Heart valve disease in primary antiphospholipid syndrome

OBJECTIVES

APS-associated heart valve disease (HVD) is well described. Nonetheless, limited data exist on clinical parameters associated with the course of primary APS (pAPS) patients with HVD. The goal of this study was to assess clinical features and related outcomes in patients with APS-associated HVD.

METHODS

In this multicentre retrospective study, we identified 33 pAPS patients with HVD (pAPS-HVD group) and compared their clinical course with 128 pAPS patients with normal heart valves on echocardiography (pAPS-control group).

RESULTS

pAPS-HVD patients had more cerebrovascular events (56.3% vs 25%, P = 0.005) and livedo reticularis (24.2% vs 7.8%, P = 0.013) than pAPS-controls. Furthermore, catastrophic-APS (CAPS) (12.1% vs 2.4%, P = 0.034), recurrent thrombosis (33.3% vs 4.7%, P < 0.001) and need for advanced therapy (i.e. IVIG, plasmapheresis or rituximab) were more frequent in pAPS-HVD patients. Anti-β2-glycoprotein 1 IgG (84.8% vs 63.2%, P = 0.034), anti-cardiolipin IgG (90.9% vs 64.8%, P = 0.005) and triple positive aPL (75.8% vs 56.5%, P = 0.047) were commoner in pAPS-HVD patients vs pAPS-controls. Ten of the 33 patients with pAPS-HVD underwent valve surgery, which was associated with male gender, smoking, arterial limb ischaemia and livedo reticularis.

CONCLUSION

pAPS-HVD patients had a more severe APS clinical course including CAPS and thrombotic events as well as a specific serology, namely IgG isotype aPL antibodies and triple positivity. Our data suggest that pAPS-HVD represents a high-risk subgroup of APS patients.

Infrequent associations of cutis marmorata telangiectatica congenita: a two-case report

INTRODUCTION

Cutis marmorata telangiectatica congenita (CMTC) is a rare capillary malformation characterized by persistent reticular and violaceous erythema. We present two cases of CMTC.

CLINICAL OBSERVATION

The first case involved a 13-month-old male with a reticular violaceous macule on the left gluteal region and a brownish papule with Darier's sign on the inner malleolus of the left foot, which was biopsied, revealing > 15 mast cells per field, leading to a diagnosis of CMTC and solitary cutaneous mastocytoma. The second case involved a newborn with a characteristic CMTC lesion without other malformations at birth, who subsequently developed two cutaneous tumors consistent with infantile hemangiomas during follow-up.

DISCUSSION

CMTC is a benign condition. However, approximately 50% of cases exhibit associated anomalies. When CMTC is suspected, musculoskeletal, ophthalmological, and cutaneous malformations should be ruled out. To the best of our knowledge, this is the first report of CMTC associated with mastocytoma and one of the few cases associated with infantile hemangioma.

Hepatitis C Virus-associated Cryoglobulinemic Livedo Reticularis Improved with Direct-acting Antivirals

We herein report a case of hepatitis C virus (HCV)-associated cryoglobulinemic livedo reticularis in a woman in her 60s that improved with direct-acting antivirals (DAAs). Hyperpigmentation was observed in both lower legs, and a skin biopsy confirmed livedo reticularis, suggesting a relationship with cryoglobulinemia and HCV infection. DAAs with an NS5A inhibitor+NS3/4A protease inhibitor (glecaprevir/pibrentasvir) were administered for eight weeks, and a sustained virological response (SVR) was obtained. The disappearance of serum cryoglobulin was confirmed approximately two years after an SVR was obtained and livedo reticularis was improved. DAA therapy can be an effective therapeutic option for extrahepatic complications associated with HCV infection.

Sickle cell crisis presenting as livedo racemosa

Sickle cell disease is a monogenic hemoglobinopathy that results in the abnormal production of hemoglobin S, which yields the characteristic sickle-shaped red blood cells. Sickle cell vaso-occlusive crisis is a painful complication of sickle cell disease caused by red blood cell entrapment within the microcirculation. The resulting tissue ischemia triggers a secondary inflammatory process involved in the pathogenesis of varying inflammatory skin conditions. Chronic leg ulcers are the most common skin presentation in sickle cell disease. A 58-year-old woman with sickle cell disease presented with systemic edematous plaques with the most notable involvement of her bilateral legs, which exhibited reticulated purpuric patches with central pallor. We report a case highlighting an unusual presentation of livedo racemosa as the presenting sign in a patient with sickle cell disease in vaso-occlusive crisis.

The simultaneous occurrence of livedoid vasculopathy and lymphocytic thrombophilic arteritis in six cases

Lymphocytic thrombophilic arteritis and livedoid vasculopathy may both present with livedo racemosa and ulceration. We present 6 cases with features of both conditions, raising the possibility that they are either closely linked or are part of a spectrum of the same condition.

Multifaceted approach to a rare clinical case of calciphylaxis in a renal transplant recipient

Calcific uremic arteriolopathy (CUA) is a highly morbid condition usually found in ESRD patients that has rarely been reported after renal transplantation and renal function restoration. Furthermore, little is known about the optimal management of CUA in this setting. Herein, we report on the clinical case of AB, a 70-year-old woman who developed CUA after renal transplantation and renal function restoration. However, other risk factors for CUA such as diabetes and warfarin treatment, due to mechanical aortic valve implantation, were present. Thirty-eight months after renal transplantation she developed erythema and livedo reticularis in both legs and a gradually enlarging skin ulcer in the right leg. A skin biopsy of the ulcer showed features compatible with the CUA, such as sub-intimal calcification and luminal obstruction of the small dermal arterioles, tissue ischemia and signs of adipocytes degeneration. A multidisciplinary approach was adopted, including medical and non-medical treatments such as surgical debridement and vacuum-assisted closure therapy. Medical treatments included a five weeks course of once a week intravenous infusion of pamidronate and intravenous sodium thiosulfate (STS) at increasing doses. Four months after beginning the therapy with STS, a complete healing of the ulcer on the right leg and the disappearance of the livedo reticularis on the left leg was noted. In conclusion, although rare CUA may develop also in renal transplanted patients, a timely and combined therapeutic approach is essential for its resolutive treatment. Sodium thiosulfate therapy has proven to be effective and tolerated.

Sneddon Syndrome: A Comprehensive Overview

Sneddon syndrome (SS) is an episodic or chronic, slowly progressive disorder and characterized by generalized livedo racemosa (patchy, violaceous, skin discoloration) and recurrent cerebrovascular events. The histopathology of skin and brain is remarkable for a noninflammatory thrombotic vasculopathy involving medium- and small-sized dermal and cerebral arteries, respectively. Approximately 80% of the SS patients are women with a median age of diagnosis at 40 years. However, the onset of the disease during childhood have been reported. Etiopathogenesis of SS is unknown with 2 primary mechanisms proposed - autoimmune/inflammatory versus thrombophilia. SS is primarily classified as antiphospholipid positive or negative type. Neurological manifestations usually occur in 3 phases: (1) prodromal symptoms such as headaches, dizziness, and vertigo, (2) recurrent strokes, and (3) early onset dementia. Livedo racemosa precedes the onset of recurrent strokes by more than 10 years, but in many instances, the significance of the skin lesion is recognized only after the appearance of the stroke. The involvement of the heart valves, systolic labile hypertension, and retinal changes are also commonly associated with this syndrome. Treatment of SS is primarily based on anecdotal reports. Antiplatelet and antithrombotic agents are used for secondary stroke prophylaxis, and a recent study showed a relatively lower stroke recurrence rate with the universal use of antiplatelet/antithrombotic agents. Routine use of anti-inflammatory or immunosuppressive therapies is controversial. Neuropsychiatric prognosis of SS is relatively poor with predominant deficits in the concentration, attention, visual perception, and visuospatial skills.

Oxalosis in a Patient with Livedo Reticularis

A 27-year-old man with terminal renal failure requiring peritoneal dialysis for the past 2 years was referred to the dermatologist for evaluation of red violaceous macular skin lesions consistent with livedo reticularis. These lesions had appeared suddenly on his legs (Figure 1). He had first experienced recurrent nephrolithiasis at the age of 14. Results from urine analysis and abdominal ultrasound revealed chronic kidney failure. Because the patient had a sister with similar findings, primary hyperoxaluria (PH) was suspected and genetic testing was performed in all members of his family. The results confirmed PH type 1 (PH1) in both our patient and his sister, who had died 8 years after the establishment of the diagnosis. A biopsy of the livedo reticularis lesions revealed deposits of a yellowish brown crystalline material within the lumen and the media of medium vessels in the hypodermis associated with a histiocytic giant cell reaction (Figure 2a). There was no evidence of extravascular calcium deposition in the sections examined. The deposits were intensely birefringent under polarized light, and classic speculated crystals of oxalate salts were observed (Figure 2b). No focal epidermal or superficial dermal necrosis was seen. On the basis of the histopathologic findings, the diagnosis of oxalate crystal-induced vascular disease was established. The patient subsequently developed complications including pancreatitis and peritonitis. He underwent hemodialysis until a combined liver-kidney transplant could be performed.

Idiopathic livedo racemosa presenting with splenomegaly and diffuse lymphadenopathy

Sneddon syndrome (SS) is a rare condition and the diagnosis is made only when other more common disease entities have been excluded. Common manifestations in SS patients include hypertension, coronary artery disease, venous thrombosis, miscarriages, psychiatric disturbances, and arterial and venous thrombotic events. Most patients present in their early 30s with classic neurovascular and dermatologic signs. Currently, the main criteria for the diagnosis of SS include livedo racemosa, focal neurological deficits or evidence of stroke on magnetic resonance imaging, or characteristic vascular alterations seen on biopsy. We present the case of a 37-year-old woman with extensive livedo racemosa, chronic migraine headaches, splenomegaly, and lymphadenopathy. Cutaneous biopsies demonstrated a superficial perivascular lymphocytic infiltrate without the subendothelial proliferative changes or fibrosis seen in some patients with SS. The patient's medical history suggested idiopathic livedo racemosa with possible full progression to SS. This case highlights the variability in the clinical presentation of SS and that the disease often can be diagnosed before neurovascular events. Earlier diagnosis can lead to prevention of chronic occlusive neurovascular manifestations and irreversible damage such as myocardial infarction and stroke. Familiarity with the highly variable early course of SS can aid in diagnosis and reduction of morbidity and mortality that is associated with this disease.

Cutis marmorata and cerebral arterial gas embolism

Dr Kemper and colleagues reported that, when air was injected into the cerebral circulation of pigs, they developed a rash that looked very similar to cutis marmorata of cutaneous decompression illness (DCI) and to livido reticularis. They postulated that cutaneous DCI in divers may be centrally mediated as a result of cerebral gas embolism. It would be helpful if Kemper et al. described the distribution of the rash in their pigs. In divers, cutaneous DCI is generally confined to parts of the body with significant amounts of subcutaneous fat, such as the trunk and thighs, and the rash often crosses the midline. Colleagues and I have reported that cutaneous DCI is commonly associated with significant right-to-left shunts and particularly persistent foramen ovale (PFO). We postulated that the manifestations of shunt-related DCI, whether neurological or cutaneous, are in large part determined by peripheral amplification of embolic bubbles in those tissues that are most supersaturated with dissolved nitrogen (or other inert gas) at the time that emboli arrive. Hence we postulated that cutaneous DCI is the result of amplification of gas emboli that invade cutaneous capillaries. Dr Kemper has kindly sent me a number of the publications from his department on which their report of this skin rash in pigs is based. The aim of their experiments was to produce significant brain injury by means of cerebral air embolism. Their pigs had no tissues supersaturated with inert gas. They were ventilated with a FiO₂ of 0.4 and anaesthetised with ketamine and midazolam. They were also given pancuronium and atropine, before air was injected into their cerebral circulation. If their findings in pigs and the resulting hypothesis were applicable to man, it would mean that one could get cutaneous DCI without decompression: one would only need cerebral gas embolism. During contrast echocardiography, I have produced arterial gas embolism in many hundreds of patients with right-to-left shunts and it is certain that some bubbles went into their cerebral circulations, but I have never seen and no patient has reported getting a rash. Nor am I aware of any reports of gas embolism causing a rash like cutaneous DCI without there being tissue supersaturation following some form of decompression. Kemper and colleagues injected between 0.25 and 1 ml·kg⁻¹ body weight of air into the ascending pharyngeal artery (roughly equivalent to human internal carotid artery) of pigs weighing 30-40kg. That immediately produced significant elevation of blood pressure and heart rate suggesting a 'sympathetic surge'. This is similar to the haemodynamic effects that can occur with subarachnoid haemorrhage and some other catastrophic brain injuries. That effect may have been potentiated by pre-treatment with atropine. There was also a considerable increase in intracranial pressure and major adverse effects on cerebral metabolism. Some pigs died quickly and the survivors were killed at the end of the experiment. I suspect that no pig would have survived the experiments without major neurological injury if they had not been killed. Most people with cutaneous DCI have no detectable neurological manifestations at the time that they have a rash. In those that do have neurological manifestations, it is rarely catastrophic. The increases in heart rate and blood pressure reported in the pigs are similar to the effects of a phaeochromocytoma, which can cause livido reticularis in man. Therefore, I wonder whether an alternative explanation for these observations might be that the cerebral injury in the pigs was so massive that the sympathetic surge was comparable to the effects of catecholamine release from a phaeochromocytoma and caused a rash similar to that seen in patients with a phaeochromocytoma.

The Dermatological Manifestations of Postural Tachycardia Syndrome: A Review with Illustrated Cases

Postural tachycardia syndrome (POTS) is a syndrome of excessive tachycardia with orthostatic challenge, and relief of such symptoms with recumbence. There are several proposed subtypes of the syndrome, each with unique pathophysiology. Numerous symptoms such as excessive tachycardia, lightheadedness, blurry vision, weakness, fatigue, palpitations, chest pain, and tremulousness are associated with orthostatic intolerance. Other co-morbid conditions associated with POTS are not clearly attributable to orthostatic intolerance. These include chronic headache, fibromyalgia, functional gastrointestinal or bladder disorders, cognitive impairment, and sleep disturbances. Dermatological manifestations of POTS are also common and wide ranging, from livedo reticularis to Raynaud's phenomenon, from cutaneous flushing to erythromelalgia. Here, we provide three illustrative cases of POTS with dermatological manifestations. We discuss the potential pathophysiology underlying such dermatological manifestations, and how such mechanisms could in turn help guide development of management.

Cutis marmorata in decompression illness may be cerebrally mediated: a novel hypothesis on the aetiology of cutis marmorata

INTRODUCTION

Cutaneous decompression sickness (DCS) is often considered to be a mild entity that may be explained by either vascular occlusion of skin vessels by bubbles entering the arterial circulation through a right-to-left shunt or bubble formation due to saturated subcutaneous tissue during decompression. We propose an alternative hypothesis.

METHODS

The case is presented of a 30-year-old female diver with skin DCS on three separate occasions following relatively low decompression stress dives. Also presented are the findings of cutaneous appearances in previously reported studies on cerebral arterial air embolism in pigs.

RESULTS

There was a close similarity in appearance between the skin lesions in this woman (and in other divers) and those in the pigs, suggesting a common pathway.

CONCLUSIONS

From this, we hypothesize that the cutaneous lesions are cerebrally mediated. Therefore, cutaneous DCS might be a more serious event that should be treated accordingly. This hypothesis may be supported by the fact that cutis marmorata is also found in other fields of medicine in a non-diving context, where the rash is referred to as livedo reticularis or livedo racemosa. These are associated with a wide number of conditions but of particular interest is Sneddon's syndrome, which describes the association of livedo racemosa with cerebrovascular events or vascular brain abnormalities. Finally, there is a need for further research on the immunocytochemical pathway of cutaneous DCS.

Livedo reticularis heralding hypercalcaemia of malignancy

The term livedo reticularis is used to describe net-like purple rash usually on the lower limbs. It is an important clinical sign with diverse aetiologies. Hypercalcaemia is an uncommon but important clinical entity, sometimes associated with livedo reticularis. Generally, hypercalcaemia of renal failure and secondary hyperparathyroidism has been reported with this condition. We report a case of livedo reticularis heralding onset of hypercalcaemia of malignancy.

A case of nonepisodic angioedema with eosinophilia associated with livedo reticularis and erythema before onset of edema of the legs

The cause of angioedema with eosinophilia (AE) is unknown. Patients with AE sometimes develop pruritic eruptions or urticaria before the onset of edema. We report a case of a 37-year-old woman with nonepisodic AE who presented with erythema and livedo reticularis before the onset of edema. The patient noticed erythema on both heels as well as livedo reticularis on her right great toe 1 month prior to presentation. A biopsy specimen from the heel revealed numerous eosinophils with degranulation infiltrating the subcutaneous tissue. One month later, she developed edema on the legs. Histopathologic findings of biopsy specimens obtained from the legs revealed edema and eosinophils in the subcutaneous tissue. Some patients with AE present with pruritic eruptions prior to the onset of edema. The diagnosis of AE in our patient with leg edema of unknown cause was considered prior to the appearance of any pruritic eruptions.

Use of corticosteroids in the treatment of cholesterol crystal embolism after cardiac catheterization: a report of four Japanese cases

Cholesterol crystal embolism (CCE) is a serious complication associated with invasive vascular procedures. The prognosis of the renal involvement type of CCE is very poor, and there is currently no established treatment, other than supportive therapy. We herein report four cases of CCE with severe atherosclerosis wherein the renal function progressively deteriorated after cardiac catheterization. In three of the four patients, low-dose corticosteroids (0.3 mg/kg/day) improved the renal function, whereas the fourth patient died from CCE of the digestive system. This report reviews the literature on CCE and discusses possible therapeutic options.

[Livedo reticular: classification, causes and differential diagnoses]

Livedo reticularis (LR) is a common finding and results from a physiological vasospastic response to cold or systemic disease, characterized by a pattern of cyanotic discoloration, or erythematous-cyanotic aspect. LR can be congenital or acquired. Among the acquired LR stand out from the physiological or cutis marmorata, the idiopathic, the induced vasospastic, those due to intravascular diseases or even in the wall of the vessels. This article reviews several clinical features, differential diagnosis and various causes of livedo.

[Livedoid vasculitis in a patient with antiphospholipid syndrome]

The authors present a clinical case of a 30 year old male patient admitted to the hospital for recurrent cyanosis and feet pain lasting for one year. In addition he presented bilateral purpuric lesions in the lateral maleolar region, one of which with ulceration. The finding of anticardiolipin antibodies associated with intraluminal thrombosis in the dermal vessels, allowed to conclude for Antiphospholipid syndrome. The cutaneous changes identified are named livedoid vasculitis.

[Cholesterol crystal embolism and renal insufficiency: case report and literature review]

Cholesterol crystal embolism with renal impairment is increasingly recognised as an iatrogenic complication of invasive vascular procedures. We present a 58-year-old patient in whom the presence of a classic triad of precipitating event (coronary angiography), subacute presentation of renal failure and cutaneous lesions (livedo reticularis and Blue Toe syndrome) suggested this entity. The confirmatory diagnosis was made by means of renal biopsy which revealed cholesterol crystals lodged in arteries. In our patient severe renal insufficiency requiering hemodialysis ensued. Glucocorticoid and statin therapy failed to recover the renal function. The patient died from acute myocardial infarction. Invasive cardiac procedures are increasing in number especially in the elderly population so higher incidence of cholesterol crystal embolism coud be expected in the future. Increased awareness of this syndrome is necessary for early recognition, which is crucial for treatment, and defining the high-risk patient in whom other modalities of coronary diagnostics coud be considered.

[Diagnosis and treatment of livedo reticularis on the legs]

The term livedo reticularis refers to a reddish-violet reticular discoloration of the skin that mainly affects the limbs. It is caused by an interruption of blood flow in the dermal arteries, either due to spasm, inflammation, or vascular obstruction, and is associated with diseases of varying etiology and severity. To establish the cause of livedo reticularis, it is essential to determine its course (chronic, acute, or fulminant), the presence of other cutaneous signs such as nodules, retiform purpura or necrosis, and the possible association of general symptoms or laboratory findings that suggest a particular systemic process. The aim of this review is to describe the diagnosis and treatment of the disease.

Microembolization from an abdominal aortic aneurysm after thoracic aortic replacement

A 66-year-old man with thoracic and abdominal aortic aneurysm suffered from microembolism in the lower extremities after total arch replacement. He presented with livedo reticularis with palpable peripheral pulses, and the serum creatinine kinase level elevated up to 7,695. The abdominal aortic aneurysm, but not the thoracic aorta, was the origin of this complication. The morphological change of thrombus in the abdominal aorta detected by ultrasonography was the key to the diagnosis. Graft replacement of the abdominal aorta finally resolved his problem.

Nasal septal perforation and antiphospholipid syndrome (Hughes syndrome)

We present the case of a 19-year-old woman who developed a nasal septal perforation and atrophic rhinitis following septal surgery. During the subsequent five years, she also experienced intermittent episodes of swelling and ischaemia of the left foot, as well as livedo reticularis. Ultimately, haematological investigations revealed the presence of lupus anticoagulant and elevated antiphospholipid immunoglobulin M levels. A diagnosis of antiphospholipid syndrome (Hughes syndrome) was made.A search of the literature revealed that nasal septal perforation has been described in up to 0.8 per cent of patients with antiphospholipid syndrome. However, it is undescribed in the otorhinolaryngological literature. The impact of this syndrome on otorhinolaryngology practice is examined.

Buerger's disease manifesting nodular erythema with livedo reticularis

We report a patient with Buerger's disease (BD) who showed painful nodular erythema with livedo reticularis as an initial symptom. The patient developed this cutaneous manifestation in both lower extremities, and a skin biopsy demonstrated perivascular infiltration of mononuclear cells in the border zone between the dermis and subcutaneous tissue. Both nodular erythema and livedo reticularis were successfully treated with oral prednisolone, but both feet developed necrosis with ulcerations and had to be amputated 1.5 years later because of acute gangrene. Histopathology of the amputated tissue showed acute inflammation and multiple thrombi with recanalization in the posterior tibial arteries, leading to a diagnosis of BD. This disease should be considered as a possible diagnosis in refractory patients with nodular erythema and livedo reticularis, particularly when ulcerations and necrosis rapidly worsen.