Association between ambient air pollution exposure in pregnant women with antiphospholipid syndrome in Nanjing, China

Antenatal exposure to air pollutants is thought to be associated with a variety of maternal blood markers as well as adverse birth outcomes. However, the dysgenic influence of air pollutants on the antiphospholipid syndrome (APS) in mothers and their pregnancy outcomes remains unclear. In the current study, 371 mother-infant pairs (189 healthy: 182 APS) from Nanjing Maternal and Child Health Hospital as well as air pollutants concentration from their living environment were used to investigate correlations between air pollution with maternal blood indicators and fetal birth weight in the groups of APS and healthy mothers. Generalized linear model was used to evaluate the contributions of air pollutant exposure during pregnancy to the blood indicators variation. The relationships between birth weight with specific air pollutant and blood index were analyzed using ridge regression. Results showed that APS fetal birth weight was significantly impacted by air pollutant exposure during pregnancy, in particular, the birth weight decreased significantly along with increasing fine particulate matter 2.5 (PM2.5) and fine particulate matter 10 (PM10) exposure concentrations throughout pregnancy. In contrast, birth weight increased significantly with sulfur dioxide (SO2) exposure. In addition, APS-related blood indicators comprised of platelet distribution width (PDW), total bilirubin (TBIL), mean platelet volume (MPV), platelet-larger cell ratio (P_LCR), homocysteine (HCY), alkaline phosphatase (ALP), direct bilirubin (DBIL), basophilic granulocyte (BAS), platelet thrombocytocrit (PCT), preprandial glucose levels (OGTT0), monocytes (MON), and monocytes ratio (MON_ratio) were also strongly related with prenatal exposure to PM2.5 and PM10, in which PDW levels showed most strongly negative impaction on fetal birth weight. Together, we showed that prenatal exposure to air pollutant (PM2.5 and PM10) may exacerbate the poor birth outcomes of low birth weight by impacting APS maternal blood indicators especially for PDW.

Catastrophic antiphospholipid syndrome in lupus-associated immune thrombocytopenia treated with eltrombopag A case series and literature review

BACKGROUND

Eltrombopag, a thrombopoietin receptor (TPO-R) agonist, is considered a second-line treatment for patients with refractory immune thrombocytopenia (ITP). Systemic lupus erythematosus (SLE) is frequently associated with ITP. In some cases, thrombocytopenia in SLE patients is attributed to concurrent antiphospholipid antibodies (APLA). Currently, data regarding treatment with TPO-R agonists for ITP in SLE or APLA patients are limited. The incidence of SLE flare or antiphospholipid syndrome while on TPO-R agonists has not been well-studied.

CASES

We report 2 cases of female patients with SLE and concurrent triple positive APLA, without thrombotic events in their medical history, in our rheumatology clinic, who were treated for refractory ITP with eltrombopag. Both developed catastrophic antiphospholipid syndrome a few weeks after beginning treatment with eltrombopag. They were admitted to the intensive care unit and treated with solumedrol, plasmapheresis, anticoagulation and rituximab.

CONCLUSIONS

We describe a severe possible side-effect of eltrombopag as a trigger of catastrophic antiphospholipid syndrome, a rare initial manifestation of antiphospholipid syndrome, in SLE patients with APLA. We suggest that APLA should be tested before initiating eltrombopag in patients with SLE-associated ITP. The safety of this treatment should be considered in these cases.

Primary antiphospholipid syndrome during aromatase inhibitors therapy: A case report and review of the literature

RATIONALE

Aromatase inhibitors (AIs) are a class of drugs widely used in the treatment of estrogen sensitive breast and ovarian cancer which convert testosterone to estradiol and androstenedione to estrogen. The AIs of third generation, including anastrazole, letrozole and exemestane, have actually become the standard of care of estrogen-receptor-positive breast cancer in menopausal women and are recommended as adjuvant treatment after surgery in place of/or following tamoxifen. Their main side-effects include reduction in bone mineral density, occurrence of menopausal manifestations and development of musculoskeletal symptoms which are, usually, transient, but sometimes evolve into a typical form of arthritis, such as rheumatoid arthritis (RA). Recently, a pathogenic linkage with other autoimmunity diseases, such as Sjogren syndrome (SjS), anti-synthetase antibody syndrome (ASAS), systemic sclerosis (SS) and subacute cutaneous lupus erythematosus (SCLE), was also described.

PATIENT CONCERNS

Here, we report the first case of a patient with primary antiphospholipid syndrome (APS) developed during treatment with anastrazole.

DIAGNOSIS

The patient developed a sudden onset of speech disturbance and disorientation, due to ischemic lesions, after 6 months of AIs therapy and the laboratory examination showed the positivity of anti-Cardiolipin antibodies, anti-β2 Glycoprotein 1 antibodies and Lupus Anticoagulant, so a certain diagnosis of APS was achieved.

INTERVENTIONS

The patient was treated with warfarin associated to hydroxychloroquine and monthly cycles of low doses intravenous immunoglobulins.

OUTCOMES

A good control of the disease was obtained despite the continuation of anastrazole; the patient's clinical and laboratory situation remained not modified after AIs withdrawal.

LESSONS

We discussed the possible role of anastrazole treatment in inducing APS in our patient, reporting the available literature data about the association between AIs treatment and autoimmune diseases. Furthermore, we analyzed the mechanism of action of estrogens in the pathophysiology of autoimmune rheumatic disorders.

Hydroxychloroquine partially prevents endothelial dysfunction induced by anti-beta-2-GPI antibodies in an in vivo mouse model of antiphospholipid syndrome

Background

Antiphospholipid syndrome is associated with endothelial dysfunction, which leads to thrombosis and early atheroma. Given that hydroxychloroquine has anti-thrombotic properties in lupus, we hypothesized that it could reduce endothelial dysfunction in an animal model of antiphospholipid syndrome. We evaluated the effect of hydroxychloroquine in preventing endothelial dysfunction in a mouse model of antiphospholipid syndrome.

Methods

Antiphospholipid syndrome was induced by an injection of monoclonal anti-beta-2-GPI antibodies. Vascular reactivity was evaluated in mesenteric resistance arteries isolated from mice 3 weeks (APL3W) after receiving a single injection of anti-beta-2-GPI antibodies and after 3 weeks of daily oral hydroxychloroquine treatment (HCQ3W) compared to control mice (CT3W). We evaluated endothelial dysfunction by measuring acetylcholine-mediated vasodilation. A pharmacological approach was used to evaluate NO synthase uncoupling (tetrahydrobiopterin) and the generation of reactive oxygen species (Tempol).

Results

Impaired acetylcholine-mediated dilation was evidenced in mice 3 weeks after anti-beta-2-GPI antibodies injection compared to CT3W, by reduced maximal dilation (p<0.0001) and sensitivity (pKd) (p = 0.01) to acetylcholine. Hydroxychloroquine improved acetylcholine-dependent dilation, on pKd (p = 0.02) but not maximal capacity compared to untreated mice. The addition of tetrahydrobiopterin (p = 0.02) and/or Tempol (p = 0.0008) improved acetylcholine-mediated dilation in APL3W but not in HCQ3W.

Conclusions

We demonstrated that endothelial dysfunction in mouse resistance arteries persisted at 3 weeks after a single injection of monoclonal anti-beta-2-GPI antibodies, and that hydroxychloroquine improved endothelium-dependent dilation at 3 weeks, through improvement of NO synthase coupling and oxidative stress reduction.

Emerging therapeutic uses of direct-acting oral anticoagulants: An evidence-based perspective

Direct-acting oral anticoagulants (DOACs) were claimed to cause a potential paradigm shift in the therapeutic scenario of patients requiring short- and long-term anticoagulation, by virtue of their pharmacological properties, perceived as innovative. The evidence gathered so far (from pre-approval pivotal trials to real-world post-marketing observational data) consistently confirmed that DOACs are overall comparable to vitamin-K antagonists (VKAs) in terms of safety, efficacy and effectiveness and unequivocally documented a consistent and clinically relevant reduced risk of intracranial bleeding in the settings of non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). Interestingly, two parallel paths can be identified in the current research scenario: A) in the aforementioned consolidated therapeutic indications, an innovative approach is directed towards tailored treatment strategies, to identify patients most likely to benefit from one of the different anticoagulant drugs, in particular subpopulations at increased risk of adverse events (e.g., bleeding); B) in unconventional settings, DOACs are gaining interest for potential use in emerging diseases characterized by arterial and venous thromboembolic risk. In these scenarios, the risk-benefit profile of DOACs, as compared to VKAs or heparins, is less defined. The aim of this review is to critically assess the body of evidence underlying emerging therapeutic uses of DOACs (e.g., heparin-induced thrombocytopenia, anti-phospholipid antibody syndrome), including evolving issues in special populations (e.g., patients with VTE and cancer or cirrhosis). This will be achieved by analyzing the strength (i.e., systematic reviews, randomized clinical trials, observational studies, case report/series) and consistency (i.e., concordance) of both published and unpublished evidence registered in major public repositories.

Antiphospholipid antibody syndrome secondary to trimethoprim/sulfamethoxazole

Antiphospholipid antibody syndrome (APS) results from autoantibodies to cell surface phospholipids or phospholipid-binding proteins resulting in clotting anomalies and can have devastating sequelae, including stroke, deep venous thrombosis, pulmonary embolism, and recurrent spontaneous abortions. However, cutaneous manifestations are the first sign of APS in up to 41% of patients. We present a case report of APS that developed several days after taking trimethoprim/sulfamethoxazole. The clinical and pathological features of this unique presentation, differential diagnoses, and treatments are discussed.

Concurrent antiphospholipid syndrome and cutaneous [corrected] sarcoidosis due to interferon alfa and ribavirin treatment for hepatitis C

Autoimmune phenomena are common in both hepatitis C infection and interferon alfa treatment; however, the development of antiphospholipid syndrome is rare. This article reports the case of a patient who developed antiphospholipid syndrome in addition to cutaneous sarcoidosis in the setting of pegylated interferon alfa and ribavirin treatment for hepatitis C.

Autoimmune diseases induced by TNF-targeted therapies: analysis of 233 cases

Tumor necrosis factor (TNF)-targeted therapies are increasingly used for a rapidly expanding number of rheumatic and autoimmune diseases. With this use and longer follow-up periods of treatment, there are a growing number of reports of the development of autoimmune processes related to anti-TNF agents. We have analyzed the clinical characteristics, outcomes, and patterns of association with the different anti-TNF agents used in all reports of autoimmune diseases developing after TNF-targeted therapy found through a MEDLINE search of articles published between January 1990 and December 2006. We identified 233 cases of autoimmune diseases (vasculitis in 113, lupus in 92, interstitial lung diseases in 24, and other diseases in 4) secondary to TNF-targeted therapies in 226 patients. The anti-TNF agents were administered for rheumatoid arthritis (RA) in 187 (83%) patients, Crohn disease in 17, ankylosing spondylitis in 7, psoriatic arthritis in 6, juvenile RA in 5, and other diseases in 3. The anti-TNF agents administered were infliximab in 105 patients, etanercept in 96, adalimumab in 21, and other anti-TNF agents in 3. We found 92 reported cases of lupus following anti-TNF therapy (infliximab in 40 cases, etanercept in 37, and adalimumab in 15). Nearly half the cases fulfilled 4 or more classification criteria for systemic lupus erythematosus (SLE), which fell to one-third after discarding preexisting lupus-like features. One hundred thirteen patients developed vasculitis after receiving anti-TNF agents (etanercept in 59 cases, infliximab in 47, adalimumab in 5, and other agents in 2). Leukocytoclastic vasculitis was the most frequent type of vasculitis, and purpura was the most frequent cutaneous lesion. A significant finding was that one-quarter of patients with vasculitis related to anti-TNF agents had extracutaneous involvement. Twenty-four cases of interstitial lung disease associated with the use of anti-TNF agents were reported. In these patients, 2 specific characteristics should be highlighted: the poor prognosis in spite of cessation of anti-TNF therapy, and the possible adjuvant role of concomitant methotrexate. In conclusion, the use of anti-TNF agents has been associated with an increasing number of cases of autoimmune diseases, principally cutaneous vasculitis, lupus-like syndrome, SLE, and interstitial lung disease.

[Inaugural unilateral adrenal hematoma of an antiphospholipid syndrome]

INTRODUCTION

A primary antiphospholipid syndrome is a very rare cause of adrenal haemorrhage.

OBSERVATION

A 51 year-old man presented with a unilateral adrenal haemorrhage, enhanced by the prescription of Synacthène during the 4 days that preceded. There was no adrenal deficiency but the immunological control revealed the presence of anti-phospholipid antibodies. After 2 years of follow-up, adrenal controls have not shown any underlying tumour or endocrine insufficiency.

COMMENTS

Adrenal involvement is described in the anti-phospholipid syndrome and may present in the form of adrenal deficiency in the case of occasionally only microscopic bilateral haemorrhages. Furthermore, Synacthène is known to induce adrenal haemorrhages although this complication remains rare. Moreover, any unilateral adrenal haemorrhage requires subsequent follow-up for several months or even years in order to eliminate any underlying tumour and to control the absence of any adrenal deficiency if the involvement is bilateral.

[Effect of TFX preparation on the course of pregnancy in rabbits with experimental antiphospholipid syndrome]

Recurrent thrombo-embolic episodes and pregnancy loss, thrombocytopenia and the presence of antiphospholipid antibodies, first described in 1983 by Hughes and defined by Harris in 1987, are characteristic of the primary antiphospholipid syndrome (APS). APS is the cause of obstetrical problems in the form of recurrent miscarriages, intrauterine fetal death or growth retardation, and EPH gestosis. Clinical symptoms described above are probably mediated by antiphospholipid antibodies which interact with endothelial and trophoblastic cells, blood platelets, embryonic tissue cells, as well as with coagulation factors and proteins involved in the coagulation cascade or in antibody binding. Management of APS includes antiaggregation, anticoagulation, immunosuppression, and intravenous administration of gamma globulins. Successful treatment is not always the case and search for more efficient therapies continues. The importance of animal experiments led to the design at the Department of Pathology of Pregnancy and Labour of an APS model in pregnant and nonpregnant rabbits. As Turowski et al. have confirmed the immunomodulating action of TFX in rabbits, it seemed justified to examine the properties of this preparation in pregnant rabbits with experimentally induced APS. The material consisted of 30 pregnant New Zealand rabbits, divided into the following groups: I--10 pregnant rabbits (and 63 fetuses) treated intradermally twice weekly since the 10th day of pregnancy with cardiolipin together with adjuvant; I-K--5 pregnant rabbits (and 17 fetuses) treated with cardiolipin and adjuvant in the same manner as group I and additionally with intramuscular injections of 0.9% NaCl on the 20th, 21st, and 22nd day; I-T--10 pregnant rabbits (and 66 fetuses) treated with cardiolipin with adjuvant in the same manner as group I and additionally with intramuscular injections of 10 mg/day of TFX (Jelfa, Poland) on the 20th, 21st, and 22nd day of pregnancy; K--5 pregnant rabbits (and 27 fetuses) treated with injections of 0.9% NaCl twice weekly. Blood samples for laboratory analysis were collected by cardiac puncture before immunization (sample I) and on the day of caesarean section (sample II). Platelet counts and APTT tests were done. Numbers of live and dead newborns, resorbed fetuses, body mass, newborn viability and survival rates were recorded. TFX administered to pregnant rabbits with experimentally induced antiphospholipid syndrome increased the number of live newborns, reduced the incidence of fetal resorption, increased the viability and survival rate of newborn rabbits. The beneficial effect of TFX on APTT and platelet count was revealed, such that these parameters remained within the normal range despite immunization. Morphological changes observed in the placenta were not specific.

Cardiac manifestations of the antiphospholipid antibody syndrome: a review

The antiphospholipid antibody syndrome (APLAS), though an uncommon entity involves multiple organs in the body. The antiphospholipid antibodies (APLA) refer to several groups of autoantibodies against negatively charged phospholipids occurring independently or in association with systemic lupus erythematosus (SLE) and related autoimmune disorders. Several studies to date found those patients with APLA, predominantly IgG and to lesser extent IgM isotype and lupus anticoagulant (LAC) are associated with arterial and venous thrombosis, recurrent fetal loss, thrombocytopenia, and livedo reticularis. We have described two cases of APLAS, one primary and the other secondary, their management and cardiac manifestations. Cardiac manifestations of the syndrome include coronary artery thrombosis and valvular heart disease. These can be serious and difficult to treat. Although the exact treatment of the cardiac manifestations of APLAS is not clear, anticoagulation is the currently recommended therapy.

Induction and treatment of the antiphospholipid syndrome--lessons from animal models

The diagnosis of antiphospholipid syndrome (APS) is based on a combination of clinical and serological criteria. This review summarizes the literature regarding animal models of APS. Animal models of this syndrome help to elucidate pathogenic roles of the characteristic antiphospholipid antibodies in pregnancy morbidity, vascular thrombosis, neurologic disease and atherosclerosis. Furthermore, these models also provide measures to evaluate novel therapies for APS. These include bone-marrow transplantation, intravenous immunoglobulin, anticoagulation, interleukin-3, in addition to other therapies. Experimental induction and treatment of APS largely contributes to our understanding of the disease and to better management of its clinical characteristics.

Antiphospholipid syndrome associated with progressive systemic sclerosis

We report a case of secondary antiphospholipid syndrome (APS) occurring in a progressive systemic sclerosis (PSS) patient who took herbal medication. Clinical findings compatible with APS included positive IgM anticardiolipin antibody (ACL), thrombocytopenia, and obstruction of the left radial artery on digital subtraction angiography (DSA). Clinical findings compatible with PSS included sclerodactyly and digital ulcers, Raynaud's phenomenon, pulmonary fibrosis and pulmonary hypertension, proteinuria and renal mesangial reaction, and myocarditis.

Protean clinical presentation of antiphospholipid-protein antibodies (APA)

Antiphospholipid-protein antibodies (APA) are a family of immunoglobulins which have been defined by varying laboratory test systems. Lupus anticoagulants (LA) and anticardiolipin antibodies (ACA) are the two most prominent members of this family of antibodies. LA are detected utilizing various phospholipid (PL) dependent tests of coagulation (e.g., activated partial thromboplastin time [APTT], Kaolin Clotting Time [KCT], dilute Russell Viper Venom Time [dRVVT]). Originally, LA were thought to be a laboratory nuisance since the vast majority of individuals with LA did not bleed. Paradoxically, patients with LA were found to have an increased incidence of thromboembolic events and also recurrent spontaneous abortions (RSA). Thus, the laboratory detection of LA has become part of the work up of patients with thromboembolic disorders and RSA. ACA are detected using solid phase assay systems (radioimmunoassay or ELISA). The presence of ACA has the same clinical implications as that of LA. Although originally it was suggested ACA and LA were the same antibody, it is now well accepted that they, in many instances, are different antibodies. Therefore, it is critical for laboratories to evaluate patient samples for both LA and ACA. In approximately 60% of circumstances, both antibodies will be found. In the remaining cases, there will be discordance between the two test systems. The question of whether APA are causative, coincidental, or a consequence of the clinical complications of RSA and thrombosis remains controversial. Recent evidence based on prospective clinical studies and analysis of markers of in vivo coagulation suggests APA are causative.(ABSTRACT TRUNCATED AT 250 WORDS)

Lupus anticoagulant in the elderly may be associated with both quinine and quinidine usage

Thirty-one patients aged over 60 yrs and with lupus anticoagulant (LA) were reviewed for their drug intake. Twenty-three (73%) were taking cinchona alkaloids, 10 (32%) quinine for night cramps, 11 (35%) quinidine for cardiac arrhythmia and 2 (6%) were taking both. These frequencies of drugs usage differed significantly from age and sex matched controls (p < 0.001). Five patients had features suggestive of the antiphospholipid syndrome. Repeat testing showed persistent LA activity in all but 2 of 5 patients in whom the relevant drug had been ceased. This is the first description of a possible causal association between LA and quinine therapy.

Induction of experimental anti-phospholipid syndrome associated with SLE following immunization with human monoclonal pathogenic anti-DNA idiotype

MIV-7 is a human monoclonal antibody that binds to DNA and carries a pathogenic anti-DNA idiotype 16/6. The antibody was generated by fusing peripheral blood lymphocytes of a healthy donor which were stimulated with an anti-idiotypic antibody to B11 (a human mAb anti-mouse mammary tumor virus-MMTV). The MIV-7, in addition to being an anti-DNA antibody, also binds to MMTV glycoproteins. Following immunization into the footpad of naive BALB/c mice with MIV-7, the mice developed anti-phospholipid syndrome (APLS) and SLE. The APLS was characterized by thrombocytopenia, the presence of anticardiolipin antibodies, lupus anticoagulant (prolonged APTT), high resorption rate of fetuses and lower mean weights of the placentae and fetuses. The SLE was characterized by serological markers (e.g. anti-DNA), laboratory (increased sedimentation rate and proteinuria) and histological findings (deposition of immune complexes in the glomeruli). Active immunization of mice with mouse monoclonal anti-cardiolipin antibodies led to the induction of primary APLS without SLE. The results add to our previous passive transfer model in which mouse monoclonal anti-cardiolipin antibody generated from immunized mice (CAM) was infused into the tail vein and also resulted in induction of pure APLS [11]. Our results demonstrate the ability to induce secondary APLS to SLE following immunization with a pathogenic idiotype of anti-DNA antibodies and to induce primary APLS with anti-cardiolipin mAb. The existence of these experimental models may permit controlled studies of novel therapeutic models.

Production of anticardiolipin antibodies by cultured human lymphocytes

Antibodies against negatively charged phospholipids, such as those to cardiolipin, can often be detected in the serum of patients with autoimmune related conditions, chronic infections and in patients treated with phenothiazines. In the present study, peripheral blood lymphocytes from nine healthy controls and eight patients with phenothiazine-induced IgM anticardiolipin antibodies (ACA) and the lupus anticoagulant were placed in vitro. Culture supernatants were assayed for ACA by measurement of optical densities using an ELISA. A significant difference (p less than 0.05) was demonstrated between the mean concentration of culture supernatant ACA from the patients as compared to healthy controls. The concentration of ACA in culture supernatants strongly correlated (r = 0.85) with that from the serum. There was a weak correlation between serum and culture supernatant ACA concentration and the lupus anticoagulant activity as measured by prolongation of the partial thromboplastin time. This technique uses readily accessible peripheral blood lymphocytes and should permit dissection of cytokine and cellular immune pathways regulating APA production.