Diffuse alveolar hemorrhage and Libman-Sacks endocarditis as a manifestation of possible primary antiphospholipid syndrome

Risk and triggering factors for diffuse alveolar hemorrhage in primary antiphospholipid syndrome. An observational follow-up study and a systematic review of the literature

BACKGROUND

Diffuse alveolar hemorrhage (DAH) represents a serious, life-threatening complication of primary antiphospholipid syndrome (PAPS), a thrombophilic disorder mainly characterized by vascular thrombosis and/or pregnancy morbidity. Risk factors for DAH in PAPS patients and the comorbidities that may trigger DAH were investigated here in the effort to identify possible independent predictors of DAH in PAPS patients.

METHODS

Only PAPS patients fulfilling the Sydney criteria were taken into consideration. The DAH diagnosis was based on the patient's clinical presentation (acute illness manifesting with dyspnoea, hypoxia, cough, anemia and less frequently hemoptysis and fever), the presence of transient lung infiltrates on chest radiographs, a rapidly changing ground-glass appearance on computed tomography, and a positive response to high dose steroid therapy prescribed during an acute phase. The PAPS patients manifesting DAH signs and symptoms were considered the study group; the remaining served as the control group. The following comorbidities were investigated: i) left-sided heart valve diseases, ii) left heart failure and iii) hemolytic anemia. The clinical and laboratory characteristics and comorbidities of the PAPS-associated DAH patients were recorded and compared with those of the control group and those of the PAPS-associated DAH patients identified by a literature review.

RESULTS

The subjects considered for inclusion were 197 PAPS patients (142 women and 55 men) all suffering from thrombosis, which was associated with pregnancy morbidity in 30 (21.1 %) of the women. Eight (4.1 %) of these patients (five men and three women) experienced one or more episodes of DAH. When the clinical and laboratory characteristics of the PAPS-associated DAH patients were compared with those of the controls a significant prevalence of the male gender (p = 0.0399), of the multiple types of vascular involvement profile (p = 0.0048) and of high antiphospholipid antibody (aPL) titers (p = 0.0011) was noted in the former. Triple aPL positivity and microcirculation thrombosis were also more frequent in that group, although not to a significant degree. The prevalence of comorbidities including left-sided heart valve diseases, left heart failure and hemolytic anemia was likewise significantly higher in the PAPS-associated DAH patients (p = 0.0253, 0.0451 and 0.0358, respectively). According to logistic regression analysis, multiple types of vascular involvement profile, left-sided heart valve diseases and hemolytic anemia were found to be independent risk factors for DAH (p = 0.030, 0.022 and 0.007, respectively). Twenty-four studies (one case-control, three small case series, and 20 case reports) reporting on 55 PAPS-associated DAH patients were identified by a review of the literature. The clinical and laboratory characteristics and comorbidities of our PAPS-associated DAH patients were not significantly different from those of the DAH patients identified by literature review. Only hemolytic anemia was significantly less frequent in the literature-review DAH patients than in ours.

CONCLUSION

Some risk factors and comorbidities characterizing PAPS-associated DAH patients were identified when the clinical and laboratory characteristics of a group of these subjects were compared with those of a control group and of PAPS-associated DAH patients pinpointed by a literature review. In the event that these results are confirmed by larger multicenter studies, they could contribute to identifying PAPS patients at risk of developing DAH.

Embolic myocardial infarction with cardiac arrest as an initial manifestation of non-bacterial thrombotic endocarditis

Non-bacterial thrombotic endocarditis, characterised by sterile vegetations, is commonly caused by systemic lupus erythematosus and is known to be complicated with embolic cerebrovascular disease. Embolic myocardial infarction with non-bacterial thrombotic endocarditis is extremely rare. We report a case of ventricular fibrillation arrest from presumed coronary embolisation in non-bacterial thrombotic endocarditis. While there are no standardised guidelines on the management of embolic myocardial infarction in endocarditis, it requires a multidisciplinary approach unique for every encountered clinical scenario.

Clinical features, risk factors, and outcomes of diffuse alveolar hemorrhage in antiphospholipid syndrome: A mixed-method approach combining a multicenter cohort with a systematic literature review

BACKGROUND

Antiphospholipid syndrome (APS) is a systemic autoimmune disease clinically associated with thrombotic and obstetric events. Additional manifestations have been associated with APS, like diffuse alveolar hemorrhage (DAH). We aimed to summarize all the evidence available to describe the presenting clinical features, their prognostic factors, and short- and long-term outcomes.

METHODS

We performed a mixed-method approach combining a multicenter cohort with a systematic literature review (SLR) of patients with incident APS-associated DAH. We described their clinical features, treatments, prognostic factors, and outcomes (relapse, mortality, and requirement of mechanical ventilation [MV]). Kaplan-Meier methods were used to estimate relapse and mortality rates, and Cox and logistic regression models were used to assess the factors associated as appropriate.

RESULTS

We included 219 patients with incident APS-associated DAH (61 from Mayo Clinic and 158 from SLR). The median age was 39.5 years, 51% were female, 29% had systemic lupus erythematosus, and 34% presented with catastrophic APS (CAPS). 74% of patients had a history of thrombotic events, and 26% of women had a history of pregnancy morbidity; half of the patients had a history of thrombocytopenia, and a third had valvulopathy. Before DAH, 55% of the patients were anticoagulated. At DAH onset, 65% of patients presented hemoptysis. The relapse rate was 47% at six months and 52% at one year. Triple positivity (HR 4.22, 95% CI 1.14-15.59) was associated with relapse at six months. The estimated mortality at one and five years was 30.3% and 45.8%. Factors associated with mortality were severe thrombocytopenia (< 50 K/μL) (HR 3.10, 95% CI 1.39-6.92), valve vegetations (HR 3.22, 95% CI 1.14-9.07), CAPS (HR 3.80, 95% CI 1.84-7.87), and requirement of MV (HR 2.22, 95% CI 1.03-4.80). Forty-two percent of patients required MV on the incident DAH episode. Patients presenting with severe thrombocytopenia (OR 6.42, 95% CI 1.77-23.30) or CAPS (OR 4.30, 95% CI 1.65-11.16) were more likely to require MV.

CONCLUSION

APS-associated DAH is associated with high morbidity and mortality, particularly when presenting with triple positivity, thrombocytopenia, valvular involvement, and CAPS.

Immunoadsorption and autologous transplantation for life-threatening primary antiphospholipid syndrome

Reduction of APL antibodies by immunoadsorption may be a lifesaving therapy for the management of DAH with high titer of APL antibodies. Autologous HSCT may be a valid treatment option in patients with primary APS and no response to standard immunosuppressive therapy.

Clinical Insights into Diffuse Alveolar Hemorrhage in Antiphospholipid Syndrome

PURPOSE OF REVIEW

Diffuse alveolar hemorrhage (DAH) is a rare but devastating manifestation of antiphospholipid syndrome (APS) patients with or without other systemic autoimmune diseases. Data regarding diagnosis and treatment are limited to case series. We review diagnostic and therapeutic strategies employed in APS patients with DAH and discuss our experience in managing these complex patients.

RECENT FINDINGS

Pulmonary capillaritis likely contributes to the pathogenesis, however is only observed in half of the biopsies. Corticosteroids induce remission in the majority of patients, however almost half recur and require a steroid-sparing immunosuppressive to maintain remission. Cyclophosphamide- or rituximab-based regimens achieve the highest remission rates (50%); other strategies include intravenous immunoglobulin, plasmapheresis, mycophenolate mofetil, and/or azathioprine. Given the rarity of DAH in APS, treatment is guided by interdisciplinary experience. Why certain patients achieve full remission with corticosteroids while others require immunosuppressive agents is unknown; future research should focus on the pathophysiology and optimal management.