Spontaneous Superior Ophthalmic Vein Thrombosis in a Transgender Man with Systemic Lupus Erythematosus

Risk Factors for Antiphospholipid Antibodies and Antiphospholipid Syndrome

Persistence of serum antiphospholipid antibodies (aPL) is associated with a high thrombotic risk, both arterial and venous, and with pregnancy complications. Due to the potential morbidity and mortality associated with the presence of aPL, identifying and recognizing risk factors for the development of aPL and thrombosis in aPL carriers may help to prevent and reduce the burden of disease. Multiple elements are involved in the pathomechanism of aPL development and aPL-related thrombosis such as genetics, malignancy, and infections. This review will address the role of both well-known risk factors and their evolution, and of emerging risk factors, including COVID-19, in the development of aPL and thrombosis in aPL carriers.

Ophthalmic Vein Thrombosis Associated with Factor V Leiden and MTHFR Mutations

Superior ophthalmic vein thrombosis (SOVT) is a rare clinical entity that may be associated with hypercoagulability status. We present a case of a 77-year-old woman who presented to the emergency department complaining of eye ptosis, chemosis and conjunctival congestion in the right eye (RE). The ophthalmological examination revealed best-corrected visual acuity (BCVA) was 0.5 for the right eye (RE) 0.5 and 0.06 for the left eye (LE). Intraocular pressure (IOP) was 25 mmHg in RE and 14 mmHg in LE. Non-contrast computed tomography (CT) of the brain and orbits revealed a hyperreflectivity at the level of the right ophthalmic vein and inferior rectus muscle hypertrophy. An extensive hypercoagulable panel was completed and we found a positive result for Factor V Leiden (heterozygous mutation) and methyl-enetetrahydrofolate reductase (MTHFR-C677T homozygous mutations). Systemic steroidal anti-inflammatory and anticoagulant treatments were started immediately. Gradual resolution of symptoms was noted during the hospitalization, and BCVA in her RE was established at 0.7 at the 10-week follow-up.

Challenges of caring for transgender and gender diverse patients with rheumatic disease: presentation of seven patients and review of the literature

PURPOSE OF REVIEW

As perspectives on sex and gender identity have evolved, there has been an increase in the practice of transgender medicine. Within rheumatology, however, there is a dearth of information about rheumatic disease in transgender and gender diverse (TGGD) individuals. This is important, as sex hormones affect the etiopathogenesis and expression of autoimmune diseases. We therefore sought to identify TGGD patients with rheumatic disease, review their clinical courses, and appraise existing literature about this population.

RECENT FINDINGS

Of 1053 patients seen at the Los Angeles County and University of Southern California Medical Center from 2019 through 2021, five transgender men and two transgender women with rheumatic disease were identified. Most patients' disease courses were not overtly impacted by gender affirming hormone therapy (GAHT). Six of seven patients had psychosocial barriers to care. Our systematic review found 11 studies with 11 transgender women and two transgender men. In 12 of 13 patients, GAHT possibly modulated the patients' rheumatic disease.

SUMMARY

Our observations suggest GAHT need not be a strict contraindication in TGGD patients with rheumatic disease. TGGD patients often face significant psychosocial barriers. Additional information about this population and empathy toward their health disparities are needed.

Inmune-mediated inflammatory rheumatic diseases in transgender people: A scoping review

BACKGROUND

In immune-mediated inflammatory rheumatic diseases (IMIRD), there are differences between cis-men and cis-women in epidemiology, clinical feature, therapeutic approach, treatment response, and prognosis. In transgender individuals, information concerning IMIRD is not substantial. The assessment of information concerning rheumatic diseases in transgenders is crucial because transgenders may undergo treatments with potential impacts on IMIRD. We aim to collect and discuss current knowledge on IMIRD in transgender individuals, determine the coverage of the literature, identify the knowledge gaps, and highlight opportunities for future research.

METHODS

We did a scoping review of publications collected through a systematic search of transgender patients with any IMIRD. Data sources were Medline, Embase, and Web of Knowledge. Synthesis of results and qualitative review of data information was collected in tables. A semi-quantification of the quality of the articles reporting clinical studies was performed.

RESULTS

There were 11 transwoman, and 3 transmen cases of systemic lupus erythematosus (5 cases), skin lupus erythematosus (2), systemic sclerosis (4), anti-synthetase syndrome (1), rheumatoid arthritis (1) and ankylosing spondylitis (1). Eleven were de novo cases and three had prior history of IMIRD and developed a comorbidity after starting hormone replacement therapy. The clinical expression of the disease was variable. Two transwomen and one transman developed thrombotic events. The lupus skin lesions in one transman improved following testosterone treatment. No clinical studies were identified. Quality of publications was disparate.

CONCLUSION

Although the number of cases is small, most cases of IMIRD occur in transwomen. The absence of solid data warrants caution in establishing recommendations regarding hormone replacement therapy in transgenders with IMIRD. There is an essential need for the consideration of cisgender and transgender particularities in future research on IMIRD.

Bilateral superior ophthalmic vein thrombosis associated with high altitude

We report a case of a 47-year-old female who experienced periorbital swelling while descending from a Himalayan mountain climb and was found to have bilateral superior ophthalmic vein thromboses (SOVT). Infectious, autoimmune, and hypercoagulability work-up were negative with no cavernous sinus involvement. Symptoms resolved upon initiation of anticoagulation and oral steroids. SOVT is a rare but serious condition and has a risk of extending into the cavernous sinus if not treated early. Although infection is the most common etiology, venous thrombosis can be precipitated under high altitude and low oxygen pressure environments. We present a case of superior ophthalmic vein thrombosis associated with high-altitude conditions.

Superior ophthalmic vein thrombosis: What radiologist and clinician must know?

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Incidental SOVT: good prognosis, self-limited and treated by anticoagulation.

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Post-traumatic and surgical SOVT: good prognosis, treated by anticoagulation.

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Septic SOVT: secondary to infections, high risk, requires specific interventions.

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Aseptic SOVT: secondary to inflammatory diseases, need to treat underlying etiology.

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CT and MRI are vital to the correct diagnosis and management of patients with SOVT.

Purpose

Superior ophthalmic vein thrombosis (SOVT) is an extremely rare condition. Few studies have been published about clinical aspects of this condition. In this study, we have studied the symptoms, underlying etiologies, treatment, pathogenesis and complication of the SOVT and we tried to classify it based on the etiology, treatment, and prognosis.

Methods

We reviewed the patients’ data from a tertiary academic referral center. Each patient with SOVT was then reviewed for symptoms associated with SOVT, underlying etiology, treatment protocol, treatment response, complications, possible pathogens, and final outcome.

Results

Twenty-four cases of SOVT were included in this study. Overall, 13 cases were diagnosed as right-sided SOVT, out of which, eight had simultaneous right-sided cavernous sinus thrombosis (CST). Eighteen cases were diagnosed to have left-sided SOVT, out of which, 11 had simultaneous left-sided CST.

Conclusions

The SOVT can be secondary to different mechanisms. The SOVT secondary to trauma, recent surgery and coagulopathy are mostly non-aggressive, and can be managed by conservative therapy and anticoagulation. The SOVT in patients with orbital cellulitis, history of active sinusitis or paranasal sinus surgery are aggressive presenting with acute orbital swelling, abscess and visual loss. This type of SOVT can be complicated by extension to the cavernous sinus and intracranial structures. These patients require urgent antibiotics therapy and sinus surgery. The most severe type of SOVT is caused by mucormycosis which may also extend intracranially resulting in stroke and is often life-threatening.