The clinical significance of antiphospholipid antibodies

Clinical features of ocular damage in systemic lupus erythematosus and risk factors for hydroxychloroquine-related complications

Ocular damage in systemic lupus erythematosus (SLE) may cause insidious visual impairment, but its clinical features and the risk of hydroxychloroquine (HCQ)-related complications are still controversial. We performed a meta-analysis to evaluate ocular damage in SLE, the correlation between eye and systemic involvement, and the ocular side effects of treatment. The database PubMed, Embase, and Ovid were used for literature from reception to July, 2023, and the calculation was carried out with R. About 48,693 patients from 66 studies were included. The results indicated that ocular damage in SLE was insidious, appearing in 28 % of patients with no complaints. The most common symptoms and manifestations were dry eye (30 %) and keratoconjunctivitis sicca (26 %). Retinopathy was detected in 10 % of patients and was related to antiphospholipid antibodies (25 % versus 8 %). The proportion of retinopathy also significantly increased in patients with lupus nephropathy or neuropsychiatric systemic lupus erythematosus (risk ratio of 2.29 and 1.95, respectively). HCQ was used in 82 % of patients, of which 4 % suffered from ocular toxicity. HCQ-related retinopathy was dose-dependent. Dosage below 5 mg/kg/d was relatively effective and safe for long-term use, while routine examination was recommended.

Impact of antiphospholipid antibodies on thrombotic events in ambulatory cancer patients

BACKGROUND

Despite the conflicting data, the positivity of antiphospholipid antibodies (aPL) in cancer patients may be associated with an increased risk of thrombosis.

OBJECTIVE

To identify the prevalence and impact of aPL on venous thromboembolic events (VTE) and arterial thrombosis (ATE) in ambulatory cancer patients.

METHODS

In this single-center, prospective cohort study, we enrolled newly diagnosed ambulatory cancer patients receiving chemotherapy. Non-cancer controls were age- and sex-matched. Participants were evaluated for aPL. Primary outcomes were the composite outcome of VTE or ATE and the prevalence of aPL positivity in cancer patients. Secondary outcomes included the risk of VTE and ATE in cancer patients and all-cause mortality at six-month follow-up duration.

RESULTS

There were 137 cases and 137 controls with mean age of 56.0±12.3 and 55.5±12.1 years, respectively. Cancer patients were more likely to have positive aPL compared to controls, with the risk difference of 9.4% (95%CI 1.5 to 17.5). Composite of ATE or VTE occurred in 9 (6.6%) in cancer patients and 2 (1.5%) in controls. Cancer patients with aPL positivity were associated with higher risk of ATE or VTE (risk ratio [RR] 3.6, 95% CI 1.04-12.4). Positive LA in cancer patients were associated with higher risk of composites of ATE or VTE (RR 5.3 95%CI 1.3-21.0), whereas the anti-β2-GPI positivity were associated with increased risk of VTE (RR 4.7, 95%CI 1.1-19.2).

CONCLUSION

aPL was more prevalent in active cancer patients and positive aPL in cancer patients was associated with arterial or venous thrombosis.

The association of adjusted Global AntiphosPholipid Syndrome Score (aGAPSS) with cardiovascular disease in subjects with antiphospholipid antibodies

BACKGROUND AND AIMS

Cardiovascular disease (CVD), including coronary artery disease and stroke/peripheral artery disease, is less commonly reported than venous thromboembolism in subjects with antiphospholipid antibodies (aPLs) and little is known about the association of CVD with adjusted Global AntiphosPholipid Syndrome Score (aGAPSS).

METHODS

Consecutive aPLs subjects were enrolled to assess the association of CVD with aGAPSS. Moreover, additional risk factors of CVD were identified by means of multivariate analysis to design an aGAPSS specific for CVD (aGAPSS_CVD).

RESULTS

A total of 192 aPLs subjects (34 males, 158 females, mean age 49.84 ± 12.0 years) were enrolled. CVD was reported in 52 subjects (27.1%), 26 episodes of coronary artery disease and 26 stroke/peripheral artery disease. The prevalence of CVD increased for increasing aGAPSS ranging from 20.5% in the lowest aGAPSS category, up to 37.9% in the highest category (p = 0.027). ROC analysis showed that aGAPSS detected 63.0% of CVD and was associated with OR for CVD of 2.52 (95%CI: 1.24-5.10, p = 0.010). When including obesity, diabetes and smoking habit in the score, we found that aGAPSSCVD detected 71.4% of CVD (72.4% for early-CVD and 69.0% for CVD after 50 years) with an OR for CVD of 4.68 (95%CI: 2.31-9.51, p < 0.001).

CONCLUSIONS

The aGAPSS_CVD, obtained after adding obesity, smoking habit and diabetes to the standard aGAPSS, showed a higher detection rate of CVD in aPLs subjects, particularly of early-CVD. These results need to be validated in ad hoc designed prospective studies.

Subclinical atherosclerosis in asymptomatic carriers of persistent antiphospholipid antibodies positivity: A cross-sectional study

BACKGROUND

Whereas the relationship between subclinical atherosclerosis and antiphospholipid syndrome (APS) has been widely investigated, little is known about subclinical atherosclerosis in asymptomatic carriers with isolated antiphospholipid antibodies positivity (APP).

METHODS

Consecutive APP carriers, APS subjects and matched controls were enrolled. Intima-media thickness of the common carotid artery (CCA-IMT) and of the Bulb (Bulb-IMT) and the prevalence of carotid plaques were assessed in all enrolled subjects.

RESULTS

A total of 104 APP carriers, 221 APS subjects, and 325 matched controls were recruited. As compared with controls, APP carriers and APS subjects showed a higher CCA-IMT (0.90 ± 0.24 vs 0.82 ± 0.12, p = 0.014 and 0.93 ± 0.42 vs 0.82 ± 0.12, p < 0.001, respectively), Bulb-IMT (1.10 ± 0.44 vs 0.95 ± 0.18, p = 0.006 and 1.22 ± 0.68 vs 0.95 ± 0.18, p < 0.001, respectively) and an increased prevalence of carotid plaques (33.7% vs 10.2%, p < 0.001 and 38.5% vs 10.2%, p < 0.001, respectively). These results were confirmed stratifying for antibody isotype, after excluding subjects with systemic lupus erythematosus or other autoimmune diseases and after adjusting for major clinical and demographic variables. CCA-IMT, Bulb-IMT and the prevalence of carotid plaques were higher in subjects with high-titer antibodies and progressively increased for an increasing number of positive antibodies.

CONCLUSIONS

Similar to APS subjects, APP carriers have enhanced subclinical atherosclerosis, a more severe disease being observed in the presence of high-titer antibodies and multiple antibodies positivity. These data argue for a strict monitoring of subclinical signs of atherosclerosis and of cardiovascular risk factors in asymptomatic APP carriers.

Recurrent Miscarriage Syndrome and Infertility Due to Blood Coagulation Protein/Platelet Defects: A Review and Update

Three-hundred fifty-one women were referred for thrombosis and hemostasis evaluation after suffering recurrent miscarriages. All patients were referred by a high-risk obstetrician or reproductive medicine specialist after anatomic, hormonal or chromosomal defects had been ruled out. These patients were assessed over a three year period. The mean patient age at referral was 34 years and the mean number of miscarriages was 2.9 (2-9). All patients underwent a thorough evaluation for thrombophilia and, when indicated, a hemorrhagic disorder. Of the 351 patients, 29 (8%) had no defect. Of the remaining 322 patients, 7 (2%) had a bleeding disorder: 3 with platelet dysfunction, 1 with Factor XIII deficiency, 3 with von Willebrand’s and 3 with Osler-Weber-Rendu. The remainder of the patients had a thrombophilia as follows: 195 (60%) had antiphospholipid syndrome, 64 (20%) had Sticky Platelet Syndrome, 38 (12%) had MTHFR mutation, 23 (7.1%) had PAI-1 polymorphism, 12 (3.7%) had Protein S deficiency, 12 (3.7%) had Factor V Leiden, 3 (1%), had AT deficiency, 3 (1%) had Heparin-Cofactor II deficiency, 3 (1%) had TPA deficiency, and 6 (2%) had Protein C deficiency. There were a total of 364 defects found in the 312 patients harboring thrombophilia; thus, several harbored two and a few harbored three separate defects. All patients with thrombophilia were treated with preconception ASA at 81 mg/day with the immediate post-conception addition of heparin or LMW heparin (Dalteparin). Both ASA and heparin/LMW heparin were used to term. The first 120 patients were treated with unfractionated heparin at 5,000 U every 24 hours, subcutaneously and the last 192 have been treated with Dalteparin at 5,000 U/day subcutaneously. The patients with MTHFR were also treated with folate at 5 mg/day + pyridoxine at 50 mg/day. All patients were carefully monitored with CBC and platelet counts, anti-Xa levels, frequent ultrasounds and physical exams. Only 2 of the thrombophilia patients suffered another miscarriage; all others had a normal term delivery. There were no pregnancy-related thromboses, no delivery complications and no episodes of post-partum thrombosis. The only bleeding consisted of 1-4 cm bruises at injection sites. No episodes of thrombocytopenia (HIT) were noted. In our experience, thrombophilia is a common cause of recurrent miscarriage and all patients with no anatomical, hormonal or chromosomal defect should be evaluated for thrombophilia or a bleeding disorder. The success rate of normal term delivery in these 312 patients was 94% using ASA + heparin or Dalteparin. In addition, side effects of therapy were minimal.

Markers of cardiovascular risk in patients with antiphospholipid syndrome: a meta-analysis of literature studies

Several studies reported on the association between antiphospholipid syndrome (APS) and venous thrombosis. In contrast, little is known about cardiovascular (CV) risk in APS. We performed a meta-analysis on the impact of APS on major markers of CV risk. Studies on the relationship between APS and common carotid artery intima-media thickness (CCA-IMT), internal carotid artery IMT (ICA-IMT), carotid bifurcation IMT (BIF-IMT), prevalence of carotid plaques, flow-mediated dilation (FMD), nitrate-mediated dilation (NMD), and ankle-brachial index (ABI) were systematically searched in PubMed, Web of Science, Scopus, and EMBASE databases. Twenty case-control studies (668 cases, 678 controls) were included. Compared to controls, APS patients showed a higher CCA-IMT (mean difference [MD] 0.11 mm; 95% CI 0.07, 0.14), ICA-IMT (MD 0.08 mm; 95% CI 0.05, 0.11), BIF-IMT (MD 0.09 mm; 95% CI 0.06, 0.12) and a higher frequency of carotid plaques (OR 3.87; 95% CI 1.61, 9.31). Moreover, a lower FMD was found in APS subjects than in controls (MD -4.49%; 95% CI -6.20, -2.78), with no differences in NMD (MD -1.80%; 95% CI -4.01, 0.42). Finally, an increased prevalence of pathological ABI was found in APS patients compared to controls (OR 7.26; 95% CI 1.77, 29.71). Despite heterogeneity among studies, APS appears significantly associated with markers of subclinical atherosclerosis and CV risk. These findings can be useful to plan adequate prevention strategies and therapeutic approaches.

Antiphospholipid syndrome in pregnancy

During the past 5 years the author and his colleagues have assessed carefully 351 women referred for evaluation of thrombosis and hemostasis after they had suffered recurrent miscarriages. This article describes the flow protocol the author and associates follow to maximize success and keep the costs of evaluation of recurrent miscarriage syndrome/infertility at a minimum while providing the best chances for defining a cause and thus providing optimal therapy for successful term pregnancy outcome. It presents the outcomes of the author's protocol and those of others in treating women who have antiphospholipid syndrome and who have suffered recurrent miscarriages.

Isolated digital gangrene complicating hepatitis a infection in a child

Hepatitis A virus is rarely associated with extrahepatic complications. A child presented with a history suggesting Raynaud's phenomenon and severe digital gangrene, as a complication of hepatitis A infection. Coagulation study results (protein C, protein S, antithrombin III, and activated protein C resistance) were all normal except for anticardiolipin antibodies, which were present on initial presentation and resolved later. Antinuclear antibodies, rheumatoid factor, lupus anticoagulant, antineutrophilic cytoplasmic antibodies, and Venereal Disease Research Laboratory test were all negative. Cryoglobulins were not detected. C3 and C4 levels were normal. Blood urea nitrogen and creatinine levels were normal as well. The patient was treated with aspirin and diclofenac, and improved slowly with complete resolution of gangrene and symptoms after 3 months. She remains asymptomatic 4 years later. Transient antiphospholipid syndrome or isolated Raynaud's phenomenon may be added to the list of extrahepatic complications of hepatitis A.

Elevated anticardiolipin antibodies in acute liver failure

Antibodies to cardiolipin (aCLA), a phospholipid primarily localized in inner mitochondrial membranes, were transiently elevated (P<0.01) when mice were exposed to an industrial surfactant and then infected with influenza B virus, a model of acute liver failure (ALF). Children with ALF also had elevated levels of aCLA.

Isolated fascicular oculomotor nerve palsy as the initial presentation of the antiphospholipid syndrome

This case report describes a 24-year-old female who presented with sudden onset of painless diplopia and ptosis in her left eye. Examination identified an isolated incomplete pupil-sparing left oculomotor nerve palsy. Magnetic resonance imaging demonstrated focal hyperintensity in the left midbrain with infarction suggested by diffusion-weighted imaging. A diagnosis of primary antiphospholipid syndrome was made with the demonstration of a positive lupus anticoagulant. Other autoimmune markers were present on initial assessment, but did not fulfil diagnostic criteria for systemic lupus erythematosus. Anticoagulation with warfarin was commenced, with gradual resolution of neurological deficits. This case illustrates an unusual initial manifestation of primary antiphospholipid syndrome causing midbrain stroke in a young woman.

Anticardiolipin antibody positivity in diabetic patients with and without diabetic foot

Anticardiolipin (aCL) antibodies may play a role in the enhancement of platelet aggregation and/or progression of the macrovascular diabetic complications. Also, aCL antibodies may cause or promote ischemia and thrombosis. Therefore, we aimed to investigate IgG aCL and IgM aCL antibodies positivity in type 2 diabetic patients with and without ischemic diabetic foot. In this case-control study, we examined 40 diabetic patients without diabetic foot problem and 35 diabetic patients with ischemic diabetic foot. Forty diabetic patients (19 females, 21 males) without diabetic foot served as Group 1 and 35 diabetic patients (17 females, 18 males) who had ischemic diabetic foot served as Group 2. In the control group, 35 nondiabetic healthy subjects (18 females, 17 males) were included in Group 3. The groups were similar in age and sex, which is not statistically significant (P>.05). There was no difference in the IgG aCL antibodies positivity between Groups 1 and 3 (P>.05). However, IgG aCL antibodies positivity in Group 2 was significantly higher than those of the other groups (P<.05). IgG aCL antibodies were found positive in 10% (4/40) of Group 1, 34.3% (12/35) of Group 2 and 8.6% (3/35) of Group 3. When Groups 1 and 2 were compared, the odds ratio adjusted for age, gender, hypertension, coronary artery disease history, cigarette smoking, duration of diabetes mellitus, cholesterol, and haemoglobin A(1C) (HbA1c) was 6.8 [95% confidence interval (CI), 1.41-32.66; P=.016] for aCL positivity. In conclusion, although available evidence does not prove a causal association between positivity of aCL and diabetic foot, we believe that a causal association is supported by the data obtained from this study.

Cofactor dependence and isotype distribution of anticardiolipin antibodies in viral infections

BACKGROUND

Antibodies to cardiolipin (aCLs) are often detected in patients with autoimmune disorders or infectious diseases.

OBJECTIVE

To investigate the distribution of aCL isotypes and requirement of protein cofactor in viral infections in order to establish the importance, if any, of these antibodies in these infectious diseases.

PATIENTS AND METHODS

The isotype distribution of aCLs in the sera from 160 patients with infection caused by HIV-1 (n=40), hepatitis A virus (n=40), hepatitis B virus (n=40), or hepatitis C virus (n=40) was studied by standardised enzyme linked immunosorbent assay (ELISA) in the presence and absence of protein cofactor (mainly beta2-glycoprotein I). Serum samples from healthy volunteers and patients with syphilis and antiphospholipid syndrome were also included and served as negative and positive control groups respectively.

RESULTS

The prevalence of one or more aCL isotypes in serum of patients with HIV-1, hepatitis A virus, hepatitis B virus, or hepatitis C virus infection was 47%, 92%, 42%, and 17% respectively (principally IgM and/or IgA). Most of these antibodies were mainly cofactor independent.

CONCLUSIONS

The presence of aCLs in viral infections is principally cofactor independent, suggesting that cofactor dependence of the aCLs should be assessed to distinguish subjects most likely to suffer from clinical symptoms observed in the presence of these antibodies.

Recurrent miscarriage syndrome and infertility caused by blood coagulation protein or platelet defects

Recurrent miscarriage syndrome and infertility are common problems in the United States. Recurrent miscarriage affects more than 500,000 women annually. If properly screened through a cost-effective protocol, the cause will be found in almost all women. The most common singular defect in women with RMS is a hemostasis defect, and if a thorough APLS evaluation is performed, the most common of these is found to be APLS. Other hereditary and acquired procoagulant defects are also commonly found, if looked for. It is important to evaluate women with RMS appropriately, because if a cause for the RMS is found, most women will achieve normal-term delivery. Hemorrhagic defects are rare hemostasis causes of RMS, but these defects also are treatable in many instances and should be considered in appropriate women. Treatment of the common procoagulant defects consists of preconception low-dose ASA at 81 mg/day followed by immediate postconception low-dose unfractionated porcine heparin. LMWH may be a suitable alternative.

Recurrent miscarriage syndrome due to blood coagulation protein/platelet defects: prevalence, treatment and outcome results. DRW Metroplex Recurrent Miscarriage Syndrome Cooperative Group

Although first-time miscarriages are usually caused by chromosomal defects, about 55% of recurrent miscarriages are caused by procoagulant defects that induce thrombosis and infarction of placental vessels. Of recurrent miscarriages, about 7% are caused by chromosome defects, 15% to hormonal defects, and 10% to 15% to anatomical defects. Recurrent miscarriage involves more than 500,000 women in the United States each year. During the past 4 years, 179 patients, prescreened for chromosomal, hormonal, and anatomical defects, and found to harbor none, underwent hemostasis defect evaluation. A total of 160 of these have been analyzed. A hemostasis defect was found in 150 of 160 women (n = 94% of screened women). The mean age was 33 years; the mean number of miscarriages before referral was three. All women with a procoagulant defect (149) were treated with preconception ASA at 81 mg/d, and unfractionated porcine heparin at 5000 U every 12 hours was added immediately postconception; both agents were used to term delivery. Only two of 149 patients failed therapy. The defects found were as follows: antiphospholipid syndrome, 67%; sticky platelet syndrome, 21%; tissue plasminogen activator (TPA) deficiency, 9%; factor V Leiden, 7%; high PAI-1, 6%; protein S, 5%; high LP(a), 3%; AT, 2%; protein C, 1%. Thirty-eight patients had more than one defect. In the group with antiphospholipid syndrome, 24% only had a subgroup antibody (antiphosphatidyl-serine, -inositol, -ethanolamine, -choline, -glycerol) or antiphosphatidic acid antibody, in the absence of anticardiolipin antibody or lupus anticoagulant. This finding is similar to that recently reported in early age ischemic stroke patients (<50 years old). In summary, about 55% of patients with recurrent miscarriage harbor a procoagulant defect to account for placental vascular occlusion. More than 98% will have a normal term delivery with preconception aspirin (ASA) and addition of postconception heparin to term. Patients should be screened by an obstetrician or by reproductive specialists for hormonal and anatomic defects before initiating a procoagulant evaluation; if such prescreening is done, the yield of a defect is high and appropriate therapy leads to an excellent outcome.

Transthoracic echocardiographic demonstration of massive pulmonary thrombus caused by protein C deficiency

Few cases of pulmonary embolism detected by transthoracic echocardiography (TTE) have been reported. We present a case of a patient affected by pulmonary embolism caused by protein C deficiency. Transthoracic echocardiography showed a thrombus in transit (ie, visualization of a thrombus within the pulmonary artery). A hypercoagulable state caused by deficiency of protein C is a rare cause of pulmonary thromboembolism. Our experience demonstrates a massive pulmonary thrombus resulting from such a deficiency. Transthoracic echocardiography should be considered as the first diagnostic method for patients with suspected pulmonary embolism.

Do antibodies to beta2-glycoprotein 1 contribute to the better characterization of the antiphospholipid syndrome?

The aim of this study was to determine if the measurement of anti-beta2-glycoprotein I antibodies (abeta2-GPI) in serum levels contributes to the better characterization of the clinical situation of patients with antiphospholipid syndrome (APS). For this purpose abeta2-GPI of both isotypes was measured in 42 patients with APS and 32 SLE patients without APS. Clinical records of all patients were thoroughly reviewed. The presence of abeta2-GPI was correlated with the clinical manifestations of APS and compared with the presence of anticardiolipin antibodies (aCL) and lupus anticoagulant (LA) activity. There was a positive correlation between levels of aCL and abeta2-GPI for both IgG and IgM isotypes (rho of Spearman=0.82 and 0. 64 respectively, P=0.0001). Both antibodies presented significantly higher titres in LA positive patients (P<0.05). The specificity for APS was 91% for IgG abeta2-GPI vs 75% for IgG aCL and 87% for IgM abeta2-GPI vs 81% for IgM aCL. 68% of patients with thrombosis of 100% of patients with thrombocytopenia showed positive tests for all three markers (aCL, LA, abeta2-GPI). Simultaneous presence of circulating LA and high titres of both aCL and abeta2-GPI identify a subset of patients with primary APS (PAPS) who have a more severe clinical course of the disease. Although the specificity of abeta2-GPI IgG is higher than that of aCL IgG, when all three tests are performed abeta2-GPI testing provides only additional information to that of aCL and LA. Therefore, we concluded that the abeta2-GPI test should not be considered as a substitute for conventional LA or aCL assays. However, performance of abeta2-GPI seems to be important in PAPS with high aCL titres, to alert the physician about the risk for the worst course of the illness.