- Department of Pulmonary and Critical Care Medicine, Chosun University Hospital, Gwangju, Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Do Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Center for Pulmonary Hypertension and Venous Thrombosis, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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8
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Tana C, Lauretani F, Ticinesi A, Prati B, Nouvenne A, Meschi T. Molecular and Clinical Issues about the Risk of Venous Thromboembolism in Older Patients: A Focus on Parkinson's Disease and Parkinsonism. Int J Mol Sci 2018; 19:ijms19051299. [PMID: 29701703 PMCID: PMC5983741 DOI: 10.3390/ijms19051299] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 04/18/2018] [Accepted: 04/24/2018] [Indexed: 01/06/2023] Open
Abstract
Venous thromboembolism (VTE) is a common and potentially life-threatening condition which includes both deep-vein thrombosis (DVT) and pulmonary embolism (PE). VTE has a significant clinical and epidemiological impact in the elderly, and its incidence increases to more than 1% per year in older patients, suggesting the presence of specific age-related risk factors in this population. Immobilization seems to predominate as the main cause in patients admitted for medical acute illness in medicine wards, and there is evidence of a high risk in older patients with immobilization resulting from advanced forms of Parkinson’s disease (PD), regardless of the presence of an acute medical condition. In this review, we would to discuss the recent evidence on clinical, molecular and epidemiological features of VTE in older frail subjects focusing on patients with PD and parkinsonism. We also discuss some therapeutic issues about the risk prevention and we suggest a thorough comprehensive geriatric assessment that can represent an optimal strategy to identify and prevent the VTE risk in these patients.
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Affiliation(s)
- Claudio Tana
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
| | - Fulvio Lauretani
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
- Department of Medicine and Surgery, University-Hospital of Parma, 43126 Parma, Italy.
- Cognitive and Motor Center, Medicine and Geriatric-Rehabilitation Department of Parma, University-Hospital of Parma, 43126 Parma, Italy.
| | - Andrea Ticinesi
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
- Department of Medicine and Surgery, University-Hospital of Parma, 43126 Parma, Italy.
| | - Beatrice Prati
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
| | - Antonio Nouvenne
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
| | - Tiziana Meschi
- Internal Medicine and Critical Subacute Care Unit, Medicine and Geriatric-Rehabilitation Department, University-Hospital of Parma, 43126 Parma, Italy.
- Department of Medicine and Surgery, University-Hospital of Parma, 43126 Parma, Italy.
- Cognitive and Motor Center, Medicine and Geriatric-Rehabilitation Department of Parma, University-Hospital of Parma, 43126 Parma, Italy.
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9
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Riolo M, Giussani G, Scaccabarozzi C, Lunghi A, Salmaggi A. A case of recurrent stroke due to late onset antiphospholipid syndrome. Neurol Sci 2017; 38:2221-2222. [PMID: 28780708 DOI: 10.1007/s10072-017-3070-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 07/12/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Marianna Riolo
- Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche (BioNec), Università degli Studi di Palermo, Palermo, Italy.,Neuroscience Department- Neurology/Stroke Unit, Ospedale A. Manzoni, ASST Lecco, Italy
| | - G Giussani
- Neuroscience Department- Neurology/Stroke Unit, Ospedale A. Manzoni, ASST Lecco, Italy
| | - C Scaccabarozzi
- Neuroscience Department- Neurology/Stroke Unit, Ospedale A. Manzoni, ASST Lecco, Italy
| | - A Lunghi
- Neuroradiologia, Ospedale A. Manzoni, ASST Lecco, Italy
| | - Andrea Salmaggi
- Neuroscience Department- Neurology/Stroke Unit, Ospedale A. Manzoni, ASST Lecco, Italy.
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10
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Intractable headaches, ischemic stroke, and seizures are linked to the presence of anti-β2GPI antibodies in patients with systemic lupus erythematosus. PLoS One 2015; 10:e0119911. [PMID: 25781014 PMCID: PMC4362944 DOI: 10.1371/journal.pone.0119911] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 01/17/2015] [Indexed: 11/25/2022] Open
Abstract
Background Neuropsychiatric systemic lupus erythematosus (NPSLE) is a common and potentially fatal manifestation of SLE. Antiphospholipid antibodies (aPL) such as lupus anticoagulant (LA), anticardiolipin (aCL) and antibodies to β2glycoprotein I (anti-β2GPI), the most important aPL antigen, are thought to play a role in some forms of NPSLE. As of yet, their specific roles in NPSLE manifestations remain to be elucidated. Methodology/Principal Findings 57 SLE patients (53 women) were assessed for LA, aCL and anti-β2GPI twice, to determine persistent positivity. All patients were examined by neurology and psychiatry specialists. 69 healthy subjects were assessed as controls. NPSLE was diagnosed in 74% of patients. Headaches were the most prevalent manifestation of NPSLE (39%), followed by cerebrovascular disease (CVD) (23%), depressive disorders (19.0%), and seizures (14%). NPSLE and non-NPSLE patients showed comparable SLE activity and corticosteroid use. In 65% of patients neuropsychiatric manifestations preceded SLE diagnosis. aPL profiles of NPSLE patients and non-NPSLE patients were similar. Headaches and ischemic stroke were independently associated with anti-β2GPI-IgM (OR=5.6; p<0.05), and seizures were linked to anti-β2GPI-IgG (OR=11.3; p=0.01). Conclusions In SLE patients, neuropsychiatric manifestations occur frequently and early, often before the disease is diagnosed. Autoantibodies to β2GPI are linked to non-specific headaches, ischemic stroke and seizures, and show a better predictive value than aCL and LA. These findings may help to improve the diagnosis of NPSLE and should prompt further studies to characterize the role of anti-β2GPI in the pathogenesis of this condition.
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11
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Cherif Y, Jallouli M, Hriz H, Gouiaa R, Marzouk S, Snoussi M, Frikha F, Masmoudi H, Bahloul Z. Late-onset primary antiphospholipid syndrome in the elderly: a report of seven cases. Int J Rheum Dis 2014; 18:103-7. [PMID: 25530096 DOI: 10.1111/1756-185x.12494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM We describe the clinical profile of elderly with primary antiphospholipid syndrome (APS). METHODS Charts of seven elderly patients diagnosed with APS between 1996 and 2012 were retrospectively assessed. RESULTS The mean age at diagnosis was 77 ± 6 years (67-84 years). Two patients had experienced frequent miscarriages. Five patients presented with deep venous thrombosis of the lower limb, one had venous thrombosis of the upper limb and brachiocephalic vein and another had a cerebral ischemic stroke. The antiphospholipid antibodies tests revealed the presence of significant amounts of anticardiolipin antibodies, 12 weeks apart, twice in four patients. The antibodies to β2-glycoprotein 1 were positive twice in two patients and lupus anticoagulant in one of these. All patients were treated with heparin and long-term anti-vitamin K and thrombosis was cleared in all cases. Two patients presented with bleeding complications: hematuria and hematoma of the buttock in one patient and rectal bleeding in another case. Two elderly developed a colon cancer and lymphoma 1 year later. CONCLUSION In this report, we report on primary APS in the elderly, to discuss its prevalence and the clinical significance of positive antiphospholipid antibodies in subjects over the age of 65 years.
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Affiliation(s)
- Yosra Cherif
- Department of Internal Medicine, Hedi Chaker University Hospital, Sfax, Tunisia
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12
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Plasma antiphospholipid antibody levels in age-related macular degeneration. Can J Ophthalmol 2012; 47:264-8. [DOI: 10.1016/j.jcjo.2012.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 11/21/2011] [Accepted: 01/09/2012] [Indexed: 11/18/2022]
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13
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Tincani A, Filippini M, Scarsi M, Galli M, Meroni PL. European attempts for the standardisation of the antiphospholipid antibodies. Lupus 2009; 18:913-9. [DOI: 10.1177/0961203309106919] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
According to the Sydney criteria, antiphospholipid syndrome (APS) diagnosis is closely related to the demonstration of antiphospholipid antibodies (aPL) in patients sera. For this purpose, three different assays are conventionally accepted: lupus anticoagulant (LA), anticardiolipin (aCL) and anti-β2 glycoprotein I (β2GPI) antibodies. LA, described in the 1950s is a coagulation-based functional assay, which indirectly detects the presence of aPL. The aCL ELISA was developed in 1985; the identification of β2GPI as a major target of aPL, allowed the introduction of anti-β2GPI ELISA. Even if the diagnostic criteria for APS have been well defined, the laboratory detection of aPL is not always reproducible for many reasons. To achieve a univocal diagnostic definition of APS, efforts were made to reduce the inter- and/or intra-laboratory variability of the diagnostic tests. In this article, we analyse the studies performed to standardise aPL assays that were developed within the European Forum on Antiphospholipid Antibodies.
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Affiliation(s)
- A Tincani
- Unit of Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Italy
| | - M Filippini
- Unit of Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Italy
| | - M Scarsi
- Unit of Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Italy
| | - M Galli
- Department of Hematology, Ospedali Riuniti, Bergamo, Italy
| | - PL Meroni
- Department of Internal Medicine, IRCCS Istituto Auxologico Italiano and University of Milan, Italy
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14
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Bertolaccini ML, Khamashta MA. Diagnosis of antiphospholipid syndrome. Expert Rev Hematol 2008; 1:183-8. [PMID: 21082923 DOI: 10.1586/17474086.1.2.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antiphospholipid syndrome is a multisystem autoimmune disease, characterized by recurrent vascular thrombosis and/or pregnancy losses in the presence of persistently positive antiphospholipid antibodies. In clinical practice, testing for anticardiolipin antibodies and lupus anticoagulant is mandatory for the laboratory diagnosis of antiphospholipid syndrome. Identification of patients with antiphospholipid syndrome is important, as prophylactic anticoagulant therapy may prevent thrombosis from recurring, and treatment during pregnancy can improve fetal and maternal outcome.
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Affiliation(s)
- Maria Laura Bertolaccini
- Lupus Research Unit, The Rayne Institute, King's College London School of Medicine at Guy's, King's and St Thomas' Hospitals, St Thomas' Hospital, London, UK.
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15
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Baker WF, Bick RL. The clinical spectrum of antiphospholipid syndrome. Hematol Oncol Clin North Am 2008; 22:33-52, v-vi. [PMID: 18207064 DOI: 10.1016/j.hoc.2007.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Antiphospholipid syndrome (APS) is a disorder characterized by a wide variety of clinical manifestations. Virtually any organ system or tissue may be affected by the consequences of large- or small-vessel thrombosis. There is a broad spectrum of disease among individuals with antiphospholipid antibodies (aPL). Patients may exhibit clinical features suggesting APS but not fulfill the International Criteria for a "definite" diagnosis. Seronegative APS patients demonstrate typical idiopathic thromboses but aPL are not initially detected. Patients defined with definite APS demonstrate nearly identical sites of venous and arterial thrombosis, regardless of the presence or absence of systemic lupus erythematosus. Microangiopathic APS may present with isolated tissue and organ injury or as the overwhelming "thrombotic storm" observed in catastrophic APS.
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Affiliation(s)
- William F Baker
- David Geffen School of Medicine, Center for Health Sciences, University of California, Los Angeles, Los Angeles, CA, USA.
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16
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Goel A, Dey AB. Antiphospholipid syndrome: considerations in the elderly. INDIAN JOURNAL OF RHEUMATOLOGY 2007. [DOI: 10.1016/s0973-3698(10)60065-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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17
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Palomo I, Pinochet C, Alarcón M, Sandoval R, Gonzalez J, Monsalves F, Forastiero R. Prevalence of antiphospholipid antibodies in Chilean patients with rheumatoid arthritis. J Clin Lab Anal 2007; 20:190-4. [PMID: 16960897 PMCID: PMC6807502 DOI: 10.1002/jcla.20131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Antiphospholipid (aPL) antibodies found in patients with autoimmune diseases are also detected in those with inflammatory diseases. The purpose of this study was to examine the prevalence of these antibodies in patients with rheumatoid arthritis (RA), and to evaluate the association of these antibodies with thrombosis and/or other clinical characteristics of this inflammatory disorder. Eighty-four patients with RA and 82 normal controls were studied. Anticardiolipin (aCL), anti-beta(2) glycoprotein I (anti-beta(2)GPI), and antiprothrombin (aPT) antibodies and the lupus anticoagulant (LA) activity were determined. Seven out of 84 (8.3%) patients were positive for aCL, six out of 84 (7.2%) for anti-beta(2)GPI, and six out of 84 (7.2%) for aPT, while in controls the overall prevalence of aPL antibodies was 3.6% (3 out of 82). All patients and controls were LA negative. There was no correlation between the presence of aPL with thrombosis and/or other clinical features of the antiphospholipid syndrome. We found aPL antibodies in 19.1% (16 out of 84) of the patients with rheumatoid arthritis and this prevalence was statistically higher than in normal controls (P<0.003). In this study, the presence of aPL antibodies was not associated with the development of thrombosis and/or thrombocytopenia. Whether the presence of aPL antibodies implies an increased risk for thrombosis and atherosclerosis in these patients should be studied further.
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Affiliation(s)
- Iván Palomo
- Cardiovascular Disease Risk Factor Research Program, Department of Clinical Biochemistry and Immunohematology, Faculty of Health Sciences, Universidad de Talca, Talca, Chile.
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Ben-Ami D, Bar-Meir E, Shoenfeld Y. Stenosis in antiphospholipid syndrome: a new finding with clinical implications. Lupus 2007; 15:466-72. [PMID: 16898184 DOI: 10.1191/0961203306lu2335oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a variety of clinical manifestations. Recent studies suggest arterial stenosis is involved in APS. Furthermore, arterial stenosis may be a relevant and treatable cause for hypertension, renal, CNS and gastrointestinal manifestations of APS. Our objective was to overview the published data regarding arterial stenosis in APS--the clinical presentation, diagnosis, suggested therapies and the possible mechanisms. We searched PUBMED (1951-2006) reference lists for the role of arterial stenosis in APS. APS patients might present with arterial stenosis. Its recognition has important diagnostic and therapeutic implications. Articles suggest that anticoagulation treatment with INR above three may reverse the artery stenosis and achieve subsequent clinical improvement. Currently, there are no specific guidelines for the management of APS patients with arterial stenosis. The exact mechanism of arterial stenosis in APS patients remains unclear.
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Affiliation(s)
- D Ben-Ami
- Department of Medicine B and Center for Autoimmune Diseases, Sheba Medical Center (affiliated to Tel-Aviv University), Tel-Hashomer, Israel
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19
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Abstract
Systemic lupus erythematosus is an autoimmune multi-system disease of uncertain aetiology with highly variable clinical manifestations. Women of child-bearing age are most often affected; however, approximately 10-20% of cases occur in older patients. Elderly-onset lupus has been defined in various studies as onset of lupus after age 50-65 years. Menopause and changes in cellular immunity with aging may contribute to development of lupus in older adults. Many studies suggest that the clinical and serological features of elderly-onset lupus differ from those of lupus in younger patients. Arthritis, fever, serositis, sicca symptoms, Raynaud's syndrome, lung disease and neuropsychiatric symptoms are more common in patients with elderly-onset lupus, while malar rash, discoid lupus and glomerulonephritis are less common in elderly-onset patients compared with younger lupus patients. Most elderly-onset lupus patients have a positive anti-nuclear antibody test, but the prevalence of anti-double-stranded DNA and hypocomplementaemia is lower in elderly-onset patients than in younger patients. Rheumatoid factor, anti-Ro/Sjögren's syndrome (SS) A and anti-La/SSB are more often positive in elderly-onset patients. The diagnosis of elderly-onset lupus may be delayed for many months: insidious onset, low prevalence and similarity to other more common disorders make the diagnosis of lupus challenging in this population. Treatment of lupus in the elderly may be complicated by co-morbidities and increased risk of toxicities from usual treatments. Optimal management of elderly-onset lupus is empiric because of a lack of randomised controlled studies. However, the approach to treatment is similar regardless of the age of the patient. This article discusses the prevalence, clinical course, serological features, prognosis and treatment of elderly-onset systemic lupus erythematosus.
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Affiliation(s)
- Deana Lazaro
- Department of Medicine, Division of Rheumatology, SUNY Downstate Medical Center, Brooklyn, New York, USA.
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20
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Ruiz-Irastorza G, Khamashta MA. Antiphospholipid syndrome: treatment controversies. ACTA ACUST UNITED AC 2006. [DOI: 10.2217/17460816.1.3.345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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Paccalin M, Manic H, Bouche G, Landron C, Mercié M, Boinot C, Gombert JM, Roblot P, Dighiero P. Antiphospholipid syndrome in patients with retinal venous occlusion. Thromb Res 2006; 117:365-9. [PMID: 16461072 DOI: 10.1016/j.thromres.2005.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2005] [Revised: 03/29/2005] [Accepted: 03/30/2005] [Indexed: 11/20/2022]
Abstract
INTRODUCTION We conducted a prospective study to determine the prevalence and the prognosis of antiphospholipid syndrome (APS) in patients with retinal venous occlusion (RVO). PATIENTS Consecutive patients presenting with retinal vein occlusion were screened for vascular risk factors (diabetes mellitus, hypertension, hyperlipidemia) and for antiphospholipid antibodies (aPL): anticardiolipin (aCL), anti-beta2-glycoprotein I, and lupus anticoagulant. Patients with a serum sample positive for aPL returned at least 6 weeks later for a new screening to determine the prevalence of antiphospholipid syndrome. All patients were followed to determine the outcome. RESULTS Sixty-eight patients presented with RVO, 16 had vascular risk factors for RVO. After two screenings for aPL, nine cases of antiphospholipid syndrome associated with RVO were diagnosed (13.2%). Eight patients were over age 50 years and none had a previous thrombotic event before RVO. All patients were treated with aspirin (160 mg/day). With a mean follow-up of 26.1+/-8.2 months (range, 16-36 months), there were no recurrences. CONCLUSION Retinal venous occlusion is multifactorial in origin. In patients aged 50 years and older, without previous thrombotic event, aPL might not be predictive of recurrences and treatment with aspirin might be sufficient. In such patients, the routine screening for aPL does not appear warranted, but a randomized study should be conducted to really ascertain the pathogenic role of aPL and the most appropriate treatment in RVO.
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Affiliation(s)
- M Paccalin
- Department of Internal Medicine, University hospital La Milétrie, Poitiers, France.
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22
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Abstract
The incidence of thrombosis--arterial and venous--increases with age. This is the case for atheromatous diseases, atrial fibrillation and even venous thromboembolic disease. Ischemic heart disease is the most common cause of death in the elderly. Atrial fibrillation, an independent risk factor for cerebral vascular accidents, affects around 10% of persons older than 80 years. The incidence of venous thromboembolic disease increases with age, reaching 12.5 per 1000 people older than 75 years, compared with 5 per 1000 aged 60-75 and 2.5 per 1000 aged 40-59. Elderly persons often have two or more cardiovascular or venous thromboembolic risk factors and thus a still higher risk of thrombotic events. Their risk of thrombosis justifies the systematic search for acquired risk factors to assess the level of risk and take appropriate prevention measures.
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Affiliation(s)
- I Mahé
- Service de Médecine A, Hôpital Lariboisière, Paris (75).
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23
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Meroni PL, Mari D, Monti D, Coppola R, Capri M, Salvioli S, Tincani A, Gerli R, Franceschi C. Anti-beta 2 glycoprotein I antibodies in centenarians. Exp Gerontol 2004; 39:1459-65. [PMID: 15501015 DOI: 10.1016/j.exger.2004.08.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2004] [Revised: 08/05/2004] [Accepted: 08/13/2004] [Indexed: 11/20/2022]
Abstract
BACKGROUND Non-organ-specific autoantibodies are present in centenarians without evidence of autoimmune diseases but conflicting or no data on anti-phospholipid and anti-phospholipid binding proteins were reported. OBJECTIVE To investigate the presence and antigen specificity of anti-phospholipid and anti-phospholipid binding proteins in centenarians. METHODS Seventy-seven centenarians, 70 adult controls, 65 unselected elderly subjects, and 38 old SENIEUR volunteers were investigated. Anti-cardiolipin, anti-human beta 2 glycoprotein I, and lupus anticoagulant were detected. Antigen specificity was assayed against plates coated with anionic, neutral and cationic phospholipids and beta 2 glycoprotein I-dependence was also evaluated. RESULTS 54.3% of the centenarians were positive for IgG and 8.6% for IgM anti-beta 2 glycoprotein I antibodies, while only 20.7% centenarians were positive for anti-cardiolipin IgG and 2.59% for IgM; none resulted positive for lupus anticoagulant. Anti-cardiolipin positive sera cross-reacted with negatively charged phospholipids and displayed decreased binding to serum-free cardiolipin-coated plates that was restored by human beta 2 glycoprotein I or fetal calf serum. CONCLUSIONS Centenarians display high reactivity against human beta 2 glycoprotein I but low binding to the bovine molecule in the anti-cardiolipin assay. In spite of the presence of antibodies comparable to those found in patients with the anti-phospholipid syndrome, no vascular events were reported suggesting the presence of unknown protective factors and/or the lack of triggering factors.
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Affiliation(s)
- P L Meroni
- Allergy, Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, University of Milan, IRCCS Istituto Auxologico Italiano, Via G. Spagnoletto 3, 20149 Milan, Italy.
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Lavalle-Graef A, Villegas-Acosta L, Lavalle C. Trends of anticardiolipin antibodies after low-dose methylprednisolone and cyclophosphamide treatment of systemic lupus erythematosus. Arch Med Res 2004; 35:421-7. [PMID: 15610913 DOI: 10.1016/j.arcmed.2004.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2003] [Accepted: 05/07/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND The aim of the study is to analyze retrospectively the effect of low-dose methylprednisolone (MP) and cyclophosphamide (CYC) pulse therapy on anticardiolipin antibodies (aCL) serum levels in patients with systemic lupus erythematosus (SLE). METHODS For aCL determinations, a beta2-glycoprotein I-dependent enzyme-linked immunosorbent test (ELISA) was performed. Lupus anticoagulant was investigated by Russell venom time with platelet neutralization. Antinuclear antibodies were performed by standardized methods. All SLE patients (from a total of 137) with aCL determinations who were assayed before and after MP and CYC pulse therapy were included in the study. RESULTS Nine patients had aCL determinations before and after MP-CYC pulse therapy. All active patients with SLE improved clinically without severe MP-CYC side effects; 21 had IgG-aCL determinations, and 19 IgM-aCL determinations (40 assays) were performed in all nine patients during the observation period (zero time to 21 months). Three patients had secondary antiphospholipid syndrome (APLS)-related clinical manifestations. In all patients, IgG aCL antibodies decreased significantly (p <0.05). CONCLUSIONS Decrease of IgG aCL serum levels as a consequence of the MP-CYC therapy herein reported might help to redefine previous concepts with regard to modulation of antiphospholipid antibody (aPL) immune response by immunosuppressive therapy. These findings might also have prognostic and therapeutic implications in SLE, on pregnancy in SLE, and in antiphospholipid syndrome (APL) as well, although prospective studies are required.
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Ishikura K, Wada H, Kamikura Y, Hattori K, Fukuzawa T, Yamada N, Nakamura M, Nobori T, Nakano T. High prevalence of anti-prothrombin antibody in patients with deep vein thrombosis. Am J Hematol 2004; 76:338-42. [PMID: 15282665 DOI: 10.1002/ajh.20124] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The present study was designed to determine the prevalence of lupus anticoagulant (LA) antibody and several antibodies for antiphospholipid syndrome (APS) in patients with deep vein thrombosis (DVT)/pulmonary embolism (PE) (n = 48), cerebral thrombosis (CT, n = 30), systemic lupus erythematosus (SLE, n = 22), and idiopathic thrombocytopenic purpura (ITP, n = 30). The presence of antibodies was examined by using the respective ELISA kits. LA was positive in 38.6% of patients with DVT/PE, suggesting that LA is one of the most important risk factors in DVT/PE. The highest prevalence of anti-beta(2) glycoprotein I (beta(2)GPI) IgG was in CT and SLE, followed by DVT, and none in ITP and healthy volunteers (control, n = 40), suggesting that it is related to thrombosis, particularly arterial thrombosis. The highest prevalence of anti-prothrombin (aPT) IgG antibody was in DVT, followed by CT and SLE, and none in ITP and the control, suggesting that it is related to thrombosis, especially venous thrombosis. The highest prevalence of antiphospholipid (aPL) IgG was in DVT, CT, and SLE, but 0% in ITP and control. On the other hand, aPL IgM, anti-annexin V IgG, and anti-annexin V IgM were positive in patients both with and without thrombosis, suggesting that they are not related to thrombosis. Our results indicated that among the anti-phospholipid antibodies, LA is the most sensitive marker for APS while anti-beta(2)GPI IgG, aPT IgG, and aPL IgG are risk factors for thrombosis. In particular, aPT IgG is a significant marker for DVT/PE.
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Affiliation(s)
- Ken Ishikura
- First Department of Internal Medicine, Mie University School of Medicine, Tsu, Mie, Japan
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Ramos-Casals M, García-Carrasco M, Brito MP, López-Soto A, Font J. Autoimmunity and geriatrics: clinical significance of autoimmune manifestations in the elderly. Lupus 2004; 12:341-55. [PMID: 12765297 DOI: 10.1191/0961203303lu383ed] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The immune system undergoes continuous morphologic and functional changes throughout the years, and it is now believed that the immune response has its peak function in puberty and gradually decreases with age (immunosenescence). Recent studies in healthy octogenarian patients suggest that the immune system, instead of suffering a generalized deterioration, undergoes a remodelling/readjustment of its major functions. Increase in two contrasting phenomena coexist in immunosenescence: on the one hand, a decrease in the capacity of the immune response and, on the other hand autoantibody production. The possible consequences of this progressive 'ageing' of the immune system are the increase in autoimmune phenomena, incidence of neoplasia and predisposition to infections. The study of autoimmune manifestations in elderly populations should be considered a priority for future medical research because of increasing life expectancy, especially in developed countries. This review analyses the main immune disorders associated with immunosenescence, the prevalence and clinical significance of autoantibodies in the elderly and the clinical expression of the main autoimmune diseases in older patients.
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Affiliation(s)
- M Ramos-Casals
- Department of Autoimmune Diseases, Clinical Institute of Infections and Immunology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.
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André M, Delèvaux I, Amoura Z, Corbi P, Courthaliac C, Aumaître O, Piette JC. Ovarian vein thrombosis in the antiphospholipid syndrome. ACTA ACUST UNITED AC 2004; 50:183-6. [PMID: 14730615 DOI: 10.1002/art.11435] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Ovarian vein thrombosis (OVT) is an unusual condition mainly observed during the postpartum period. It has not been reported to date in the antiphospholipid syndrome. Two female patients with definite antiphospholipid syndrome, ages 33 years and 73 years, were diagnosed as having OVT by computed tomography (CT) scan, according to the radiologic criteria described by Zerhouni et al. In 1 of the women, the left vein was affected by OVT, while in the other woman, the right vein was affected. One of the patients had a pulmonary embolism; the diagnosis of OVT was established after she underwent a cesarean section and a right atrium thrombectomy. The other patient had no vascular manifestations. OVT was asymptomatic in both patients. Searches for associated thrombophilic states yielded negative results. With the continuation of anticoagulation therapy, the 2 patients have remained in good condition. Resolution of the OVT was observed in the patient who underwent a CT scan during followup. To our knowledge, this is the first report of OVT occurring in the antiphospholipid syndrome. Given that it may develop in the absence of pelvic clinical manifestations, this complication may be underdiagnosed.
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Affiliation(s)
- Marc André
- Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
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28
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Tincani A, Allegri F, Balestrieri G, Reber G, Sanmarco M, Meroni P, Boffa MC. Minimal requirements for antiphospholipid antibodies ELISAs proposed by the European Forum on antiphospholipid antibodies. Thromb Res 2004; 114:553-8. [PMID: 15507291 DOI: 10.1016/j.thromres.2004.06.035] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2004] [Revised: 06/20/2004] [Accepted: 06/23/2004] [Indexed: 10/26/2022]
Abstract
Antiphospholipid ELISAs are part of the Antiphospholipid Antibodies Syndrome classification criteria, having the same diagnostic value as lupus anticoagulant. However, sometimes their results appear scarcely meaningful especially when wide metanalyses studies are performed, probably because of their well-known inter-laboratory variability. The application of a common protocol was shown to improve the test reproducibility, but this observation did not have any influence on the routine performances. After discussion among experts at the European level, we identified four conditions named "minimal requirements" considered useful to decrease the inter-laboratory variability: (1) to run the samples in duplicate; (2) to determine the cut off level in each laboratory analysing at least 50 samples from normal subjects, possibly age- and sex-matched with the patient population usually attending the Centre; (3) to calculate the cut-off level in percentiles; (4) to use stable external control in the tests. A collaborative study involving 36 European centres proved that the use of monoclonal anti-beta2 glycoprotein I antibodies, HCAL (IgG) and EY2C9 (IgM) as standards, can help to reduce the inter-laboratory coefficient of variation both in anticardiolipin (aCL) and anti-beta2GPI (anti-beta2 glycoprotein I) ELISA. Therefore, we propose HCAL and EY2C9 as external controls, but other monoclonal or polyclonal preparations may be considered. During an interactive workshop held last May in Italy, 16 companies producing these tests agreed to consider the introduction of the "requirements" in their products. We suggest to adopt these "requirements" particularly in clinical studies, in order to compare more easily the literature data.
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Affiliation(s)
- Angela Tincani
- Rheumatology and Clinical Immunology, Ospedale Civile di Brescia, Piazza Spedali Civili 1, 25125 Brescia, Italy.
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Abstract
The antiphospholipid (aPL) antibody syndrome is an autoimmune condition in which vascular thrombosis and/or recurrent pregnancy losses occur in patients with laboratory evidence for antibodies that bind to phospholipids. There have been significant advances in the recognition of the role of phospholipid-binding cofactors, primarily beta2GPI, as the true immunologic targets of the antibodies. Recent evidence suggests that the antibodies disrupt phospholipid-dependent anticoagulant mechanisms and/or that aPL antibodies induce the expression of procoagulant and proadhesive molecules on endothelial cells. Current diagnosis is based on clinical findings and empirically derived tests, such as assays for antibodies that bind to phospholipids or putative cofactors and coagulation assays that detect inhibition of phospholipid-dependent coagulation reactions. Current treatment relies primarily on anticoagulant therapy. Research advances are expected to bring mechanistically based diagnostic tests and improved therapy that target the roots of the disease process.
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Affiliation(s)
- Jacob H Rand
- Department of Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA.
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Gaujard S, Broussolle C, Cathebras P, Dupond JL, Massot C, Ninet J, Perrot H, Durand DV, Rousset H. [Systemic lupus erythematosus with disease onset after age 65]. Rev Med Interne 2003; 24:288-94. [PMID: 12763174 DOI: 10.1016/s0248-8663(03)00052-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Systemic lupus erythematosus with disease-onset in the elderly has rarely been studied (only one report about 21 patients with disease onset at 65 and older). Is the management of this pathology modified in this population? METHODS Seventeen hospitalised cases of lupus patients with disease onset at 65 or older are retrospectively reported between 1988 and 2000. The results are compared with those of younger subjects. RESULTS The female to male ratio is 1.83. Mean age at disease onset is 71.9 +/- 3.5 years. Mean duration of follow-up is 3.5 +/- 2.4 years. Main initial symptoms are: deterioration of general status (41%), arthritis (35%), cutaneous manifestations (35%), thrombo-embolism (24%) and pleuritis (18%). Malar rash is uncommon (12%). Nephropathy is never a revealing symptom and is rarely serious during the disease's evolution. Like in neurologic manifestations, the etiology has to be discussed in relation to associated co-morbidities. Concerning haematologic features, lymphopenia is found in 82% of the cases with a questionable specificity. Antinuclear antibodies are constant, anti-dsDNA antibodies are found in 82% of the cases, antibodies to extractable nuclear antigens in 50%, and anticoagulant circulating activity in 59%. Prognosis is difficult to assess in such a limited series but 5-years survival probability is 83%. Glucocorticoid lead to 50% of major complications. CONCLUSIONS This study focuses on the particular initial manifestations of systemic lupus erythematosus in the elderly (deterioration of general status, thrombosis, unusual cutaneous symptoms), and on the specificity of differential diagnosis and treatment.
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Affiliation(s)
- S Gaujard
- Hôpital gériatrique Antoine-Charial, centre hospitalier universitaire de Lyon, 40, avenue de la Table-de-Pierre, 69340 Francheville, France.
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Magy N, Gil H, Racadot E, Dupond JL. [Relative value of different antiphospholipid antibodies detected in a department of internal medicine: retrospective study of 124 patients]. Rev Med Interne 2002; 23:696-702. [PMID: 12360751 DOI: 10.1016/s0248-8663(02)00644-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE The value of antiphospholipid antibodies (aPL) detected in the sera of the patients of an Internal Medicine department is not univocal and is still much debated. To test the contribution of such new markers, we reviewed the records of patients having antiphospholipid antibodies detected between 1996 and 1997. METHODS One hundred and twenty four patients, having at least one of these two aPL: lupus anticoagulant (LA), anticardiolipin antibodies (aCL), or one of these two anti-proteins: anti-beta 2glycoprotéin I antibodies (anti-beta 2GPI) or anti-prothrombin antibodies (aPT), were studied. LA was detected by a PTT-LA technique and aCL, anti-beta 2GPI and aPT by ELISA-sandwich techniques. For each patient we recorded sex, age, personal and familial history of thrombosis, fetal losses and systemic disease, the reason of aPL detection, the final diagnosis, activated partial thromboplastin time (aPTT), platelets count and type of aPL. RESULTS The population was composed of 77 women (62%) and 47 men (38%) with a mean age of 54 years [12-92 years]. A thrombocytopenia was strongly correlated to aCL presence (OR = 6.15 et p = 0.03). The reason of aPL detection was venous thrombosis, recurrent fetal losses, systemic disease, infectious disease or fortuitous discovery of a prolonged aPTT. The final diagnosis was a systemic disease in 57% of cases, an infectious disease in 14.5%, a thrombosis in 4.5% and a neoplasia in 3%. LA was detected in 54% of patients, aCL in 39.5%, anti-beta 2GPI in 23% and aPT in 31%. No relationship between the aPTT value and the type of aPL could be established. CONCLUSION Our study shows that familial histories of venous thrombosis or systemic disease are useful to enhance antiphospholipid antibodies detection; that LA is mostly associated to systemic and infectious diseases; that aCL and anti-beta 2GPI are predominant in case of venous thrombosis and that thrombocytopenia has to enhance aCL detection and the discussion about a possible APS.
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Affiliation(s)
- N Magy
- Service de médecine interne et immunologie clinique, CHU Jean-Minjoz, 2, boulevard Fleming, 25030 Besançon, France
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Dobado-Berrios PM, López-Pedrera C, Velasco F, Cuadrado MJ. The role of tissue factor in the antiphospholipid syndrome. ARTHRITIS AND RHEUMATISM 2001; 44:2467-76. [PMID: 11710702 DOI: 10.1002/1529-0131(200111)44:11<2467::aid-art426>3.0.co;2-u] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Liozon E, Loustaud V, Jauberteau MO, Jaccard A, Soria P, Bordessoule D, Julia A, Vidal E. [Non-simultaneous malignant lymphoma and antiphospholipid syndrome: 4 cases]. Rev Med Interne 2001; 22:360-70. [PMID: 11586520 DOI: 10.1016/s0248-8663(01)00348-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We report four cases of non-synchronous antiphospholipid syndrome (APS) and malignant lymphoma, which highlight the complex relationship that seems to exist between these illnesses. METHODS In a retrospective study conducted in two departments (internal medicine and clinical hematology) of a university hospital, we collected all observations of patients with both APS and malignant lymphoma diagnosed throughout the past decade. RESULTS An association of APS with malignant lymphoma was recorded in three female and one male patient, median age 42.5 years at the time of diagnosis of the first disease. In each case, the primary APS was diagnosed, with arterial thrombotic events in three cases and venous thrombotic events in one case. One patient had isolated IgG anticardiolipin antibody, whereas the others had a combination of IgG anticardiolipin antibody and lupus anticoagulant with or without IgG anti-beta 2 glycoprotein I antibody. One patient also had an acquired inhibitor to factor VIII:C and a chronic C virus hepatitis. The mean time apparently separating the two illnesses ranged from 18 months to 9 years, but in two cases the diagnosis of APS was delayed due to a progressive, atypical, neurological onset. In two instances, the APS took place at a distance from a cured malignant lymphoma (Hodgkin's disease and nodal large cell B-cell lymphoma), whilst in the others it preceded a B-cell lymphoma (nodal and cutaneous, small cells and primary hepatic, large cells). Treatment resulted in complete haematological response in both cases, with disappearance of anticardiolipin antibody and lupus anticoagulant in the latter following a double autologous peripheral blood stem cell transplantation. In addition, late carcinomas (breast, kidney, thyroid) were seen in two patients. CONCLUSIONS Our data indicate that the diagnosis of a malignant lymphoma should be considered in patients with a primary APS and peripheral lymph node enlargement or unexplained constitutional symptoms. Conversely, a late onset of arterial or venous thrombotic diathesis after a malignant lymphoma may indicate not only late relapse of malignant lymphoma but also a subsequent APS.
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Affiliation(s)
- E Liozon
- Service de médecine interne A, hôpital Dupuytren, CHU, 2, rue Martin-Luther-King, 87042 Limoges, France
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Cuadrado MJ, Khamashta MA. The anti-phospholipid antibody syndrome (Hughes syndrome): therapeutic aspects. Best Pract Res Clin Rheumatol 2000; 14:151-63. [PMID: 10882220 DOI: 10.1053/berh.1999.0083] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite the enormous amount of work focused on the pathogenesis and clinical manifestations of the Hughes or anti-phospholipid syndrome (APS), there is little published on management. Usually, the diagnosis of APS is made after the first thrombotic event, when a thrombophilia screen is performed. These patients have a high risk of recurrent thromboses and current therapy centres on the use of thromboprophylaxis with warfarin. However, a number of clinical questions keep recurring: do arterial and venous thrombosis require the same intensity of anti-coagulation? When should warfarin be stopped? Should patients who develop thrombosis when other risk factors (oral contraceptive pill, prolonged resting etc.) are present be treated like those without any risk factors but the presence of anti-phospholipid antibodies (aPL)? How to manage a patient with recurrent thrombosis despite a high intensity anti-coagulation (International normalized ratio (INR) between 3.0-4.0)? Since many of the patients with aPL are fertile women, a substantial group of patients are diagnosed after recurrent pregnancy loss. Low-dose aspirin for those patients without previous thrombosis and aspirin plus heparin for patients with a history of thrombotic events are the current therapeutic options. However, some questions remain unanswered: does the addition of heparin to low-dose aspirin in women with first trimester recurrent miscarriage but without previous thrombosis improve foetal outcome over and above aspirin alone? Which is the best therapeutic regime during pregnancy for patients with aPL-associated stroke? When should high-dose intravenous gammaglobulin be considered? Finally, very little is known about the risk of thrombosis in individuals positive for aPL but still free of thrombosis. Should these individuals receive any treatment? If so, which one? In this review we attempt to address some of these questions taking into account available data from retrospective and prospective studies and our own clinical experience.
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Affiliation(s)
- M J Cuadrado
- Lupus Research Unit, St. Thomas' Hospital, London, UK
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Crétel E, Cacoub P, Huong DL, Gompel A, Amoura Z, Piette JC. Massive ovarian haemorrhage complicating oral anticoagulation in the antiphospholipid syndrome: a report of three cases. Lupus 1999; 8:482-5. [PMID: 10483020 DOI: 10.1177/096120339900800614] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report three cases of severe haemorrhagic rupture of luteal ovarian cyst requiring surgical haemostasis in young women treated with long-term oral anticoagulation for antiphospholipid syndrome (APS) who used no contraception. At the time of bleeding, the international normalized ratios were 3.78, 4.24, and 7.11. Anticoagulation was resumed post-operatively, in association with antigonadotropic progestins to induce ovulatory suppression. A systematic use of these progestins should probably be discussed in young women receiving long-term warfarin for APS. Ovarian haemorrhage must be considered when such patients develop acute abdominal pain.
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Affiliation(s)
- E Crétel
- Service de Médecine Interne, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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Ranke C, Trappe HJ. [Angiology update]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 1999; 94:251-63. [PMID: 10408187 DOI: 10.1007/bf03045049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C Ranke
- Medizinische Klinik II (Schwerpunkte Kardiologie und Angiologie), Universitätsklinik Marienhospital Herne, Ruhr-Universität Bochum.
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Abstract
A workshop to be held in Sapporo will attempt to upgrade criteria for the antiphospholipid syndrome (APS). These criteria should probably be based on a scoring system using both clinical and biological items. Clinical criteria could be categorized between 'major', that is thrombosis or obstetrical criteria, and 'minor', to be selected among livedo, heart valve lesions, chorea, adrenal hemorrhage, thrombocytopenia, and others. A similar approach could be proposed for biological criteria, with persistent strong LA, high IgG aCL or antibodies to beta2GPI as major criteria if the workshop accepts antibodies directed to co-factors as APS criteria. Minor criteria could include IgM aCL, low/medium IgG aCL, and VDRL. Whether anti-prothrombin, anti-oxidised LDL, and M5 anti-mitochondrial antibodies should be added to the minor criteria, is open to discussion. In our mind, other parameters should be taken into account such as: young age--a method to avoid the questionable exclusion of arteriosclerosis in cases of arterial thrombosis--and the presence of personal and/or first-degree familial features of auto-immunity. Lastly, a differential diagnosis section is probably needed.
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Affiliation(s)
- J C Piette
- Service de Médecine Interne, Hôpital Pitié-Salpêtrière, Paris.
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Piette JC, Amoura Z, Wechsler B, Frances C. [Neurological manifestations of antiphospholipid syndrome]. Rev Med Interne 1998; 19 Suppl 1:39S-45S. [PMID: 9789526 DOI: 10.1016/s0248-8663(98)80028-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- J C Piette
- Service de médecine interne, groupe hospitalier Pitié-Salpêtrière, Paris, France
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