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Pandya J, Onel K, Erkan D. The clinical relevance of different antiphospholipid antibody profiles in pediatric rheumatology patients. Pediatr Rheumatol Online J 2024; 22:46. [PMID: 38671480 PMCID: PMC11046946 DOI: 10.1186/s12969-024-00954-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/29/2023] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The clinical relevance of different antiphospholipid antibody (aPL) profiles, including low level anticardiolipin (aCL) and anti-β2-glycoprotein-I (aβ2GPI) antibodies, is ill-defined in the pediatric population. Our purpose is to describe the demographic, clinical, and laboratory characteristics of aPL positive pediatric patients based on different aPL profiles. FINDINGS In this single center retrospective cohort study, based on the screening of our pediatric (age ≤ 18) rheumatology electronic medical records (2016-2022), we identified patients who had at least one "positive" aPL (lupus anticoagulant [LA], aCL IgG/M, or aβ2GPI IgG/M) result. Patients were grouped into high- (LA positive and/or aCL/aβ2GPI IgG/M > 40U [ELISA]) and low-risk (LA negative and aCL/aβ2GPI IgG/M 20-39U) aPL profiles; those with persistently positive aPL were descriptively analyzed for demographic and clinical characteristics. Of 57 included patients, 34 (59%) had initial high- and 23 (40%) had initial low-risk profiles. Based on subsequent aPL results available in 42/57 (74%) patients, 25/27 (93%) in the high-, and 7/15 (47%) in the low-risk groups remained still positive. Of these 32 patients with persistently positive aPL, moderate-to-large vessel or microvascular thrombosis occurred in nine (28%) patients with high-risk and in none with low-risk aPL profiles; non-thrombotic aPL-related manifestations were reported in 15 (47%) patients with persistent aPL positivity. CONCLUSION An initial high-risk aPL profile was persistent in approximately 90% of our cohort, a third of whom had thrombosis, and half had non-thrombotic aPL manifestations. Our results underscore the need for a large-scale effort to better characterize aPL-related manifestations in pediatric patients with persistent high-risk aPL-profiles.
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Affiliation(s)
- Jheel Pandya
- Department of Pediatric Rheumatology, Hospital for Special Surgery, 535 E 70th Street, 10021, New York, NY, USA.
| | - Karen Onel
- Department of Pediatric Rheumatology, Hospital for Special Surgery, 535 E 70th Street, 10021, New York, NY, USA
| | - Doruk Erkan
- Hospital for Special Surgery, Barbara Volcker Center for Women and Rheumatic Disease, Weill Cornell Medicine, 535 E70th Street, 10021, New York, NY, USA
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Dong Q, Yin J, Su H, Ni Q. Primary catastrophic antiphospholipid syndrome in children with midbrain infarction: a case report. Front Pediatr 2024; 12:1370843. [PMID: 38650992 PMCID: PMC11033311 DOI: 10.3389/fped.2024.1370843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024] Open
Abstract
Background Catastrophic antiphospholipid syndrome (CAPS) is a multi-system autoimmune disease characterized by extensive thrombosis. Pediatric CAPS is extremely rare and associated with a high mortality rate, especially when midbrain infarction is involved. Hence, early diagnosis and prompt initiation of appropriate treatment for CAPS complicated by midbrain infarction are of utmost importance in achieving favorable outcomes. Case presentation In this report, we present the case of a 14-year-old girl who presented with neurological symptoms and digestive system infection and was initially diagnosed with an "intracranial infection". After a series of rigorous diagnostic procedures, the patient was ultimately diagnosed with primary CAPS and was immediately transferred to the intensive care unit where she was treated with anticoagulation, glucocorticoids, intravenous immunoglobulin (IVIG) therapy, and multiple plasma infusions. Twenty-seven days after admission, the patient's condition improved with standardized treatment, and she was discharged and followed up regularly. Conclusion This case report provides a description of the clinical features observed in a pediatric patient with CAPS and concurrent midbrain infarction, highlighting the crucial role of early diagnosis and timely treatment in influencing patient prognosis.
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Affiliation(s)
- Qinghua Dong
- The Second Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Jianyun Yin
- The Second Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Hang Su
- The Second Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Qian Ni
- Pediatric Respiratory Medicine, Lanzhou University Second Hospital, Lanzhou, China
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Sloan EE, Kmetova K, NaveenKumar SK, Kluge L, Chong E, Hoy CK, Yalavarthi S, Sarosh C, Baisch J, Walters L, Nassi L, Fuller J, Turnier JL, Pascual V, Wright TB, Madison JA, Knight JS, Zia A, Zuo Y. Non-criteria antiphospholipid antibodies and calprotectin as potential biomarkers in pediatric antiphospholipid syndrome. Clin Immunol 2024; 261:109926. [PMID: 38355030 DOI: 10.1016/j.clim.2024.109926] [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: 12/18/2023] [Accepted: 02/03/2024] [Indexed: 02/16/2024]
Abstract
Our study aimed to evaluate the presence, clinical associations, and potential mechanistic roles of non-criteria antiphospholipid antibodies (aPL) and circulating calprotectin, a highly stable marker of neutrophil extracellular trap release (NETosis), in pediatric APS patients. We found that 79% of pediatric APS patients had at least one non-criteria aPL at moderate-to-high titer. Univariate logistic regression demonstrated that positive anti-beta-2 glycoprotein I domain 1 (anti-D1) IgG (p = 0.008), anti-phosphatidylserine/prothrombin (aPS/PT) IgG (p < 0.001), and aPS/PT IgM (p < 0.001) were significantly associated with venous thrombosis. Positive anti-D1 IgG (p < 0.001), aPS/PT IgG (p < 0.001), and aPS/PT IgM (p = 0.001) were also associated with non-thrombotic manifestations of APS, such as thrombocytopenia. Increased levels of calprotectin were detected in children with APS. Calprotectin correlated positively with absolute neutrophil count (r = 0.63, p = 0.008) and negatively with platelet count (r = -0.59, p = 0.015). Mechanistically, plasma from pediatric APS patients with high calprotectin levels impaired platelet viability in a dose-dependent manner.
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Affiliation(s)
- Elizabeth E Sloan
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA; Scottish Rite for Children, Dallas, TX, USA; Children's Medical Center, Dallas, TX, USA
| | - Katarina Kmetova
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Lyndsay Kluge
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Emily Chong
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Claire K Hoy
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Srilakshmi Yalavarthi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Cyrus Sarosh
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeanine Baisch
- Gale and Ira Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA
| | | | - Lorien Nassi
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA; Scottish Rite for Children, Dallas, TX, USA; Children's Medical Center, Dallas, TX, USA
| | - Julie Fuller
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA; Scottish Rite for Children, Dallas, TX, USA; Children's Medical Center, Dallas, TX, USA
| | - Jessica L Turnier
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Virginia Pascual
- Gale and Ira Drukier Institute for Children's Health, Weill Cornell Medicine, New York, NY, USA
| | - Tracey B Wright
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA; Scottish Rite for Children, Dallas, TX, USA; Children's Medical Center, Dallas, TX, USA
| | - Jacqueline A Madison
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Pediatric Rheumatology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ayesha Zia
- Children's Medical Center, Dallas, TX, USA; Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
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Agrawal A, Bhagawati J, Kumar S, Acharya S. Black Digits Matter: A Multispecialty Enigma. Cureus 2024; 16:e55133. [PMID: 38558690 PMCID: PMC10979651 DOI: 10.7759/cureus.55133] [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: 01/28/2024] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction Digital ischemia is alike any other visceral ischemic event leading to severe tissue damage ultimately causing necrosis of the involved extremity. It's like a preview of the upcoming systemic disorder and can present itself in any specialty and hence everyone, be it a physician or a surgeon must be primed toward how to proceed with a case of digital ischemia. In this case series, we present six such cases that presented with digital ischemic events either as a sole presentation or were followed by other systemic manifestations that led to their evaluation and ultimately the etiology behind it. Material and method Patients visiting Rheumatology OPD with complaints suggestive of digital ischemia were included in this study. All patients underwent thorough history taking and clinical examination to establish the cause of digital ischemia. Patients with probable infective, trauma, cardiac, and drug-induced causes and malignancies were excluded. As per probable autoimmune causes, patients underwent evaluation via antinuclear antibodies by immunofluorescence (ANA by IF), antiphospholipid antibodies like lupus anticoagulant (LAC), anticardiolipin antibodies (AcL) and anti Beta2GP1 antibodies, extractable nuclear antigens (ENA) and in cases of suspected vasculitis doppler ultrasound and angiography. Results Six patients were identified as cases primarily presenting with digital ischemia or with a prior history of digital ischemia. Two patients were of the pediatric age group, one 16-year-old male presenting with acute arthritis and a history of digital ischemia one year back, and the other was a 12-year-old female with blackening of the second toe in her left foot with a history of similar complaints in the left great toe for which she underwent amputation of that toe. Other four cases were of the adult age group, with two cases of scleroderma, one with systemic lupus erythematosus, and one with Takayasu arteritis. All of these patients primarily presented to departments other than rheumatology. Conclusion Digital ischemia is a pan-specialty problem with the etiologies spreading across a vast spectrum of rheumatological disorders, many of which may present to different specialties initially, later discovered to be part of the systemic manifestation of autoimmune diseases. Hence, it becomes imperative to have a rheumatological perspective in these cases of digital ischemia which all specialities should be aware of, and timely referral may prevent permanent loss of the digits and in some cases the entire limb.
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Affiliation(s)
- Abhijeet Agrawal
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Jahnabi Bhagawati
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Wardha, IND
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Molinari AC, Martini T, Banov L, Ierardi A, Leotta M, Strangio A, Santoro RC. Lupus Anticoagulant Detection under the Magnifying Glass. J Clin Med 2023; 12:6654. [PMID: 37892792 PMCID: PMC10607820 DOI: 10.3390/jcm12206654] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
Diagnosis of antiphospholipid syndrome (APS) requires the presence of a clinical criterion (thrombosis and/or pregnancy morbidity), combined with persistently circulating antiphospholipid antibodies (aPL). Lupus anticoagulant (LA) is one of the three laboratory parameters (the others being antibodies to either cardiolipin or β2-glycoprotein I) that defines this rare but potentially devastating condition. For the search for aCL and aβ2-GP-I, traditionally measured with immunological solid-phase assays (ELISA), several different assays and detection techniques are currently available, thus making these tests relatively reliable and widespread. On the other hand, LA detection is based on functional coagulation procedures that are characterized by poor standardization, difficulties in interpreting the results, and interference by several drugs commonly used in the clinical settings in which LA search is appropriate. This article aims to review the current state of the art and the challenges that clinicians and laboratories incur in the detection of LA.
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Affiliation(s)
- Angelo Claudio Molinari
- Thrombosis and Hemostasis Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy; (A.C.M.); (L.B.)
| | - Tiziano Martini
- Immuno-Haematology and Transfusion Medicine, Center for Congenital Bleeding Disorders, Cesena General Hospital, 47521 Cesena, Italy
| | - Laura Banov
- Thrombosis and Hemostasis Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy; (A.C.M.); (L.B.)
| | - Antonella Ierardi
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
| | - Marzia Leotta
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
| | - Alessandra Strangio
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
| | - Rita Carlotta Santoro
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
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6
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Bashir BA, Mohamed MH, Hussain MA, Osman W, Mothana RA, Hasson S. Trends of Coagulation Parameters in Human Immunodeficiency Virus Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1826. [PMID: 37893544 PMCID: PMC10608449 DOI: 10.3390/medicina59101826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/01/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: HIV disease is recognized to cause inconsistencies in coagulation via various pathways during infection. Some studies have indicated that HIV-infected patients are prone to developing thrombocytopenia, thrombosis, or autoantibodies that may cause difficulties in diagnosis. This study is intended to measure the trend of coagulation parameters in Sudanese patients with HIV. Materials and Methods: A cross-sectional study was carried out in patients with HIV admitted to the Sudan National AIDS Program (SNAP) from January 2018 to December 2019. Prothrombin time (PT), partial thromboplastin time (PTT), thrombin time (TT), D-dimer (DD), hemoglobin (HB), total lymphocyte count (TLC), platelet count (PLT), and a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 (ADAMTS13), were evaluated among HIV Sudanese patients. Results: Out of the 44 HIV patients included, 6 (13.6%) were found to have thrombotic thrombocytopenic purpura-like events and 12 (27.2%) had antiphospholipid antibodies, of whom 8 (66.6%) showed anticardiolipin antibody (1gG (75%) and IgM (25%)) and 4 showed lupus anticoagulants. The HB, TLC, and PLT values were found to be significantly lower in HIV patients than in control (p = 0.000, 0.000, and 0.050, respectively). The PT and ADAMTS13 values showed no significant difference between HIV patients and control (p = 0.613 and 0.266, respectively). The PTT, TT, and DD values were found to be augmented in HIV patients versus the control (p = 0.000). Conclusions: Thrombotic thrombocytopenic purpura-like events among HIV Sudanese patients were explored. In addition, antiphospholipid antibodies were strikingly seen in these patients. Additional research is anticipated to confirm these diagnoses.
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Affiliation(s)
- Bashir Abdrhman Bashir
- Department of Hematology, Faculty of Medical Laboratory Sciences, Port Sudan Ahlia College, Port Sudan 33312, Sudan
| | - Mohamed Hassan Mohamed
- Department of Hematology, Faculty of Medical Laboratory Science, National University, Khartoum 11111, Sudan;
| | - Mohamed A. Hussain
- Department of Pharmaceutical Microbiology, Faculty of Pharmacy, International University of Africa, Khartoum 11111, Sudan;
| | - Wadah Osman
- Department of Pharmacognosy, Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave., Khartoum 11111, Sudan;
| | - Ramzi A. Mothana
- Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Sidgi Hasson
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK;
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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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Sloan EE, McCurdy D. The Antiphospholipid Syndrome in the Pediatric Population. Adv Pediatr 2022; 69:107-121. [PMID: 35985703 DOI: 10.1016/j.yapd.2022.03.013] [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: 11/26/2022]
Abstract
Pediatric antiphospholipid syndrome (APS) is characterized by autoantibodies directed against protein complexes on cellular membranes and leads to a prothrombotic, proinflammatory state. A child with APS may present with venous, arterial, or small vessel thrombosis. Other manifestations of APS include nonthrombotic manifestations, such as hematologic and neurologic symptoms. APS may be a primary condition or related to other autoimmune diseases. If APS-related thrombosis is unrecognized, the child may suffer recurrent thrombotic events after the withdrawal of anticoagulation. Thus, it is important to consider APS as a cause of thrombosis in children. Appropriate testing confirms the diagnosis and directs further care.
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Affiliation(s)
- Elizabeth E Sloan
- Department of Pediatrics, Division of Rheumatology, University of Texas Southwestern Medical Center, Scottish Rite for Children and Children's Medical Center Dallas, 2222 Welborn Street, Dallas, TX 75219, USA.
| | - Deborah McCurdy
- Department of Pediatrics, Division of Allergy/Immunology/Rheumatology, David Geffen School of Medicine, UCLA, Mattel Children's Hospital, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
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9
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Dungan JR, Qin X, Gregory SG, Cooper-Dehoff R, Duarte JD, Qin H, Gulati M, Taylor JY, Pepine CJ, Hauser ER, Kraus WE. Sex-dimorphic gene effects on survival outcomes in people with coronary artery disease. AMERICAN HEART JOURNAL PLUS: CARDIOLOGY RESEARCH AND PRACTICE 2022; 17. [PMID: 35959094 PMCID: PMC9365120 DOI: 10.1016/j.ahjo.2022.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: Ischemic coronary heart disease (IHD) is the leading cause of death worldwide. Genetic variation is presumed to be a major factor underlying sex differences for IHD events, including mortality. The purpose of this study was to identify sex-specific candidate genes associated with all-cause mortality among people diagnosed with coronary artery disease (CAD). Methods: We performed a sex-stratified, exploratory genome-wide association (GWAS) screen using existing data from CAD-diagnosed males (n = 510) and females (n = 174) who reported European ancestry from the Duke Catheterization Genetics biorepository. Extant genotype data for 785,945 autosomal SNPs generated with the Human Omni1-Quad BeadChip (Illumina, CA, USA) were analyzed using an additive inheritance model. We estimated instantaneous risk of all-cause mortality by genotype groups across the 11-year follow-up using Cox multivariate regression, covarying for age and genomic ancestry. Results: The top GWAS hits associated with all-cause mortality among people with CAD included 8 SNPs among males and 15 among females (p = 1 × 10−6 or 10−7), adjusted for covariates. Cross-sex comparisons revealed distinct candidate genes. Biologically relevant candidates included rs9932462 (EMP2/TEKT5) and rs2835913 (KCNJ6) among males and rs7217169 (RAP1GAP2), rs8021816 (PRKD1), rs8133010 (PDE9A), and rs12145981 (LPGAT1) among females. Conclusions: We report 20 sex-specific candidate genes having suggestive association with all-cause mortality among CAD-diagnosed subjects. Findings demonstrate proof of principle for identifying sex-associated genetic factors that may help explain differential mortality risk in people with CAD. Replication and meta-analyses in larger studies with more diverse samples will strengthen future work in this area.
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Madison JA, Gockman K, Hoy C, Tambralli A, Zuo Y, Knight JS. Pediatric antiphospholipid syndrome: clinical features and therapeutic interventions in a single center retrospective case series. Pediatr Rheumatol Online J 2022; 20:17. [PMID: 35197077 PMCID: PMC8867616 DOI: 10.1186/s12969-022-00677-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND/PURPOSE Pediatric antiphospholipid syndrome (APS) is a thromboinflammatory disease characterized by the presence of circulating antiphospholipid antibodies and either thrombotic events or pregnancy morbidity. The objective of this study was to review a large institution's experience to better understand the characteristics of children with APS. METHODS We conducted a retrospective review of pediatric APS at a tertiary referral center. The electronic medical record system was queried from 2000 through 2019, and 21 cases were included based on meeting the revised Sapporo Classification criteria by age 18 or younger. Comparisons between primary and secondary APS patients were made with two-tailed t-tests. RESULTS Twenty-one patients were included with a median age at diagnosis of 16 years and median follow-up of 5.8 years. Secondary APS was slightly more common than primary APS (11 vs. 10 cases) and was primarily diagnosed in the context of systemic lupus erythematosus. Two thirds of patients (67%) also had "non-criteria" manifestations of APS including thrombocytopenia, autoimmune hemolytic anemia, and livedo reticularis/racemosa. Almost half of patients (43%) had recurrent thrombosis, typically when patients were subtherapeutic or non-adherent with anticoagulation. Damage Index in Patients with Thrombotic APS (DIAPS) scores indicated a chronic burden of disease in both primary and secondary APS patients. CONCLUSION This case series of pediatric APS provides important context regarding disease phenotypes displayed by children with APS. High prevalence of non-criteria clinical manifestations highlights the need to consider these characteristics when developing pediatric-specific classification criteria and when considering this relatively rare diagnosis in pediatric practice.
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Affiliation(s)
- Jacqueline A. Madison
- grid.214458.e0000000086837370Department of Pediatrics, Division of Pediatric Rheumatology, University of Michigan, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Kelsey Gockman
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Claire Hoy
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Ajay Tambralli
- grid.214458.e0000000086837370Department of Pediatrics, Division of Pediatric Rheumatology, University of Michigan, Ann Arbor, MI USA ,grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Yu Zuo
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Jason S. Knight
- grid.214458.e0000000086837370Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI 48109 USA
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11
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Reading J, Bhatt R, Kilbey L, Breene R, Hall G, Kavirayani A, Joseph R, Ramdas S. Double Trouble: Stroke in a Child with Down's Syndrome. JOURNAL OF PEDIATRIC NEUROLOGY 2022. [DOI: 10.1055/s-0042-1742688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractDown's syndrome (trisomy 21) is well recognized to be associated with several autoimmune conditions such as hypothyroidism, celiac disease, and diabetes mellitus. Antiphospholipid syndrome (APS), an immune disorder, can cause a stroke due to the prothrombotic state. APS is associated with several autoimmune diseases including systemic lupus erythematosus, rheumatoid arthritis, and systemic vasculitis, as well as Down's syndrome. Down's syndrome is linked to several other risk factors for stroke including congenital heart disease, moyamoya disease, and arterial dissection. We present the case of a 3-year-old girl child patient with Down's syndrome, who presented with an acute arterial ischemic stroke secondary to carotid artery dissection and subsequently was also confirmed to have APS. We review the literature on Down's syndrome and APS, the proposed pathophysiology, and management strategies. We present a case of a 3-year-old girl with Down's syndrome and who presented with stroke, review previously published cases, and discuss the conditions and their management. Autoimmune conditions, such as antiphospholipid syndrome, are more common in individuals with Down's syndrome, and as such should be investigated when these children present with symptoms suggestive of stroke.
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Affiliation(s)
- Jacob Reading
- Department of Pediatrics, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Ree'Thee Bhatt
- Department of Pediatrics, Milton Keynes University Hospital National Health Service Foundation Trust, Milton Keynes, United Kingdom
| | - Laura Kilbey
- Department of Pediatrics, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Richard Breene
- Department of Pediatrics, Northampton General Hospital National Health Service Trust, Northampton, United Kingdom
| | - Georgina Hall
- Department of Pediatric Hematology, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Akhila Kavirayani
- Department of Pediatric Rheumatology, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Robin Joseph
- Department of Radiology, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Sithara Ramdas
- Department of Pediatric Neurology, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
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12
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Jones D, CA J, Joshi A, AS S, Kumar H. Deep Vein Thrombosis in Lepromatous Leprosy: A Case Report of Secondary Pediatric Antiphospholipid Syndrome. Cureus 2022; 14:e21361. [PMID: 35198275 PMCID: PMC8853942 DOI: 10.7759/cureus.21361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/13/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a rare autoimmune disorder characterized by thromboembolic events, fetal loss during pregnancy, and evidence of antiphospholipid (aPL) antibodies such as beta-2-glycoprotein I (B2-GPI) and anticardiolipin (aCL). The diagnosis and treatment of this condition in the pediatric population have limited literature evidence due to the rarity of the condition in this age group. Guidelines have been adopted from the adult counterpart of the affected population, thereby giving rise to diagnostic and therapeutic challenges. In this report, we describe a rare case of a 15-year-old male who presented with lepromatous leprosy and developed deep vein thrombosis in his right leg. The laboratory evidence of positive aPL antibodies guided our diagnosis of APS and treatment with oral anticoagulants. This report highlights the importance of screening and timely diagnosis of APS in the pediatric population presenting with venous thrombosis in the backdrop of infection.
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13
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Gallagher KL, Patel P, Beresford MW, Smith EMD. What Have We Learnt About the Treatment of Juvenile-Onset Systemic Lupus Erythematous Since Development of the SHARE Recommendations 2012? Front Pediatr 2022; 10:884634. [PMID: 35498799 PMCID: PMC9047745 DOI: 10.3389/fped.2022.884634] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 03/21/2022] [Indexed: 11/14/2022] Open
Abstract
Introduction Juvenile-onset systemic lupus erythematous (JSLE) is a rare multisystem autoimmune disorder. In 2012, the Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) initiative developed recommendations for the diagnosis/management of JSLE, lupus nephritis (LN) and childhood-onset anti-phospholipid syndrome (APS). These recommendations were based upon available evidence informing international expert consensus meetings. Objective To review new evidence published since 2012 relating to the management of JSLE, LN and APS in children, since the original literature searches informing the SHARE recommendations were performed. Method MEDLINE, EMBASE and CINAHL were systematically searched for relevant literature (2012-2021) using the following criteria: (1) English language studies; (2) original research studies regarding management of JSLE, LN, APS in children; (3) adult studies with 3 or more patients <18-years old, or where the lower limit of age range ≤16-years and the mean/median age is ≤30-years; (4) randomized controlled trials (RCTs), cohort studies, case control studies, observational studies, case-series with >3 patients. Three reviewers independently screened all titles/abstracts against predefined inclusion/exclusion criteria. All relevant manuscripts were reviewed independently by at least two reviewers. Data extraction, assessment of the level of evidence/methodological quality of the manuscripts was undertaken in-line with the original SHARE processes. Specific PUBMED literature searches were also performed to identify new evidence relating to each existing SHARE treatment recommendation. Results Six publications met the inclusion/exclusion criteria for JSLE: three RCTs, one feasibility trial, one case series. For LN, 16 publications met the inclusion/exclusion criteria: eight randomized trials, three open label prospective clinical trials, five observational/cohort studies. For APS, no publications met the inclusion criteria. The study with the highest evidence was an RCT comparing belimumab vs. placebo, including 93 JSLE patients. Whilst the primary-endpoint was not met, a significantly higher proportion of belimumab-treated patients met the PRINTO/ACR cSLE response to therapy criteria. New evidence specifically addressing each SHARE recommendation remains limited. Conclusion Since the original SHARE literature searches, undertaken >10-years ago, the main advance in JSLE treatment evidence relates to belimumab. Additional studies are urgently needed to test new/existing agents, and assess their long-term safety profile in JSLE, to facilitate evidence-based practice.
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Affiliation(s)
- Kathy L Gallagher
- Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Pallavi Patel
- Department of Public Health, Liverpool City Council, Liverpool, United Kingdom
| | - Michael W Beresford
- Institute of Life Course and Medical Science, University of Liverpool, Liverpool, United Kingdom.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Eve Mary Dorothy Smith
- Institute of Life Course and Medical Science, University of Liverpool, Liverpool, United Kingdom.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
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14
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Islabão AG, Trindade VC, da Mota LMH, Andrade DCO, Silva CA. Managing Antiphospholipid Syndrome in Children and Adolescents: Current and Future Prospects. Paediatr Drugs 2022; 24:13-27. [PMID: 34904182 PMCID: PMC8667978 DOI: 10.1007/s40272-021-00484-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 11/28/2022]
Abstract
Pediatric antiphospholipid syndrome (APS) is a rare acquired multisystem autoimmune thromboinflammatory condition characterized by thrombotic and non-thrombotic clinical manifestations. APS in children and adolescents typically presents with large-vessel thrombosis, thrombotic microangiopathy, and, rarely, obstetric morbidity. Non-thrombotic clinical manifestations are frequently seen in pediatric APS and may be present even before the vascular thrombotic events occur. We review insights into the pathogenesis of APS and discuss potential targets for therapy. The identification of multiple immunologic abnormalities in patients with APS reveals molecular targets for current or future treatment. Management strategies, especially for APS in adolescents, require screening for additional prothrombotic risk factors and consideration of counseling regarding contraceptive strategies, lifestyle recommendations, treatment adherence, and mental health issues associated with this autoimmune thrombophilia. The main goal of therapy in pediatric APS is the prevention of thrombosis. The management of acute thrombosis events in children and adolescents is the same as for primary APS, which involves isolated occurrences, and secondary APS, which is seen in association with another autoimmune disease, e.g., systemic lupus erythematosus. A pediatric hematologist should be consulted so other differential thrombophilic conditions can be eliminated. Therapy includes unfractionated heparin or low-molecular-weight heparin followed by vitamin K antagonists. Treatment of catastrophic APS involves triple therapy (anticoagulation, intravenous corticosteroid pulse therapy, and plasma exchange) and may include intravenous immunoglobulin for children and adolescents with this condition. New drugs such as eculizumab and sirolimus seem to be promising drugs for APS.
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Affiliation(s)
- Aline Garcia Islabão
- Pediatric Rheumatology Unit, Hospital da Criança de Brasília Jose Alencar, Brasília, DF Brazil ,Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, DF Brazil
| | - Vitor Cavalcanti Trindade
- Faculdade de Medicina, Children and Adolescent Institute, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647-Cerqueira César, São Paulo, SP 05403-000 Brazil
| | - Licia Maria Henrique da Mota
- Programa de Pós-graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, DF Brazil ,Rheumatology Unit, Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
| | | | - Clovis Artur Silva
- Faculdade de Medicina, Children and Adolescent Institute, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647-Cerqueira César, São Paulo, SP, 05403-000, Brazil. .,Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.
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15
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OUP accepted manuscript. Rheumatology (Oxford) 2022; 61:4465-4471. [DOI: 10.1093/rheumatology/keac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/19/2022] [Indexed: 11/14/2022] Open
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16
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Lupus anticoagulant in children – a confounding factor in diagnosis and targeted therapy. REV ROMANA MED LAB 2021. [DOI: 10.2478/rrlm-2021-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Introduction: Lupus anticoagulant (LAC) belongs to a heterogeneous group of antibodies directed against negatively charged phospholipid-binding proteins, inhibiting phospholipid-dependent reactions. We assessed the frequency, etiological background, clinical and biological expression as well as the appropriate management and outcome of LAC in a pediatric population.
Patients and methods: We included 19 pediatric patients diagnosed with a positive LAC test during a period of 1 year. LAC detection was carried out according to the ISTH/SCC guidelines 2012. Coagulometric assays were performed in order to check for coagulation factor activities. The presence of specific inhibitors has been tested by the Bethesda assay.
Results: LAC was positive in 0.4% of the patients monitored for increased activated partial thromboplastin time (aPTT) during the study period of 1 year. In contrast to the asymptomatic clinical image presented by the majority of our patients, the biological picture was dominated by an elevated aPTT (79 %), the aPTT ratio correlating significantly with the strength of LAC. In 58 % of the patients LAC became negative within 12 weeks, in another 4 (21%) patients within 20 weeks, whereas in 4 (21%) patients LAC remained positive throughout the follow-up.
Conclusion: Albeit usually innocent in asymptomatic patients, LAC needs to be seriously taken into consideration from the diagnostic point of view in order to avoid dangerous therapeutic attitudes..
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17
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Hasbani GE, Taher AT, Sunji N, Sciascia S, Uthman I. Antiphospholipid antibodies and cerebrovascular thrombosis in the pediatric population: Few answers to many questions. Lupus 2021; 30:1365-1377. [PMID: 34082580 DOI: 10.1177/09612033211021488] [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: 11/17/2022]
Abstract
Most of the knowledge in pediatric antiphospholipid syndrome (APS) is derived from studies performed on the adult population. As in adults, antiphospholipid antibodies (aPL) can contribute to thrombosis, especially cerebrovascular thrombosis, in neonates and children. Since aPL have the potential to cross the placental barrier, and since the pediatric population is prone to infections, re-testing for their positivity is essential to specify their role in cerebrovascular thrombosis.In this review, we aimed at assessing the prevalence of aPL, criteria or non-criteria, in neonatal and childhood ischemic stroke and sinovenous thrombosis trying to find an association between aPL and cerebrovascular thrombosis in the neonatal and pediatric population. Also, we looked into the effect of aPL and anticoagulants/antiplatelets on the long term neurological outcomes of affected neonates or children. The questions regarding the prevalence of aPL among pediatric patients with cerebrovascular thrombosis, the relationship between the titers of aPL and incidence and recurrence of cerebrovascular events, the predictability of the long term neurological outcomes, and the most optimal anticoagulation plan are still to be answered. However, it is crucial for clinicians to screen neonates and children with cerebrovascular thrombosis for aPL and confirm their presence if positive.
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Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadine Sunji
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases, Coordinating Center of Piemonte and Aosta Valley Network for Rare Diseases, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy.,Department of Clinical and Biological Sciences, School of Specialization of Clinical Pathology, University of Turin, Turin, Italy.,Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Imad Uthman
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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18
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Sloan E, Wright T, Zuo Y. Identifying additional risk factors for arterial and venous thrombosis among pediatric antiphospholipid antibodies carriers. Lupus 2021; 30:828-832. [PMID: 33736541 DOI: 10.1177/09612033211002256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Antiphospholipid antibodies (aPL) have been extensively reported in children, but investigations into thrombotic risks associated with aPL positivity in pediatric patients is scarce. Positive aPL are not uncommon in pediatric connective tissue diseases (CTD), but identification and management of these patients is challenging due to lack of validated criteria and a paucity of data. In this study, we identify potential additional risk factors for thrombosis in a unique cohort of pediatric aPL positive carriers. METHODS Retrospective chart review was performed on 491 pediatric patients with CTD seen in our institution from 2001 to 2019. Patients without persistently moderate to high titer aPL at least 12 weeks apart were excluded. Univariate analysis was performed to evaluate correlation between different risk factors and thrombotic events. RESULTS Seventy-one aPL positive children with underlying CTD are included in this cohort. The majority (87%) are female and of Hispanic ethnicity (56%). Mean age of the cohort at the diagnosis of connective tissue disease is 12.7 (SD 2.6) years, and mean age of first positive aPL is 13.3 (SD 2.5) years. Average length of follow-up is 4.3 (SD 2.5) years. Four (5.6%) patients experienced arterial thrombosis, and 11 (15.5%) had venous thrombosis. Fifty-seven (80.3%) patients did not have any thromboembolic events. Among traditional risk factors and signs of endothelial injury, only Raynaud's phenomena demonstrated significant association with arterial thrombosis (OR = 8.4, 95%CI 1.13-111, P = 0.039), and hypertension or anti-hypertensive use demonstrated significant association with venous thrombosis (OR = 8.387, 95%CI 1.2 - 94, P = 0.02). CONCLUSION Data from our cohort suggest that Raynaud's phenomenon is a potential predictor of arterial thrombosis while the presence of hypertension or anti-hypertensive medication use is a potential predictor of venous thrombosis in aPL positive pediatric carriers. Further studies investigating pediatric aPL profiles and risk factors for development of thrombosis are needed to help guide clinicians in caring for these challenging patients.
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Affiliation(s)
- Elizabeth Sloan
- Division of Pediatric Rheumatology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, USA.,Division of Pediatric Rheumatology, Department of Pediatrics, Texas Scottish Rite Hospital for Children, Dallas, USA.,Division of Pediatric Rheumatology, Department of Pediatrics, Children's Medical Center, Dallas, USA
| | - Tracey Wright
- Division of Pediatric Rheumatology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, USA.,Division of Pediatric Rheumatology, Department of Pediatrics, Texas Scottish Rite Hospital for Children, Dallas, USA.,Division of Pediatric Rheumatology, Department of Pediatrics, Children's Medical Center, Dallas, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, USA
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19
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Han H, Hensch L, Hui SKR, Teruya J. Evaluation and Management of Coagulopathies and Thrombophilias in Pediatric Patients. Clin Lab Med 2020; 41:83-100. [PMID: 33494887 DOI: 10.1016/j.cll.2020.10.006] [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: 10/22/2022]
Abstract
The diagnosis of coagulopathy or thrombophilia in pediatric patients can be challenging. Congenital coagulopathies often present in the pediatric period and require appropriate work-up for diagnosis and ongoing management. Acquired coagulopathies of childhood are frequently encountered in hospitalized children and warrant appropriate coagulation testing for goal-directed therapy. The incidence of thrombosis is increasing in pediatric patients. After identifying the presence of thrombus, acute management includes initiating therapeutic anticoagulation. Choice of anticoagulant depends on patient's clinical status, along with availability of the anticoagulant. Thrombophilia evaluation is performed when children present with spontaneous thrombosis. Thrombophilia tests are inaccurate during acute illness.
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Affiliation(s)
- HyoJeong Han
- Pathology & Immunology, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
| | - Lisa Hensch
- Pathology & Immunology, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
| | - Shiu-Ki Rocky Hui
- Pathology & Immunology, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
| | - Jun Teruya
- Pathology & Immunology, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA.
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20
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Madison JA, Zuo Y, Knight JS. Pediatric antiphospholipid syndrome. Eur J Rheumatol 2020; 7:S3-S12. [PMID: 31804173 PMCID: PMC7004270 DOI: 10.5152/eurjrheum.2019.19160] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022] Open
Abstract
Despite its potential to cause significant morbidity in children, pediatric antiphospholipid syndrome (APS) is an understudied condition. In this review, we will cover what is known about pediatric APS epidemiology and how the clinician might approach the diagnosis of pediatric APS. We will highlight similarities and differences with the adult disease, both for primary APS and in the context of lupus. Clinical manifestations beyond thrombosis, especially neurologic and hematologic in nature, will be discussed. We will also consider what unique implications antiphospholipid antibody-positivity may have for children with lupus and for neonates born to mothers with APS. The approach to treatment will be covered, including the unique impact of APS medications on children as compared with adults. Finally, the importance of future mechanistic research is emphasized as physicians endeavor to provide the personalized care that children with APS clearly deserve.
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Affiliation(s)
- Jacqueline A. Madison
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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