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Zhang J, Li C, Han X, Chen Z, Adhikari BK, Wang Y, Wang Y, Sun J. The digestive system involvement of antiphospholipid syndrome: pathophysiology, clinical characteristics, and treatment strategies. Ann Med 2021; 53:1328-1339. [PMID: 34409894 PMCID: PMC8381908 DOI: 10.1080/07853890.2021.1962964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 07/25/2021] [Indexed: 02/03/2023] Open
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease mainly characterised by vascular thrombosis and pregnancy morbidity. APS has broad spectrum of clinical manifestations. The digestive system involvement of antiphospholipid syndrome is a critical but under-recognised condition. Digestive system involvement may be the result of direct (autoimmune-mediated) or indirect (thrombotic) mechanisms. Liver is the most commonly involved organ, followed by intestines, oesophagus, stomach, pancreas and spleen. This review describes possible digestive system manifestations in APS patients, and illustrates the epidemiology and possible pathophysiology of APS. The role of different treatment strategies in the management of digestive system manifestations of APS were also discussed.Key messagesAntiphospholipid syndrome is a multi-organ, multi-system disease and its clinical manifestation spectrum is gradually expanding. Since the first diagnosis of APS, the clinical manifestations of digestive system have been reported successively. This narrative review describes the major digestive system manifestations of APS and illustrates the epidemiology, pathophysiology and the role of therapeutic strategies of these patients.
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Affiliation(s)
- Jin Zhang
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Cheng Li
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Xiaorong Han
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Zhongbo Chen
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Binay Kumar Adhikari
- Department of Medicine, Nepal Armed Police Force Command and Staff hospital, Kathmandu, Nepal
| | - Yinghui Wang
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Yonggang Wang
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
| | - Jian Sun
- Department of Cardiovascular Center, Jilin University First Hospital, Changchun, China
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Jacobs AR, Ben-Yosef N, Tiram Y, Juravel E, Nachshon A, Scheiman Elazary A, Szalat A, Zimran E, Muszkat M. Bilateral Adrenal Hemorrhage in a Patient with Antiphospholipid Syndrome Following Reversal of Warfarin-induced Over-anticoagulation. Isr Med Assoc J 2021; 23:387-389. [PMID: 34155857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Aviya R Jacobs
- Department of Medicine, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Noam Ben-Yosef
- Department of Medicine, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Yariv Tiram
- Department of Medicine, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Elchanan Juravel
- Department of Medicine, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Akiva Nachshon
- Intensive Care Unit, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Anat Scheiman Elazary
- Department of Medicine, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Rheumatology Clinic, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Auryan Szalat
- Department of Medicine, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Center of Osteoporosis, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Eran Zimran
- Department of Medicine, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Hematology, Hadassah-Hebrew University Medical Center (Ein Karem Campus), Jerusalem, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah University Hospital (Mount Scopus) Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Gul M, Azari Jafari A, Shah M, Mirmoeeni S, Haider SU, Moinuddin S, Chaudhry A. Molecular Biomarkers in Multiple Sclerosis and Its Related Disorders: A Critical Review. Int J Mol Sci 2020; 21:E6020. [PMID: 32825639 PMCID: PMC7547375 DOI: 10.3390/ijms21176020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 12/17/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic autoimmune disease affecting the central nervous system (CNS) which can lead to severe disability. Several diseases can mimic the clinical manifestations of MS. This can often lead to a prolonged period that involves numerous tests and investigations before a definitive diagnosis is reached. As well as the possibility of misdiagnosis. Molecular biomarkers can play a unique role in this regard. Molecular biomarkers offer a unique view into the CNS disorders. They help us understand the pathophysiology of disease as well as guiding our diagnostic, therapeutic, and prognostic approaches in CNS disorders. This review highlights the most prominent molecular biomarkers found in the literature with respect to MS and its related disorders. Based on numerous recent clinical and experimental studies, we demonstrate that several molecular biomarkers could very well aid us in differentiating MS from its related disorders. The implications of this work will hopefully serve clinicians and researchers alike, who regularly deal with MS and its related disorders.
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Affiliation(s)
- Maryam Gul
- Precision Rheumatology INC, 2050 South Euclid Street, Anaheim, CA 92802, USA
| | - Amirhossein Azari Jafari
- Student Research Committee, School of Medicine, Shahroud University of Medical Sciences, Shahroud 3614773947, Iran; (A.A.J.); (S.M.)
| | - Muffaqam Shah
- Deccan College of Medical Sciences, P.O. Kanchanbagh, DMRL ‘X’ Road, Santhosh Nagar, Hyderabad 500058, Telangana State, India;
| | - Seyyedmohammadsadeq Mirmoeeni
- Student Research Committee, School of Medicine, Shahroud University of Medical Sciences, Shahroud 3614773947, Iran; (A.A.J.); (S.M.)
| | - Safee Ullah Haider
- Shaikh Khalifa Bin Zayed Al-Nahyan Medical College, Shaikh Zayed Medical Complex, Lahore 54000, Pakistan;
| | - Sadia Moinuddin
- Department of Internal Medicine, San Antonio Regional Medical Center, 999 San Bernardino Rd, Upland, CA 91786, USA;
| | - Ammar Chaudhry
- Department of Radiology, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA;
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Sahashi Y, Serge Yanagimoto T, Endo S, Ushikoshi H, Okura H. Sudden Cardiac Arrest as the First Manifestation in a Patient with Catastrophic Antiphospholipid Syndrome. Intern Med 2020; 59:1457-1460. [PMID: 32161219 PMCID: PMC7332628 DOI: 10.2169/internalmedicine.4123-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022] Open
Abstract
We herein report a 26-year-old woman with sudden cardiac arrest who had no remarkable medical history. While resuscitation was successfully performed with adrenalin administration and extracorporeal membrane oxygenation, the cause of cardiac arrest could not be determined for over two weeks. Given the presence of autoimmune disease along with the findings of refractory renal insufficiency and thrombocytopenia, a kidney biopsy and blood examinations, including lupus anticoagulant testing, were performed, which proved the presence of antiphospholipid syndrome. The patient was successfully treated with steroid pulse therapy. This drastic case scenario highlighted the fact that autoimmune disease can be the cause of sudden cardiac arrest.
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Affiliation(s)
- Yuki Sahashi
- Department of Cardiology, Gifu University, Graduate School of Medicine, Japan
| | | | - Susumu Endo
- Department of Cardiology, Gifu University, Graduate School of Medicine, Japan
| | - Hiroaki Ushikoshi
- Department of Cardiology, Gifu University, Graduate School of Medicine, Japan
| | - Hiroyuki Okura
- Department of Cardiology, Gifu University, Graduate School of Medicine, Japan
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Luigi Meroni P, Toubi E, Shoenfeld Y. Are Anti-Phospholipid Syndrome and Systemic Lupus Erythematosus Two Different Diseases? A 10-Year Late Remake. Isr Med Assoc J 2019; 21:491-493. [PMID: 31507127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Pier Luigi Meroni
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Elias Toubi
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Cheng CY, Zhang YX, Denas G, Du Y, Jing ZC, Pengo V. Prevalence of antiphospholipid (aPL) antibodies among patients with chronic thromboembolic pulmonary hypertension: a systematic review and meta-analysis. Intern Emerg Med 2019; 14:521-527. [PMID: 30603858 DOI: 10.1007/s11739-018-02021-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
How thrombophilia may contribute to the development of chronic thromboembolic pulmonary hypertension (CTEPH) is unknown. We searched on PubMed and EMBASE (until 15 April 2018), studies on CTEPH reporting data on inherited or acquired thrombophilia. Starting from 367 articles mentioning the search terms, 347 were excluded mainly as duplicate articles or articles not in English. After reading the full text of remaining articles, ten were excluded for being reviews, editorials, letters or case reports, and two were further removed from the analysis because of the potential selection bias. All the eight considered studies provided the proportion of patients positive for antiphospholipid (aPL) antibodies. The crude rate of aPL in CTPEH patients is 11.8% (95% CI 10.09-13.8%). The meta-analysis considering the weighted mean proportion and 95% confidence intervals (CIs) yields a rate of aPL antibody-positive profile of 12.06% (95% CI 8.12-16.65%) among the patients with CTEPH in the random effects model (I2 76.33%; 95% CI 52.75-88.14%, p = 0.0001). The sensibility analysis confirms the result. No predictors of heterogeneity are found in a meta-regression analysis. Our results suggest that aPL antibodies are frequently associated with CTEPH underlining the need to test for aPL antibodies in young patients with "idiopathic" and "provoked" PE caused by mild provoking risk factors.
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Affiliation(s)
- Chun-Yan Cheng
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Yi-Xin Zhang
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Gentian Denas
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Yao Du
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Zhi-Cheng Jing
- Key Laboratory of Pulmonary Vascular Medicine & FuWai Hospital, State Key Laboratory of Cardiovascular Disease, Chinese Academy Medical Sciences & Peking Union Medical College, 167, Bei-li-shi Road, Beijing, 100037, People's Republic of China
| | - Vittorio Pengo
- Cardiology Clinic, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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Vaidya B, Nakarmi S, Joshi R, Baral R. A Simplified Understanding of the Black Swan: Anti-phospholipid Antibody Syndrome. JNMA J Nepal Med Assoc 2019. [PMID: 31477950 PMCID: PMC8827589 DOI: 10.31729/jnma.4226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Anti-phospholipid Antibody Syndrome or Hugh's syndrome is a heterogeneous disorder, first fully described in 1980s. The syndrome is caused by the presence of specific antibodies against phospholipid binding plasma proteins in the serum of the patient, with or without underlying autoimmune diseases, that causes prolongation of tests of coagulation. High index of clinical suspicion is required for the diagnosis of Anti-phospholipid Antibody Syndrome. Stroke or myocardial infarction in young, unprovoked recurrent deep vein thrombosis and recurrent pregnancy loss are typical scenarios where Anti-phospholipid Antibody Syndrome should be suspected. Presence of non-criteria manifestations like livedo reticularis, skin ulcers, nephropathy, valvular heart disease and thrombocytopenia adds to the diagnostic clue for the presence of Anti-phospholipid Antibody Syndrome. Treatment of Anti-phospholipid Antibody Syndrome has preventive and therapeutic aspects that usually focus on thrombotic and obstetric manifestations of the disease. Therapeutic anti-coagulation with heparin followed by warfarin is required for patients presenting with acute thrombosis. Those with venous thrombosis are given moderate intensity warfarin (International Normalized Ratio, 2–3), whereas those with arterial thrombosis or recurrent venous thrombosis even on warfarin are treated with high intensity warfarin (International Normalized Ratio, 3–4). Similarly, anticoagulation with heparin is advised in patients with obstetric Anti-phospholipid Antibody Syndrome throughout pregnancy and up to six weeks postpartum. Treatment recommendations are still not clear for asymptomatic Anti-phospholipid Antibody Syndrome positive patients and in those with non-criteria manifestations of the disease. Steroids, intravenous immunoglobulin and immunosuppressant are reported to be effective in severe cases of catastrophic antiphospholipid syndrome characterized by rapid small vessel thrombotic involvement of multiple organ systems. Studies are evaluating the efficacy of direct thrombin inhibitors in the management of refractory cases.
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Affiliation(s)
- Binit Vaidya
- Department of Rheumatology, National Center for Rheumatic Diseases, Ratopul, Kathmandu, Nepal
- Correspondence: Dr. Binit Vaidya, Department of Rh eumatology, National Center for Rheumatic Diseases, Ratopul, Kathmandu, Nepal. , Phone: +977-9801122501
| | - Shweta Nakarmi
- Department of Rheumatology, National Center for Rheumatic Diseases, Ratopul, Kathmandu, Nepal
| | - Rakshya Joshi
- Department of Rheumatology, National Center for Rheumatic Diseases, Ratopul, Kathmandu, Nepal
| | - Rikesh Baral
- Department of Rheumatology, National Center for Rheumatic Diseases, Ratopul, Kathmandu, Nepal
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Dima A, Caraiola S, Delcea C, Ionescu RA, Jurcut C, Badea C. Self-reported disease severity in women with systemic lupus erythematosus. Rheumatol Int 2018; 39:533-539. [PMID: 30415452 DOI: 10.1007/s00296-018-4203-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/06/2018] [Indexed: 01/08/2023]
Abstract
Systemic lupus erythematosus (SLE), pathology with net feminine predominance, is one of the most complex autoimmune diseases and has major impact on patients' life. The aim is to identify patient and disease-related factors associated with self-perceived disease severity in female SLE patients. This cross-sectional study enrolled 73 women fulfilling the 2012 Systemic Lupus International Collaborating Clinic (SLICC) criteria. SLE disease activity was assessed by the Systemic Lupus Activity Measure (SLAM) score and overall damage by the SLICC/American College of Rheumatology (ACR) index. Patients' general characteristics, associated conditions as well as SLE specific clinical involvements and therapeutic principles were also noted. Fatigue was assessed by FACIT-fatigue scale. Self-perceived disease severity was assessed using numerical rating scales (1-10 NRSs), to evaluate the disease severity at inclusion (1-10 NRS now) and worst severity anytime during disease history (1-10 NRS worst ever). In regard to worst ever lupus severity, 54.8% of patients responded with 9 or 10, while none with 1 or 2 even if only 22.9% of the patients responded with 7 or more for disease severity at inclusion (1-10 NRS now). Women with higher 1-10 NRS now answers had also higher 1-10 NRS worst ever, SLAM, SLICC, and FACIT-fatigue scores. They associated more frequently anxiety/depression diagnosis, antiphospholipid syndrome, joint involvement as well as treatments with corticosteroids. Self-reported disease severity worst ever, anxiety/depression diagnosis, fatigue, and the daily dose of corticosteroids were independently associated with patients' perception on lupus severity at inclusion: OR (95% CI), 2.13 (1.15-3.94) p = 0.017, 6.67 (1.11-39.97) p = 0.038, 1.10 (1.02-1.19) p = 0.018, and 1.11 (1.02-1.21) p = 0.020, respectively. The vast majority of patients identified severe and very severe events during their disease history, results that raise awareness of burden concerning lupus occurrence in women's life. Self-perceived lupus severity is multifactorial, influenced also by factors less considered in the SLE management like fatigue and the depression/anxiety disorders, but also by the previous patient's experience.
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Affiliation(s)
- A Dima
- Internal Medicine Department, Carol Davila UMF, Dionisie Lupu Street 37, 020022, Bucharest S2, Romania.
- Internal Medicine Department, Colentina Clinical Hospital, Bucharest, Romania.
| | - S Caraiola
- Internal Medicine Department, Carol Davila UMF, Dionisie Lupu Street 37, 020022, Bucharest S2, Romania
- Internal Medicine Department, Colentina Clinical Hospital, Bucharest, Romania
| | - C Delcea
- Internal Medicine Department, Carol Davila UMF, Dionisie Lupu Street 37, 020022, Bucharest S2, Romania
- Internal Medicine Department, Colentina Clinical Hospital, Bucharest, Romania
| | - R A Ionescu
- Internal Medicine Department, Carol Davila UMF, Dionisie Lupu Street 37, 020022, Bucharest S2, Romania
- Internal Medicine Department, Colentina Clinical Hospital, Bucharest, Romania
| | - C Jurcut
- Dr Carol Davila Central University Emergency Military Hospital, Bucharest, Romania
| | - C Badea
- Internal Medicine Department, Carol Davila UMF, Dionisie Lupu Street 37, 020022, Bucharest S2, Romania
- Internal Medicine Department, Colentina Clinical Hospital, Bucharest, Romania
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Weaver JC, Krilis SA, Giannakopoulos B. Oxidative post-translational modification of βeta 2-glycoprotein I in the pathophysiology of the anti-phospholipid syndrome. Free Radic Biol Med 2018; 125:98-103. [PMID: 29604397 DOI: 10.1016/j.freeradbiomed.2018.03.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/23/2018] [Accepted: 03/28/2018] [Indexed: 12/13/2022]
Abstract
The anti-phospholipid syndrome (APS) is a prothrombotic autoimmune disorder characterized by either thrombosis or pregnancy complications in the setting of persistent anti-phospholipid antibodies (aPL). βeta 2-glycoprotein I (β2-GPI) is the major autoantigen in APS that binds anionic phospholipids as well as specific receptors on platelets and endothelial cells resulting in activation of prothrombotic pathways. β2-GPI consists of 5 Domains that exist in a circular or linear form, with the latter occurring after binding to anionic phospholipids. β2-GPI also undergoes dynamic posttranslational modification between oxidized and free thiol forms. The relationship between posttranslational modification and structural conformation is yet to be definitively clarified. Compared with controls, patients with the APS have higher levels of total β2-GPI and lower levels of free thiol β2-GPI. This raises the possibility of using quantification of β2-GPI posttranslational modification as a redox biomarker in the management and diagnosis of the APS.
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Affiliation(s)
- James C Weaver
- Department of Cardiology, St George Hospital, Sydney, Australia; Department of Medicine, University of NSW, Sydney, Australia
| | - Steven A Krilis
- Department of Medicine, University of NSW, Sydney, Australia; Department of Infectious Diseases, Immunology and Sexual Health, St George Hospital, Sydney, Australia
| | - Bill Giannakopoulos
- Department of Medicine, University of NSW, Sydney, Australia; Department of Infectious Diseases, Immunology and Sexual Health, St George Hospital, Sydney, Australia; Department of Rheumatology, St George Hospital, Sydney, Australia.
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Abstract
Antiphospholipid syndrome is a complex autoimmune disease, characterized by the presence of vascular thrombosis, obstetric, hematologic, cutaneous, and cardiac manifestations. Renal disease in patients with antiphospholipid syndrome was not recognized in the first descriptions of the disease, but later on, the renal manifestations of the syndrome have been investigated widely. Renal manifestations of antiphospholipid syndrome conform a wide spectrum of diverse renal syndromes. Hypertension is one of the most frequent, but less commonly recognized renal alteration. It can be difficult to control as its origin is renovascular. Renal vascular thrombosis can be arterial or venous. Other alterations are renal infarction and vascular thrombosis in arterial territories. Venous thrombosis can be present in primary and secondary antiphospholipid syndrome; it presents with worsening of previous proteinuria or de novo nephrotic syndrome, hypertension and renal failure. Antiphospholipid syndrome nephropathy is a vascular disease that affects glomerular tuft, interstitial vessels, and peritubular vessels; histopathology characterizes the renal lesions as acute or chronic, the classic finding is thrombotic microangiopathy, that leads to fibrosis, tubule thyroidization, focal cortical atrophy, and glomerular sclerosis. Antiphospholipid syndrome nephropathy can also complicate patients with systemic lupus erythematosus, and there is vast information supporting the worse renal prognosis in this group of patients with the classic histopathologic lesions. Treatment consists of anticoagulation, as for other thrombotic manifestations of antiphospholipid syndrome. There is some evidence of glomerulonephritis as an isolated lesion in patients with antiphospholipid syndrome. The most frequently reported glomerulonephritis is membranous; with some reports suggesting that immunosuppressive treatment may be effective. Patients with end stage renal disease commonly are positive for antiphospholipid antibodies, but it is not clear what is the role of aPL in this setting. Patients with vascular access may have complications in the presence of antibodies so that anticoagulation is recommended. Patients ongoing renal transplant with persistent antiphospholipid antibody positivity may have early and late graft failure.
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Affiliation(s)
| | | | - Mary-Carmen Amigo
- Internal Medicine Rheumatology Service, Centro Médico ABC, Mexico City, Mexico
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Demyanova KA, Kozlovskaya NL, Bobrova LA, Kozlov LV, Andina SS, Yurova VA, Kuchieva AM, Roshchupkina SV, Shilov EM. [Complement System Abnormalities in Patients with Atypical Hemolytic Uremic Syndrome and Catastrophic Antiphospholipid Syndrome]. Vestn Ross Akad Med Nauk 2018; 72:42-52. [PMID: 29308852 DOI: 10.15690/vramn769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background The role of the alternative complement pathway (AP) abnormalities in the pathogenesis of aHUS is well studied. Clinical and morphological manifestations of atypical HUS and catastrophic APS are often similar. However, studies on the state of AP in patients with CAPS are virtually absent. Aims The aim of our study was to assess the state of AP in patients with CAPS and aHUS. Patients and methods: The study enrolled 67 patients (pts) with a diagnosis of CAPS (28 pts) and aHUS (39 pts). Studies of the complement system are made of 10 pts with CAPS and 20 aHUS. Factor H, I, B, D content, functional activity of factor H, and complement components C3, C4 was determined in serum by ELISA kit. Results Patients with CAPS and aHUS showed similar changes in complement biomarkers. The factor H level in the serum was significantly higher than the standard value. However, the specific activity of factor H reduced, mean rate 59% for aHUS and 26% for CAPS. The median value of factor D was twice higher than the normal range in both groups, indicating the activation of the AP. Conclusions There are indications of an AP activation not only in pts with aHUS but in CAPS pts too. We suppose that the activity of factor H is a more sensitive indicator of complement system changes than factor H level. Patients with CAPS and aHUS have similar clinical and laboratory characteristics. However, CAPS is more severe, with the involvement of a larger number of vascular beds. Perhaps this is due to the double damaging effects on the endothelium ― of antiphospholipid antibodies (aPL) and activated complement. So we hypothesize that CAPS can be called aPL-mediated TMA in pts with a complement system defect.
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Jingi AM, Mfeukeu-Kuate L, Tankeu AT, Ateba NA, Wawo Yonta E, Noubiap JJ. Challenges in the diagnosis and management of anti-phospholipid syndrome: a case from Cameroon. BMC Res Notes 2017; 10:375. [PMID: 28789672 PMCID: PMC5549352 DOI: 10.1186/s13104-017-2689-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/23/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Anti-phospholipid syndrome (APLS) is a condition characterized by the presence of raised plasma levels of anti-phospholipid antibodies associated with thrombo-embolic disease and/or poor obstetrical outcomes in women. The epidemiology of APLS is unknown in most sub-Saharan African countries due to limited access to diagnosis tools. We report the case of APLS in a 29-year-old obese woman that was preceded by pre-eclampsia and fetal death. The diagnosis of APLS was made during a thrombo-embolic episode 4 years after the poor obstetrical outcome. Her management was challenging, as she had three thrombo-embolic events within 18-months despite treatment with anti-coagulant (acenocoumarol). CONCLUSION This case highlights the need for screening for APLS after an episode of hypertensive disease in pregnancy or fetal death, and the challenges faced with the treatment, such as resistance to antivitamin K anti-coagulants and the desire for maternity.
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Affiliation(s)
- Ahmadou M. Jingi
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Liliane Mfeukeu-Kuate
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Division of Cardiology, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Aurel T. Tankeu
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Narcisse Assene Ateba
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Edvine Wawo Yonta
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Jean Jacques Noubiap
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, 7925 Observatory, Cape Town, South Africa
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Vasylyev D, Chernobay L, Vasylieva O, Oliinyk M, Vashuk M. CLINICAL AND GENETIC PECULIARITIES OF VASCULAR MANIFESTATIONS OF ANTIPHOSPHOLIPID SYNDROME (CASE REPORT). Georgian Med News 2017:114-119. [PMID: 28726667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Pathogenetic mechanisms of the development of antiphospholipid syndrome (APS) are considered in the article, which is the basis for the development of clinical manifestations and laboratory markers of APS. The modern literature data are analyzed, according to which the presence of antiphospholipid antibodies is a hypercoagulable background, and the formation of thrombi occurs under the influence of other allowing procoagulation factors. The classification of the main types of hereditary thrombophilia is given, which is the primary disorder, against the background of which an autoimmune thrombosis APS develops. A clinical observation of a young age patient is given, whose heterozygous carriage of mutations in the genes responsible for blood coagulation (F7, PAI-1 and ITGB3-β-integrin), as well as homozygous carriage of a mutation in the MTRR gene associated with a violation of homocysteine methylation, APS was developed, which led to the processes of thrombosis. Timely diagnosis and individually developed pathogenetic therapy allow avoiding life-threatening complications of APS and improving the patients' quality of life. A conclusion about the need for APS and hereditary thrombophilias' examination to all patients of young age with unprovoked thrombosis of deep veins of lower extremities and PE was made.
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Affiliation(s)
- D Vasylyev
- 1Kharkiv Medical Academy of Postgraduate Study; 2Kharkiv National Medical University, Ukraine
| | - L Chernobay
- 1Kharkiv Medical Academy of Postgraduate Study; 2Kharkiv National Medical University, Ukraine
| | - O Vasylieva
- 1Kharkiv Medical Academy of Postgraduate Study; 2Kharkiv National Medical University, Ukraine
| | - M Oliinyk
- 1Kharkiv Medical Academy of Postgraduate Study; 2Kharkiv National Medical University, Ukraine
| | - M Vashuk
- 1Kharkiv Medical Academy of Postgraduate Study; 2Kharkiv National Medical University, Ukraine
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14
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Abstract
AIM to evaluate the functional state of the retina in patients with antiphospholipid syndrome (APS) through different types of electroretinography (ERG). MATERIAL AND METHODS The total ERG (t-ERG), local macular ERG (m-ERG), and oscillatory potentials (OP) were recorded in 56 patients with verified APS. RESULTS In most patients with APS, ERG was of abnormal appearance, particularly, t-ERG was notable for reliably lower a- and b-wave amplitudes (70% of cases), m-ERG - for lower amplitudes and shorter latency (64% of cases). Pathological changes of t-ERG and m-ERG components were equally common in patients with and without retinal vascular occlusions. Linear dependence was established between the decrease in b-wave amplitude of subnormal t-ERG and the Vs value in the central retinal artery. A decrease in the OP index and OP configuration distortion were found in 82% of patients. At that, OP indices tended to be lower in patients from the retinal vascular occlusions group. CONCLUSION The use of different types of ERG enable detection of not only local, but also generalized retinal changes in APS. Regardless of the presence of retinal occlusion, APS patients show suppression of biopotential in most of cellular elements of the retina due to ischemia. Despite high visual acuity, the local macular potential gets significantly reduced in more than half of APS patients. Oscillatory potentials recording is a highly sensitive method for diagnosis of retinal ischmia in APS.
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Affiliation(s)
- T V Smirnova
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russia, 119021
| | - V M Sheludchenko
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russia, 119021
| | - N L Kozlovskaya
- I.M. Sechenov First Moscow State Medical University 11 str. 4 Rossolimo St, Moscow, Russia, 119991
| | - M V Budzinskaya
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russia, 119021
| | - I A Velieva
- Research Institute of Eye Diseases, 11 A,B Rossolimo St., Moscow, Russia, 119021
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Li CZ, Li CC, Hsieh CC, Lin MC, Hueng DY, Liu FC, Chen YH. Fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery for a pituitary tumor: A case report. Medicine (Baltimore) 2017; 96:e5774. [PMID: 28072724 PMCID: PMC5228684 DOI: 10.1097/md.0000000000005774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The fatal type of antiphospholipid syndrome is a rare but life-threating condition. It may be triggered by surgery or infection. Endoscopic transnasal-transsphenoidal surgery is a common procedure for pituitary tumor. We report a catastrophic case of a young woman died of fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery. METHODS AND RESULT A 31-year-old woman of a history of stroke received endoscopic transnasal-transsphenoidal surgery for a pituitary tumor. The whole procedure was smooth. However, the patient suffered from acute delirium on postoperative day 4. Then, her consciousness became comatose state rapidly with dilatation of pupils. Urgent magnetic resonance imaging of brain demonstrated multiple acute lacunar infarcts. The positive antiphosphoipid antibody and severe thrombocytopenia were also noted. Fatal antiphospholipid syndrome was diagnosed. Plasma exchange, corticosteroids, anticoagulant agent were prescribed. The hemodynamic condition was gradually stable. However, the consciousness was still in deep coma. The patient died of organ donation 2 months later. CONCLUSION If patients have a history of cerebral stroke in their early life, such as a young stroke, the APS and higher risk of developing fatal APS after major surgery should be considered. The optimal management of APS remains controversial. The best treatment strategies are only early diagnosis and aggressive therapies combing of anticoagulant, corticosteroid, and plasma exchange. The intravenous immunoglobulin is prescribed for patients with refractory APS.
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Affiliation(s)
- Chiao-Zhu Li
- Department of Neurological Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei Department of Surgery, Kaohsiung Armed Forces General Hospital Department of Surgery, Zoying Branch, Kaoshiung Armed Forces General Hospital Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Padjas A, Płazak W, Celińska-Lowenhoff M, Mazurek A, Perricone C, Podolec P, Musiał J. Myocardial Ischaemia, Coronary Atherosclerosis and Pulmonary Pressure Elevation in Antiphospholipid Syndrome Patients. ADV CLIN EXP MED 2016; 25:1199-1205. [PMID: 28028974 DOI: 10.17219/acem/63753] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/07/2016] [Accepted: 06/17/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Thrombotic events in antiphospholipid syndrome (APS) involve venous and arterial circulation with the possible involvement of coronary or pulmonary microcirculation. OBJECTIVES To evaluate the influence of antiphospholipid antibodies (aPL) and on myocardial ischaemia assessed by single-photon emission computerized tomography (SPECT), coronary atherosclerosis assessed by multidetector computerized tomography (MDCT) and pulmonary pressure assessed by transthoracic echocardiography (TTE) in patients with primary antiphospholipid syndrome (PAPS). MATERIAL AND METHODS TTE, SPECT (Tc 99m sestamibi) and MDCT-based coronary calcium scoring were performed in 26 consecutive PAPS patients (20 females, 6 males, aged 20-61, mean 39.7) without any signs of other autoimmunological disease and without clinical symptoms of heart disease. RESULTS Out of 26 patients, TEE showed normal left and right ventricle function in 25 (96.2%) and elevated (≥ 30 mm Hg) right ventricle systolic pressure in 7 (26.9%) patients. SPECT revealed myocardial perfusion defects in 15 (57.7%) patients: exercise-induced in 6 (23.1%) and persistent in 11 (42.3%). MDCT revealed coronary calcifications in 4 (15.4%) patients. The number of plaques ranged from 1 to 11 (median 2), volume 3-201.7 mm³ (median 7), calcium scores 1.3-202.6 (median 5.7). In the group with perfusion defects or coronary calcifications (n = 15), all the patients showed elevated aCL IgG. CONCLUSIONS In most of the relatively young APS patients, without any symptoms of ischemic heart disease, SPECT showed myocardial perfusion defects, and coronary calcifications in 1/6 of them. Right ventricle systolic pressure was elevated in 1/4 of APS patients. These pathologies, well known as cardiovascular risk markers, were associated with elevated levels of the IgG class of both anti-cardiolipin and antiB2 GPI antibodies. Thus, in a high percentage of APS patients, clinically silent myocardial ischaemia, pulmonary pressure elevation and coronary atherosclerosis are present and related to the presence of antiphospholipid antibodies.
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Affiliation(s)
- Agnieszka Padjas
- Department of Internal Medicine, Allergy and Immunology, Jagiellonian University Medical College, Kraków, Poland
| | - Wojciech Płazak
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Kraków, Poland
| | - Magdalena Celińska-Lowenhoff
- Department of Internal Medicine, Allergy and Immunology, Jagiellonian University Medical College, Kraków, Poland
| | - Adam Mazurek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Kraków, Poland
| | - Carlo Perricone
- Rheumatology Unit, Department of Medicine, Sapienza University, Rome, Italy
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Kraków, Poland
| | - Jacek Musiał
- Department of Internal Medicine, Allergy and Immunology, Jagiellonian University Medical College, Kraków, Poland
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Chang Y, Dabiri G, Damstetter E, Baiyee Ebot E, Powers JG, Phillips T. Coagulation disorders and their cutaneous presentations: Pathophysiology. J Am Acad Dermatol 2016; 74:783-92; quiz 793-4. [PMID: 27085225 DOI: 10.1016/j.jaad.2015.08.072] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 08/19/2015] [Accepted: 08/20/2015] [Indexed: 12/21/2022]
Abstract
Hypercoagulable states are inherited or acquired predispositions to venous or arterial thromboses that are best understood in the context of the coagulation cascade. Dermatologists can play a critical role in diagnosing and treating patients with hypercoagulable states because cutaneous symptoms may be a presenting manifestation, thereby reducing morbidity and mortality related to these conditions. This review focuses on the epidemiology and pathophysiology of hypercoagulable states, while the accompanying article iterates the basic clinical features, diagnostic testing, and management of patients who have these conditions.
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Affiliation(s)
- Yunyoung Chang
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Ganary Dabiri
- Department of Dermatology and Skin Surgery, Roger Williams Medical Center/Boston University School of Medicine, Providence, Rhode Island
| | - Elizabeth Damstetter
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Emily Baiyee Ebot
- Department of Hematology and Oncology, University Medical Group, Providence, Rhode Island
| | | | - Tania Phillips
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts.
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Abstract
Catastrophic antiphospholipid syndrome (CAPS) is a rare complication of antiphospholipid syndrome. lt is a disseminated severe vascular pathology which presents with multi-organic dysfunction that progresses rapidly. Prognosis ends up being fatal in half of the cases. It may appear during pregnancy, surgery, infection, or after suspension of anticoagulation therapy. We studied two female patients with CAPS who survived after treatment with anticoagulation therapy and intravenous corticosteroids. The evolution of our two patients, after 17 months of follow-up under oral anticoagulant treatment was favourable and they are currently asymptomatic. In these patients the early diagnosis and treatment were essential to enhance their possibilities of survival.
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Affiliation(s)
- N Navarrete
- Service of Internal Medicine, Virgen de las Nieves University Hospital, Granada, Spain.
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19
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Abstract
Our objective was to study the endocrinologic manifestations of the antiphospholipid syndrome (APS). We reviewed the medical literature from 1968 until 2005 using MEDLINE and the key words: APS, anticardiolipin antibodies, lupus anticoagulant, antiphospholipid antibodies, adrenal, thyroid, parathyroid, pituitary, diabetes, ovaries and testes. Adrenal insufficiency is the most common endocrinologic manifestation and can be the presenting symptom of APS. In patients with autoimmune thyroid disease circulating aPL have been detected. However, no clinical manifestations of APS have been described. A few cases of hypopituitarism have been reported, including a case of Sheehan’s syndrome. aPL has been detected in the sera of diabetic patients, probably associated with some macroangiopathic complications. Finally only very few cases of ovarian and testicular involvement have been reported. The adrenals are the most commonly involved glands in the APS. Clinicians should keep a high index of suspicion for adrenal insufficiency in patients with APS.
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Affiliation(s)
- I Uthman
- Division of Rheumatology, Faculty of Medicine, American University of Beirut, Lebanon.
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20
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Tatsukawa H, Ishii K, Haranaka M, Kumagi M, Hino I, Yoshimatsu H. Evaluation of average amount of cerebral blood flow measured by brain perfusion index in patients with neuropsychiatric systemic lupus erythematosus. Lupus 2016; 14:445-9. [PMID: 16038108 DOI: 10.1191/0961203305lu2127oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We used the brain perfusion index (BPI), an indicator of the average amount of cerebral blood flow (CBF), to evaluate the usefulness of the average amount of CBF for neuropsychiatric systemic lupus erythematosus (NPSLE). Of the seventy three SLE patients examined in this study (total 100 scans), 16 patients (23 scans) had already been diagnosed with NPSLE based on clinical symptoms indicative of central nervous system involvement. In addition, 12 patients (17 scans) exhibited the antiphospholipid antibody syndrome (APS). BPI is significantly influenced by age and we therefore used the BPI ratio (ratio of age predicted BPI to measured BPI value) for each assessment. The mean BPI value of 100 scans was 11.2 + 2.79, and the mean BPI ratio was 0.99 + 0.24 in all SLE patients. The mean BPI ratio among NPSLE (0.84 + 0.19) was significantly lower than that of the non-NPSLE patients (1.04 + 0.24) (P, 0.0005). However, there was no difference in the mean BPI ratio between APS patients (0.98 + 0.24) and non-APS patients (0.99 + 0.25). These results indicate that the mean CBF assessed by the BPI ratio using SPECT is of use in the evaluation of central nervous system involvement in SLE patients.
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Affiliation(s)
- H Tatsukawa
- Department of Internal Medicine I, Faculty of Medicine, Oita University, Oita, Japan.
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21
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Abstract
β2-glycoprotein I (β2GPI) is a major antigenic target for antiphospholipid antibodies. Oxidized low-density lipoprotein (oxLDL) is the principal lipoprotein found in atherosclerotic lesions, and it colocalizes with β2GPI and immunoreactive lymphocytes. oxLDL/β2GPI complexes appeared in the blood circulation of patients with diseases, such as systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), systemic sclerosis, diabetes mellitus and chronic renal diseases. Thus, the complexes may be associated with systemic and chronic inflammation of the vasculature. IgG anti-oxLDL/β2GPI complexes autoantibodies and their immune complexes were detected only in SLE/APS patients and in its animal model and were strongly associated with arterial thrombosis. The oxLDL/β2GPI complexes were internalized by macrophages via IgG anti-β2GPI antibody-mediated phagocytosis. In contrast, IgM anti-oxLDL antibodies derived from hyperlipidemic mice reduced the incidence of atherosclerosis. The distribution patterns of IgG and IgM anti-oxLDL antibodies in patients suggest the different roles of these antibodies.
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Affiliation(s)
- E Matsuura
- Department of Cell Chemistry, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan.
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22
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Abstract
The heart lesions of rheumatic fever and the heart involvement in antiphospholipid syndrome (APS), have different clinical pictures. Yet, there are several common characteristics linking both diseases: 1) central nervous system (CNS) and heart involvement; 2) molecular mimicry between the a pathogen and the origin of the disease; 3) cross reacting antibodies between the pathogen and self molecules; 4) endothelial cell activation in the ‘crime-area’ i.e., the valves; 5) some of the patients with RF have circulating antiphospholipid antibodies, while APS may be associated with streptococcal infection; and 6) recently, a cross-reactivity between antibodies directed to the streptococcal M-protein and its synthetic derivative in rheumatic fever (RF) and antibodies derived from APS patients targeting the beta-2-glycoprotein-I (β2GPI) and a β2GPI related synthetic peptide. In the current paper, we summarize the possible links between the heart involvement in RF and APS.
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Affiliation(s)
- M Blank
- Department of Internal Medicine B, The Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel-Aviv University, Israel
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23
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Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease, associated with a hypercoagulable state and fetal loss and with other clinical manifestations including cardiac involvement. Cardiac manifestations of APS are valve abnormalities (valve thickening and vegetations), occlusive arterial disease (atherosclerosis and myocardial infarction), intracardiac emboli, ventricular dysfunction, and pulmonary hypertension. Antiphospholipid antibodies (aPLs) may have a role in the accelerated atherosclerotic arterial disease observed in APS, related to their ability to induce endothelial activation. aPLs have been incriminated in the pathogenesis of heart valve lesions in APS patients. Markers of endothelial cell activation are up-regulated with prominent deposition of aPL in heart valves, suggesting aPL deposition initiates an inflammatory process that recruits complement leading to the valve lesion. Autoantibody-mediated endothelial cell activation probably plays a role in sustaining a proadhesive, proinflammatory, and procoagulant phenotype. The heterogeneity of APS clinical manifestations is likely linked to the varied effects that aPL can induce on endothelial cells and to the different functions that endothelial cells display depending on the anatomic localization.
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Affiliation(s)
- F Tenedios
- Department of Rheumatology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, USA.
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Abstract
One of the major clinical concerns of the antiphospholipid syndrome (APS) is the propensity of antiphospholipid(aPL) antibodiesto cause thrombosis in both the large and small vessels of the brain. In this article, we review the current understandingof haemostasis in cerebral circulation and discuss this in the context of antiphospholipidantibodies. The systemic-defect-local-phenotypeparadox is of particular importance in this discussion. In this paradigm, a systemic defect in thrombosis and haemostasis leads to a localized pattern of thrombotic disease because the regional physiological variations in the several prothromboticand anticoagulantfactors and the defect interact so as to favour thrombosis at a particular site. One possible mechanism of initiation of thrombosis in APS is the activation of endothelialcells by aPL that could occur in the cerebral vessels and provoke thrombosis. We review the evidence from gene knockout mice, other animal models and human postmortem examination studies as to which pro- and antithrombotic mechanisms are effecting haemostasis in the cerebral circulation. We conclude that there are large deficits in the understanding of the regulation of haemostasis in the human brain. As a consequencethere is a lack of knowledgeabout the effect of aPL on cerebral endothelium and thrombosis. Recent developments in gene expression profiling may have an impact on our understandingof endothelialfunctionin the brain. More research is required.
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Affiliation(s)
- P Connor
- Departments of Haematology and Lupus Unit, Guy's and St Thomas' Trust, London SE1 7EH, UK
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Der H, Kerekes G, Veres K, Szodoray P, Toth J, Lakos G, Szegedi G, Soltesz P. Impaired endothelial function and increased carotid intima-media thickness in association with elevated von Willebrand antigen level in primary antiphospholipid syndrome. Lupus 2016; 16:497-503. [PMID: 17670848 DOI: 10.1177/0961203307080224] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Primary antiphospholipid syndrome (APS) is characterized by venous or arterial thrombotic events and/or recurrent abortions, fetal death, preeclasmpsia, eclampsia in the presence of anticardiolipin antibodies or lupus anticoagulant, in the absence of accompanying diseases. Antiphospholipid antibodies can activate endothelial cells, and were recently implicated in atherosclerosis. To assess potential endothelial impairment and early signs of atherosclerosis, flow-mediated (endothelium-dependent) and nitrate-mediated (endothelium independent) vasodilation, as well as von Willebrand factor antigen level and carotid artery intima-media thickness (IMT) were measured in patients with primary antiphospholipid syndrome and in healthy controls. Flow-mediated vasodilation in patients with primary APS was significantly lower than that of controls (3.43 ± 2.86% versus 7.96 ± 3.57%; P < 0.0001). We also found significantly higher von Willebrand antigen levels in patients with primary APS than in the control group (157.91 ± 52.45% versus 125.87 ± 32.8%; P = 0.012). Moreover, carotid artery IMT was significantly larger in the primary APS group compared to controls (0.714 ± 0.2 mm versus 0.58 ± 0.085 mm; P = 0.0037). Our results reflect ongoing endothelial damage and accelerated atherosclerosis in patients with primary APS, and suggest that vasoprotective therapy may be beneficial in the treatment of these patients. Lupus (2007) 16, 497—503.
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Affiliation(s)
- H Der
- 3rd Department of Medicine, Institute for Internal Medicine, University of Debrecen, Medical and Health Science Center, Debrecen, Hungary
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Abstract
Antiphospholipid syndrome (APS) is a clinical entity characterized by arterial and venous thrombosis, adverse obstetric outcome and the presence of antibodies against phospholipids in serum or plasma. The objective of the present study is to describe a rare case of APS that occurred in a neonate born from a patient previously diagnosed as primary APS. A male, preterm born twin infant, whose mother had been diagnosed as primary APS, developed thrombocytopenia, livedo reticularis, pericardial effusion and thrombosis of the left subclavian and external jugular veins concomitantly with severe respiratory tract infection soon after his delivery, that culminated with his death two months after the birth, in spite of the large spectrum antibiotic therapy and all supportive measures. Laboratory findings included high titers of IgM anticardiolipin antibodies and moderate titers of IgG isotype and negative antinuclear antibody, configuring a case of neonatal APS. Neonatal APS is a rare clinical condition, with only a few cases described in the literature. Its occurrence may depend on the passage of antibodies through the placenta or, as it seems to have occurred in the present case, by the production of de novo antibodies by the fetus. The present case illustrates the necessity of a higher surveillance of the neonates born from mothers with primary APS or systemic lupus erythematosus (SLE) for the eventual development of such complication.
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Affiliation(s)
- A M Soares Rolim
- Clínica Pediátrica do Itaigara, Hospital da Criança-Obras Sociais Irmã Dulce and Universidade Federal da Bahia, Brazil
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Abstract
Catastrophic antiphospholipid syndrome is a rapidly progressive life-threatening disease that causes multiple organ thromboses and dysfunction in the presence of antiphospholipid antibodies. A high index of clinical suspicion and careful investigation are required to make an early diagnosis so that treatment with anticoagulation and corticosteroids can be initiated; plasma exchange and/or intravenous immunoglobulins can be added if the life-threatening condition persists. Despite aggressive treatment and intensive care unit management, patients with catastrophic antiphospholipid syndrome have a 48% mortality rate, primarily attributable to cardiopulmonary failure. This article reviews the current information on the etiopathogenesis, clinical manifestations, diagnosis, management, and prognosis of catastrophic antiphospholipid syndrome.
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Affiliation(s)
- Setu K Vora
- Pulmonary Physicians of Norwich, Norwich, Connecticut, USA
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29
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Negrini S, Pappalardo F, Murdaca G, Indiveri F, Puppo F. The antiphospholipid syndrome: from pathophysiology to treatment. Clin Exp Med 2016; 17:257-267. [PMID: 27334977 DOI: 10.1007/s10238-016-0430-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/15/2016] [Indexed: 01/19/2023]
Abstract
Antiphospholipid antibody syndrome (APS) is an autoimmune acquired thrombophilia characterized by recurrent thrombosis and pregnancy morbidity in the presence of antiphospholipid antibodies (aPL). APS can be primary, if it occurs in the absence of any underlying disease, or secondary, if it is associated with another autoimmune disorder, most commonly systemic lupus erythematosus. The exact pathogenetic mechanism of APS is unknown, but different, not mutually exclusive, models have been proposed to explain how anti-PL autoantibodies might lead to thrombosis and pregnancy morbidity. Diagnosis of APS requires that a patient has both a clinical manifestation (arterial or venous thrombosis and/or pregnancy morbidity) and persistently positive aPL, but the clinical spectrum of the disease encompasses additional manifestations which may affect every organ and cannot be explained exclusively by a prothrombotic state. Treatment for aPL-positive patients is based on the patient's clinical status, presence of an underlying autoimmune disease, and history of thrombotic events. In case of aPL positivity without previous thrombotic events, the treatment is mainly focused on reduction of additional vascular risk factors, while treatment of patients with definite APS is based on long-term anticoagulation. Pregnancy complications are usually managed with low-dose aspirin in association with low molecular weight heparin. Refractory forms of APS could benefit from adding hydroxychloroquine and/or intravenous immunoglobulin to anticoagulation therapy. Promising novel treatments include anti-B cell monoclonal antibodies, new-generation anticoagulants, and complement cascade inhibitors. The objective of this review paper is to summarize the recent literature on APS from pathogenesis to current therapeutic options.
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Affiliation(s)
- Simone Negrini
- Department of Internal Medicine, Clinical Immunology Unit, University of Genoa, Viale Benedetto XV, 6, 16132, Genoa, Italy.
- Centre of Excellence for Biomedical Research, University of Genoa, Genoa, Italy.
| | | | - Giuseppe Murdaca
- Department of Internal Medicine, Clinical Immunology Unit, University of Genoa, Viale Benedetto XV, 6, 16132, Genoa, Italy
| | - Francesco Indiveri
- Department of Internal Medicine, Clinical Immunology Unit, University of Genoa, Viale Benedetto XV, 6, 16132, Genoa, Italy
| | - Francesco Puppo
- Department of Internal Medicine, Clinical Immunology Unit, University of Genoa, Viale Benedetto XV, 6, 16132, Genoa, Italy
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Lackner KJ, Müller-Calleja N. Pathogenesis of the antiphospholipid syndrome revisited: time to challenge the dogma. J Thromb Haemost 2016; 14:1117-20. [PMID: 26998919 DOI: 10.1111/jth.13320] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 03/10/2016] [Indexed: 01/27/2023]
Abstract
For more than a decade the antiphospholipid syndrome (APS) has been reported to be caused mainly by antiphospholipid antibodies (aPL), which are not directed against phospholipids but against a complex of phospholipids and phospholipid binding proteins, so called cofactors (e.g. β2-glycoprotein I [β2GPI]). In fact, many researchers propose that the only relevant antigens in the APS are the cofactors themselves, with β2GPI being the most important. Antibodies that bind to phospholipids in a cofactor-independent manner are considered insignificant for the pathogenesis of the APS. We review the evidence for this current pathophysiologic concept and argue that it has never been proven and is now clearly no longer tenable. First, there is undisputable evidence that cofactor-independent aPL are pathogenic and present in the blood of APS patients. Second, available epidemiologic and clinical studies do not support a dominant pathogenic role for anti-β2GPI.
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Affiliation(s)
- K J Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Centre Mainz, Mainz, Germany
| | - N Müller-Calleja
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Centre Mainz, Mainz, Germany
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31
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Budnevskiy AV, Kutashov VA, Kravchenko AY. [Clinical manifestations of antiphospholipid syndrome associated with lesions of the central nervous system]. Klin Med (Mosk) 2016; 94:391-394. [PMID: 30289654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Antiphospholipid syndrome (APS) is one of the important but poorly known conditions. Its symptoms are ofparticular interest for neurologists since thrombi are most often localized in the cerebral blood vessels which leads to ischemic cerebrovascular accidents (AICS). APS can also manifest itself in the following symptoms: epileptic attacks, dementia, headache, chorea, peripheral neuropathy, myelo- and encephalopathy phenomenologically similar to multiple sclerosis. This article presents a clinical case of secondary APS with the neurological manifestations in a 25-year-old female patient.
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Habe K, Wada H, Matsumoto T, Ohishi K, Ikejiri M, Matsubara K, Morioka T, Kamimoto Y, Ikeda T, Katayama N, Mizutani H. Presence of Antiphospholipid Antibodies as a Risk Factor for Thrombotic Events in Patients with Connective Tissue Diseases and Idiopathic Thrombocytopenic Purpura. Intern Med 2016; 55:589-95. [PMID: 26984073 DOI: 10.2169/internalmedicine.55.5536] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Antiphospholipid syndrome (APS) is a well-known complication of habitual abortion and/or thrombosis and is frequently associated with autoimmune diseases. METHODS We retrospectively investigated the relationships between the presence of antiphospholipid antibodies (aPLs) and the incidence of thrombotic events (THEs) in 147 patients with various connective tissue diseases (CTD) suspected of having APS and 86 patients with idiopathic thrombocytopenic purpura (ITP). THEs were observed in 41 patients, including 14 cases of venous thrombosis, 21 cases of arterial thrombosis and eight cases of complications of pregnancy. RESULTS The prevalence of THE was significantly high in the systemic lupus erythematosus (SLE) patients compared with the other CTD patients and ITP patients. The frequency of lupus anticoagulant (LA), anticardiolipin antibodies (aCL)-β2-glycoprotein (GPI) complex IgG and aPL was significantly high in the SLE patients compared with the ITP patients. Subsequently, the rate of development of THE was significantly high in the patients with aPLs. In particular, the incidence of THE was significantly high in the SLE or ITP patients with LA, aCL-β2GPI IgG or aPL. The optimal cut-off values for LA, aCL IgG and aCL-β2GPI complex IgG for the risk of THEs were higher in the SLE patients in comparison to the values obtained when using the kit provided by the manufacturer. CONCLUSION Although aPLs is frequently associated with SLE and is a causative factor for thrombosis, the optimal cut-off value for aPL for predicting the occurrence of THEs varies among different underlying diseases.
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MESH Headings
- Adult
- Antibodies, Antiphospholipid/blood
- Antibodies, Antiphospholipid/immunology
- Antiphospholipid Syndrome/blood
- Antiphospholipid Syndrome/complications
- Antiphospholipid Syndrome/immunology
- Antiphospholipid Syndrome/physiopathology
- Biomarkers/blood
- Female
- Humans
- Male
- Predictive Value of Tests
- Pregnancy
- Pregnancy Complications, Hematologic/blood
- Pregnancy Complications, Hematologic/etiology
- Pregnancy Complications, Hematologic/physiopathology
- Prevalence
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/physiopathology
- Retrospective Studies
- Risk Factors
- Venous Thrombosis/blood
- Venous Thrombosis/etiology
- Venous Thrombosis/physiopathology
- beta 2-Glycoprotein I/blood
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Affiliation(s)
- Koji Habe
- Department of Dermatology, Mie University Graduate School of Medicine, Japan
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Stojanovich L, Djokovic A, Kontic M. Antiphospholipid-mediated thrombosis: interplay between type of antibodies and localisation of lung, and cardiovascular incidences in primary antiphospholipid syndrome. Clin Exp Rheumatol 2015; 33:531-536. [PMID: 26088955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 03/23/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The aim of this study was to analyse prevalence and type of pulmonary manifestations in patients with primary antiphospholipid syndrome (PAPS), their association to antiphospholipid antibody (aPL) type and localisation of peripheral vascular thrombosis, and possible relationship to existing cardiac manifestations. METHODS Our cross-sectional study comprised 318 PAPS patients, enrolled in the study as the Serbian APS Registry. aPL analysis included detection of aCL (IgG/IgM), ß2GPI (IgG/IgM) and LA, served to evaluate associations with cardiac and pulmonary manifestations. RESULTS In patients with pulmonary embolism and infarction, we observed significant prevalence of myocardial infarction (p=0.044), unstable angina pectoris (p=0.001), venous thrombosis (p=0.007) arterial thrombosis (p=0.0001), deep venous thrombosis of the low extremities (p=0.008), and superficial thrombophlebitis of the low extremities (p=0.023). Patients with primary pulmonary hypertension were more prone to unstable angina pectoris (p=0.009), while patients with secondary pulmonary hypertension were more prone to venous thrombosis (p=0.04) and deep venous thrombosis of the inferior extremities (p=0.04). Patients with pulmonary microthrombosis were more prone to unstable angina pectoris (p=0.026), arterial thrombosis (p=0.002), venous thrombosis (p=0.001), deep venous thrombosis of the inferior extremities (p=0.001), and superficial thrombophlebitis of the inferior extremities (p=0.001). The presence of LA was significantly higher in patients with pulmonary embolism and infarction (p=0.001), secondary pulmonary hypertension (p=0.032), and pulmonary microthrombosis (p=0.001). CONCLUSIONS Presence of LA was associated with distinct pulmonary manifestations in the Serbian APS cohort. There is a strong link between some cardiovascular and pulmonary manifestations in PAPS patients, suggesting complexity and evolutionary nature of PAPS.
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Affiliation(s)
- Ljudmila Stojanovich
- Internal medicine, "Bezanijska Kosa", University Medical Center, Belgrade,Serbia
| | - Aleksandra Djokovic
- Internal medicine, "Bezanijska Kosa", University Medical Center, Belgrade; and Medical Faculty, University of Belgrade, Serbia
| | - Milica Kontic
- Medical Faculty, University of Belgrade, and Clinic for Pulmonology, Clinical Center of Serbia, Belgrade, Serbia
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Conti F, Ceccarelli F, Gigante A, Perricone C, Barbano B, Massaro L, Spinelli FR, Alessandri C, Valesini G, Cianci R. Ultrasonographic Evaluation of Resistive Index and Renal Artery Stenosis in Patients with Anti-Phospholipid Syndrome: Two Distinct Mechanisms? Ultrasound Med Biol 2015; 41:1814-1820. [PMID: 25800790 DOI: 10.1016/j.ultrasmedbio.2015.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 02/16/2015] [Accepted: 02/19/2015] [Indexed: 06/04/2023]
Abstract
Renal involvement in anti-phospholipid syndrome (APS) is still relatively unknown and probably underestimated. The described lesions consist of renal artery stenosis (RAS), venous renal thrombosis and glomerular lesions. The resistive index (RI) of intra-renal arteries, expression of the degree of vascular resistance, has been analyzed in different nephropathies and observed to be associated with functional parameters and some histologic features. In contrast, there are no studies on patients with APS. We evaluated the presence of a pathologic RI and RAS in a cohort of patients with APS. The study protocol included ultrasonographic assessment to measure the RI (RIs >0.7 were considered pathologic) and to determine the presence of RAS. We enrolled 36 patients with APS, 13 with primary APS and 23 with the form associated with systemic lupus erythematosus (SLE, secondary APS). As controls, we enrolled 10 anti-phospholipid antibody carriers, 10 patients with SLE without renal involvement and 14 age- and sex-matched healthy patients. A pathologic RI was identified in five patients with APS (13.9%) and in none of the anti-phospholipid antibody carriers (p = 0.00007). Four of the five (80%) patients with a pathologic RI had secondary APS. Three patients, all with primary APS, had RAS. The almost exclusive association of a pathologic RI with secondary APS and of RAS with primary APS suggests the involvement of two pathogenic pathways in the development of these different manifestations. The hypercoagulability status driven by APS could play a central role in the determination of RAS in patients with primary APS, whereas the activation of mTORC (mammalian target of rapamycin complex) pathways could be the pathogenic mechanism inducing development of a pathologic RI.
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Affiliation(s)
- Fabrizio Conti
- Lupus Clinic, Rheumatology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy.
| | - Fulvia Ceccarelli
- Lupus Clinic, Rheumatology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Antonietta Gigante
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Carlo Perricone
- Lupus Clinic, Rheumatology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Biagio Barbano
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Laura Massaro
- Lupus Clinic, Rheumatology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesca Romana Spinelli
- Lupus Clinic, Rheumatology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Cristiano Alessandri
- Lupus Clinic, Rheumatology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Guido Valesini
- Lupus Clinic, Rheumatology Unit, Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Rosario Cianci
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
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Rodríguez-Pintó I, Soriano A, Espinosa G, Shoenfeld Y, Cervera R. Catastrophic antiphospholipid syndrome: an orchestra with several musicians. Isr Med Assoc J 2014; 16:585-586. [PMID: 25351020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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36
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Watanabe N, Yamaguchi K, Motomura K, Hisano M, Sago H, Murashima A. Combination therapy with anticoagulants, corticosteroids and intravenous immunoglobulin for women with severe obstetric antiphospholipid syndrome. Clin Exp Rheumatol 2014; 32:299-300. [PMID: 24447427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 12/11/2013] [Indexed: 06/03/2023]
Affiliation(s)
- N Watanabe
- Department of Maternal-Fetal and Neonatal Medicine, National Center for Child Health and Development, 2-10-1, Okura Setagaya, Tokyo, Japan.
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Vamvakidou A, Konstantinou D, Salam S, Mahmoud M. A patient with pleuritic chest pain and abnormal blood clotting tests. Acute Med 2014; 13:174-177. [PMID: 25521088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
We present the case of a 58 year old man who developed pleuritic chest while an in-patient; investigations revealed pulmonary embolism, despite a significantly raised Activated Partial Thromboplastin Time (APTT), which was subsequently attributed to Antiphospholipid syndrome (APS). The diagnosis and initial management of APS in the acute setting is discussed.
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Affiliation(s)
| | | | - S Salam
- Consultant Rehabilitation Medicine, Bishop Auckland Hospital
| | - M Mahmoud
- Consultant Haematologist, Darlington Memorial Hospital
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38
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Shiber S, Yair M. Catastrophic antiphospholipid syndrome: a case series. Isr Med Assoc J 2013; 15:481-484. [PMID: 24340837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is an autoimmune disease with clinical manifestations of arterial and venous thrombosis, obstetric manifestations, and the presence of antiphospholipid antibodies or lupus anticoagulant. Catastrophic APS is a rare variant of APS, defined as acute failure of at least three tissues, organs or systems caused predominantly by small vessel thrombosis confirmed by histopathologic evidence. Catastrophic APS develops rapidly and leads to death in 30% of cases. METHODS We evaluated 11 patients with catastrophic APS -8 of them with a probable diagnosis of catastrophic APS and 3 with a definite diagnosis--admitted to Beilinson hospital during the period 2003-2011. RESULTS Overall venous events numbered 18 and overall arterial events 10. The event duration per patient was 2.6 +/- 1.2 weeks (mean +/- SD). Deep vein thrombosis of the legs was quite common (7 events), as was venous intraabdominal thrombosis (10 events). Eight patients had microangiopathic anemia with schizocytes seen in the blood smear. The mean +/- SD hemoglobin level was 10.3 +/- 3.6 g/dl and the mean +/- SD creatinine level 0.98 +/- 0.78 mg/dl. All our patients had high acute-phase reactant and all had lupus anticoagulant positivity, The most common positive antibodies were immunoglobulin G anticardiolipin (8 patients) and IgG beta2-glycoprotein (7 patients). During the events warfarin was stopped and the patients were given intravenous heparin. All the patients received steroids in variable doses. Five patients underwent plasma exchange, two patients received rituximab and two patients intravenous immunoglobulin. CONCLUSIONS Catastrophic APS, a rare syndrome, is important because of its major morbidity and mortality among young patients.
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Affiliation(s)
- Shachaf Shiber
- Rheumatology Unit, Rabin Medical Center (Beilinson Campus), Petah Tikva, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
| | - Molad Yair
- Rheumatology Unit, Rabin Medical Center (Beilinson Campus), Petah Tikva, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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39
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Zandman-Goddard G, Shoenfeld Y. Hemophagocytic syndrome with hyperferritinemia: a stormy immunological response. Isr Med Assoc J 2013; 15:187-188. [PMID: 23781756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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40
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Sacks S, Finn J, Sanna G, Khamashta MA, Chowdhury F, Hunt BJ, Bell R, D'Cruz DP. N2010 adult-onset Still's disease complicated by hemophagocytic syndrome and catastrophic antiphospholipid syndrome resulting in four limb amputation. Isr Med Assoc J 2013; 15:192-194. [PMID: 23781758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Sarah Sacks
- Louise Coote Lupus Unit, Guy's and St Thomas' Hospital, London, England.
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41
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Affiliation(s)
- Bill Giannakopoulos
- Department of Infectious Diseases, Immunology, and Sexual Health, St. George Hospital, Kogarah, Sydney, NSW 2217, Australia.
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42
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Selivanenko VT, Martakov MA, Ivashkin BV, Vashchenko AV, Pronina VP, Dudakov VA, Zaĭnetdinov EM. [Thrombectomy from pulmonary artery and right ventricle with cava-filter implantation in patient with antiphospholipid syndrome]. Khirurgiia (Mosk) 2013:59-61. [PMID: 23715426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Abstract
The antiphospholipid syndrome (APS) is diagnosed when patients with thrombotic complications or foetal losses have elevated levels of antiphospholipid antibodies in their plasmas. The term APS is confusing, because the pathogenic auto-antibodies are not directed against phospholipids but towards a plasma protein, β(2)-glycoprotein I. For many years the reason why auto-antibodies against β(2)-glycoprotein I were pro-thrombotic was unclear, because man and mice deficient in β(2)-glycoprotein I do not express a clear phenotype. Animal models in which passive transfer of patient antibodies into mice resulted in an increased thrombotic response have provided novel insights in the importance of this protein in the pathology of APS.
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Affiliation(s)
- P G de Groot
- Department of Clinical Chemistry and Haematology, University Medical Center, Utrecht, The Netherlands.
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Gladigau G, Haselmayer P, Scharrer I, Munder M, Prinz N, Lackner K, Schild H, Stein P, Radsak MP. A role for Toll-like receptor mediated signals in neutrophils in the pathogenesis of the anti-phospholipid syndrome. PLoS One 2012; 7:e42176. [PMID: 22860075 PMCID: PMC3409186 DOI: 10.1371/journal.pone.0042176] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 07/03/2012] [Indexed: 01/30/2023] Open
Abstract
The anti-phospholipid syndrome (APS) is characterized by recurrent thrombosis and occurrence of anti-phospholipid antibodies (aPL). aPL are necessary, but not sufficient for the clinical manifestations of APS. Growing evidence suggests a role of innate immune cells, in particular polymorphonuclear neutrophils (PMN) and Toll-like receptors (TLR) to be additionally involved. aPL activate endothelial cells and monocytes through a TLR4-dependent signalling pathway. Whether this is also relevant for PMN in a similar way is currently not known. To address this issue, we used purified PMN from healthy donors and stimulated them in the presence or absence of human monoclonal aPL and the TLR4 agonist LPS monitoring neutrophil effector functions, namely the oxidative burst, phagocytosis, L-Selectin shedding and IL-8 production. aPL alone were only able to induce minor activation of PMN effector functions at high concentrations. However, in the additional presence of LPS the activation threshold was markedly lower indicating a synergistic activation pathway of aPL and TLR in PMN. In summary, our results indicate that PMN effector functions are directly activated by aPL and boosted by the additional presence of microbial products. This highlights a role for PMN as important innate immune effector cells that contribute to the pathophysiology of APS.
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Affiliation(s)
- Gerd Gladigau
- Institute of Immunology, Johannes Gutenberg-University Medical Center, Mainz, Germany
| | - Philipp Haselmayer
- Institute of Immunology, Johannes Gutenberg-University Medical Center, Mainz, Germany
| | - Inge Scharrer
- Third Department of Medicine, Johannes Gutenberg-University Medical Center, Mainz, Germany
| | - Markus Munder
- Third Department of Medicine, Johannes Gutenberg-University Medical Center, Mainz, Germany
| | - Nadine Prinz
- Institute of Clinical Chemistry and Laboratory Medicine, Johannes Gutenberg-University Medical Center, Mainz, Germany
| | - Karl Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, Johannes Gutenberg-University Medical Center, Mainz, Germany
| | - Hansjörg Schild
- Institute of Immunology, Johannes Gutenberg-University Medical Center, Mainz, Germany
| | - Pamela Stein
- Institute of Immunology, Johannes Gutenberg-University Medical Center, Mainz, Germany
- * E-mail: (MPR); (PS)
| | - Markus P. Radsak
- Institute of Immunology, Johannes Gutenberg-University Medical Center, Mainz, Germany
- Third Department of Medicine, Johannes Gutenberg-University Medical Center, Mainz, Germany
- * E-mail: (MPR); (PS)
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Hai A, Aslam M, Ashraf TH. Symmetrical peripheral gangrene: a rare presentation of antiphospholipid syndrome. Intern Emerg Med 2012; 7 Suppl 1:S71-3. [PMID: 22042628 DOI: 10.1007/s11739-011-0714-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 10/13/2011] [Indexed: 10/16/2022]
Affiliation(s)
- Abdul Hai
- Department of Surgery, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard University, New Delhi, India.
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[The levels of plasminogen and inhibitor of plasminogen activators of type 1 in antiphospholipid syndrome]. TERAPEVT ARKH 2012; 84:50-7. [PMID: 22830213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
AIM To estimate the levels of of plasminogen (Pg) and inhibitor of plasminogen activators of type 1 (IPA-1) in patients with antiphospholipid syndrome (APS) and to reveal correlations between their content and clinical-laboratory characteristics of APS. MATERIAL AND METHODS A Pg level was measured in 78 APS patients: 35 of them had systemic lupus erythematosus (SLE), 43 had primary APS and 19 with idiopathic thrombosis (IT). IPA-1 was detected in 63 APS patients: in 26, 37 and 18 patients, respectively. The control group consisted of 10 subjects free of autoimmune disease and thrombosis. The patients were matched by age. Pg and IPA-1 levels were estimated kinetically. The Pg level was stratified. normal (1.5-2.0 mcM high (above 2.0 mcM), low (under 1.5 mcM). Thromboses in the past occurred in 67 patients: arterial (n=32), venous (n=53), of combined localization (n=14). RESULTS Of 78 APS patients, Pg level was normal in 34 (44%), high--in 20 (25%), low--in 24 (31%). Of 43 primary APS patients, low Pg was in 8 (19%), of 35 patients with SLE+APS--in 16 (46%) patients. A Pg concentration (1.59 [1.4; 1.98] mcM) was significantly less in APS patients with thrombosis than in patients with IT (2.4 [1.74; 2.99] mcM). Pg tended to lower levels than in the controls (1.95 [1.63; 2.26] mcM). IPA-I varied in primary APS from 0.45 to >1 nM, in SLE+APS--from 0.44 to >1 nM, in IT--from 0.65 to 0.81 nM. The levels of active IPA-1 in all the patients with APS and IT were higher than in healthy donors and varied from 0.44 to >1 nM Most of APS patients had high level of IPA-1--52 (83%) (IPA-1 from 0.1 to 1), of them 22 (85%) patients with SLE+APS and 30 (73%)--with primary APS. 11 (17%) APS patients had high IPA-1 (>1), of them 4 (15%) with SLE+APS and 7 (27%) with primary APS. All IT patients had moderately high IPA-1 level. CONCLUSION A low level of Pg in APS patients was seen significantly more frequently than in IT patients and controls and was associated with thrombosis, primarily arterial. Moderate high IPA-1 occurred in 83% of 63 APS patients, high--in 17%. IT patients had moderately high IPA-1. High IPA-1 was associated in APS with thrombosis, primarily arterial.
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Kujovich J, Merrill PA. Antiphospholipid antibodies and antithrombin deficiency: double trouble for pregnancy. Am J Hematol 2011; 86:1028-31. [PMID: 21948382 DOI: 10.1002/ajh.22157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 07/20/2011] [Accepted: 07/24/2011] [Indexed: 11/11/2022]
Affiliation(s)
- Jody Kujovich
- Department of Pediatrics, The Hemophilia Center, Oregon Health & Science University, 707 SW Gaines Road, Portland, OR 97239, USA.
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48
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Poindron V, Berat R, Knapp AM, Toti F, Zobairi F, Korganow AS, Chenard MP, Gounou C, Pasquali JL, Brisson A, Martin T. Evidence for heterogeneity of the obstetric antiphospholipid syndrome: thrombosis can be critical for antiphospholipid-induced pregnancy loss. J Thromb Haemost 2011; 9:1937-47. [PMID: 21848640 DOI: 10.1111/j.1538-7836.2011.04475.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Antiphospholipid antibodies are associated with thrombosis and repeated pregnancy losses during the antiphospholipid syndrome. Several experimental findings indicate that purified antiphospholipid antibodies are directly responsible for inflammation-induced pregnancy losses, or for disruption of the annexin A5 shield at the trophoblastic interface. We previously showed that passive transfer of CIC15, a monoclonal antiphospholipid antibody binding to cardiolipin and annexin A5 that was isolated from a patient with primary antiphospholipid syndrome, induces fetal resorption in pregnant mice. OBJECTIVES To investigate the mechanisms of CIC15-induced pregnancy loss. METHODS/RESULTS We show that CIC15 induces fetal loss through a new mechanism that is probably related to procoagulant activity. The time course is different from those of previously described models, and histologic analysis shows that the placentas are devoid of any sign of inflammation but display some signs of thrombotic events. Despite these differences, the CIC15 and 'inflammatory' models share some similarities: lack of FcγRI/III dependency, and the efficacy of heparin in preventing fetal losses. However, this latter observation is here mostly attributable to anticoagulation rather than complement inhibition, because fondaparinux sodium and hirudin show similar efficiency. In vitro, CIC15 enhances cardiolipin-induced thrombin generation. Finally, using a combination of surface-sensitive methods, we show that, although it binds complexes of cardiolipin-annexin A5, CIC15 is not able to disrupt the two-dimensional ordered arrays of annexin A5. CONCLUSIONS This human monoclonal antibody is responsible for pregnancy loss through a new mechanism involving thrombosis. This mechanism adds to the heterogeneity of the obstetric antiphospholipid syndrome.
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Affiliation(s)
- V Poindron
- National Referral Center for Systemic Autoimmune Diseases, Clinical Immunology Department, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg and CNRS UPR 9021, Strasbourg, France.
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Armentia A, Mazón A, Pineda F, Palacios R, Crespo J, Inglada L, Martín-Santos JM, García-Frade J, Martín-Armentia B. Food anaphylaxis in antiphospholipid syndrome and thrombosis. Allergol Immunopathol (Madr) 2011; 39:212-21. [PMID: 21216082 DOI: 10.1016/j.aller.2010.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 06/29/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND We have observed that some cases of food anaphylaxis were followed by severe thrombosis associated to anticardiolipin antibodies. Food anaphylaxis associated with antiphospholipid syndrome has seldom been published. OBJECTIVE The aims were: 1) to test anticardiolipin antibodies in an important number of patients with anaphylaxis due to vegetal foods and their relationship with possible thrombosis; and 2) to study seed and fruit hypersensitivity in patients with previous thrombotic events associated with antiphospholipid antibodies (aCL). METHODS We included 30 patients diagnosed of thrombosis associated with aCL, 52 patients who suffered from anaphylaxis due to seeds or fruits, and 120 control patients. Haematological, cardiopulmonary vascular and rheumatologic studies had been performed as needed. In vivo and in vitro allergy tests with a large battery of vegetal allergens were carried out in all the patients. Measurement of IgG aCL antibodies and specific IgE to vegetal food was done by ELISA and CAP-FEIA (Phadia). Immunodetection and inhibitions with lipoproteins belonging to seeds were performed. RESULTS Seventy-five percent of the patients diagnosed as having antiphospholipid primary syndrome had specific IgE against different proteins from different vegetable allergens, most of them seeds, and clearly against lipoproteins that were also recognised by the patients with food anaphylaxis but not by the control cases. Among the patients with anaphylaxis, 28% had anticardiolipin antibodies and 17.3% thrombosis. CONCLUSION Our study suggests that seed lipoproteins which cause severe food anaphylaxis might have a potential role in the antiphospholipid syndrome and related thrombosis.
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Affiliation(s)
- A Armentia
- Allergy Section, UMDAI, Hospital Universitario Rio Hortega, Valladolid, Spain.
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Stalc M, Tomsic M, Jezovnik MK, Poredos P. Endothelium-dependent and independent dilation capability of peripheral arteries in patients with systemic lupus erythematosus and antiphospholipid syndrome. Clin Exp Rheumatol 2011; 29:616-623. [PMID: 21813059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Accepted: 02/14/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVES The study evaluated the systemic inflammatory response and endothelium-dependent and independent function of the brachial artery (BA) in systemic lupus erythematosus (SLE) patients with and without antiphospholipid syndrome (APS). METHODS The study group consisted of 42 women with SLE (21 without APS; mean age 36.1 ± 9.1, and 21 with APS; mean age 43.9 ± 13.1) and 22 healthy controls (mean age 43.5 ± 10.3). Endothelium-dependent functional response was evacuate using the flow-mediated vasodilatation (FMD) of brachial artery and endothelium-independent vasodilatation by application of glyceryl trinitrate (GTN). Using biochemical methods, circulating inflammatory markers were determined. RESULTS In comparison to controls, in both groups of patients endothelium-dependent dilation of BA was significantly reduced, and there were no differences in FMD between patients with or without APS: SLE - 7.7% (11.9-12.1), SLE+APS 7.8% (2.4-12.8), controls - 14.6% (11.2-21.1), p<0.001. However, endothelium-independent dilation of the brachial artery was significantly lower in SLE-APS patients than in controls and also lower than in the SLE group: SLE - 24.3% (15.0-28.6), SLE+APS-17.4% (13.1-22.6), controls - 23.0% (17.8-30.1), p=0.015 vs. p=0.027. Patients with SLE had significantly higher values of VCAM-1, hs-CRP, and fibrinogen than controls. In patients with SLE+APS, an additional significant increase of inflammatory markers was registered. CONCLUSIONS The results of our study indicate that patients with SLE have deteriorated endothelium-dependent and those with APS also independent vascular function which could be, together with increased inflammatory response, involved in vascular complications in these patients. The presence of APS aggravates systemic inflammatory response.
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Affiliation(s)
- M Stalc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia
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