Livedo Reticularis in Systemic Lupus Erythematosus

Antiphospholipid syndrome: the need for new international classification criteria

Introduction: As soon as the association of lupus anticoagulant (LAC) and anticardiolipin antibodies (aCL) with thrombosis and miscarriages was described in the 1980s, the definition of the antiphospholipid syndrome (APS) became a need. Early descriptions of the disease by members of the Graham Hughes team included broad categories and unexplained laboratory inclusions. Over time, new clinical and experimental data refined the criteria, especially the obstetric manifestations, as well as the laboratory criteria.Areas covered: The authors performed a review of the literature using the PubMed database, and the following keywords were used: 'antiphospholipid antibody', 'antiphospholipid syndrome', and 'criteria of antiphospholipid'. The history of antiphospholipid criteria, clinical and experimental advancements, and other expert opinions were included in this paper.Expert opinion: It has been 14 years since an international congress on antiphospholipid antibodies has generated new classification based on the recent extensive research performed in the field. Currently, there is a need to update the international APS classification taking into consideration the inclusion of new clinical criteria such as aPL-related nephropathy as well as new standardized antibody specificities (e.g., anti-phosphatidylserine/prothrombin antibodies) with the adoption of a standardized scoring system that can stratify APS patients.

The skin and hypercoagulable states

Hypercoagulable states (HS) are inherited or acquired conditions that predispose an individual to venous and/or arterial thrombosis. The dermatologist can play a vital role in diagnosing a patient's HS by recognizing the associated cutaneous manifestations, such as purpura, purpura fulminans, livedo reticularis, livedo vasculopathy (atrophie blanche), anetoderma, chronic venous ulcers, and superficial venous thrombosis. The cutaneous manifestations of HS are generally nonspecific, but identification of an abnormal finding can warrant a further workup for an underlying thrombophilic disorder. This review will focus on the basic science of hemostasis, the evaluation of HS, the skin manifestations associated with hypercoagulability, and the use of antiplatelet and anticoagulant therapy in dermatology.

Post-partum pituitary insufficiency and livedo reticularis presenting a diagnostic challenge in a resource limited setting in Tanzania: a case report, clinical discussion and brief review of existing literature

BACKGROUND

Pituitary disorders following pregnancy are an important yet under reported clinical entity in the developing world. Conversely, post partum panhypopituitarism has a more devastating impact on women in such settings due to high fertility rates, poor obstetric care and scarcity of diagnostic and therapeutic resources available.

CASE PRESENTATION

A 37 year old African female presented ten years post partum with features of multiple endocrine deficiencies including hypothyroidism, hypoadrenalism, lactation failure and secondary amenorrhea. In addition she had clinical features of an underlying autoimmune condition. These included a history of post-partum thyroiditis, alopecia areata, livedo reticularis and deranged coagulation indices. A remarkable clinical response followed appropriate hormone replacement therapy including steroids. This constellation has never been reported before; we therefore present an interesting clinical discussion including a brief review of existing literature.

CONCLUSION

Post partum pituitary insufficiency is an under-reported condition of immense clinical importance especially in the developing world. A high clinical index of suspicion is vital to ensure an early and correct diagnosis which will have a direct bearing on management and patient outcome.

Antiphospholipid antibodies

OBJECTIVE

To review the role of lupus anticoagulants in the pathogenesis of both venous and arterial thromboembolic events, as well as in recurrent spontaneous abortions. The pathophysiology of lupus anticoagulants and associated antiphospholipid antibodies (eg, anticardiolipin antibodies) is also discussed.

DATA SOURCES

Review of the recent medical literature.

DATA EXTRACTION AND SYNTHESIS

Key articles in the recent medical literature dealing with lupus anticoagulants and their role in pathogenesis of thromboembolic events were reviewed. Plasma proteins that have an affinity for binding to "perturbed cellular membranes" have been identified as the antigenic targets for antiphospholipid antibodies. Thus, the concept of antiphospholipid antibodies needs to be reevaluated. Perhaps a better term is antiprotein-phospholipid antibodies. The principal antigenic protein targets are beta(2)-glycoprotein I, prothrombin, and a wide range of additional proteins that interact with activated cellular membranes, including protein C, protein S, annexin V, etc. Most research reported in the literature has focused on beta(2)-glycoprotein I and human prothrombin.

Type 1 diabetes mellitus associated with livedo reticularis: case report and review of the literature

Livedo reticularis (LR) has been associated with numerous systemic diseases. Its relationship to diabetes mellitus (DM), however, has been poorly characterized. We report a case of LR in a 17-year-old with type 1 DM.

The spectrum of livedo reticularis and anticardiolipin antibodies

We document a study of 65 patients presenting to our clinics, over a 2-year period, with livedo reticularis. All patients were screened for the presence of anti-cardiolipin antibodies and assessed for the presence of central nervous system disease and features of the 'antiphospholipid' syndrome, including venous and arterial thromboses and foetal loss. Patients were also assessed for other clinical features such as Raynaud's phenomenon and valvular lesions. Twenty-eight anti-cardiolipin positive patients were compared with 37 anti-cardiolipin negative patients. There was a statistically significant difference in the incidence of cerebrovascular disease (including strokes and transient ischaemic attacks) thrombocytopenia, valvular heart lesions and foetal loss in the anti-cardiolipin positive patients as compared with the anticardiolipin negative groups.

Recurrent stroke and multi-infarct dementia in systemic lupus erythematosus: association with antiphospholipid antibodies

Four patients with recurrent stroke and multi-infarct dementia are presented in whom the dementia was progressive and severe. Three of the patients developed the dementia during the course of an illness which was punctuated by repeated episodes of cerebral infarction demonstrated by computed tomographic (CT) scans. The fourth patient presented with an illness dominated by progressive and deteriorating higher mental functions, which culminated in a major stroke 18 months later. Three patients fulfilled the American Rheumatism Association (ARA) criteria for the classification of systemic lupus erythematosus, the fourth had a 'lupus-like' disease. All had livedo reticularis, severe migraines, and also demonstrated antibodies to phospholipids. All four patients suffered deep vein thromboses.