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Hoy CK, NaveenKumar SK, Navaz SA, Sugur K, Yalavarthi S, Sarosh C, Smith T, Kmetova K, Chong E, Peters NF, Rysenga CE, Norman GL, Figueroa-Parra G, Nelson D, Girard J, Ahmed AZ, Schaefer JK, Gudjonsson JE, Kahlenberg JM, Madison JA, Knight JS, Crowson CS, Duarte-García A, Zuo Y. Calprotectin Impairs Platelet Survival in Patients With Primary Antiphospholipid Syndrome. Arthritis Rheumatol 2024; 76:928-935. [PMID: 38225923 PMCID: PMC11136595 DOI: 10.1002/art.42801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/29/2023] [Accepted: 01/12/2024] [Indexed: 01/17/2024]
Abstract
OBJECTIVE While thrombosis and pregnancy loss are the best-known clinical features of antiphospholipid syndrome (APS), many patients also exhibit "extra-criteria" manifestations, such as thrombocytopenia. The mechanisms that drive APS thrombocytopenia are not completely understood, and no clinical biomarkers are available for predicting antiphospholipid antibody (aPL)-mediated thrombocytopenia. Calprotectin is a heterodimer of S100A8 and S100A9 that is abundant in the neutrophil cytoplasm and released upon proinflammatory neutrophil activation. Here, we sought to evaluate the presence, clinical associations, and potential mechanistic roles of circulating calprotectin in a cohort of primary APS and aPL-positive patients. METHODS Levels of circulating calprotectin were determined in plasma by the QUANTA Flash chemiluminescent assay. A viability dye-based platelet assay was used to assess the potential impact of calprotectin on aPL-mediated thrombocytopenia. RESULTS Circulating calprotectin was measured in 112 patients with primary APS and 30 aPL-positive (without APS criteria manifestations or lupus) patients as compared to patients with lupus (without APS), patients with unprovoked venous thrombosis (without aPL), and healthy controls. Levels of calprotectin were higher in patients with primary APS and aPL-positive patients compared to healthy controls. After adjustment for age and sex, calprotectin level correlated positively with absolute neutrophil count (r = 0.41, P < 0.001), positively with C-reactive protein level (r = 0.34, P = 0.002), and negatively with platelet count (r = -0.24, P = 0.004). Mechanistically, we found that calprotectin provoked aPL-mediated thrombocytopenia by engaging platelet surface toll-like receptor 4 and activating the NLRP3-inflammasome, thereby reducing platelet viability in a caspase-1-dependent manner. CONCLUSION These data suggest that calprotectin has the potential to be a functional biomarker and a new therapeutic target for APS thrombocytopenia.
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Affiliation(s)
- Claire K. Hoy
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Sherwin A. Navaz
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kavya Sugur
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Srilakshmi Yalavarthi
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Cyrus Sarosh
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tristin Smith
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Katarina Kmetova
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Emily Chong
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Noah F. Peters
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Christine E. Rysenga
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Gary L. Norman
- Headquarters & Technology Center Autoimmunity, Werfen, San Diego, CA, USA
| | - Gabriel Figueroa-Parra
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dava Nelson
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer Girard
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Asra Z. Ahmed
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jordan K. Schaefer
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - J. Michelle Kahlenberg
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jacqueline A. Madison
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Cynthia S. Crowson
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Alí Duarte-García
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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2
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Raschi E, Borghi MO, Tedesco F, Meroni PL. Antiphospholipid syndrome pathogenesis in 2023: an update of new mechanisms or just a reconsideration of the old ones? Rheumatology (Oxford) 2024; 63:SI4-SI13. [PMID: 38320591 DOI: 10.1093/rheumatology/kead603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/27/2023] [Indexed: 02/08/2024] Open
Abstract
Antibodies against phospholipid (aPL)-binding proteins, in particular, beta 2 glycoprotein I (β2GPI), are diagnostic/classification and pathogenic antibodies in antiphospholipid syndrome (APS). β2GPI-aPL recognize their target on endothelium and trigger a pro-thrombotic phenotype which is amplified by circulating monocytes, platelets and neutrophils. Complement activation is required as supported by the lack of aPL-mediated effects in animal models when the complement cascade is blocked. The final result is a localized clot. A strong generalized inflammatory response is associated with catastrophic APS, the clinical variant characterized by systemic thrombotic microangiopathy. A two-hit hypothesis was suggested to explain why persistent aPL are associated with acute events only when a second hit allows antibody/complement binding by modulating β2GPI tissue presentation. β2GPI/β2GPI-aPL are also responsible for obstetric APS, being the molecule physiologically present in placental/decidual tissues. Additional mechanisms mediated by aPL with different characteristics have been reported, but their diagnostic/prognostic value is still a matter of research.
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Affiliation(s)
- Elena Raschi
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Maria Orietta Borghi
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Francesco Tedesco
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, Milan, Italy
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3
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Wei LK, Sule AA. Challenges in Treating Extensive Deep Vein Thrombosis with Severe Thrombocytopenia in Patients with Antiphospholipid Syndrome-A Follow-up of 2 Years. Int J Angiol 2024; 33:66-69. [PMID: 38352633 PMCID: PMC10861292 DOI: 10.1055/s-0039-1693996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Thrombocytopenia is one of the most common manifestations of antiphospholipid syndrome (APS). There is little evidence or definitive guidelines regarding the treatment of APS with thrombocytopenia. We describe a patient with APS and moderate-to-severe thrombocytopenia and the challenges of balancing anticoagulation with thrombocytopenia. A 19-year-old male patient presented with right lower limb swelling to the emergency department with a history of gradually worsening right leg swelling for 1 week and was diagnosed with right leg proximal deep vein thrombosis. Ultrasound Doppler of the right lower limb revealed complete venous thrombosis from the level of the popliteal vein to the distal superficial femoral vein. Subsequently, he was found to have triple-positive APS and moderate-to-severe immune thrombocytopenia, with a platelet count nadir of 31 × 10 to the ninth power/L. He was started on anticoagulation with warfarin. The severe thrombocytopenia was not treated with immunosuppressants and the platelets fluctuated in the range of moderate-to-severe thrombocytopenia but did not develop any rethrombotic or bleeding events. His platelets varied from 31 × 10 to the ninth power/L to 106 × 10 to the ninth power/L. This case report demonstrates that it may be safe to hold off treatment for thrombocytopenia in APS, even in cases of severe thrombocytopenia. Treatment with immunosuppressants may be instituted only when platelet levels fall below 20 × 10 to the ninth power/L or when there is clinically significant bleeding, as in primary immune thrombocytopenia.
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Affiliation(s)
- Lee Kai Wei
- Student Assistantship Programme, Lee Kong Chian School of Medicine, Singapore
| | - Ashish Anil Sule
- Department of General Medicine, Subspecialty of Vascular Medicine and Hypertension, Tan Tock Seng Hospital, Singapore
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Aguirre Del-Pino R, Monahan RC, Huizinga TWJ, Eikenboom J, Steup-Beekman GM. Risk Factors for Antiphospholipid Antibodies and Antiphospholipid Syndrome. Semin Thromb Hemost 2024. [PMID: 38228166 DOI: 10.1055/s-0043-1776910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
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.
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Affiliation(s)
- Rodrigo Aguirre Del-Pino
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Division of Rheumatology, A Coruña University Hospital (CHUAC), Galicia, Spain
| | - Rory C Monahan
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Jeroen Eikenboom
- Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gerda M Steup-Beekman
- Department of Rheumatology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Department of Rheumatology, Haaglanden Medical Center, The Hague, The Netherlands
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5
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Zuily S, Cervera R, Foret T, Bertocchi S, Tincani A. Thrombocytopenia in antiphospholipid syndrome: Is anticoagulation and/or antiaggregation always required? Autoimmun Rev 2024; 23:103417. [PMID: 37619905 DOI: 10.1016/j.autrev.2023.103417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023]
Abstract
The antiphospholipid syndrome (APS) is an autoimmune and prothrombotic condition defined by the association of thrombotic events and/or obstetrical complications and the persistence of antiphospholipid antibodies (aPL) over time. Among the new criteria recently included in the 2023 ACR/EULAR classification criteria for APS, thrombocytopenia is one of the most frequent. The occurrence of thrombocytopenia in aPL/APS patients is important to consider because it could predict APS-related clinical events with a 3-fold increased risk for thrombotic events or obstetrical morbidity or all-cause deaths. A debate on the need or not of anticoagulation and/or antiaggregation in APS patients and aPL carriers with thrombocytopenia took place on the 7th edition of the International Congress on Controversies in Rheumatology and Autoimmunity (CORA), that was organized in Turin, Italy, on March 18th, 2023, and this review summarizes the main arguments that were discussed in this session.
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Affiliation(s)
- Stephane Zuily
- CHRU-Nancy, Vascular Medicine Division, French Referral Center for Rare Systemic and Autoimmune Diseases, F-54000 Nancy, France; Université de Lorraine, INSERM, DCAC, F-54000 Nancy, France
| | - Ricard Cervera
- Department of Autoimmune Diseases, Reference Centre for Systemic Autoimmune Diseases (UEC/CSUR) of the Catalan and Spanish Health Systems-Member of ERN-ReCONNET, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain.
| | - Thomas Foret
- CHRU-Besancon, Vascular Medicine Unit, Vascular and Endovascular Surgery Department, F-25000 Besancon, France
| | - Stefania Bertocchi
- Rheumatology and Clinical Immunology Unit, Dpt. of Clinical and Experimental Science, ASST-Spedali Civili and University of Brescia, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, Dpt. of Clinical and Experimental Science, ASST-Spedali Civili and University of Brescia, Italy
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Shindo R, Abe R, Oku K, Tanaka T, Matsueda Y, Wada T, Arinuma Y, Tanaka S, Ikenoue T, Miyakawa Y, Yamaoka K. Involvement of the complement system in immune thrombocytopenia: review of the literature. Immunol Med 2023; 46:182-190. [PMID: 37237432 DOI: 10.1080/25785826.2023.2213976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Immune thrombocytopenia (ITP) is a thrombocytopenic condition induced by autoimmune mechanisms and includes secondary ITP with underlying diseases such as connective tissue diseases (CTD). In recent years, it has been elucidated that the subsets of the ITP are associated with complement abnormalities but much remains unclear. To perform a literature review and identify the characteristics of complement abnormalities in ITP. PUBMED was used to collect the literature published up to June 2022 related to ITP and complement abnormalities. Primary and secondary ITP (CTD-related) were examined. Out of the collected articles, 17 were extracted. Eight articles were related to primary ITP (pITP) and 9 to CTD-related ITP. Analysis of the literature revealed that the ITP severity was inversely correlated with serum C3, C4 levels in both ITP subgroups. In pITP, a wide range of complement abnormalities was reported, including abnormalities of initial proteins, complement regulatory proteins, or the end products. In CTD-related ITP, reported complement abnormalities were limited to the initial proteins. Activation of the early complement system, mainly through activation of C3 and its precursor protein C4, was reported for both ITPs. On the other hand, more extensive complement activation has been reported in pITP.
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Affiliation(s)
- Risa Shindo
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Ryohei Abe
- Department of Hematology, Saitama Medical University Hospital, Saitama, Japan
| | - Kenji Oku
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomoki Tanaka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yu Matsueda
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tatsuhiko Wada
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yoshiyuki Arinuma
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
| | - Sumiaki Tanaka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
- Department of Rheumatology, Kitasato University Medical Center, Kitamoto, Japan
| | - Tatsuyoshi Ikenoue
- Data Science and AI Innovation Research Promotion Center, Shiga University, Hikone, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshitaka Miyakawa
- Department of Hematology, Saitama Medical University Hospital, Saitama, Japan
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Sagamihara, Japan
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7
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Shi Y, Huang C, Zhou Y, Jiang H, Zhao Y, Li M, Zeng X, Zhao J. Tacrolimus shows adequate efficacy in patients with antiphospholipid antibodies associated thrombocytopenia: a retrospective cohort study. Clin Exp Med 2023; 23:5433-5443. [PMID: 37930607 DOI: 10.1007/s10238-023-01248-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
Thrombocytopenia is a common manifestation associated with the presence of antiphospholipid antibodies (aPL). The aim of this study is to investigate the efficacy and safety of tacrolimus treatment in aPL associated thrombocytopenia. This is a single-center retrospective study. Patients who had persistent positive aPL and thrombocytopenia that was treated with tacrolimus were included. A total of 49 patients [38 females (77.6%)] were enrolled from Nov 2013 to Apr 2022 with a median treatment duration of 22 months. Seventeen fulfilled classification criteria of antiphospholipid syndrome (APS), 18 systemic lupus erythematosus (SLE). The median age of study patients was 37 years (IQR 31, 48). Forty-three (87.8%) patients were on concomitant use of glucocorticoids, 6 on tacrolimus monotherapy. The overall response rate in this cohort was 85.7% (n = 42), including 49% of complete responses (n = 24). The median time to achieve a response was 3 months. Nine (18.4%) patients with overall response experienced a loss of response. The response rate during follow-up in patients with monotherapy was noninferior. Patients with positive antinuclear antibody (ANA) showed the tendency of maintaining response (p = 0.028). The 19 patients who were on medium and high dosage of glucocorticoids (> 15 mg prednisone/d) managed to taper glucocorticoids rapidly. Side effects were reported in 12.2% (n = 6) of the patients (elevated creatinine, general malaise, elevated liver enzyme). Tacrolimus has adequate efficacy, steroid-sparing effect and is well tolerated for aPL associated thrombocytopenia. Patients with positive ANA might benefit the most from tacrolimus treatment.
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Affiliation(s)
- Yu Shi
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Can Huang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yangzhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Hui Jiang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yongqiang Zhao
- Department of Hematology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
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8
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Fu Y, Zhao L, Ye S. Intention to treat: The management of connective tissue disease-related immune thrombocytopenia. Int J Rheum Dis 2023; 26:1885-1888. [PMID: 37807615 DOI: 10.1111/1756-185x.14811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Yakai Fu
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Liling Zhao
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shuang Ye
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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9
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Mittal P, Quattrocchi G, Tohidi-Esfahani I, Sayar Z, Chandratheva A, Cohen H. Antiphospholipid syndrome, antiphospholipid antibodies, and stroke. Int J Stroke 2023; 18:383-391. [PMID: 36571450 DOI: 10.1177/17474930221150349] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Antiphospholipid syndrome (APS) is a prothrombotic autoimmune disease with heterogeneous clinicopathological manifestations and is a well-established cause of acute ischemic stroke (AIS) and transient ischemic attack (TIA), particularly in younger patients. There is growing recognition of a wider spectrum of APS-associated cerebrovascular lesions, including white matter hyperintensities, cortical atrophy, and infarcts, which may have clinically important neurocognitive sequalae. Diagnosis of APS-associated AIS/TIA requires expert review of clinical and laboratory information. Management poses challenges, given the potential for substantial morbidity and recurrent thrombosis, additional risk conferred by conventional cardiovascular risk factors, and limited evidence base regarding optimal antithrombotic therapy for secondary prevention. In this review, we summarize key features of APS-associated cerebrovascular disorders, with focus on clinical and laboratory aspects of diagnostic evaluation. The current status of prognostic markers is considered. We review the evidence base for antithrombotic treatment in APS-associated stroke and discuss uncertainties, including the optimal intensity of anticoagulation and efficacy of direct oral anticoagulants. Clinical practice recommendations are provided, covering antithrombotic treatment, supportive management, and options for anticoagulant-refractory cases, and we highlight the benefits of adopting a considered, multidisciplinary team approach.
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Affiliation(s)
- Prabal Mittal
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Graziella Quattrocchi
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Neurology, North Middlesex NHS Trust, London, UK
| | - Ibrahim Tohidi-Esfahani
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Zara Sayar
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Haematology, Whittington Health NHS Trust, London, UK
| | - Arvind Chandratheva
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
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El Hasbani G, Saliba AN, Uthman I, Taher AT. Hematological manifestations of antiphospholipid syndrome: Going beyond thrombosis. Blood Rev 2023; 58:101015. [PMID: 36175215 DOI: 10.1016/j.blre.2022.101015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
Abstract
Thrombotic complications are a hallmark of antiphospholipid syndrome (APS). These vascular - arterial, venous, and/or small vessel - complications are well described and known to hematologists and healthcare providers caring for patients with this disease. In this review, we shed light on other hematological manifestations of the disease, including bleeding, thrombocytopenia, autoimmune hemolytic anemia, and thrombotic microangiopathy syndromes. While these manifestations are not bona fide clinical criteria for the diagnosis of APS, they frequently interact and contribute to the complexity of clinical management of APS.
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Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, Hartford Healthcare, St. Vincent's Medical Center, Bridgeport, CT 06606, USA
| | - Antoine N Saliba
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Imad Uthman
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali T Taher
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon..
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Pires da Rosa G, Ferreira E, Sousa-Pinto B, Bettencourt P, Espinosa G, Cervera R. Patients with laboratory criteria of anti-phospholipid syndrome and 'non-criteria' manifestations: a multicenter cohort. Scand J Rheumatol 2023; 52:190-195. [PMID: 35723613 DOI: 10.1080/03009742.2022.2082114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Patients with laboratory criteria for anti-phospholipid syndrome (APS) but presenting only 'non-criteria' clinical manifestations are scarcely characterized in the literature. We aimed to analyse a cohort of these patients regarding the most prevalent manifestations, antibody profile, and treatments, while establishing a comparison with definite APS patients. METHOD A retrospective analysis was conducted of individuals fulfilling APS laboratory criteria assessed in two tertiary European hospitals between 2005 and 2020. Patients without clinical criteria but with non-criteria manifestations (termed 'clinical non-criteria') and age-/gender-matched controls were included. RESULTS Altogether, 75 clinical non-criteria patients were analysed, with haematological (thrombocytopenia, haemolytic anaemia) and 'mild' neurological manifestations (white-matter lesions, migraine) as the most prevalent non-obstetric involvements. These patients displayed more thrombocytopenia [odds ratio (OR) = 3.6, 95% confidence interval (CI) 1.7-7.6; p = 0.001] than controls with APS, but severe manifestations, such as valvular heart disease (p < 0.001), livedoid vasculopathy, seizures, chorea, transverse myelitis, bone necrosis, and alveolar haemorrhage, occurred only in definite APS patients. Corticosteroids were required by 40% of patients with thrombocytopenia. Manifestations in anticoagulated patients included white-matter lesions, nephropathy, superficial vein thrombosis, amaurosis fugax, and livedoid vasculopathy. Suspicion of progression towards systemic lupus erythematosus (SLE) occurred in 19% of non-SLE individuals. CONCLUSION 'Clinical non-criteria' patients displayed significant treatment use, predominantly haematological involvement, and less severe manifestations than definite APS controls. Some patients may additionally progress to future SLE. The impact of certain manifestations flags them as potential future contributors to classifying individuals as definite APS.
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Affiliation(s)
- G Pires da Rosa
- Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - E Ferreira
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Internal Medicine, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - B Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences; Faculty of Medicine, University of PortoMEDCIDS , Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Porto, Portugal
| | - P Bettencourt
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Internal Medicine, Hospital CUF, Porto, Portugal
| | - G Espinosa
- Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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12
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Garra W, Carmi O, Kivity S, Levy Y. Catastrophic antiphospholipid syndrome in lupus-associated immune thrombocytopenia treated with eltrombopag A case series and literature review. Medicine (Baltimore) 2023; 102:e32949. [PMID: 36820549 PMCID: PMC9907943 DOI: 10.1097/md.0000000000032949] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Eltrombopag, a thrombopoietin receptor (TPO-R) agonist, is considered a second-line treatment for patients with refractory immune thrombocytopenia (ITP). Systemic lupus erythematosus (SLE) is frequently associated with ITP. In some cases, thrombocytopenia in SLE patients is attributed to concurrent antiphospholipid antibodies (APLA). Currently, data regarding treatment with TPO-R agonists for ITP in SLE or APLA patients are limited. The incidence of SLE flare or antiphospholipid syndrome while on TPO-R agonists has not been well-studied. CASES We report 2 cases of female patients with SLE and concurrent triple positive APLA, without thrombotic events in their medical history, in our rheumatology clinic, who were treated for refractory ITP with eltrombopag. Both developed catastrophic antiphospholipid syndrome a few weeks after beginning treatment with eltrombopag. They were admitted to the intensive care unit and treated with solumedrol, plasmapheresis, anticoagulation and rituximab. CONCLUSIONS We describe a severe possible side-effect of eltrombopag as a trigger of catastrophic antiphospholipid syndrome, a rare initial manifestation of antiphospholipid syndrome, in SLE patients with APLA. We suggest that APLA should be tested before initiating eltrombopag in patients with SLE-associated ITP. The safety of this treatment should be considered in these cases.
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Affiliation(s)
- Wakar Garra
- Department of Internal Medicine E, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- * Correspondence: Wakar Garra, Department of Internal Medicine E, Meir Medical Center, 59 Tshernichovsky St., Kfar Saba 4428164 Israel (e-mail: )
| | - Or Carmi
- Department of Internal Medicine E, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Unit, Meir Medical Center, Kfar Saba, Israel
| | - Shaye Kivity
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Unit, Meir Medical Center, Kfar Saba, Israel
| | - Yair Levy
- Department of Internal Medicine E, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Rheumatology Unit, Meir Medical Center, Kfar Saba, Israel
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13
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Jin J, Xu X, Hou L, Hou Y, Li J, Liang M, Li C. Thrombocytopenia in the first trimester predicts adverse pregnancy outcomes in obstetric antiphospholipid syndrome. Front Immunol 2022; 13:971005. [PMID: 36059524 PMCID: PMC9433896 DOI: 10.3389/fimmu.2022.971005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background Thrombocytopenia is a common manifestation of antiphospholipid syndrome (APS), and is a main concern for bleeding on the standard treatment of low dose aspirin (LDA) and low molecular weight heparin (LMWH) in obstetric APS (OAPS). Objective This study assesses the possible relationship between thrombocytopenia during the first trimester and adverse pregnancy outcomes (APOs) in OAPS patients. Methods A case-control study was conducted at Peking University People’s Hospital, Beijing, China. The clinical, immunologic, and pregnancy outcomes of the OAPS patients were collected. Univariate and multivariate logistic regression analyses were applied to assess the relationship between APOs and thrombocytopenia in the first trimester. Results A total of 115 participants were included in the analysis. There were no difference on antepartum and postpartum hemorrhage between the two groups. The gestational age in the thrombocytopenia group was less than that in the control group (34.12 ± 8.44 vs. 37.44 ± 3.81 weeks, p = 0.002). Hypocomplementemia, double aPL positive, and high titers of anti-β2 glycoprotein I were more frequent in APS patients with thrombocytopenia (p < 0.05). Compared to the control group, thrombocytopenia in the first trimester was correlated with SGA (12.12% vs. 31.25%, p = 0.043), premature birth <37 weeks (16.16% vs 43.75%, p = 0.010) and intrauterine fetal death (2.02% vs 12.50%, p = 0.033). Thrombocytopenia in first-trimester independently increased the risk of preterm birth <37 weeks (OR = 5.40, 95% CI: 1.35-21.53, p = 0.02) after adjusting for demographic and laboratory factors. After adding medication adjustments, these factors above become insignificant (p > 0.05). Of note, the number of platelets increased after delivery in 14 thrombocytopenia patients with live fetuses (p = 0.03). Conclusion This study demonstrates that thrombocytopenia in the first trimester increases the risks of preterm birth in women with APS. The effective OAPS treatments may improve pregnancy outcomes and not increase the risk of antepartum and postpartum hemorrhage.
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Affiliation(s)
- Jiayang Jin
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing, China
- Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Xue Xu
- Obstetrics and Gynecology Department, Peking University People’s Hospital, Beijing, China
| | - Lei Hou
- The Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Yuke Hou
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing, China
- Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Jing Li
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing, China
- Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Meiying Liang
- Obstetrics and Gynecology Department, Peking University People’s Hospital, Beijing, China
- *Correspondence: Chun Li, ; Meiying Liang,
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People’s Hospital, Beijing, China
- Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
- *Correspondence: Chun Li, ; Meiying Liang,
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14
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Shi M, Gao W, Jin Y, Zhu J, Liu Y, Wang T, Li C. Antiphospholipid Syndrome-Related Pulmonary Embolism: Clinical Characteristics and Early Recognition. Front Cardiovasc Med 2022; 9:872523. [PMID: 35898271 PMCID: PMC9309373 DOI: 10.3389/fcvm.2022.872523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/03/2022] [Indexed: 11/29/2022] Open
Abstract
Background Pulmonary thromboembolism is a common disease frequently encountered in the emergency room and has a high mortality rate. Antiphospholipid syndrome (APS) is a high-risk factor for recurrent pulmonary embolism (PE). It is critical to effectively administer anticoagulants to avoid the recurrence of thrombotic events. This study aims to identify the clinical characteristics of APS patients with PE (APS-PE) and to develop a risk score for determining the presence of APS in PE patients in the emergency situations. Methods We retrospectively enrolled 76 PE patients in this study, with 46 patients in the APS-PE group and 30 patients in the non-APS-PE group. We compared differences in demographics, laboratory parameters, and early mortality risk between the two groups. Risk factors for APS-PE were screened using logistic regression analysis. We also developed an early risk score using multivariate analysis weighted points proportional to the β- regression coefficient values and calculated the sensitivity and specificity for APS in PE patients. Results In the APS-PE group, we observed a higher proportion of males (43.6 vs. 20%), a higher proportion of low-risk patients (58.7 vs. 10%), lower levels of white blood cells and platelets (PLT), longer activated partial thromboplastin time (APTT), and a slight increase in D-dimer levels. Patients who were triple positive for antiphospholipid antibodies (aPLs) were younger. The APTT gradually increased as the number of positive aPLs increased. The risk factors for APS included male (OR = 5.565, 95% CI 1.176–26.341), decreased PLT (OR = 0.029, 95% CI 0.003–0.330), slightly increased D-dimer (OR = 0.089, 95% CI 0.019–0.426), and prolonged APTT (OR = 4.870, 95% CI 1.189–19.951). The risk score was named MPDA and included male, PLT, D-dimer and APTT, which can predict APS in PE patients with the AUC at 0.888 (95% CI 0.811–0.965). Conclusion The risk factors for APS in PE patients are male, low PLT, prolonged APTT and slightly increased D-dimer. The MPDA is a quantitative scoring system which is highly suggestive of APS in PE patients.
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Affiliation(s)
- Maojing Shi
- Trauma Center, Peking University People's Hospital, Beijing, China
| | - Weibo Gao
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Yuebo Jin
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
| | - Jihong Zhu
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Yuansheng Liu
- Department of Emergency, Peking University People's Hospital, Beijing, China
- Yuansheng Liu
| | - Tianbing Wang
- Trauma Center, Peking University People's Hospital, Beijing, China
- Tianbing Wang
| | - Chun Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China
- *Correspondence: Chun Li
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15
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Knight JS, Kanthi Y. Mechanisms of immunothrombosis and vasculopathy in antiphospholipid syndrome. Semin Immunopathol 2022; 44:347-362. [PMID: 35122116 PMCID: PMC8816310 DOI: 10.1007/s00281-022-00916-w] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/19/2022] [Indexed: 12/14/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune thrombophilia propelled by circulating antiphospholipid antibodies that herald vascular thrombosis and obstetrical complications. Antiphospholipid antibodies recognize phospholipids and phospholipid-binding proteins and are not only markers of disease but also key drivers of APS pathophysiology. Thrombotic events in APS can be attributed to various conspirators including activated endothelial cells, platelets, and myeloid-lineage cells, as well as derangements in coagulation and fibrinolytic systems. Furthermore, recent work has especially highlighted the role of neutrophil extracellular traps (NETs) and the complement system in APS thrombosis. Beyond acute thrombosis, patients with APS can also develop an occlusive vasculopathy, a long-term consequence of APS characterized by cell proliferation and infiltration that progressively expands the intima and leads to organ damage. This review will highlight known pathogenic factors in APS and will also briefly discuss similarities between APS and the thrombophilic coagulopathy of COVID-19.
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Affiliation(s)
- Jason S Knight
- Division of Rheumatology, University of Michigan, 1150 West Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Yogendra Kanthi
- Division of Intramural Research National Heart, Lung, and Blood Institute, Bethesda, MD, USA
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16
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Sun S, Urbanus RT, ten Cate H, de Groot PG, de Laat B, Heemskerk JWM, Roest M. Platelet Activation Mechanisms and Consequences of Immune Thrombocytopenia. Cells 2021; 10:cells10123386. [PMID: 34943895 PMCID: PMC8699996 DOI: 10.3390/cells10123386] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/15/2022] Open
Abstract
Autoimmune disorders are often associated with low platelet count or thrombocytopenia. In immune-induced thrombocytopenia (IIT), a common mechanism is increased platelet activity, which can have an increased risk of thrombosis. In addition, or alternatively, auto-antibodies suppress platelet formation or augment platelet clearance. Effects of the auto-antibodies are linked to the unique structural and functional characteristics of platelets. Conversely, prior platelet activation may contribute to the innate and adaptive immune responses. Extensive interplay between platelets, coagulation and complement activation processes may aggravate the pathology. Here, we present an overview of the reported molecular causes and consequences of IIT in the most common forms of autoimmune disorders. These include idiopathic thrombocytopenic purpura (ITP), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), drug-induced thrombocytopenia (DITP), heparin-induced thrombocytopenia (HIT), COVID-19 vaccine-induced thrombosis with thrombocytopenia (VITT), thrombotic thrombocytopenia purpura (TTP), and hemolysis, the elevated liver enzymes and low platelet (HELLP) syndrome. We focus on the platelet receptors that bind auto-antibodies, the immune complexes, damage-associated molecular patterns (DAMPs) and complement factors. In addition, we review how circulating platelets serve as a reservoir of immunomodulatory molecules. By this update on the molecular mechanisms and the roles of platelets in the pathogenesis of autoimmune diseases, we highlight platelet-based pathways that can predispose for thrombocytopenia and are linked thrombotic or bleeding events.
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Affiliation(s)
- Siyu Sun
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (S.S.); (H.t.C.)
- Synapse Research Institute, 6217 KD Maastricht, The Netherlands; (P.G.d.G.); (B.d.L.)
| | - Rolf T. Urbanus
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands;
| | - Hugo ten Cate
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (S.S.); (H.t.C.)
- Maastricht University Medical Center, Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Philip G. de Groot
- Synapse Research Institute, 6217 KD Maastricht, The Netherlands; (P.G.d.G.); (B.d.L.)
| | - Bas de Laat
- Synapse Research Institute, 6217 KD Maastricht, The Netherlands; (P.G.d.G.); (B.d.L.)
| | - Johan W. M. Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (S.S.); (H.t.C.)
- Synapse Research Institute, 6217 KD Maastricht, The Netherlands; (P.G.d.G.); (B.d.L.)
- Correspondence: (J.W.M.H.); (M.R.); Tel.: +31-68-1032534 (J.W.M.H. & M.R.)
| | - Mark Roest
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (S.S.); (H.t.C.)
- Synapse Research Institute, 6217 KD Maastricht, The Netherlands; (P.G.d.G.); (B.d.L.)
- Correspondence: (J.W.M.H.); (M.R.); Tel.: +31-68-1032534 (J.W.M.H. & M.R.)
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Zhang B, Lang Y, Zhang W, Cui L, Deng F. Characteristics and Management of Autoimmune Disease-Associated Cerebral Venous Sinus Thrombosis. Front Immunol 2021; 12:671101. [PMID: 34367137 PMCID: PMC8339549 DOI: 10.3389/fimmu.2021.671101] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022] Open
Abstract
Cerebral venous sinus thrombosis (CVST) is a central nervous system disease characterised by thrombosis in cerebral venous or dural sinuses. Autoimmune diseases, a series of diseases caused by immune responses to autoantigens, are important causes of CVST. The most common diseases that lead to CVST are Behçet’s syndrome, systemic lupus erythematosus, antiphospholipid syndrome, and Sjögren’s syndrome. Each of these diseases have different clinical and imaging manifestations and treatment for CVST varies by aetiology. This review summarises the characteristics and the current management strategies for autoimmune disease-associated CVST and emphasises controversial therapeutic strategies to provide informative reference information for diagnosis and treatment. Risk factors of autoimmune antigens should not be neglected when unconventional CVST occurs, and both drugs and interventional therapy need further standardisation and discussion with more prospective clinical studies.
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Affiliation(s)
- Baizhuo Zhang
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Yue Lang
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Weiguanliu Zhang
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Li Cui
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Fang Deng
- Department of Neurology, Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China
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18
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Nauseef JT, Lim HI, DeSancho MT. Successful outcome with eculizumab treatment in a patient with antiphospholipid syndrome presenting with an unusual thrombotic storm. J Thromb Thrombolysis 2020; 52:597-600. [PMID: 33222114 DOI: 10.1007/s11239-020-02343-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 12/26/2022]
Abstract
Catastrophic Antiphospholipid Syndrome (CAPS) is a life-threatening complication of APS requiring complex management to optimize patient outcome. We describe a 54-year-old man with APS with history of splanchnic vein thrombosis, a Factor II G20210A heterozygote, autoimmune hemolytic anemia and thrombocytopenia. He developed sudden onset of severe flank pain due to spontaneous bilateral adrenal hemorrhage while on warfarin with a therapeutic INR. Despite unfractionated heparin and initial clinical improvement, severe thrombocytopenia developed requiring dexamethasone, rituximab, and romiplostim. Hospitalization was complicated further by thrombosis of the inferior vena cava, pulmonary embolism, and painful violaceous patches on his neck and ear cartilages. Punch biopsy of lesions revealed C5b-C9 deposition of small vessel thromboses. Although the inciting event for his thrombotic storm remains uncertain, anti-complement therapy with eculizumab provided rapid and durable lesion resolution. Eculizumab was discontinued after 6 months and patient remains in remission without recurrent thrombosis. This case provides insight on the management of CAPS, including the use of eculizumab.
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Affiliation(s)
- Jones T Nauseef
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Hana I Lim
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA.
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Abstract
PURPOSE OF THE REVIEW To review the available evidence on the management of a variety of non-criteria manifestations in antiphospholipid syndrome (APS), including valvular disease, alveolar hemorrhage, thrombocytopenia, hemolytic anemia, APS nephropathy, skin ulcers, livedo reticularis, cognitive dysfunction, and epilepsy. RECENT FINDINGS Current treatment relies on low-level evidence and mainly on expert consensus due to the rarity and the heterogeneity of non-criteria APS manifestations and the diversity in management approaches. Conventional anticoagulation and/or antiplatelet APS treatment do not adequately control most of non-criteria manifestations. Increasing knowledge about the contribution of inflammatory in addition to, or independently of, thrombotic mechanisms in non-criteria APS manifestations provides insight into the potential effect of novel therapies targeting B-cells, mammalian target of rapamycin, neutrophil, and complement or interferon pathways. Existing evidence is limited by lack of high-quality studies. Better understanding of the pathophysiology and clinical phenotypes of APS and well-designed prospective studies of homogenous populations are needed to provide evidence-based recommendations for the management of non-criteria APS manifestations.
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Aneja J, Kuppili PP, Paul K, Panda S, Purohit A. Antiphospholipid syndrome presenting as treatment resistant bipolar disorder and thrombocytopenia in a young male. J Neuroimmunol 2020; 343:577238. [PMID: 32305000 DOI: 10.1016/j.jneuroim.2020.577238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 01/17/2023]
Abstract
Antiphospholipid syndrome (APS), an autoantibody mediated disease, is characterized by presence of antibodies against the proteins bound to the phospholipid membranes. The antibodies are predominantly formed against beta-2-glycoprotein I (b2GPI) which is considered pathogenic, but presence of lupus anticoagulant is a predictor of thrombotic events. The thrombotic events in APS may manifest as venous or arterial or small vessel thrombosis in any tissue or organ and pregnancy related complications namely, recurrent (three or more) and early spontaneous miscarriages before 10 weeks of gestation or unexplained deaths of normal fetus at or beyond 10 weeks, eclampsia or severe pre-eclampsia, intra-uterine growth retardation and pre-term births. However, lately its role as an etiological mechanism in causation of certain neuro-psychiatric disorders has been put forth. It has been suggested that one should suspect APS in psychiatric manifestations which are atypical, resistant to treatment, associated with cognitive decline and dementia, abnormal involuntary movements, livedo reticularis, migraine, thrombotic events like stroke or transient ischemic attacks, obstetrical complications. In this brief communication, we describe the case of young male who has been suffering from treatment resistant and difficult to manage bipolar affective disorder (BPAD) with fluctuating thrombocytopenia and neurological findings with positive lupus anticoagulant. We propose it to be a consequence of an atypical presentation of APS.
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Affiliation(s)
- Jitender Aneja
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India.
| | - Pooja Patnaik Kuppili
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Karandeep Paul
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Samhita Panda
- Department of Neurology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Abhishek Purohit
- Department of Pathology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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