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Carrara C, Mataj B, Gastoldi S, Ruggenenti P, Sciascia S, Roccatello D. Case report: Timing of eculizumab treatment in catastrophic antiphospholipid syndrome. Front Immunol 2024; 15:1460317. [PMID: 39318635 PMCID: PMC11419984 DOI: 10.3389/fimmu.2024.1460317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 08/20/2024] [Indexed: 09/26/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening condition of small-vessel thrombosis with acute multiple-organ involvement and visceral damage. In this report, we present a case of a patient with CAPS who is refractory to conventional therapy. For the first time in a patient with CAPS, marked C5b-9 formation was demonstrated on microvascular endothelial cells, suggesting the usefulness of therapeutic complement inhibition in this setting. Eculizumab, a C5-blocking monoclonal antibody, is remarkably effective in the treatment of different forms of thrombotic microangiopathy by controlling complement system hyperactivation. It halted the "thrombotic storm" and promptly achieved full recovery of thrombocytopenia. However, kidney function did not recover, possibly because eculizumab was administered too late. Conceivably, the timing of treatment is crucial to achieving disease remission before irreversible structural damage occurs in target organs, thereby preventing their complete functional recovery.
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Affiliation(s)
- Camillo Carrara
- Unit of Nephrology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
- Istituto di Ricerche Farmacologiche Mario Negri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Bergamo, Italy
| | - Blerina Mataj
- Unit of Nephrology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Sara Gastoldi
- Istituto di Ricerche Farmacologiche Mario Negri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Bergamo, Italy
| | - Piero Ruggenenti
- Unit of Nephrology, Azienda Socio-Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
- Istituto di Ricerche Farmacologiche Mario Negri Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Bergamo, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital ASL Città di Torino and Department of Clinical and Biological Sciences, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hub Hospital ASL Città di Torino and Department of Clinical and Biological Sciences, Turin, Italy
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Azoulay LD, Frapard T, Larcher R, Pène F, Argaud L, Mayaux J, Jamme M, Coudroy R, Mathian A, Gibelin A, Azoulay E, Tandjaoui-Lambiotte Y, Dargent A, Beloncle FM, Raphalen JH, Bréchot N, de Prost N, Devaquet J, Contou D, Gaugain S, Trouiller P, Grangé S, Ledochowski S, Lemarie J, Faguer S, Degos V, Frere C, Quentric P, Moyon Q, Luyt CE, Combes A, Amoura Z, Pineton de Chambrun M. Hematological features and alternate diagnoses in critically ill thrombotic antiphospholipid syndrome patients. Clin Rheumatol 2024; 43:2889-2898. [PMID: 39073513 DOI: 10.1007/s10067-024-07051-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/14/2024] [Accepted: 06/26/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVES Severe thrombotic antiphospholipid syndrome (APS) frequently affects the kidney, heart, and central nervous system. The precise frequency, clinical picture, differential diagnoses, and outcome of APS-related hematological involvement are lacking, especially in patients requiring ICU admission. This study aimed to describe the hematological manifestations associated with critically ill thrombotic APS patients and catastrophic antiphospholipid syndrome. METHODS This French, national, multicenter, retrospective study, conducted, from January 2000 to September 2018, included all APS patients admitted to 24 participating centers' ICUs with any new thrombotic manifestation. The prevalence of hematological manifestations and their associated outcomes were studied. RESULTS One hundred and thirty-four patients, female 72%, median [IQR] age 45 [34-56] years, with 152 episodes were included. Anemia was present in 95% of episodes and thrombocytopenia in 93%. The lowest values for hemoglobin and platelets were 7.1 [6.3-8.8] g/dL and 38 [21-60] g/L, respectively. The lowest platelet count below 20 g/L was significantly associated with a higher in-ICU mortality rate (50%, p < 0.0001). A thrombotic microangiopathy syndrome (TMA) syndrome was seen in 16 patients (12%) and was associated with higher in-hospital mortality (p = 0.05). Median ADAMTS-13 levels were 44% [27-74]. Anti-ADAMTS13 antibodies were tested in 11 patients and found negative in all. A suspicion of heparin-induced thrombocytopenia (HIT) was raised in 66 patients but only four patients were classified as definite HIT. Disseminated intravascular coagulation (DIC) was seen in 51% of patients. CONCLUSION Thrombocytopenia is very frequent in severe APS patients and may be related to TMA, HIT, or DIC. Deciphering the mechanisms of thrombocytopenia is decisive in CAPS patients. Key Points • Thrombocytopenia is the hallmark laboratory finding in CAPS. • A complete thrombotic microangiopathy pattern is infrequent in CAPS patients. • Alternate diagnoses of CAPS, especially heparin-induced thrombocytopenia, need to be adequately investigated.
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Affiliation(s)
- Levi-Dan Azoulay
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
| | - Thomas Frapard
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
| | - Romaric Larcher
- Service de Médecine Intensive-Réanimation, Hôpital Lapeyronie, Centre Hospitalier Universitaire (CHU) de Montpellier, PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Frédéric Pène
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, APHP, Université Paris Descartes, Paris, France
| | - Laurent Argaud
- Service de Médecine Intensive-Réanimation, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Lyon, France
| | - Julien Mayaux
- AP-HP, Hôpital La Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive Et Réanimation Médicale, Département R3S, Sorbonne Université, INSERM UMRS1158, Neurophysiologie Respiratoire Expérimentale Et Clinique, Paris, France
| | - Matthieu Jamme
- Sorbonne Université, AP-HP, Hôpital Tenon, Service d'Urgences Néphrologiques Et de Transplantation Rénale, Paris, France
| | - Remi Coudroy
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Université de Poitiers, INSERM CIC 1402, IS-ALIVE Research Group, 86000, Poitiers, France
| | - Alexis Mathian
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
| | - Aude Gibelin
- Service de Médecine Intensive Réanimation, Hôpital Tenon, AP-HP, Faculté de Médecine Sorbonne Université, Paris, France
| | - Elie Azoulay
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Yacine Tandjaoui-Lambiotte
- Pneumologie & Infectiologie, CH Saint Denis, 93200, Saint Denis, France
- INSERM UMR 1137 IAME, Paris, France
- INSERM UMR 1272 Hypoxie & Poumon, Bobigny, France
| | - Auguste Dargent
- Service de Médecine Intensive-Réanimation, CHU Dijon, INSERM UMR 1231 LabEx Lipstic, Dijon, France
| | - François-Michel Beloncle
- Département de Médecine Intensive-Réanimation Et Médecine Hyperbare, CHU d'Angers, Université d'Angers, Angers, France
| | - Jean-Herlé Raphalen
- Service d'Anesthésie Et de Réanimation, Hôpital Necker, Université Paris Descartes, AP-HP, Paris, France
| | - Nicolas Bréchot
- Service de Médecine Intensive-Réanimation, Hôpital Européen George-Pompidou, Université Paris Descartes, AP-HP, Paris, France
| | - Nicolas de Prost
- Service de Médecine Intensive-Réanimation, CHU Henri-Mondor, AP-HP, Créteil, France
| | - Jérôme Devaquet
- Service de Réanimation Polyvalente, Hôpital Foch, Suresnes, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor-Dupouy, Argenteuil, France
| | - Samuel Gaugain
- Département d'Anesthésie Et Réanimation, Hôpital Saint-Louis-Lariboisière, Université Paris Diderot, AP-HP, Paris, France
| | - Pierre Trouiller
- Service de Réanimation Polyvalente Et Unité de Surveillance Continue, Hôpital Antoine-Béclère, Hôpitaux Universitaires Paris-Sud, AP-HP, Clamart, France
| | - Steven Grangé
- Service de Néphrologie, Hôpital Charles-Nicolle, CHU de Rouen, Rouen, France
| | - Stanislas Ledochowski
- Service de Réanimation Polyvalente, Médipôle Lyon-Villeurbanne, Ramsay Santé, Villeurbanne, France
| | - Jérémie Lemarie
- Service de Réanimation Médicale, Hôpital Central, CHRU de Nancy, Nancy, France
| | - Stanislas Faguer
- Département de Néphrologie Et Transplantation d'Organes, Unité de Réanimation, Centre de Référence Des Maladies Rénales Rares, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Vincent Degos
- Département d'Anesthésie-Réanimation, Unité d'Anesthésie-Réanimation Tête Et Cou, Sorbonne Université, Hôpital La Pitié-Salpêtrière, APHP, Paris, France
| | - Corinne Frere
- Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Service d'Hematologie Biologique Et d'Hemostase, Paris, France
| | - Paul Quentric
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
- Sorbonne Université, Inserm, Centre d'Immunologie Et Des Maladies Infectieuses, CIMI-Paris, Paris, France
| | - Quentin Moyon
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme Et Nutrition (ICAN), Paris, France
| | - Charles-Edouard Luyt
- Sorbonne Université, Inserm, Centre d'Immunologie Et Des Maladies Infectieuses, CIMI-Paris, Paris, France
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
| | - Alain Combes
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme Et Nutrition (ICAN), Paris, France
| | - Zahir Amoura
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France
- Sorbonne Université, Inserm, Centre d'Immunologie Et Des Maladies Infectieuses, CIMI-Paris, Paris, France
| | - Marc Pineton de Chambrun
- Syndrome Des Anticorps Anti-Phospholipides Et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Institut E3M, Service de Médecine Interne 2, Centre de Référence National Lupus Systémique, Paris, France.
- Sorbonne Université, Inserm, Centre d'Immunologie Et Des Maladies Infectieuses, CIMI-Paris, Paris, France.
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme Et Nutrition (ICAN), Paris, France.
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Kyoung J, Workman L, Spurgeon-Hess T, Tadrousse KS, Oostra D, Simman R. Catastrophic antiphospholipid syndrome: a case report and literature review. J Wound Care 2024; 33:S23-S26. [PMID: 39283884 DOI: 10.12968/jowc.2024.0285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
Catatrophic antiphospholipid syndrome (CAPS), a rare variant of antiphospholipid syndrome (APS), is associated with rapid multiorgan failure. While APS is associated with single medium-to-large blood vessel occlusions, CAPS is most often associated with several, concurrent vascular occlusions of small vessels, commonly of the kidneys, heart, skin and brain. We present a case of a 21-year-old female patient with a history of immune thrombocytopenia purpura and APS, who eventually developed concurrent cerebral venous sinus thrombosis, diffuse alveolar haemorrhage, renal thrombotic microangiopathy, and a necrotic, vasculitic wound on her forearm. Despite hospitalisation and treatment, her condition worsened and the patient eventually died after succumbing to suspected CAPS.
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Affiliation(s)
- Jun Kyoung
- University of Toledo, College of Medicine and Life Sciences, Toledo, Ohio, USA
| | - Lauren Workman
- University of Toledo, College of Medicine and Life Sciences, Toledo, Ohio, USA
| | | | | | - Drew Oostra
- Jobst Vascular Institute, ProMedica Health Network, Hematology Oncology, Toledo, Ohio, USA
| | - Richard Simman
- Jobst Vascular Institute, ProMedica Health Network, Wound Care Program, Toledo, Ohio, USA
- University of Toledo, College of Medicine and Life Science, Department of Surgery, Toledo, Ohio, USA
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4
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Franchini M, Focosi D, Pezzo MP, Mannucci PM. Catastrophic Thrombosis: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 39151904 DOI: 10.1055/s-0044-1788790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2024]
Abstract
Catastrophic thrombosis is a severe condition characterized by a hypercoagulable tendency, leading to multiple thromboembolic events in different blood vessels, usually within a short timeframe. Several conditions have been associated with the development of catastrophic thrombosis, including the catastrophic antiphospholipid syndrome, thrombotic anti-platelet factor 4 immune disorders, thrombotic microangiopathies, cancers, the hyper-eosinophilic syndrome, pregnancy, infections, trauma, and drugs. Thrombotic storm represents a medical emergency whose management represents a serious challenge for physicians. Besides the prompt start of anticoagulation, a patient's prognosis depends on early recognition and possible treatment of the underlying condition. In this narrative review, we summarize the main characteristics of catastrophic thrombosis, analyzing the various conditions triggering such life-threatening complication. Finally, an algorithm with the diagnostic workup and the initial management of patients with catastrophic thrombosis is presented.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | | | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Zajc Avramovic M, Avcin T. Antiphospholipid syndrome in children. Best Pract Res Clin Rheumatol 2024:101986. [PMID: 39138042 DOI: 10.1016/j.berh.2024.101986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/22/2024] [Accepted: 07/18/2024] [Indexed: 08/15/2024]
Abstract
Antiphospholipid syndrome (APS) in children is a rare disease associated with significant morbidity and mortality. In comparison with APS in adults, pediatric APS has a more severe presentation with frequent recurrences of thrombotic events and a higher probability of life-threatening catastrophic APS. Nonthrombotic manifestations are also more common in the pediatric age group and can precede thrombosis. New classification criteria have been introduced recently and have not yet been assessed in pediatric patients with APS. In addition to anticoagulation drugs, other novel therapies have emerged including the use of B cell and complement inhibitors, especially in catastrophic APS. The purpose of this review is to provide a broad overview of aPL-related clinical manifestations in pediatric patients based on the analysis of published cohorts and data from the international pediatric APS registry. We also aim to illustrate APS in infants caused by transplacentally transferred maternal aPL, which is very rarely associated with acute thrombotic events in the perinatal period and more frequently with long-term neurodevelopmental abnormalities.
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Affiliation(s)
- Mojca Zajc Avramovic
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Center Ljubljana, Slovenia; Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Slovenia.
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Center Ljubljana, Slovenia; Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Slovenia.
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6
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Varotto L, Spigolon L, Dotto A, Leonardi D, Bragantini G, Cerrito LF, Deluca C, Hoxha A. Myocardial Involvement in Catastrophic Antiphospholipid Syndrome during Pregnancy or Puerperium: A Case of a Young Breastfeeding Woman and Literature Review. J Clin Med 2024; 13:4732. [PMID: 39200874 PMCID: PMC11355751 DOI: 10.3390/jcm13164732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/27/2024] [Accepted: 07/27/2024] [Indexed: 09/02/2024] Open
Abstract
Catastrophic Antiphospholipid Syndrome (CAPS) is a rare complication that can occur in patients with Antiphospholipid Syndrome (APS). CAPS occurs even more rarely during pregnancy/puerperium and pregnant patients, even less likely to show cardiac involvement without signs of damage on ultrasound and angiography with non-obstructive coronary arteries. We present a case of a 26-year-old breastfeeding woman, the youngest described with CAPS and acute myocardial infarction, whose diagnosis was made with cardiac magnetic resonance imaging (CMRI). A literature review of pregnant patients with similar problems was performed. There are diagnostic and therapeutic difficulties in treating these patients. CMRI demonstrated a transmural late enhancement area. A combination of therapies led to rapid clinical improvement. CMRI is an underused tool that reaffirms the pathophysiology of CAPS and leads clinicians to the possibility of a diffuse thrombotic process. CAPS involves more organs with high mortality rates. CMRI could be optimized in order to reach an early diagnosis and the most effective treatment. This study provides real-world evidence of the feasibility of MRI in a primary care setting during pregnancy/puerperium. Evidence from this study may influence future APS screening and inform policymakers regarding the use of leading MRI technology in the detection of the thrombotic process in a primary care setting.
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Affiliation(s)
- Leonardo Varotto
- Department of Cardiology, San Bortolo Hospital, viale Rodolfi 37, 36100 Vicenza, Italy; (G.B.); (L.F.C.)
| | - Luca Spigolon
- Department of Radiology, San Bortolo Hospital, Viale Rodolfi 37, 36100 Vicenza, Italy;
| | - Alberto Dotto
- Department of Medicine—Division of Cardiology, University of Verona, Piazzale A. Stefani 1, 37126 Verona, Italy; (A.D.); (D.L.)
| | - Denis Leonardi
- Department of Medicine—Division of Cardiology, University of Verona, Piazzale A. Stefani 1, 37126 Verona, Italy; (A.D.); (D.L.)
| | - Giulia Bragantini
- Department of Cardiology, San Bortolo Hospital, viale Rodolfi 37, 36100 Vicenza, Italy; (G.B.); (L.F.C.)
| | - Luca Felice Cerrito
- Department of Cardiology, San Bortolo Hospital, viale Rodolfi 37, 36100 Vicenza, Italy; (G.B.); (L.F.C.)
| | - Cristina Deluca
- Department of Neurology, San Bortolo Hospital, Viale Rodolfi 37, 36100 Vicenza, Italy;
| | - Ariela Hoxha
- Internal Medicine Unit, Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University of Padua, via Giustiniani 2, 35128 Padova, Italy;
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Rodriguez-Pintó I, Espinosa G, Cervera R. Catastrophic antiphospholipid syndrome: Lessons from the "CAPS Registry". Med Clin (Barc) 2024; 163 Suppl 1:S31-S35. [PMID: 39174151 DOI: 10.1016/j.medcli.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/13/2024] [Accepted: 02/22/2024] [Indexed: 08/24/2024]
Abstract
The catastrophic antiphospholipid syndrome (CAPS) is a rare life-threatening clinical condition that represents the most severe clinical presentation of the antiphospholipid syndrome (APS). It was first described in 1992 in a group of patients that presented with multiorgan involvement and microangiopathic features of APS. Most of the current knowledge of CAPS comes from the analysis of all cases collected at the "CAPS Registry" that was created in 2000 to perform studies on this condition. Most cases are triggered by a prothrombotic situation that leads to a multiorgan thrombosis and a cytokine storm. The analysis of cases included in the "CAPS Registry" has shown that the triple therapy with anticoagulation, glucocorticoids, and plasma exchange and/or intravenous immunoglobulins is associated to a better prognosis of CAPS. The improvement of the knowledge allowed a decrease from the 50% mortality rate reported in the first series to 25-30% in the most recent publications.
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Affiliation(s)
- Ignasi Rodriguez-Pintó
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain.
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Ji J, Jiang L, Wang W, Chi X, Dong J, Lu L, Huang M, Wei X, Pang G, Pang J, Xiong B, Xiang S. AngioJet thrombectomy with extracorporeal membrane oxygenation support for an acute large-scale pulmonary embolism with bilateral atrial thrombosis: a case report of catastrophic antiphospholipid syndrome. Front Cardiovasc Med 2024; 11:1409775. [PMID: 39015680 PMCID: PMC11249738 DOI: 10.3389/fcvm.2024.1409775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 06/11/2024] [Indexed: 07/18/2024] Open
Abstract
Background Catastrophic Antiphospholipid Syndrome (CAPS), a severe systemic autoimmune disorder, predominantly causes life-threatening multi-organ failure, with a high mortality rate. It primarily affects small vessels, seldom impacting large vessels. Notably, acute massive pulmonary embolism (PE) with bilateral atrial thrombosis is an exceptional occurrence in CAPS. Acute pulmonary embolism (PE) is a common cardiovascular disease that progresses rapidly and has a high mortality rate. Acute massive PE combined with bilateral atrial thrombosis has an even higher mortality rate. PE treatments primarily include pharmaceuticals, catheter interventions, and surgical measures, with integrated treatment strategies demonstrating promising outcomes in clinical practice. Extracorporeal membrane oxygenation (ECMO) can provide cardiopulmonary support for the treatment of high-risk PE patients and is a proven therapeutic measure. Methods This report presents the case of a 52-year-old male admitted due to fever and sudden onset of impaired consciousness, with cardiac ultrasound and pulmonary artery CT angiography revealing an acute large-scale pulmonary embolism accompanied by bilateral atrial thrombosis, with the condition rapidly worsening and manifesting severe respiratory and circulatory failure. With ECMO support, the patient underwent a thrombectomy using an AngioJet intervention. The diagnosis of CAPS was confirmed through clinical presentation and laboratory examination, and treatment was adjusted accordingly. Results The patient made a successful recovery and was subsequently discharged from the hospital. Conclusion In CAPS patients, the rare instance of acute massive PE accompanied by bilateral atrial thrombosis significantly risks severe respiratory and circulatory failure, adversely affecting prognosis. Early initiation of ECMO therapy is crucial, offering a vital opportunity to address the root cause. In this case report the patient was successfully treated with an AngioJet thrombectomy supported by ECMO.
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Affiliation(s)
- Jianyu Ji
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Lei Jiang
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Wei Wang
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Guangxi Health Commission Key Laboratory of Diagnosis and Treatment of Acute Respiratory Distress Syndrome, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Xinyu Chi
- Guangxi Health Commission Key Laboratory of Diagnosis and Treatment of Acute Respiratory Distress Syndrome, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Jinda Dong
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of Blood Transfusion, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Liqiu Lu
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Minyan Huang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Xiutian Wei
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Guangbao Pang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Jing Pang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Bin Xiong
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Shulin Xiang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
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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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10
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Vélez-Páez JL, Carranza-Jara JM, Almeida-Posso DC, Witkin SS, de Almeida-Neto C. Oligosymptomatic infection by SARS-Cov-2 in catastrophic antiphospholipid syndrome, a singular coincidence: a case report in an Ecuadorian hospital. Hematol Transfus Cell Ther 2024; 46:316-320. [PMID: 37455218 PMCID: PMC11221254 DOI: 10.1016/j.htct.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/17/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023] Open
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11
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Pons I, Jeréz A, Espinosa G, Rodríguez-Pintó I, Erkan D, Shoenfeld Y, Cervera R. Cardiac involvement in the catastrophic antiphospholipid syndrome (CAPS): Lessons from the "CAPS registry". Semin Arthritis Rheum 2024; 66:152439. [PMID: 38552300 DOI: 10.1016/j.semarthrit.2024.152439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/28/2024] [Accepted: 03/25/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE To analyze the demographic, clinical, and laboratory characteristics of catastrophic antiphospholipid syndrome (CAPS) patients with cardiac involvement, and to identify the factors associated with this cardiac involvement. MATERIAL AND METHODS Based on the analysis of the "CAPS Registry", the demographic, clinical, and serological characteristics of patients with cardiac involvement were analyzed. Cardiac involvement was defined as heart failure, valvular disease, acute myocardial infarction, pericardial effusion, pulmonary arterial hypertension, systolic dysfunction, intracardiac thrombosis, and microvascular disease. Univariate and multivariate analysis was used for multiple comparisons. RESULTS 749 patients (293 [39 %] women and mean age 38.1 ± 16.2 years) accounting for 778 CAPS events were included, of them 404 (52 %) had cardiac involvement. The main cardiac manifestations were heart failure in 185/377 (55 %), valve disease in 116/377 (31 %), and acute myocardial infarction in 104/378 (28 %). Of 58 patients with autopsy/biopsy, 48 (83 %) had cardiac thrombotic microangiopathy, Stroke (29% vs. 21 %, p = 0.012), transient cerebral vascular accident (2% vs. 1 %, p = 0.005), pulmonary infarction (26% vs. 3 %, p = 0.017), renal infarction (46% vs. 35 %, p = 0.006), acute kidney injury (70% vs. 53 %, p < 0.001), and livedo reticularis (24% vs. 17 %, p = 0.016) were significantly more frequent during CAPS events with versus without heart involvement. Multivariate analysis identified acute kidney injury (OR 1.068, IC 95 % 1.8-4.8, p < 0.001) as the only clinical characteristics that were, independently, associated with cardiac involvement in CAPS events. Cardiac involvement was not related to higher mortality. CONCLUSIONS Cardiac involvement is frequent in CAPS, with association with kidney involvement, and it is not related to higher mortality. The presence of cardiac microthrombosis was demonstrated in most biopsies/autopsies performed.
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Affiliation(s)
- Isaac Pons
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Department of Internal Medicine, Althaia Xarxa Assistencial Universitària de Manresa, Facultat de Medicina, Universitat de Vic-Universitat Central de Catalunya (uVic-UCC), Manresa, Catalonia, Spain
| | - Alba Jeréz
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Department of Internal Medicine, Systemic Autoimmune Diseases Unit, Hospital Mútua de Terrassa, Terrassa, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
| | - Ignasi Rodríguez-Pintó
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Reichman University, Herzelya, Israel
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERNReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
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12
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Abbas A, Almarzooqi N, Harhara T. First presentation of Graves' thyroid storm complicated by catastrophic antiphospholipid antibody syndrome: A case report. SAGE Open Med Case Rep 2024; 12:2050313X241252809. [PMID: 38737564 PMCID: PMC11088809 DOI: 10.1177/2050313x241252809] [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: 12/11/2023] [Accepted: 04/18/2024] [Indexed: 05/14/2024] Open
Abstract
Catastrophic antiphospholipid antibody syndrome is a rare and severe subtype of antiphospholipid syndrome with multisystemic organ failure due to thromboembolic events, resulting in high mortality rates. The association between catastrophic antiphospholipid antibody syndrome and autoimmune thyroid diseases is rarely reported in the literature. We report a case of a 35-year-old previously healthy female with Graves' thyroid storm, positive lupus antibodies, and probable catastrophic antiphospholipid antibody syndrome. Her hospital course was complicated by extensive venous thromboembolism, superior vena cava syndrome, thromboembolic strokes, and Takotsubo cardiomyopathy. Eventually, this led to an unfortunate death secondary to profound shock after 8 days despite emergent treatment. Our case report discusses the link between autoimmune thyroid disorders and catastrophic antiphospholipid antibody syndrome. We emphasize the difficulty in diagnosing catastrophic antiphospholipid antibody syndrome in extremely ill patients and stress the significance of considering it as a possible cause in thyrotoxicosis patients with multiple organ failure and hypercoagulability. Early recognition and prompt management are crucial in improving outcomes in these patients.
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Affiliation(s)
- Aymen Abbas
- Department of Education, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Noura Almarzooqi
- Department of Education, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Thana Harhara
- Department of Education, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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13
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Niznik S, Rapoport MJ, Avnery O, Kidon M, Shavit R, Ellis MH, Agmon-Levin N. Heart valve disease in primary antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:1397-1402. [PMID: 37572296 DOI: 10.1093/rheumatology/kead399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/17/2023] [Accepted: 07/16/2023] [Indexed: 08/14/2023] Open
Abstract
OBJECTIVES APS-associated heart valve disease (HVD) is well described. Nonetheless, limited data exist on clinical parameters associated with the course of primary APS (pAPS) patients with HVD. The goal of this study was to assess clinical features and related outcomes in patients with APS-associated HVD. METHODS In this multicentre retrospective study, we identified 33 pAPS patients with HVD (pAPS-HVD group) and compared their clinical course with 128 pAPS patients with normal heart valves on echocardiography (pAPS-control group). RESULTS pAPS-HVD patients had more cerebrovascular events (56.3% vs 25%, P = 0.005) and livedo reticularis (24.2% vs 7.8%, P = 0.013) than pAPS-controls. Furthermore, catastrophic-APS (CAPS) (12.1% vs 2.4%, P = 0.034), recurrent thrombosis (33.3% vs 4.7%, P < 0.001) and need for advanced therapy (i.e. IVIG, plasmapheresis or rituximab) were more frequent in pAPS-HVD patients. Anti-β2-glycoprotein 1 IgG (84.8% vs 63.2%, P = 0.034), anti-cardiolipin IgG (90.9% vs 64.8%, P = 0.005) and triple positive aPL (75.8% vs 56.5%, P = 0.047) were commoner in pAPS-HVD patients vs pAPS-controls. Ten of the 33 patients with pAPS-HVD underwent valve surgery, which was associated with male gender, smoking, arterial limb ischaemia and livedo reticularis. CONCLUSION pAPS-HVD patients had a more severe APS clinical course including CAPS and thrombotic events as well as a specific serology, namely IgG isotype aPL antibodies and triple positivity. Our data suggest that pAPS-HVD represents a high-risk subgroup of APS patients.
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Affiliation(s)
- Stanley Niznik
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Micha J Rapoport
- Department of Internal Medicine 'C', Shamir Medical Center, Zerifin, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Avnery
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Mona Kidon
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Shavit
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Martin H Ellis
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Institute, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Tanariyakul M, Nebrajas K, Saowapa S, Polpichai N. Extensive Thrombosis in Catastrophic Antiphospholipid Syndrome in a Newly Diagnosed Systemic Lupus Erythematosus: A Case Report. Cureus 2024; 16:e59542. [PMID: 38826875 PMCID: PMC11144058 DOI: 10.7759/cureus.59542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
In this case report, we present the development of catastrophic antiphospholipid syndrome (CAPS), a rare and potentially fatal consequence of systemic lupus erythematosus (SLE), in a 33-year-old Micronesian woman. CAPS is characterized by extensive arterial thrombosis and multiorgan failure. The patient first showed signs of neuropsychiatric symptoms, brain infarctions on imaging, and severe hypoxic respiratory failure brought into the hospital by diffuse alveolar hemorrhage (DAH) along with lupus nephritis (LN). Blood urea nitrogen (BUN) and creatinine (Cr) were progressively elevated to 102/4.1 mg/dL, respectively. A urinalysis revealed microscopic hematuria and proteinuria with a urine protein/creatinine ratio of 6052 mg/g. She was also found to have had microangiopathic hemolytic anemia (MAHA) and severe venous thrombosis, both of which were indicative of CAPS. An aggressive approach, including immunosuppressive medication, therapeutic plasma exchange, and anticoagulation, had positive results, including renal recovery and the cessation of thrombotic episodes. This instance highlights how crucial it is to identify CAPS patients early and take appropriate action to improve patient outcomes for this difficult and sometimes deadly disorder.
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Affiliation(s)
- Manasawee Tanariyakul
- Internal Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, USA
| | - Kevin Nebrajas
- Internal Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, USA
| | - Sakditad Saowapa
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
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15
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Jacobs L, Wauters N, Lablad Y, Morelle J, Taghavi M. Diagnosis and Management of Catastrophic Antiphospholipid Syndrome and the Potential Impact of the 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria. Antibodies (Basel) 2024; 13:21. [PMID: 38534211 DOI: 10.3390/antib13010021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/28/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare and life-threatening condition characterized by the persistence of antiphospholipid antibodies and occurrence of multiple vascular occlusive events. CAPS currently remains a diagnostic challenge and requires urgent treatment. The diagnosis of CAPS is made difficult by classification criteria used as diagnostic criteria in clinical practice, knowledge derived from retrospective data and case reports, confounding clinical and biological features, and its rapid onset and mortality. The absence of prospective studies of CAPS limits the strength of evidence for guideline treatment protocols. This comprehensive review summarizes the current understanding of the disease, and discusses how the 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria impact the definition and therapeutic management of CAPS, which is considered the most severe form of APS. The correct integration of 2023 ACR/EULAR APS classification criteria is poised to facilitate CAPS diagnosis, particularly in critical situations, offering a promising avenue for improved outcomes.
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Affiliation(s)
- Lucas Jacobs
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Nephrology and Dialysis Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Internal Medicine Department, Tivoli University Hospital, Université Libre de Bruxelles, 7100 La Louvière, Belgium
| | - Nader Wauters
- Internal Medicine Department, Tivoli University Hospital, Université Libre de Bruxelles, 7100 La Louvière, Belgium
| | - Yahya Lablad
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
| | - Johann Morelle
- Division of Nephrology, Namur University Hospitals (CHU UCL Namur), 5000 Namur, Belgium
| | - Maxime Taghavi
- Internal Medicine Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
- Nephrology and Dialysis Department, Brugmann University Hospital, Université Libre de Bruxelles, 1020 Brussels, Belgium
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16
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Frederick R, Zolio L, Romas E, Ierino F. Eculizumab therapy and complement regulation in a case of resistant catastrophic antiphospholipid syndrome. BMJ Case Rep 2024; 17:e254449. [PMID: 38442982 PMCID: PMC10916160 DOI: 10.1136/bcr-2022-254449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a life-threatening form of antiphospholipid syndrome characterised by diffuse arterial and venous thrombosis, in the presence of positive antiphospholipid antibodies. The multiple sites of thrombosis in small, medium and large vessels progress to multiorgan failure, accounting for the high mortality rate associated with CAPS. Unregulated complement activation is increasingly recognised as critical to the pathogenesis of CAPS. Early diagnosis is essential to initiate prompt life-saving treatment with the triple therapy of anticoagulation, immunosuppression and either plasmapheresis or intravenous immunoglobulin. Among other immunosuppressive agents, eculizumab, a complement inhibitor has demonstrated efficacy in treatment-resistant cases.We report an instructive case of a woman presenting with both clinical and laboratory findings consistent with primary CAPS, resistant to initial treatment and responsive to eculizumab, with emphasis on genetic testing and implications for future therapy.
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Affiliation(s)
- Rachel Frederick
- Department of Nephrology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
- Department of General Medicine, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
| | - Luigi Zolio
- Department of Rheumatology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
| | - Evange Romas
- Department of Rheumatology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Frank Ierino
- Department of Nephrology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
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17
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Meade-Aguilar JA, Figueroa-Parra G, Yang JX, Langenfeld HE, González-Treviño M, Dogra P, Bancos I, Moynagh MR, Murad MH, Prokop LJ, Hanson AC, Crowson CS, Duarte-García A. Clinical presentation and outcomes in patients with antiphospholipid syndrome-associated adrenal hemorrhage. A multicenter cohort study and systematic literature review. Clin Immunol 2024; 260:109906. [PMID: 38244823 DOI: 10.1016/j.clim.2024.109906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/10/2023] [Accepted: 01/17/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Adrenal hemorrhage (AH) can occur in patients with antiphospholipid Syndrome (APS). We aimed to characterize the clinical manifestations, treatments, and outcomes of patients presenting with APS-associated AH (APS-AH) through a retrospective cohort and a systematic literature review (SLR). METHODS We performed a mixed-source approach combining a multicenter cohort with an SLR of patients with incident APS-AH. We included patients from Mayo Clinic and published cases with persistent positivity for antiphospholipid antibodies and presenting with AH, demonstrated by imaging or biopsy. We extracted demographics, clinical characteristics, laboratory findings, treatment strategies, and outcomes (primary adrenal insufficiency and mortality). We used Kaplan-Meier and Cox models for survival analysis. RESULTS We included 256 patients in total, 61 (24%) from Mayo Clinic and 195 (76%) from the SLR. The mean age was 46.8 (SD 15.2) years, and 45% were female. 69% of patients had bilateral adrenal involvement and 64% presented adrenal insufficiency. The most common symptoms at presentation were abdominal pain in 79%, and nausea and vomiting 46%. Hyponatremia (77%) was the most common electrolyte abnormality. Factors associated with primary adrenal insufficiency were bilateral adrenal involvement at initial imaging (OR 3.73, CI; 95%, 1.47-9.46) and anticardiolipin IgG positivity (OR 3.80, CI; 95%, 1.30-11.09). The survival rate at five years was 82%. History of stroke was associated with 3.6-fold increase in mortality (HR 3.62, 95% CI; 1.33-9.85). CONCLUSION AH is a severe manifestation of APS with increased mortality. Most patients developed permanent primary adrenal insufficiency, particularly those positive for anticardiolipin IgG and bilateral adrenal involvement.
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Affiliation(s)
| | | | - Jeffrey X Yang
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA.
| | - Hannah E Langenfeld
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA.
| | | | - Prerna Dogra
- Division of Endocrinology, Diabetes and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Irina Bancos
- Division of Endocrinology and Metabolism Disorders, Mayo Clinic, Rochester, MN, USA.
| | | | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA.
| | | | - Andrew C Hanson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA.
| | - Cynthia S Crowson
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA; Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA.
| | - Alí Duarte-García
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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18
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Branch DW, Lim MY. How I diagnose and treat antiphospholipid syndrome in pregnancy. Blood 2024; 143:757-768. [PMID: 38145574 DOI: 10.1182/blood.2023020727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 12/27/2023] Open
Abstract
ABSTRACT Antiphospholipid syndrome (APS) is a rare autoimmune disease characterized by arterial, venous, or microvascular thrombosis, pregnancy morbidities, or nonthrombotic manifestations in patients with persistently positive antiphospholipid antibodies. These antibodies bind cellular phospholipids and phospholipid-protein complexes resulting in cellular activation and inflammation that lead to the clinical features of APS. Our evolving understanding of APS has resulted in more specific classification criteria. Patients meeting these criteria should be treated during pregnancy according to current guidelines. Yet, despite treatment, those positive for lupus anticoagulant have at least a 30% likelihood of adverse pregnancy outcomes. Patients with recurrent early miscarriage or fetal death in the absence of preeclampsia or placental insufficiency may not meet current classification criteria for APS. Patients with only low titer anticardiolipin or anti-β(2)-glycoprotein I antibodies or immunoglobulin M isotype antibodies will not meet current classification criteria. In such cases, clinicians should implement management plans that balance potential risks and benefits, some of which involve emotional concerns surrounding the patient's reproductive future. Finally, APS may present in pregnancy or postpartum as a thrombotic microangiopathy, a life-threatening condition that may initially mimic preeclampsia with severe features but requires a very different treatment approach.
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Affiliation(s)
- D Ware Branch
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, University of Utah Health, Salt Lake City, UT
| | - Ming Y Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah School of Medicine, University of Utah Health, Salt Lake City, UT
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Ottavi M, Toulon P, Casolla B, Martis N. Four clinical and biological phenotypes in antiphospholipid syndrome: a cluster analysis of 174 patients with antinuclear antibody tests. Front Immunol 2024; 15:1361062. [PMID: 38440737 PMCID: PMC10909826 DOI: 10.3389/fimmu.2024.1361062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/05/2024] [Indexed: 03/06/2024] Open
Abstract
Introduction Antiphospholipid syndrome (APS) is an autoimmune thrombotic disease with various systemic presentations. This study aimed to identify homogeneous groups of patients based on a non-supervised hierarchical cluster analysis and assess the rate of relapse associated with antinuclear antibodies (ANA). Methods This retrospective observational study enrolled patients, over a 90-month period, who had APS as defined by the 2006 Sydney classification criteria, and for whom ANA workup was performed. Agglomerative unsupervised hierarchical clustering was conducted to classify patients into subgroups using 24 variables reflecting a range of clinical and biological baseline features associated with APS. Results Hundred and seventy-four patients were included and were categorized into four phenotypes. Cluster 1 (n=73) associated mostly middle-aged men with risk factors for cardiovascular disease. Obstetrical APS with low-risk thrombosis made up cluster 2 (n=25). Patients with venous thromboembolism (VTE), microvascular findings and double/triple positive APL antibodies (50%) were represented in cluster 3 (n=33). Whereas cluster 4 (n=43) characterized a predominantly female subpopulation with positive ANA and systemic lupus (n=23) that exhibited a high thrombotic risk and more frequent relapses (n=38) (p<0.001). Conclusions This study identified four homogenous groups of patients with APS listed as: i) cardiovascular and arterial risk, ii) obstetrical, iii) VTE and microvascular, and iv) ANA-positive APS. We found that ANA-positivity was associated with higher rates of relapse. Applying ANA status to classification criteria could constitute a novel approach to tailoring management for APS, based on phenotypic patterns and risk assessment.
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Affiliation(s)
- Marie Ottavi
- Internal Medicine Department, University Hospital of Nice, Cote d’Azur University, Nice, France
| | - Pierre Toulon
- Haematology Department , University Hospital of Nice, Cote d’Azur University, Nice, France
| | - Barbara Casolla
- Stroke Unit, UR2CA-URRIS Neurology, University Hospital Pasteur 2, Cote d’Azur University, Nice, France
| | - Nihal Martis
- Internal Medicine Department, University Hospital of Nice, Cote d’Azur University, Nice, France
- Mediterranean Centre for Molecular Medicine, Control of Gene Expression (COdEX), INSERM U1065, Nice, France
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Rodriguez-Pintó I, Espinosa G, Cervera R. What we know and what we don't know about catastrophic antiphospholipid syndrome. Rheumatology (Oxford) 2024; 63:SI46-SI53. [PMID: 38320593 DOI: 10.1093/rheumatology/kead556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/16/2023] [Indexed: 02/08/2024] Open
Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a severe condition with high mortality. Since its description in 1992, an important effort has been made to improve and disseminate knowledge on CAPS. Most of our current knowledge comes from the studies performed using the CAPS Registry, a database created in 2000 to gather as many cases as possible in order to better define this disease. It has demonstrated that this condition has multiple faces and is often triggered by a precipitating factor that leads to a thrombotic microangiopathy and cytokine storm involving almost any organ of the body. Analysis of the CAPS Registry has also shown that patients receiving anticoagulation, glucocorticoids and plasma exchange and/or IVIG have a better prognosis. However, there are still many unresolved questions. In this review we summarize what is known and what is still a matter of research in this condition.
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Affiliation(s)
- Ignasi Rodriguez-Pintó
- Autoimmune Diseases Unit, Hospital Universitari Mútua de Terrassa, Terrassa, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC, CSUR) of the Catalan and Spanish Health Systems/Member of ERN-ReCONNET, Hospital Clínic, Barcelona, Catalonia, Spain
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Leisring J, Brodsky SV, Parikh SV. Clinical Evaluation and Management of Thrombotic Microangiopathy. Arthritis Rheumatol 2024; 76:153-165. [PMID: 37610060 DOI: 10.1002/art.42681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/17/2023] [Accepted: 08/17/2023] [Indexed: 08/24/2023]
Abstract
Thrombotic microangiopathy (TMA) refers to a diverse group of diseases that share clinical and histopathologic features. TMA is clinically characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and organ injury that stems from endothelial damage and vascular occlusion. There are several disease states with distinct pathophysiological mechanisms that manifest as TMA. These conditions are associated with significant morbidity and mortality and require urgent recognition and treatment. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are traditionally considered to be primary forms of TMA, but TMA more commonly occurs in association with a coexisting condition such as infection, pregnancy, autoimmune disease, or malignant hypertension, among others. Determining the cause of TMA is a diagnostic challenge because of limited availability of disease-specific testing. However, identifying the underlying etiology is imperative as treatment strategies differ. Our understanding of the conditions that cause TMA is evolving. Recent advances have led to improved comprehension of the varying pathogenic mechanisms that drive TMA. Development of targeted therapeutics has resulted in significant improvements in patient outcomes. In this article, we review the pathogenesis and clinical features of the different TMA-causing conditions. We outline a practical approach to diagnosis and management and discuss empiric and disease-specific treatment strategies.
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Affiliation(s)
- Joshua Leisring
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Samir V Parikh
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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Bitsadze V, Yakubova F, Khizroeva J, Lazarchuk A, Salnikova P, Vorobev A, Tretyakova M, Degtyareva N, Grigoreva K, Gashimova N, Kvaratskheliia M, Makatsariya N, Kudryavtseva E, Tomlenova A, Gris JC, Elalamy I, Ay C, Makatsariya A. Catastrophic Antiphospholipid Syndrome. Int J Mol Sci 2024; 25:668. [PMID: 38203837 PMCID: PMC10779422 DOI: 10.3390/ijms25010668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/26/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Unlike classic APS, CAPS causes multiple microthrombosis due to an increased inflammatory response, known as a "thrombotic storm". CAPS typically develops after infection, trauma, or surgery and begins with the following symptoms: fever, thrombocytopenia, muscle weakness, visual and cognitive disturbances, abdominal pain, renal failure, and disseminated intravascular coagulation. Although the presence of antiphospholipid antibodies in the blood is one of the diagnostic criteria, the level of these antibodies can fluctuate significantly, which complicates the diagnostic process and can lead to erroneous interpretation of rapidly developing symptoms. Triple therapy is often used to treat CAPS, which includes the use of anticoagulants, plasmapheresis, and high doses of glucocorticosteroids and, in some cases, additional intravenous immunoglobulins. The use of LMWH is recommended as the drug of choice due to its anti-inflammatory and anticoagulant properties. CAPS is a multifactorial disease that requires not only an interdisciplinary approach but also highly qualified medical care, adequate and timely diagnosis, and appropriate prevention in the context of relapse or occurrence of the disease. Improved new clinical protocols and education of medical personnel regarding CAPS can significantly improve the therapeutic approach and reduce mortality rates.
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Affiliation(s)
- Victoria Bitsadze
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Fidan Yakubova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Jamilya Khizroeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Arina Lazarchuk
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Polina Salnikova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Alexander Vorobev
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Maria Tretyakova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Natalia Degtyareva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Kristina Grigoreva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Nilufar Gashimova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Margaret Kvaratskheliia
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Nataliya Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Ekaterina Kudryavtseva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Anna Tomlenova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
| | - Jean-Christophe Gris
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Faculty of Pharmaceutical and Biological Sciences, Montpellier University, 34093 Montpellier, France
| | - Ismail Elalamy
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Department Hematology and Thrombosis Center, Medicine Sorbonne University, 75012 Paris, France
- Hospital Tenon, 4 Rue de la Chine, 75020 Paris, France
| | - Cihan Ay
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, 1080 Vienna, Austria
| | - Alexander Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N. F. Filatov Clinical Institute of Children’s Health, I. M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (F.Y.); (J.K.); (A.L.); (P.S.); (A.V.); (M.T.); (N.D.); (K.G.); (N.G.); (M.K.); (N.M.); (E.K.); (A.T.); (J.-C.G.); (I.E.); (C.A.)
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Dumas G, Arabi YM, Bartz R, Ranzani O, Scheibe F, Darmon M, Helms J. Diagnosis and management of autoimmune diseases in the ICU. Intensive Care Med 2024; 50:17-35. [PMID: 38112769 DOI: 10.1007/s00134-023-07266-7] [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] [Received: 06/23/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023]
Abstract
Autoimmune diseases encompass a broad spectrum of disorders characterized by disturbed immunoregulation leading to the development of specific autoantibodies, resulting in inflammation and multiple organ involvement. A distinction should be made between connective tissue diseases (mainly systemic lupus erythematosus, systemic scleroderma, inflammatory muscle diseases, and rheumatoid arthritis) and vasculitides (mainly small-vessel vasculitis such as antineutrophil cytoplasmic antibody-associated vasculitis and immune-complex mediated vasculitis). Admission of patients with autoimmune diseases to the intensive care unit (ICU) is often triggered by disease flare-ups, infections, and organ failure and is associated with high mortality rates. Management of these patients is complex, including prompt disease identification, immunosuppressive treatment initiation, and life-sustaining therapies, and requires multi-disciplinary involvement. Data about autoimmune diseases in the ICU are limited and there is a need for multicenter, international collaboration to improve patients' diagnosis, management, and outcomes. The objective of this narrative review is to summarize the epidemiology, clinical features, and selected management of severe systemic autoimmune diseases.
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Affiliation(s)
- Guillaume Dumas
- Medical Intensive Care Unit, Service de Médecine Intensive-Réanimation, CHU Grenoble-Alpes, Université Grenoble-Alpes, INSERM, U1042-HP2, Grenoble, France.
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences Riyadh, Riyadh, Kingdom of Saudi Arabia
| | - Raquel Bartz
- Department of Anesthesia, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Otavio Ranzani
- Barcelona Institute for Global Health, ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Pulmonary Division, Faculdade de Medicina, Heart Institute, InCor, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Franziska Scheibe
- Department of Neurology and Experimental Neurology, Charité- Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
- NeuroCure Clinical Research Center, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Michaël Darmon
- Medical Intensive Care Unit, APHP, Hôpital Saint-Louis, Famirea Study Group, ECSTRA Team, and Clinical EpidemiologyUMR 1153, Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS, INSERM, Université Paris Cité, Paris, France
| | - Julie Helms
- Faculté de Médecine, Service de Médecine Intensive-Réanimation, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1 Place de L'Hôpital, Strasbourg, France
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Ponce A, Rodríguez-Pintó I, Espinosa G, Quintas H, Erkan D, Shoenfeld Y, Cervera R. Pulmonary involvement in catastrophic antiphospholipid syndrome: A descriptive analysis from the "CAPS Registry". Semin Arthritis Rheum 2023; 63:152265. [PMID: 37857048 DOI: 10.1016/j.semarthrit.2023.152265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 08/10/2023] [Accepted: 08/27/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVES To describe the pulmonary involvement in patients with catastrophic antiphospholipid syndrome (CAPS), focusing on its relationship with extrapulmonary involvement, laboratory, radiological, and pathological findings. METHODS This retrospective cross-sectional study includes all patients grouped in the "CAPS Registry". All cases were reviewed, and those with pulmonary thromboembolism (PE) and/or diffuse alveolar hemorrhage (DAH) were selected. Data on pulmonary and extrapulmonary clinical presentation, radiologic patterns, laboratory findings, associated autoimmune diseases, treatments, and outcomes were analyzed. Frequency distribution and measures of central tendency were used to describe the cohort. Comparison between groups regarding qualitative variables was undertaken by chi-square or Fisher exact test, while T-test for independent variables was used to compare groups regarding continuous variables. IBM-SPSS v.22 was used for data analysis. RESULTS PE was reported in 129 (48.6 %) episodes, DAH in 75 (28.3 %) episodes, and overlap (DAH plus PE) in 7 (2.6 %) episodes. Bronchoalveolar lavage (BAL) was performed in 35 (4.9 %) CAPS episodes, and lung pathology samples were obtained in 84 (10.5 %) episodes (including autopsies). A significant relationship was observed between DAH and laboratory features of thrombotic microangiopathy (TMA). A meaningful relationship was also found between triple antiphospholipid antibody positivity and pathological TMA (26.5 %) as well as hypocomplementemia and DAH (24 %). CONCLUSIONS Pulmonary involvement may include both TMA and non-thrombotic inflammation, which can be differentiated into three patterns: PE, DAH with systemic TMA with hypocomplementemia or DAH without systemic TMA with/without hypocomplementemia.
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Affiliation(s)
- Ana Ponce
- Autoimmune Diseases Unit, Department of Internal Medicine, Hospital de Viladecans, Viladecans, Catalonia, Spain
| | - Ignasi Rodríguez-Pintó
- Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Universitari Mútua de Terrassa, Terrassa, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERN-ReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Helena Quintas
- Autoimmune Diseases Unit, Department of Internal Medicine, Hospital de Viladecans, Viladecans, Catalonia, Spain
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERN-ReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain.
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Zhao Y, Qi W, Huang C, Zhou Y, Wang Q, Tian X, Li M, Zhao Y, Zeng X, Zhao J. Serum Calprotectin as a Potential Predictor of Microvascular Manifestations in Patients with Antiphospholipid Syndrome. Rheumatol Ther 2023; 10:1769-1783. [PMID: 37906398 PMCID: PMC10654303 DOI: 10.1007/s40744-023-00610-9] [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: 08/08/2023] [Accepted: 10/11/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION Microvascular manifestations constitute a subtype of antiphospholipid syndrome, and those patients have relatively poor prognoses, so it is important to find markers for microvascular manifestations. This study was conducted to explore whether serum calprotectin could be a predictor of microvascular manifestations in antiphospholipid antibody (aPL)-positive patients. METHODS Consecutive patients with persistent aPL positivity referred to Peking Union Medical College Hospital and age- and sex-matched health controls (HCs) were included. Microvascular manifestations included antiphospholipid syndrome (APS) nephropathy, livedo reticularis, valvular lesions, non-stroke central nervous system manifestations, myocarditis, catastrophic APS, and other microvascular manifestations confirmed by pathology, imaging, or clinical diagnosis. Calprotectin was measured by an enzyme-linked immunosorbent assay (ELISA). The cutoff value was defined as mean + 2 standard deviations of HCs. Multivariable logistic regression analysis was used to analyze risk factors. Pearson correlation analysis was used to detect the correlation between calprotectin and other laboratory data. RESULTS Of the 466 patients included in the study, 281 (60.3%) patients met the 2006 Sydney Revised Classification Criteria; among the latter, 77.2% were patients with primary APS. The mean age was 39.10 ± 13.05 years old, and 77.0% were female. Thirty-eight age- and sex-matched HCs were included in the study. Serum calprotectin levels were increased in aPL-positive patients compared with HCs (649.66 ± 240.79 vs 484.62 ± 149.37 ng/ml, p < 0.001), and were increased in patients with microvascular manifestations compared with patients without (693.03 ± 271.90 vs 639.43 ± 232.06 ng/ml, p = 0.044). The cutoff value was 783.36 ng/ml. Ninety-three patients (20.0%) were positive for calprotectin. Calprotectin positivity was independently associated with microvascular manifestations (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.07-3.36) and platelet count (PLT) < 100 (OR 2.04, 95% CI 1.08-3.88). Age (OR 0.98, 95% CI 0.96-1.00), systemic lupus erythematosus (OR 2.08, 95% CI 1.15-3.75), calprotectin positivity (OR 1.83, 95% CI 1.02-3.26), hypertension (OR 2.73, 95% CI 1.36-5.45), hemolytic anemia (OR 2.66, 95% CI 1.13-6.23), and anti-β2GPI antibodies (OR 2.06, 95% CI 1.11-3.83) could independently predict microvascular manifestations in aPL-positive patients. Serum calprotectin negatively correlated with PLT (R = - 0.101, p = 0.031). CONCLUSION Serum calprotectin levels are increased in aPL-positive patients and could be a potential predictor of microvascular manifestations.
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Affiliation(s)
- Yuan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Wanting Qi
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Can Huang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yangzhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China.
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Beijing, 100730, China.
- National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science and Technology, Beijing, China.
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
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Mostafa M, Mahmoud A, Egiza HA, Niu C, Elbahnasawy M, Yusuf Y, Kouides P. Severe cutaneous necrosis in antiphospholipid syndrome. Am J Hematol 2023; 98:E328-E333. [PMID: 37713504 DOI: 10.1002/ajh.27067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 08/06/2023] [Accepted: 08/09/2023] [Indexed: 09/17/2023]
Affiliation(s)
| | - Amir Mahmoud
- Rochester General Hospital, Rochester, New York, USA
| | - Hebat-Allah Egiza
- Egypt-Japan University for Science and Technology, Alexandria, Egypt
| | - Chengu Niu
- Rochester General Hospital, Rochester, New York, USA
| | | | | | - Peter Kouides
- Rochester General Hospital, Rochester, New York, USA
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Pengo V, Denas G. Antiphospholipid Syndrome in Patients with Venous Thromboembolism. Semin Thromb Hemost 2023; 49:833-839. [PMID: 35728601 DOI: 10.1055/s-0042-1749590] [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: 10/18/2022]
Abstract
Unprovoked (or provoked by mild risk factors) venous thromboembolism (VTE) in young patients, VTE in uncommon sites, or cases of unexplained VTE recurrence may be positive for antiphospholipid antibodies (aPL) and thus may be diagnosed with antiphospholipid syndrome (APS). The evaluation of aPL is standardized using immunological tests for anticardiolipin and anti-β2-glycoprotein I. The determination of functional antibodies (lupus anticoagulant) is less standardized, especially in patients on anticoagulant treatment. Patients positive for all the three tests are at high risk of recurrence, which, in turn, might lead to chronic obstruction of pulmonary vessels (chronic thromboembolic pulmonary hypertension). Randomized clinical trials have shown that triple-positive patients should be treated with vitamin K antagonists maintaining an international normalized ratio between 2 and 3. Whether patients with VTE and incomplete aPL profile can be treated with direct oral anticoagulants should be further investigated.
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Affiliation(s)
- Vittorio Pengo
- Department of Cardio-Thoracic-Vascular Sciences and Public Health, Thrombosis Research Laboratory, University of Padova, Padova, Italy
- Arianna Foundation on Anticoagulation, Bologna, Italy
| | - Gentian Denas
- Department of Cardio-Thoracic-Vascular Sciences and Public Health, Thrombosis Research Laboratory, University of Padova, Padova, Italy
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Figueroa-Parra G, Meade-Aguilar JA, Langenfeld HE, González-Treviño M, Hocaoglu M, Hanson AC, Prokop LJ, Murad MH, Cartin-Ceba R, Specks U, Majithia V, Crowson CS, Duarte-García A. Clinical features, risk factors, and outcomes of diffuse alveolar hemorrhage in antiphospholipid syndrome: A mixed-method approach combining a multicenter cohort with a systematic literature review. Clin Immunol 2023; 256:109775. [PMID: 37722463 DOI: 10.1016/j.clim.2023.109775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/29/2023] [Accepted: 09/13/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is a systemic autoimmune disease clinically associated with thrombotic and obstetric events. Additional manifestations have been associated with APS, like diffuse alveolar hemorrhage (DAH). We aimed to summarize all the evidence available to describe the presenting clinical features, their prognostic factors, and short- and long-term outcomes. METHODS We performed a mixed-method approach combining a multicenter cohort with a systematic literature review (SLR) of patients with incident APS-associated DAH. We described their clinical features, treatments, prognostic factors, and outcomes (relapse, mortality, and requirement of mechanical ventilation [MV]). Kaplan-Meier methods were used to estimate relapse and mortality rates, and Cox and logistic regression models were used to assess the factors associated as appropriate. RESULTS We included 219 patients with incident APS-associated DAH (61 from Mayo Clinic and 158 from SLR). The median age was 39.5 years, 51% were female, 29% had systemic lupus erythematosus, and 34% presented with catastrophic APS (CAPS). 74% of patients had a history of thrombotic events, and 26% of women had a history of pregnancy morbidity; half of the patients had a history of thrombocytopenia, and a third had valvulopathy. Before DAH, 55% of the patients were anticoagulated. At DAH onset, 65% of patients presented hemoptysis. The relapse rate was 47% at six months and 52% at one year. Triple positivity (HR 4.22, 95% CI 1.14-15.59) was associated with relapse at six months. The estimated mortality at one and five years was 30.3% and 45.8%. Factors associated with mortality were severe thrombocytopenia (< 50 K/μL) (HR 3.10, 95% CI 1.39-6.92), valve vegetations (HR 3.22, 95% CI 1.14-9.07), CAPS (HR 3.80, 95% CI 1.84-7.87), and requirement of MV (HR 2.22, 95% CI 1.03-4.80). Forty-two percent of patients required MV on the incident DAH episode. Patients presenting with severe thrombocytopenia (OR 6.42, 95% CI 1.77-23.30) or CAPS (OR 4.30, 95% CI 1.65-11.16) were more likely to require MV. CONCLUSION APS-associated DAH is associated with high morbidity and mortality, particularly when presenting with triple positivity, thrombocytopenia, valvular involvement, and CAPS.
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Affiliation(s)
| | | | | | | | - Mehmet Hocaoglu
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA; Department of Medicine, University of Maryland Medical Center, Midtown Campus, Baltimore, MD, USA
| | - Andrew C Hanson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vikas Majithia
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL, USA
| | - Cynthia S Crowson
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA; Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Alí Duarte-García
- Division of Rheumatology, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Agbayani E, Doig C, Noutsos T. Antiphospholipid syndrome in rural, remote, and First Nations peoples in the Top End of the Northern Territory, Australia. Res Pract Thromb Haemost 2023; 7:102227. [PMID: 38193060 PMCID: PMC10772872 DOI: 10.1016/j.rpth.2023.102227] [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: 06/01/2023] [Revised: 09/10/2023] [Accepted: 09/24/2023] [Indexed: 01/10/2024] Open
Abstract
Background The Northern Territory of Australia has a high proportion of First Nations peoples living in remote communities and a high burden of chronic autoimmune diseases. The epidemiology and clinical outcomes of antiphospholipid syndrome (APS) in First Nations Australians are poorly characterized. Objectives To determine the epidemiology, presenting features, and outcomes of patients with APS using an 18-year retrospective cohort of newly diagnosed patients presenting to Royal Darwin Hospital (2002-2020). Methods Patients admitted to Royal Darwin Hospital with a new incident diagnosis of APS between January 2002 and December 2020 were identified and followed until December 2022, with data on baseline demographics, clinical and laboratory features, and overall survival extracted from electronic and paper medical records. Results Fifty-three patients with APS were included, of whom 40 (75%) were First Nations and 46 (87%) were female. Thirty (75%) of First Nations patients with APS resided in very remote Australia vs 0 (0%) non-First Nations patients. Eighteen cases (34%) had primary APS, and 35 cases (66%) had secondary APS, most in association with lupus. Eight (15%) cases developed catastrophic APS (CAPS), all in First Nations patients. There were 13 deaths (of which 11 were among First Nations patients). Patients with CAPS had significantly shorter median overall survival (8.3 years from diagnosis), with median survival in non-CAPS patients not reached (P = .003). Conclusion There is a high prevalence of APS in First Nations patients living in very remote Australia admitted for tertiary care in the tropical north of the Northern Territory, Australia. The rate of CAPS in First Nations patients was high, and CAPS was associated with significantly shorter survival. Larger prospective studies are required to inform improved models of care for First Nations and remote Australians living with APS.
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Affiliation(s)
- Evangeline Agbayani
- Northern Territory Medical Program, College of Medicine and Public Health, Flinders University, Darwin, Australia
| | - Chris Doig
- Department of Haematology, Royal Darwin Hospital, Darwin, Australia
| | - Tina Noutsos
- Department of Haematology, Royal Darwin Hospital, Darwin, Australia
- Division of Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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De Simone E, Sciascia S, Fenoglio R, Oddone V, Barreca A, Roccatello D. Antiphospholipid Syndrome and Kidney Involvement. Kidney Blood Press Res 2023; 48:666-677. [PMID: 37734329 DOI: 10.1159/000529229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 01/07/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the development of autoantibodies and the impairment of the coagulation system. Knowledge about this syndrome is increasing over time, but kidney involvement, especially APS nephropathy, still represents a challenge for physicians. SUMMARY A "two hit" model has been hypothesized to explain APS pathophysiology, and the role played by some factors, such as the complement system, is becoming more and more clear. From a clinical point of view, along with thrombosis in any site and/or obstetric morbidities, that are the hallmarks of APS, a constellation of several other clinical symptoms is related to APS. These symptoms alone are not sufficient to fulfill Sydney criteria for APS and this could potentially lead to omitting some diagnoses. The mainstay of management of APS is antithrombotic therapy, but there are expectations for new drugs that regulate the immune system. APS could affect the kidneys in many ways and among them, APS nephropathy is an intriguing entity that has been overlooked in recent years. Novel studies on APS nephropathy are lacking. KEY MESSAGES In this review, we discuss what we currently know about APS and its relationship with the kidney, with an eye toward the future perspectives. Multicenter studies on APS nephropathy are necessary in order to develop targeted therapies.
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Affiliation(s)
- Emanuele De Simone
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy,
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
| | - Valentina Oddone
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) Including the Nephrology and Dialysis Unit, Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, San Giovanni Bosco Hub Hospital-ASL Città di Torino, University of Turin, Turin, Italy
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Bouki K, Venetsanaki V, Chrysoulaki M, Pateromichelaki A, Betsi G, Daraki V, Sbyrakis N, Spanakis K, Bertsias G, Sidiropoulos PI, Xekouki P. Primary adrenal insufficiency due to bilateral adrenal hemorrhage-adrenal infarction in a patient with systemic lupus erythematosus and antiphospholipid syndrome: case presentation and review of the literature. Hormones (Athens) 2023; 22:521-531. [PMID: 37436639 PMCID: PMC10449959 DOI: 10.1007/s42000-023-00463-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/22/2023] [Indexed: 07/13/2023]
Abstract
Primary adrenal insufficiency (PAI) is a rare disease which represents the end stage of a destructive process involving the adrenal cortex. Occasionally it may be caused by bilateral adrenal hemorrhagic infarction in patients with antiphospholipid syndrome (APS). We herein report the challenging case of a 30-year-old female patient with systemic lupus erythematosus (SLE) and secondary APS who was admitted to the emergency department (ED) due to fever, lethargy, and syncopal episodes. Hyponatremia, hyperkalemia, hyperpigmentation, shock, altered mental status, and clinical response to glucocorticoid administration were features highly suggestive of an acute adrenal crisis. The patient's clinical status required admission to the intensive care unit (ICU), where steroid replacement, anticoagulation, and supportive therapy were provided, with a good outcome. Imaging demonstrated bilateral adrenal enlargement attributed to recent adrenal hemorrhage. This case highlights the fact that bilateral adrenal vein thrombosis and subsequent hemorrhage can be part of the thromboembolic complications seen in both primary and secondary APS and which, if misdiagnosed, may lead to a life-threatening adrenal crisis. High clinical suspicion is required for its prompt diagnosis and management. A literature search of past clinical cases with adrenal insufficiency (AI) in the setting of APS and SLE was conducted using major electronic databases. Our aim was to retrieve information about the pathophysiology, diagnosis, and management of similar conditions.
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Affiliation(s)
- K Bouki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - V Venetsanaki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - M Chrysoulaki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - A Pateromichelaki
- Rheumatology and Clinical Immunology, University General Hospital of Heraklion, Crete, Greece
| | - G Betsi
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - V Daraki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece
| | - N Sbyrakis
- Emergency Department, University General Hospital of Heraklion, Crete, Greece
| | - K Spanakis
- Interventional Radiology Unit, Department of Medical Imaging, University General Hospital of Heraklion, Crete, Greece
| | - G Bertsias
- Rheumatology and Clinical Immunology, University General Hospital of Heraklion, Crete, Greece
| | - P I Sidiropoulos
- Rheumatology and Clinical Immunology, University General Hospital of Heraklion, Crete, Greece
| | - Paraskevi Xekouki
- Endocrinology and Diabetes Clinic, University Hospital of Heraklion, University of Crete School of Medicine, Voutes, 71500, Heraklion Crete, Crete, Greece.
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Amoura Z, Bader-Meunier B, Bal Dit Sollier C, Belot A, Benhamou Y, Bezanahary H, Cohen F, Costedoat-Chalumeau N, Darnige L, Drouet L, Elefant E, Harroche A, Lambert M, Martin T, Martin-Toutain I, Mathian A, Mekinian A, Pineton De Chambrun M, de Pontual L, Wahl D, Yelnik C, Zuily S. French National Diagnostic and Care Protocol for antiphospholipid syndrome in adults and children. Rev Med Interne 2023; 44:495-520. [PMID: 37735010 DOI: 10.1016/j.revmed.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023]
Abstract
Antiphospholipid syndrome (APS) is a chronic autoimmune disease involving vascular thrombosis and/or obstetric morbidity and persistent antibodies to phospholipids or certain phospholipid-associated proteins. It is a rare condition in adults and even rarer in children. The diagnosis of APS can be facilitated by the use of classification criteria based on a combination of clinical and biological features. APS may be rapidly progressive with multiple, often synchronous thromboses, resulting in life-threatening multiple organ failure. This form is known as "catastrophic antiphospholipid syndrome" (CAPS). It may be primary or associated with systemic lupus erythematosus (associated APS) and in very rare cases with other systemic autoimmune diseases. General practitioners and paediatricians may encounter APS in patients with one or more vascular thromboses. Because APS is so rare and difficult to diagnosis (risk of overdiagnosis) any suspected case should be confirmed rapidly and sometimes urgently by an APS specialist. First-line treatment of thrombotic events in APS includes heparin followed by long-term anticoagulation with a VKA, usually warfarin. Except in the specific case of stroke, anticoagulants should be started as early as possible. Any temporary discontinuation of anticoagulants is associated with a high risk of thrombosis in APS. A reference/competence centre specialised in autoimmune diseases must be urgently consulted for the therapeutic management of CAPS.
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Affiliation(s)
- Z Amoura
- Department of Internal Medicine, Institut E3M, CIMI-Paris, Faculty of medicine, National Reference Centre of Systemic Lupus, antiphospholipid syndrome, and other autoimmune diseases, Sorbonne University, AP-HP, Pitié Salpêtrière, boulevard de l'Hôpital, 75013 Paris, France.
| | - B Bader-Meunier
- Laboratory of Immunogenetics of Paediatric Autoimmune Diseases, Institute Imagine, University Paris Cité, Paris, France
| | - C Bal Dit Sollier
- Thrombosis and atherosclerosis research unit, vessels and blood institute (IVS), anticoagulation clinic (CREATIF), Lariboisière hospital, AP-HP, 75010 Paris, France
| | - A Belot
- Department of Pediatric Nephrology, Rheumatology, Dermatology, Reference Centre for Rheumatic, AutoImmune and Systemic diseases in children (RAISE), hôpital femme mère enfant, CHU de Lyon, Bron, France
| | - Y Benhamou
- National Reference Centre of MicroAngiopathies Thrombotic, Paris, France; Department of Internal Medicine, University Hospital of Rouen, Normandie University, Rouen, France
| | - H Bezanahary
- Department of Internal Medicine and Clinical Immunology, centre hospitalier universitaire de Limoges, Limoges, France
| | - F Cohen
- Department of Internal Medicine, Institut E3M, CIMI-Paris, Faculty of medicine, National Reference Centre of Systemic Lupus, antiphospholipid syndrome, and other autoimmune diseases, Sorbonne University, AP-HP, Pitié Salpêtrière, boulevard de l'Hôpital, 75013 Paris, France
| | - N Costedoat-Chalumeau
- Department of Internal Medicine, Referral Centre for Rare Autoimmune and Systemic Diseases of Île-de-France, AP-HP, Cochin Hospital, Paris, France; Centre for Epidemiology and Statistics, Institut national de la santé et de la recherche médicale, French National Institute for Agricultural Research, University Paris Cité, Paris, France
| | - L Darnige
- Biological Hematology Department, Assistance publique-Hôpitaux de Paris, hôpital européen Georges-Pompidou, Inserm, UMR-S1140, Innovative Therapies in Haemostasis, Paris, France
| | - L Drouet
- Thrombosis and atherosclerosis research unit, vessels and blood institute (IVS), anticoagulation clinic (CREATIF), Lariboisière hospital, AP-HP, 75010 Paris, France
| | - E Elefant
- Reference Center for Teratogenic Agents, hôpital Armand-Trousseau centre de référence sur les agents tératogènes, Île-de-France, Paris, France
| | - A Harroche
- Department of Hematology, Haemophilia Treatment Centre, University Hospital Necker Enfants Malades, Paris, France
| | - M Lambert
- Department of Internal Medicine and Clinical immunology, Reference Centre of Autoimmune Systemic Rare Diseases Of North And North-West of France (CeRAINO), U1167 RID-AGE, Lille University, Inserm, University hospital of Lille, 59000 Lille, France
| | - T Martin
- Department of Internal Medicine and Clinical Immunology, Strasbourg University Hospital, Strasbourg, France
| | - I Martin-Toutain
- Resource and Competence Centre for Haemorrhagic Diseases, Hospital Center of Versailles André-Mignot, Le Chesnay, France
| | - A Mathian
- Department of Internal Medicine, Institut E3M, CIMI-Paris, Faculty of medicine, National Reference Centre of Systemic Lupus, antiphospholipid syndrome, and other autoimmune diseases, Sorbonne University, AP-HP, Pitié Salpêtrière, boulevard de l'Hôpital, 75013 Paris, France
| | - A Mekinian
- Department of Internal Medicine and Inflammation-Immunopathology-Biotherapy (DMU i3), Saint-Antoine Hospital, Sorbonne University, AP-HP, 75012 Paris, France
| | - M Pineton De Chambrun
- Department of Internal Medicine, Institut E3M, CIMI-Paris, Faculty of medicine, National Reference Centre of Systemic Lupus, antiphospholipid syndrome, and other autoimmune diseases, Sorbonne University, AP-HP, Pitié Salpêtrière, boulevard de l'Hôpital, 75013 Paris, France
| | - L de Pontual
- Department of Paediatrics, Jean-Verdier Hospital, AP-HP, HUPSSD, 93140 Bondy, France
| | - D Wahl
- Vascular Medicine Division and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, CHRU de Nancy, Nancy, France
| | - C Yelnik
- Department of Internal Medicine and Clinical immunology, Reference Centre of Autoimmune Systemic Rare Diseases Of North And North-West of France (CeRAINO), U1167 RID-AGE, Lille University, Inserm, University hospital of Lille, 59000 Lille, France
| | - S Zuily
- Vascular Medicine Division and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, CHRU de Nancy, Nancy, France
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Depietri L, Veropalumbo MR, Leone MC, Ghirarduzzi A. Antiphospholipid Syndrome: State of the Art of Clinical Management. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07496-3. [PMID: 37572208 DOI: 10.1007/s10557-023-07496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/14/2023]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder clinically characterized by recurrent arterial and venous thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies. Currently, treatment is mainly focused on anticoagulation, but therapies targeting mechanisms involved in APS autoimmune pathogenesis could play an important role in specific settings. An evidence-based therapeutic approach is limited by the broad clinical spectrum of the syndrome and the nature of a "rare disease" that makes it difficult to carry out well-designed prospective studies. Vitamin K antagonists (AVK), notably warfarin, are the standard treatment for preventing recurrent venous thrombosis and perhaps also arterial thrombosis. Direct oral anticoagulants (DOACs) are not recommended at least in patients with triple positivity APS. Treatment options for the prevention of pregnancy complications in obstetric APS, as combined use of aspirin and heparin, low-dose prednisolone, hydroxychloroquine, intravenous immunoglobulin (IVIG), may improve pregnancy outcome. The catastrophic antiphospholipid syndrome (CAPS) is the most severe form of APS with acute multiple organ involvement and small vessel thrombosis. Glucocorticoids, heparin, plasma exchange or IVIG, rituximab, or eculizumab must be added to concurrent treatment of precipitating factors (e.g. infections) as rescue therapies. Finally, it has been observed that SARS COV2 infection may produce vascular complications mimicking the clinical and pathophysiological features of APS and particularly of CAPS. From this point of view, attention has been focused on the "protective" role of anticoagulant therapy in preventing thrombotic complication when these clinical conditions coexist.
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Affiliation(s)
- Luca Depietri
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.
| | - Maria Rosaria Veropalumbo
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Maria Cristina Leone
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Angelo Ghirarduzzi
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
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Rose J. Autoimmune Connective Tissue Diseases: Systemic Lupus Erythematosus and Rheumatoid Arthritis. Immunol Allergy Clin North Am 2023; 43:613-625. [PMID: 37394263 DOI: 10.1016/j.iac.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Systemic lupus erythematosus and rheumatoid arthritis are just 2 of several autoimmune connective tissue diseases that are primarily chronic in nature but can present to the emergency department by virtue of an acute exacerbation of disease. Beyond an acute exacerbation of disease, their predilection for invading multiple organ systems lends itself to the potential for patients presenting to the emergency department with either a single or isolated symptom or a myriad of signs and/or symptoms indicative of a degree of disease complexity and severity that warrant timely recognition and resuscitation.
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Affiliation(s)
- Jonathan Rose
- Department of Emergency Medicine, Memorial Healthcare System, Memorial Hospital West, 703 N Flamingo Road, Pembroke Pines, FL 33028, USA.
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Granada-Gómez M, Velásquez-Berrío M, Molina CR, Martín SS, Escudero C, Alvarez AM, Cadavid AP. Modulation of the activation of endothelial nitric oxide synthase and nitrosative stress biomarkers by aspirin triggered lipoxins: A possible mechanism of action of aspirin in the antiphospholipid syndrome. Am J Reprod Immunol 2023; 90:e13753. [PMID: 37491919 DOI: 10.1111/aji.13753] [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: 04/09/2022] [Revised: 06/20/2023] [Accepted: 07/04/2023] [Indexed: 07/27/2023] Open
Abstract
PROBLEM Antiphospholipid syndrome (APS) is characterized by the clinical manifestation of vascular thrombosis (VT) or pregnancy morbidity (PM) and antiphospholipid antibodies (aPL) that can modify the nitric oxide production. Low-dose aspirin is used in the prevention and treatment of diverse alterations of pregnancy. One of the mechanisms of action of aspirin is to induce the production of aspirin-triggered-lipoxins (ATL). The aim of this study was to evaluate the modulatory effect of ATL over the activation of endothelial nitric oxide synthase (eNOS) and nitrosative stress biomarkers induced by aPL. METHODS We used polyclonal IgG and sera from women with aPL and PM/VT or VT only, and from women with PM only and positive for non-criteria aPL (SN-OAPS). In these sera, biomarkers of nitrosative stress (nitrites and nitrotyrosine) were measured. The protein expression of nitrotyrosine and the phosphorylation of eNOS (at Ser1177) were estimated in human umbilical vein endothelial cells (HUVECs) stimulated with polyclonal IgG with or without ATL. RESULTS Women with SN-OAPS showed increased circulating levels of nitrites and nitrotyrosine. Likewise, polyclonal IgG from either SN-OAPS or VT patients stimulated nitrotyrosine expression in HUVECs. ATL decreased the nitrotyrosine expression induced by polyclonal IgG from the SN-OAPS group. ATL also recovered the reduced eNOS phosphorylation at Ser1177 in HUVECs stimulated with polyclonal IgG from women with PM/VT or SN-OAPS. CONCLUSIONS Increased nitrosative stress present in serum of women with SN-OAPS is associated with IgG-mediated impaired endothelial NO synthesis in endothelial cells. ATL prevent these cellular changes.
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Affiliation(s)
- Manuel Granada-Gómez
- Grupo Reproducción, Facultad de Medicina, Dpto. Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Manuela Velásquez-Berrío
- Grupo Reproducción, Facultad de Medicina, Dpto. Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Carolina Rúa Molina
- Grupo de Investigación en Trombosis, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Sebastián San Martín
- Biomedical Research Center School of Medicine, Universidad de Valparaiso, Valparaiso, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillan, Chile
| | - Carlos Escudero
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio, Chillán, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health), Chillan, Chile
- Red Iberoamericana de Alteraciones Vasculares Asociadas a TRanstornos del EMbarazo (RIVATREM)
| | - Angela M Alvarez
- Grupo Reproducción, Facultad de Medicina, Dpto. Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia
| | - Angela P Cadavid
- Grupo Reproducción, Facultad de Medicina, Dpto. Microbiología y Parasitología, Universidad de Antioquia UdeA, Medellín, Colombia
- Grupo de Investigación en Trombosis, Facultad de Medicina, Universidad de Antioquia UdeA, Medellín, Colombia
- Red Iberoamericana de Alteraciones Vasculares Asociadas a TRanstornos del EMbarazo (RIVATREM)
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Raccis M, Dossi F, Bernardelli A, Aste M, Berisso G, Parodi G. Catastrophic antiphospholipid syndrome immediately after coronary angiography: the unexpected complication. Blood Coagul Fibrinolysis 2023; 34:239-243. [PMID: 37115989 DOI: 10.1097/mbc.0000000000001219] [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: 04/30/2023]
Abstract
A 44-year-old woman with obstetric antiphospholipid syndrome (APS) presented to our institution with suspected non ST-elevation myocardial infarction (NSTEMI). Shortly after coronary angiography, she developed diplopia, hypotension and chest pain with inferior ST elevation in 12-lead ECG. According to multidisciplinary evaluation, she promptly underwent systemic thrombolysis, with clinical and haemodynamic improvement. Eventually, a diagnosis of catastrophic APS was made, with multiorgan ischemic involvement confirmed by blood examinations and multimodal imaging techniques. A pluridisciplinary approach was central to define optimal medical therapy and in-hospital management that lead to clinical condition improvement at discharge. In this case, catastrophic APS was triggered or worsened by catheters insertion and invasive manoeuvres within the arterial lumen during coronary angiography. Recognizing catastrophic APS and its potential triggers, can be helpful to deliver prompt and accurate medical assistance. Moreover, in APS patients undergoing coronary angiography, preventive strategies are important to prevent possible unfavourable evolution in catastrophic APS.
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Affiliation(s)
- Mario Raccis
- Arrhythmologic Centre, Department of Cardiology, ASL4 Liguria, Lavagna
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari
| | - Filippo Dossi
- Arrhythmologic Centre, Department of Cardiology, ASL4 Liguria, Lavagna
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari
| | - Alice Bernardelli
- Arrhythmologic Centre, Department of Cardiology, ASL4 Liguria, Lavagna
- Department of Internal Medicine and Medical Specialities (DIMI), University of Genoa, Genova
| | - Milena Aste
- Arrhythmologic Centre, Department of Cardiology, ASL4 Liguria, Lavagna
| | | | - Guido Parodi
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari
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Bahar Keleşoğlu Dinçer A, Erkan D. The ABCs of antiphospholipid syndrome. Arch Rheumatol 2023; 38:163-173. [PMID: 37680521 PMCID: PMC10481699 DOI: 10.46497/archrheumatol.2023.41875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 05/28/2023] [Indexed: 09/09/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a thromboinflammatory syndrome characterized by thrombotic, microvascular, obstetric, or non-thrombotic events in the setting of persistent antiphospholipid antibodies (aPL), namely anticardiolipin antibody (aCL), anti-β2 glycoprotein-I antibody (aβ2GPI), and lupus anticoagulant (LA). The diagnosis of APS requires careful assessment of the aPL profile, the clinical phenotype, and additional risk factors. The standard management of aPL-related thrombosis is anticoagulation, which is not effective for microvascular and non-thrombotic events. In parallel to our improved understanding of aPL-related mechanisms, the role of immunosuppression has been increasingly investigated. In this review, we summarize the basic concepts and future perspectives in APS.
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Affiliation(s)
- Ayşe Bahar Keleşoğlu Dinçer
- Division of Rheumatology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Türkiye
- Hospital for Special Surgery, New York, NY, USA
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, and Weill Cornell Medicine, New York, NY, USA
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38
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Bae S, Comfort L, Ng J, Sarkar K, Pachtman S. Early HELLP Syndrome or Catastrophic Antiphospholipid Syndrome? A Diagnostic Dilemma. Cureus 2023; 15:e38244. [PMID: 37252601 PMCID: PMC10225157 DOI: 10.7759/cureus.38244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
Hypertensive disorders of pregnancy typically occur in the third trimester, with earlier presentations associated with underlying disorders such as antiphospholipid syndrome (APLS). We describe a case of a young primigravida presenting at 15 weeks 6 days gestation with epigastric pain, vomiting, new-onset severe-range hypertension, and subsequent development of anemia, thrombocytopenia, and transaminitis. Antiphospholipid antibodies (aPL) were triple-positive and imaging was negative for thrombosis. She was treated with aspirin, therapeutic anticoagulation, and ultimately dilatation and evacuation with initial postoperative improvement. Her symptoms returned postoperative day 3 and resolved following re-initiation of therapeutic anticoagulation. The differential diagnosis for hypertensive disorders of pregnancy is wide, particularly in second-trimester gestation, and includes catastrophic antiphospholipid syndrome (CAPS), lupus flare, microangiopathic anemias, and acute fatty liver of pregnancy. This case was an atypical presentation not clearly explained by any of the above diagnoses and required a multidisciplinary approach. Obstetric patients with high-risk aPL must be meticulously investigated with a broad differential to guide diagnosis and treatment.
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Affiliation(s)
- Suhwoo Bae
- Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
| | - Lizelle Comfort
- Maternal Fetal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
| | - Jason Ng
- Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
| | - Kumar Sarkar
- Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
| | - Sarah Pachtman
- Maternal Fetal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, USA
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Nevras V, Milaras N, Katsioulis C, Sotiriou Z, Tsalamandris S, Gkounti G, Skevos S. Acute Coronary Syndromes in Antiphospholipid Syndrome-above Suspicion: A Systematic Review. Curr Probl Cardiol 2023; 48:101503. [PMID: 36402221 DOI: 10.1016/j.cpcardiol.2022.101503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
Antiphospholipid syndrome(APS) is an autoimmune disorder characterized clinically by vascular thrombosis and/or pregnancy morbidity, associated with persistently elevated titers of antiphospholipid antibodies on at least two measurements over 12 weeks apart. In this study, we conducted a systematic review of the literature utilizing the Pubmed platform, in order to acquire clinical information about acute coronary syndromes in patients with APS. The obtained articles were reviewed in order to register the clinical characteristics, the rate of occurrence, the prognosis and the therapeutic approach of these patients. APS should be considered in young patients with acute myocardial infarction, even in patients with normal coronary arteries. The pharmaceutical approach is mainly based on the vitamin K antagonists, and in certain occasions aspirin, without any definite guidelines on the subject. Further randomized clinical trials are imperative for a better understanding of the particular characteristics of this group of patients, so that a more complete therapeutic approach to be obtained.
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Affiliation(s)
- Vasileios Nevras
- Cardiology Department, General Hospital of Thessaloniki G.Gennimatas, Thessaloniki, Thessaloniki, Greece
| | - Nikias Milaras
- Cardiology Department, General Hospital of Athens Hippokration, Athens, Athens, Greece.
| | - Christos Katsioulis
- Cardiology Department, General Hospital of Thessaloniki G.Gennimatas, Thessaloniki, Thessaloniki, Greece
| | - Zoi Sotiriou
- Pediatrics Department, General Hospital of Karditsa, Karditsa, Karditsa, Greece
| | - Sotirios Tsalamandris
- Cardiology Department, General Hospital of Athens Hippokration, Athens, Athens, Greece
| | - Georgia Gkounti
- Cardiology Department, General Hospital of Thessaloniki G.Gennimatas, Thessaloniki, Thessaloniki, Greece
| | - Sideris Skevos
- Cardiology Department, General Hospital of Athens Hippokration, Athens, Athens, Greece
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40
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Abu-Abaa M, Al-Qaysi G, Chadalawada S, Cole A. A Probable Catastrophic Antiphospholipid Antibody Syndrome/Thrombotic Storm Presenting As Rapidly Evolving Multifocal Ischemic and Hemorrhagic Strokes: A Case Report. Cureus 2023; 15:e35584. [PMID: 37007308 PMCID: PMC10062394 DOI: 10.7759/cureus.35584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/04/2023] Open
Abstract
Catastrophic antiphospholipid antibody syndrome (CAPS) is a life-threatening disorder. It is a rare and severe form of antiphospholipid antibody (APL) syndrome characterized by widespread multisystemic thrombosis. We present a 55-year-old male patient with acute cerebellar hemorrhagic stroke who developed widespread progressive microthrombosis and macrothrombosis manifesting as progressive bilateral ischemic strokes with lower extremities deep vein thrombosis (DVT) and acute renal failure within a week of presentation. The diagnosis and initiation of therapy were established after serological confirmation. This case adds to a limited number of cases of CAPS in literature and is interesting given the rarity of CAPS and thrombotic storm (TS) as well as the lack of inciting factor triggering CAPS/thrombotic syndrome. This case also helps to remind the clinicians of the importance to consider CAPS, even prior to serological confirmation, in those with rapidly progressive thrombotic events, as delayed diagnosis and therapy can yield poor clinical outcomes.
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Abstract
Antiphospholipid syndrome (APS) is a thrombo-inflammatory disease propelled by circulating autoantibodies that recognize cell surface phospholipids and phospholipid binding proteins. The result is an increased risk of thrombotic events, pregnancy morbidity, and various other autoimmune and inflammatory complications. Although antiphospholipid syndrome was first recognized in patients with lupus, the stand alone presentation of antiphospholipid syndrome is at least equally common. Overall, the diagnosis appears to affect at least one in 2000 people. Studies of antiphospholipid syndrome pathogenesis have long focused on logical candidates such as coagulation factors, endothelial cells, and platelets. Recent work has shed light on additional potential therapeutic targets within the innate immune system, including the complement system and neutrophil extracellular traps. Vitamin K antagonists remain the mainstay of treatment for most patients with thrombotic antiphospholipid syndrome and, based on current data, appear superior to the more targeted direct oral anticoagulants. The potential role of immunomodulatory treatments in antiphospholipid syndrome management is receiving increased attention. As for many systemic autoimmune diseases, the most important future direction is to more precisely identify mechanistic drivers of disease heterogeneity in pursuit of unlocking personalized and proactive treatments for patients.
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Affiliation(s)
- Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas L Ortel
- Division of Hematology, Departments of Medicine and Pathology, Duke University, Durham, North Carolina, USA
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Corticosteroids, Plasmapheresis, Argatroban, Rituximab, and Sirolimus Provided Clinical Benefit for Catastrophic Antiphospholipid Syndrome in a Patient with a History of Heparin-Induced Thrombocytopenia. Case Rep Rheumatol 2023; 2023:3226278. [PMID: 36816449 PMCID: PMC9935868 DOI: 10.1155/2023/3226278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 12/19/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
We report a patient with catastrophic antiphospholipid syndrome who had significant improvement after corticosteroids, plasmapheresis, argatroban, rituximab, and sirolimus. Argatroban was used instead of heparin due to a history of heparin-induced thrombocytopenia.
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43
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Rivera CR, Srisuwananukorn A, Bajwa RJ, Gordeuk VR, Rauch J, Levine JS, Saraf SL. Predictors and clinical complications associated with antiphospholipid antibodies in sickle cell disease. EJHAEM 2023; 4:211-215. [PMID: 36819151 PMCID: PMC9928649 DOI: 10.1002/jha2.643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/15/2023]
Abstract
Although a higher prevalence of antiphospholipid autoantibodies (aPL) has been observed in some cohorts of sickle cell disease (SCD) patients, the clinical risk factors for the development of aPL and its associated complications remain unclear. In a retrospective study of 63 SCD patients, a lower hemoglobin concentration and higher white blood cell count were independently associated with an elevated aPL. SCD patients with elevated aPL had increased pregnancy complications (≥3 miscarriages, preterm delivery, pre-eclampsia) and venous thrombotic events. Our findings suggest that SCD may predispose to the generation of aPL and that aPL itself may contribute to the vasculopathy of SCD. Prospective testing for aPL is warranted in patients with SCD.
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Affiliation(s)
| | - Andrew Srisuwananukorn
- Department of MedicineDivision of Hematology and OncologyMt Sinai Health SystemNew York CityNew YorkUSA
| | - Rizma Jalees Bajwa
- Department of MedicineDivision of NephrologyUniversity of Illinois at ChicagoChicagoIllinoisUSA
| | - Victor R. Gordeuk
- Department of MedicineDivision of Hematology and OncologyUniversity of Illinois at ChicagoChicagoIllinoisUSA
| | - Joyce Rauch
- Department of MedicineDivision of RheumatologyResearch Institute of the McGill University Health CentreMcGill UniversityMontrealQuebecCanada
| | - Jerrold S. Levine
- Department of MedicineDivision of NephrologyUniversity of Illinois at ChicagoChicagoIllinoisUSA
- Department of MedicineDivision of NephrologyJesse Brown, Veterans Affairs Medical CenterChicagoIllinoisUSA
| | - Santosh L. Saraf
- Department of MedicineDivision of Hematology and OncologyUniversity of Illinois at ChicagoChicagoIllinoisUSA
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Capozzi A, Manganelli V, Riitano G, Caissutti D, Longo A, Garofalo T, Sorice M, Misasi R. Advances in the Pathophysiology of Thrombosis in Antiphospholipid Syndrome: Molecular Mechanisms and Signaling through Lipid Rafts. J Clin Med 2023; 12:jcm12030891. [PMID: 36769539 PMCID: PMC9917860 DOI: 10.3390/jcm12030891] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
The pathological features of antiphospholipid syndrome (APS) are related to the activity of circulating antiphospholipid antibodies (aPLs) associated with vascular thrombosis and obstetric complications. Indeed, aPLs are not only disease markers, but also play a determining pathogenetic role in APS and exert their effects through the activation of cells and coagulation factors and inflammatory mediators for the materialization of the thromboinflammatory pathogenetic mechanism. Cellular activation in APS necessarily involves the interaction of aPLs with target receptors on the cell membrane, capable of triggering the signal transduction pathway(s). This interaction occurs at specific microdomains of the cell plasma membrane called lipid rafts. In this review, we focus on the key role of lipid rafts as signaling platforms in the pathogenesis of APS, and propose this pathogenetic step as a strategic target of new therapies in order to improve classical anti-thrombotic approaches with "new" immunomodulatory drugs.
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45
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Differentiating and Managing Rare Thrombotic Microangiopathies During Pregnancy and Postpartum. Obstet Gynecol 2023; 141:85-108. [PMID: 36455925 DOI: 10.1097/aog.0000000000005024] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/04/2022] [Indexed: 12/05/2022]
Abstract
The most common thrombotic microangiopathy (TMA) of pregnancy is the well-recognized syndrome of preeclampsia with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. However, rare TMAs, including thrombotic thrombocytopenic purpura, complement-mediated hemolytic-uremic syndrome, and catastrophic antiphospholipid syndrome, may occur during pregnancy or postpartum and present with features similar to those of preeclampsia with severe features. Early recognition and treatment of these infrequently encountered conditions are key for avoiding serious maternal morbidities with long-term sequelae and possible maternal or fetal death. Differentiating between preeclampsia with severe features and these rare TMAs is diagnostically challenging as there is significant overlap in their clinical and laboratory presentation. Given the rarity of these TMAs, high-quality evidence-based recommendations on diagnosis and management during pregnancy are lacking. Using current objective information and recommendations from working groups, this report provides practical clinical approaches to diagnose and manage these rare TMAs. This report also discusses how to manage individuals with a history of these rare TMAs who are planning to conceive. To optimize favorable outcomes, a multidisciplinary approach including obstetricians, maternal-fetal medicine specialists, hematologists, and nephrologists alongside close clinical and laboratory monitoring is vital.
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46
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Wu YH, Wong CK, Fang LC, Hung WL. Acrocyanosis and retiform purpura as the first manifestation of catastrophic antiphospholipid syndrome in a child: A case report. DERMATOL SIN 2023. [DOI: 10.4103/ds.ds-d-22-00086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
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Christopher N, Periaswamy G, Arunachalam VK, Mangalakumar V, Mehta P, Cherian M. Catastrophic Antiphospholipid Syndrome: A Case Series. Indian J Radiol Imaging 2022; 33:235-239. [PMID: 37123583 PMCID: PMC10132881 DOI: 10.1055/s-0042-1759857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AbstractCatastrophic antiphospholipid syndrome (CAPS) is the rare but most severe form of antiphospholipid syndrome with multiple organ ischemia developing over a short period of time. CAPS should be considered when imaging suggests an acute and concurrent multiorgan ischemia, associated with positive antiphospholipid antibodies. As CAPS can have fulminant irreversible complications, its early recognition is important to initiate the treatment promptly. We present three patients of CAPS who were managed at our institution.
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Affiliation(s)
- Navya Christopher
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
| | - Gopinath Periaswamy
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
| | | | - V. Mangalakumar
- Department of Nephrology, Kovai Medical Center and Hospital, Coimbatore, India
| | - Pankaj Mehta
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
| | - Mathew Cherian
- Department of Radiology, Kovai Medical Center and Hospital, Coimbatore, India
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48
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Dupré A, Morel N, Yelnik C, Moguelet P, Le Guern V, Stammler R, Nguyen Y, Paule R, Dufrost V, Ackermann F, Benhamou Y, Godeau B, Lambert M, Duffau P, Mekinian A, Saadoun D, Mouthon L, Hachulla E, Maillard H, Levesque H, Morell-Dubois S, Leroux G, Piette JC, Chasset F, Costedoat-Chalumeau N. Cutaneous Involvement in Catastrophic Antiphospholipid Syndrome in a Multicenter Cohort of 65 Patients. JAMA Dermatol 2022; 159:62-67. [PMID: 36477813 PMCID: PMC9856595 DOI: 10.1001/jamadermatol.2022.5221] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Catastrophic antiphospholipid syndrome (CAPS) is a severe, rare complication of antiphospholipid syndrome (APS), but cutaneous involvement has not yet been adequately described. Objective To describe cutaneous involvement during CAPS, its clinical and pathological features, and outcomes. Design, Setting, and Participants This cohort study was a retrospective analysis of patients included in the French multicenter APS/systemic lupus erythematosus register (ClinicalTrials.gov: NCT02782039) by December 2020. All patients meeting the revised international classification criteria for CAPS were included, and patients with cutaneous manifestations were analyzed more specifically. Main Outcomes and Measures Clinical and pathological data as well as course and outcome in patients with cutaneous involvement during CAPS were collected and compared with those in the register without cutaneous involvement. Results Among 120 patients with at least 1 CAPS episode, the 65 (54%) with skin involvement (43 [66%] women; median [range] age, 31 [12-69] years) were analyzed. Catastrophic antiphospholipid syndrome was the first APS manifestation for 21 of 60 (35%) patients with available data. The main lesions were recent-onset or newly worsened livedo racemosa (n = 29, 45%), necrotic and/or ulcerated lesions (n = 27, 42%), subungual splinter hemorrhages (n = 19, 29%), apparent distal inflammatory edema (reddened and warm hands, feet, or face) (n = 15, 23%), and/or vascular purpura (n = 9, 14%). Sixteen biopsies performed during CAPS episodes were reviewed and showed microthrombi of dermal capillaries in 15 patients (94%). These lesions healed without sequelae in slightly more than 90% (58 of 64) of patients. Patients with cutaneous involvement showed a trend toward more frequent histologically proven CAPS (37% vs 24%, P = .16) than those without such involvement, while mortality did not differ significantly between the groups (respectively, 5% vs 9%, P = .47). Conclusions and Relevance In this cohort study, half the patients with CAPS showed cutaneous involvement, with a wide spectrum of clinical presentations, including distal inflammatory edema. Skin biopsies confirmed the diagnosis in all but 1 biopsied patient.
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Affiliation(s)
- Anastasia Dupré
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Nathalie Morel
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Cécile Yelnik
- Centre Hospitalo-Universitaire Claude Huriez, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Philippe Moguelet
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Tenon, Service d’Anatomopathologie, Paris, France
| | - Véronique Le Guern
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Romain Stammler
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Yann Nguyen
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Romain Paule
- Hôpital Foch, Service de Médecine Interne, Suresnes, France
| | - Virginie Dufrost
- Centre Hospitalier Régional et Universitaire de Nancy, Service de Médecine Vasculaire, Nancy, France
| | | | - Ygal Benhamou
- Normandie Université, UNIROUEN, U 1096, Centre Hospitalo-Universitaire, Service de Médecine Interne, Rouen, France
| | - Bertrand Godeau
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Mondor, Service de Médecine Interne, Créteil, France
| | - Marc Lambert
- Centre Hospitalo-Universitaire Claude Huriez, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Pierre Duffau
- Centre Hospitalo-Universitaire de Bordeaux, Service de Médecine Interne et Immunologie Clinique, Bordeaux, France
| | - Arsène Mekinian
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Centre Hospitalo-Universitaire Saint Antoine, service de médecine interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), Paris, France
| | - David Saadoun
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire La Pitié, Département de Médecine Interne et Immunologie Clinique, Paris, France
| | - Luc Mouthon
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France
| | - Eric Hachulla
- Centre Hospitalo-Universitaire Claude Huriez, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Hélène Maillard
- Centre Hospitalo-Universitaire Claude Huriez, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Hervé Levesque
- Normandie Université, UNIROUEN, U 1096, Centre Hospitalo-Universitaire, Service de Médecine Interne, Rouen, France
| | - Sandrine Morell-Dubois
- Centre Hospitalo-Universitaire Claude Huriez, Service de Médecine Interne et Immunologie Clinique, Lille, France
| | - Gaëlle Leroux
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire La Pitié, Département de Médecine Interne et Immunologie Clinique, Paris, France
| | - Jean-Charles Piette
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire La Pitié, Département de Médecine Interne et Immunologie Clinique, Paris, France
| | - François Chasset
- Sorbonne Université, Faculté de Médecine, Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Tenon, Service de Dermatologie, Paris, France
| | - Nathalie Costedoat-Chalumeau
- Assistance Publique–Hôpitaux de Paris, Centre Hospitalo-Universitaire Cochin, Service de Médecine Interne, Paris, France,Université de Paris, Centre de Recherche Épidémiologie et Biostatistiques de Sorbonne Paris Cité, Paris, France
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49
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Murarasu A, Guettrot-Imbert G, Le Guern V, Yelnik C, Queyrel V, Schleinitz N, Ferreira-Maldent N, Diot E, Urbanski G, Pannier E, Lazaro E, Souchaud-Debouverie O, Orquevaux P, Belhomme N, Morel N, Chauvet E, Maurier F, Le Besnerais M, Abisror N, Goulenok T, Sarrot-Reynauld F, Deroux A, Pasquier E, de Moreuil C, Bezanahary H, Pérard L, Limal N, Langlois V, Calas A, Godeau B, Lavigne C, Hachulla E, Cohen F, Benhamou Y, Raffray L, de Menthon M, Tieulié N, Poindron V, Mouthon L, Larosa M, Eléfant E, Sentilhes L, Molto A, Deneux-Tharaux C, Costedoat-Chalumeau N. Characterisation of a high-risk profile for maternal thrombotic and severe haemorrhagic complications in pregnant women with antiphospholipid syndrome in France (GR2): a multicentre, prospective, observational study. THE LANCET. RHEUMATOLOGY 2022; 4:e842-e852. [PMID: 38261392 DOI: 10.1016/s2665-9913(22)00308-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prospective data about the risks of thrombotic and severe haemorrhagic complications during pregnancy and post partum are unavailable for women with antiphospholipid syndrome. We aimed to assess thrombotic and haemorrhagic events in a prospective cohort of pregnant women with antiphospholipid syndrome. METHODS This multicentre, prospective, observational study was done at 76 centres in France. To be eligible for this study, women had to have diagnosis of antiphospholipid syndrome; have conceived before April 17, 2020; have an ongoing pregnancy that had reached 12 weeks of gestation; and be included in the study before 18 weeks of gestation. Exclusion criteria were active systemic lupus erythematosus nephropathy, or a multifetal pregnancy. Severe haemorrhage was defined as the need for red blood cell transfusion or maternal intensive care unit admission because of bleeding or invasive procedures, defined as interventional radiology or surgery, to control bleeding. The GR2 study is registered with ClinicalTrials.gov, NCT02450396. FINDINGS Between May 26, 2014, and April 17, 2020, 168 pregnancies in 27 centres met the inclusion criteria for the study. 89 (53%) of 168 women had a history of thrombosis. The median term at inclusion was 8 weeks gestation. 16 (10%) of 168 women (95%CI 5-15) had a thrombotic (six [4%] women; 95% CI 1-8) or severe haemorrhagic event (12 [7%] women; 95% CI 4-12). There were no deaths during the study. The main risk factors for thrombotic events were lupus anticoagulant positivity at inclusion (six [100%] of six women with thrombosis vs 78 [51%] of 152 of those with no thrombosis; p=0·030) and placental insufficiency (four [67%] of six women vs 28 [17%] of 162 women; p=0·013). The main risk factors for severe haemorrhagic events were pre-existing maternal hypertension (four [33%] of 12 women vs 11 [7%] of 156 women; p=0·014), lupus anticoagulant positivity at inclusion (12 [100%] of 12 women vs 72 [49%] of 146 women; p<0·0001) and during antiphospholipid history (12 [100%] of 12 women vs 104 [67%] of 156 women; p=0·019), triple antiphospholipid antibody positivity (eight [67%] of 12 women vs 36 [24%] of 147 women; p=0·0040), placental insufficiency (five [42%] of 12 women vs 27 [17%] of 156 women; p=0·038), and preterm delivery at 34 weeks or earlier (five [45%] of 11 women vs 12 [8%] of 145 women; p=0·0030). INTERPRETATION Despite treatment adhering to international recommendations, a proportion of women with antiphospholipid syndrome developed a thrombotic or severe haemorrhagic complication related to pregnancy, most frequently in the post-partum period. Lupus anticoagulant and placental insufficiency were risk factors for these life-threatening complications. These complications are difficult to prevent, but knowledge of the antenatal characteristics associated with them should increase awareness and help physicians manage these high-risk pregnancies. FUNDING Lupus France, association des Sclérodermiques de France, association Gougerot Sjögren, Association Francophone contre la Polychondrite chronique atrophiante, AFM-Telethon, the French Society of Internal Medicine and Rheumatology, Cochin Hospital, the French Health Ministry, FOREUM, the Association Prix Veronique Roualet, and UCB.
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Affiliation(s)
- Anne Murarasu
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Université de Paris, Centre of Research in Epidemiology and Statistics, Paris, France
| | - Gaëlle Guettrot-Imbert
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France
| | - Véronique Le Guern
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France
| | - Cécile Yelnik
- Univ Lille, Inserm, CHU Lille, Service de Médecine Interne, U1167 RID-AGE, Lille, France
| | | | - Nicolas Schleinitz
- Service de Médecine Interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | | | | | | | - Emmanuelle Pannier
- Assistance Publique-Hôpitaux de Paris, Service de Maternité Gynécologie Obstétrique Port-Royal, Université de Paris, Hôpital Cochin, Paris, France
| | - Estibaliz Lazaro
- Service de Médecine Interne, Hôpital du Haut-Lévêque, Pessac, France
| | | | | | - Nicolas Belhomme
- Service de Médecine Interne et Immunologie Clinique, Hôpital Sud, Rennes; Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, Rennes, France
| | - Nathalie Morel
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France
| | - Elodie Chauvet
- Service de Médecine Interne, Centre Hospitalier Saint Jean, Perpignan, France
| | - François Maurier
- Service de Médecine Interne et Immunologie Clinique Groupe Hospitalier UNEOS Site Hôpital Robert Schuman, Vantoux, France
| | - Maëlle Le Besnerais
- Service de Médecine Interne, CHU Rouen, Rouen, France; INSERM U 905, Université de Rouen IFRMP, Institute for Biochemical Research, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Noemie Abisror
- Sorbonne Université, Service de Médecine Interne, AP-HP, Hôpital Saint Antoine, Paris, France
| | - Tiphaine Goulenok
- Service de Médecine Interne, Hôpital Bichat Claude Bernard, AP-HP, Paris, France
| | | | - Alban Deroux
- Service de Médecine Interne, CHU Grenoble-Alpes, Grenoble, France
| | | | - Claire de Moreuil
- Service de Médecine Interne et Pneumologie, CHU de Brest, Brest, France
| | | | - Laurent Pérard
- Service de Médecine Interne, Centre Hospitalier Saint Joseph Saint Luc, Lyon, France
| | - Nicolas Limal
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, CHU Henri Mondor, Université Paris-Est Créteil, Créteil, France
| | - Vincent Langlois
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Le Havre, Le Havre, France
| | - Anne Calas
- Service de Médecine Interne, Polyclinique Saint Laurent, Rennes, Frances
| | - Bertrand Godeau
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, CHU Henri Mondor, Université Paris-Est Créteil, Créteil, France
| | | | - Eric Hachulla
- Univ Lille, Inserm, CHU Lille, Service de Médecine Interne et Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du Nord et Nord-Ouest de France (CeRAINO), U1286-INFINITE-Institute for Translational Research in Inflammation, Lille, France
| | - Fleur Cohen
- Sorbonne Université, Assistance Publique Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Service de médecine interne 2, Centre national de référence maladies auto-immunes et systémiques rares, lupus et syndrome des anticorps antiphospholipides, Paris, France
| | - Ygal Benhamou
- Service de Médecine Interne, CHU Rouen, Rouen, France; INSERM U 905, Université de Rouen IFRMP, Institute for Biochemical Research, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Loïc Raffray
- Service Médecine Interne et Dermatologie, CHU Réunion-Hôpital Félix Guyon, Saint Denis, France
| | - Mathilde de Menthon
- Assistance Publique Hôpitaux de Paris, Service de Médecine Interne et Immunologie Clinique, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | | | - Vincent Poindron
- Service d'Immunologie Clinique, Nouvel Hôpital Civil, Strasbourg, France; Centre de référence maladies autoimmunes rares Est Sud Ouest RESO, Strasbourg, France
| | - Luc Mouthon
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France
| | | | - Elisabeth Eléfant
- Centre de Reference sur les Agents Tératogènes (CRAT), Hôpital Armand-Trousseau, Paris, France
| | - Loic Sentilhes
- Service de Gynécologie Obstétrique, CHU de Bordeaux, Bordeaux, France
| | - Anna Molto
- Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Université de Paris, Centre of Research in Epidemiology and Statistics, Paris, France; Assistance Publique-Hôpitaux de Paris, Service de Rhumatologie, Hôpital Cochin, Université de Paris, Paris, France
| | - Catherine Deneux-Tharaux
- Université de Paris, U1153 Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Nathalie Costedoat-Chalumeau
- Assistance Publique-Hôpitaux de Paris, Service de Médecine Interne, Centre de Référence Maladies Auto-immunes et Systémiques Rares, Hôpital Cochin, Université de Paris, Paris, France; Assistance Publique-Hôpitaux de Paris, Centre for Clinical Epidemiology, Hôpital Hôtel-Dieu, Université de Paris, Centre of Research in Epidemiology and Statistics, Paris, France.
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50
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Azoulay LD, Pineton de Chambrun M, Larcher R, Pène F, Argaud L, Mayaux J, Jamme M, Coudroy R, Mathian A, Gibelin A, Azoulay E, Tandjaoui-Lambiotte Y, Dargent A, Beloncle F, Raphalen JH, Troger A, de Prost N, Devaquet J, Contou D, Gaugain S, Trouiller P, Grangé S, Ledochowski S, Lemarie J, Faguer S, Degos V, Moyon Q, Luyt CE, Kerneis M, Combes A, Amoura Z. Prevalence, characteristics and outcome of cardiac manifestations in critically-ill antiphospholipid syndrome patients. J Autoimmun 2022; 133:102908. [PMID: 36126365 DOI: 10.1016/j.jaut.2022.102908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 12/13/2022]
Abstract
AIMS Antiphospholipid syndrome (APS) is a rare autoimmune disease defined by thrombotic events occurring in patients with persistent antiphospholipid antibodies. Cardiac manifestations in critically-ill APS patients are poorly investigated. We conducted a study to assess the prevalence, the characteristics and the prognosis of cardiac manifestations in thrombotic APS patients admitted to intensive care unit (ICU). METHODS AND RESULTS A French, national, multicentre, retrospective study, conducted, from January 2000 to September 2018, including all APS patients admitted to 24 participating centres' ICUs with any new thrombotic (arterial, venous or microvascular) manifestation. Cardiac manifestations were defined as any new cardiac abnormalities relying on clinical examination, cardiac biomarkers, echocardiography, cardiac magnetic resonance (CMR) and coronarography. One hundred and thirty-six patients (female 72%) were included. Mean age at ICU admission was 46 ± 15years. Cardiac manifestations were present in 71 patients (53%). In patients with cardiac involvement, median left ventricular ejection fraction (LVEF) was 40% [28-55], troponin was elevated in 93% patients, coronary angiogram (n = 19, 27%) disclosing a coronary obstruction in 21%. CMR (n = 21) was abnormal in all cases, with late gadolinium enhancement in 62% of cases. Cardiac manifestations were associated with a non-significant increase of mortality (32% vs. 19%, p = 0.08). After 1-year follow-up, median LVEF was 57% [44-60] in patients with cardiac involvement. CONCLUSION Cardiac involvement is frequent in critically-ill thrombotic APS patients and may be associated to more severe outcome. Increased awareness on this rare cause of myocardial infarction with or without obstructive coronary artery is urgently needed.
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Affiliation(s)
- Lévi-Dan Azoulay
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (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, Paris, France
| | - Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (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, Paris, France; Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France; Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France; Sorbonne Université, Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), and AP-HP, Hôpital La Pitié-Salpêtrière, Département d'Immunologie, Hôpital La Pitié-Salpêtrière, Paris, France.
| | - Romaric Larcher
- Service de Médecine Intensive-Réanimation, Hôpital Lapeyronie, Centre Hospitalier Universitaire (CHU) de Montpellier, PhyMedExp, Université de Montpellier, INSERM, CNRS, Montpellier, France
| | - Frédéric Pène
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, APHP & Université Paris Descartes, Paris, France
| | - Laurent Argaud
- Service de Médecine Intensive-Réanimation, Hôpital Edouard-Herriot, Hospices Civils de Lyon, Lyon, France
| | - Julien Mayaux
- AP-HP, Hôpital La Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation Médicale, Département R3S, Sorbonne Université, INSERM UMRS1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Matthieu Jamme
- Sorbonne Université, AP-HP, Hôpital Tenon, Service d'Urgences Néphrologiques et de Transplantation Rénale, Paris, France
| | - Remi Coudroy
- Service de Médecine Intensive-Réanimation, INSERM CIC1402, Groupe ALIVE, Université de Poitiers, CHU de Poitiers, Poitiers, France
| | - Alexis Mathian
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (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, Paris, France; Sorbonne Université, Inserm, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), and AP-HP, Hôpital La Pitié-Salpêtrière, Département d'Immunologie, Hôpital La Pitié-Salpêtrière, Paris, France
| | - Aude Gibelin
- Service de Médecine intensive réanimation, Hôpital Tenon, AP-HP, Faculté de médecine Sorbonne Université, Paris, France
| | - Elie Azoulay
- Service de Médecine Intensive-Réanimation, Hôpital Saint-Louis, AP-HP, Paris, France
| | | | - Auguste Dargent
- Service de Médecine Intensive-Réanimation, CHU Dijon, INSERM UMR 1231 LabEx Lipstic, Dijon, France
| | - François Beloncle
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, CHU d'Angers, Université d'Angers, Angers, France
| | - Jean-Herlé Raphalen
- Service d'Anesthésie et de Réanimation, Hôpital Necker, Université Paris Descartes, AP-HP, Paris, France
| | - Antoine Troger
- Service de Médecine Intensive-Réanimation, Hôpital Européen George-Pompidou, Université Paris Descartes, AP-HP, Paris, France
| | - Nicolas de Prost
- Service de Médecine Intensive-Réanimation, CHU Henri-Mondor, AP-HP, Créteil, France
| | - Jérôme Devaquet
- Service de Réanimation Polyvalente, Hôpital Foch, Suresnes, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor-Dupouy, Argenteuil, France
| | - Samuel Gaugain
- Département d'Anesthésie et Réanimation, Hôpital Saint-Louis-Lariboisière, Université Paris Diderot, AP-HP, Paris, France
| | - Pierre Trouiller
- Service de Réanimation Polyvalente et Unité de Surveillance Continue, Hôpital Antoine-Béclère, Hôpitaux Universitaires Paris-Sud, AP-HP, Clamart, France
| | - Steven Grangé
- Service de Néphrologie, Hôpital Charles-Nicolle, CHU de Rouen, Rouen, France
| | - Stanislas Ledochowski
- Service de Réanimation Polyvalente, Médipôle Lyon-Villeurbanne, Ramsay Santé, France
| | - Jérémie Lemarie
- Service de Réanimation Médicale, Hôpital Central, CHRU de Nancy, Nancy, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Unité de Réanimation, Centre de Référence des Maladies Rénales Rares, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Vincent Degos
- Service de Réanimation Neurochirurgicale, Sorbonne Université, Hôpital La Pitié-Salpêtrière, APHP, Paris, France
| | - Quentin Moyon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (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, Paris, France; Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
| | - Charles-Edouard Luyt
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France; Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Mathieu Kerneis
- Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, ACTION Study Group, Département de Cardiologie, Paris, France
| | - Alain Combes
- Sorbonne Université, APHP, Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France; Sorbonne Université, INSERM, UMRS_1166-ICAN, Institut de Cardiométabolisme et Nutrition (ICAN), Paris, France
| | - Zahir Amoura
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (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, Paris, France
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