The lupus anticoagulant, pulmonary thromboembolism, and fatal pulmonary hypertension

Pulmonary hypertension in rheumatic diseases: epidemiology and pathogenesis

The focus of this review is to increase awareness of pulmonary arterial hypertension (PAH) in patients with rheumatic diseases. Epidemiology and pathogenesis of PAH in rheumatic diseases is reviewed, with recommendations for early screening and diagnosis and suggestion of possible role of immunosuppressive therapy in treatment for PAH in rheumatic diseases. A MEDLINE search for articles published between January 1970 and June 2012 was conducted using the following keywords: pulmonary hypertension, scleroderma, systemic sclerosis, pulmonary arterial hypertension, connective tissues disease, systemic lupus erythematosus, mixed connective tissue disease, rheumatoid arthritis, Sjogren's syndrome, vasculitis, sarcoidosis, inflammatory myopathies, dermatomyositis, ankylosing spondylitis, spondyloarthropathies, diagnosis and treatment. Pathogenesis and disease burden of PAH in rheumatic diseases was highlighted, with emphasis on early consideration and workup of PAH. Screening recommendations and treatment were touched upon. PAH is most commonly seen in systemic sclerosis and may be seen in isolation or in association with interstitial lung disease. Several pathophysiologic processes have been identified including an obliterative vasculopathy, veno-occlusive disease, formation of microthrombi and pulmonary fibrosis. PAH in systemic lupus erythematosus is associated with higher prevalence of antiphospholipid and anticardiolipin antibodies and the presence of Raynaud's phenomenon. Endothelial proliferation with vascular remodeling, abnormal coagulation with thrombus formation and immune-mediated vasculopathy are the postulated mechanisms. Improvement with immunosuppressive medications has been reported. Pulmonary fibrosis, extrinsic compression of pulmonary arteries and granulomatous vasculitis have been reported in patients with sarcoidosis. Intimal and medial hyperplasia with luminal narrowing has been observed in Sjogren's syndrome, mixed connective tissue disease and inflammatory myopathies. Pulmonary arterial hypertension (PAH) associated with rheumatic diseases carries a particularly grim prognosis with faster progression of disease and poor response to therapy. Though largely associated with systemic sclerosis, it is being increasingly recognized in other rheumatic diseases. An underlying inflammatory component may explain the poor response to therapy in patients with rheumatic diseases and is a rationale for consideration of immunosuppressive therapy in conjunction with vasodilator therapy in treatment for PAH. Further studies identifying pathogenetic pathways and possible targets of therapy, especially the role of immunomodulatory medications, are warranted.

Antiphospholipid antibodies as a cause of pulmonary capillaritis and diffuse alveolar hemorrhage: a case series and literature review

OBJECTIVES

To discuss the clinical manifestations and possible pathogenic mechanisms of the unusual syndrome of diffuse alveolar hemorrhage (DAH) and pulmonary capillaritis without thrombosis in the setting of the primary antiphospholipid antibody syndrome (PAPS).

METHODS

Four men with DAH and capillaritis in the setting of PAPS are identified. Their clinical presentations, laboratory, radiographic, and pathologic findings are reviewed as is their clinical course and response to therapy. In addition, the literature regarding DAH and pulmonary capillaritis in the setting of PAPS is reviewed.

RESULTS

The patients presented with dyspnea, hemoptysis, fever, hypoxia, and diffuse alveolar infiltrates; none had evidence of acute thromboembolic disease. All secondary causes of DAH were ruled out. All patients had positive testing for the lupus anticoagulant and high-titer anticardiolipin antibodies, including antibodies against the beta-2-glycoprotein I antigen. Three cases had lung biopsies that revealed pulmonary capillaritis and DAH with no evidence of thrombosis. All patients improved with high-dose corticosteroids. Recurrent disease in the setting of aggressive immunosuppression responded to intravenous immunoglobulin. Antiphospholipid antibody-mediated endothelial cell activation in the absence of thrombosis may induce capillaritis as seen in these cases.

CONCLUSIONS

The syndrome of DAH and pulmonary capillaritis is further defined. Evidence supports a causative relationship between PAPS, pulmonary capillaritis, and DAH in the absence of thromboembolic disease. Further elucidation of a possible nonthrombotic mechanism of antiphospholipid antibody-mediated pathology is needed to guide future therapies for this unusual manifestation of PAPS.

The lung in the antiphospholipid syndrome

Patients with antiphospholipid syndrome (APS) may develop a broad spectrum of pulmonary disease. Pulmonary thromboembolism and pulmonary hypertension are the most common complications, but microvascular pulmonary thrombosis, pulmonary capillaritis, and alveolar haemorrhage have also been reported. Clinicians should seriously consider these types of vascular injury when evaluating patients with APS who present with dyspnoea, fever, and infiltrates on chest radiography.

Pulmonary manifestations of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects young women. The respiratory system is more commonly involved in SLE than in any other collagen vascular disease. SLE may affect virtually all components of the respiratory system, including the upper airway, lung parenchyma, pulmonary vasculature, pleura, and respiratory muscles. Respiratory system involvement ranges from symptomatic to fulminant and life threatening. This article reviews the pulmonary manifestations of SLE, including drug-induced SLE.

Thoracic imaging features of patients with antiphospholipid antibodies

PURPOSE

Our aim was to determine the thoracic manifestations of patients with antiphospholipid antibodies (APAs).

METHOD

We performed a retrospective review of the clinical records and thoracic imaging studies of 88 patients (63 women, 25 men; mean age 47 years) with APAs to determine the spectrum of thoracic disease.

RESULTS

Nine patients (10%) had thoracic abnormalities, including eight with pulmonary embolism (PE) and one with aortic thrombus. One patient with PE had subclavian vein thrombosis. Coexistent thromboses included deep venous thrombosis of the leg in six patients.

CONCLUSION

PE was the most common thoracic abnormality in our patients. The presence of these antibodies should be suspected in patients with PE of otherwise unexplained etiology.

Primary antiphospholipid syndrome and pulmonary hypertension with prolonged survival. A case report

The outcome of patients with pulmonary hypertension (PHT) and antiphospholipid syndrome (APS) is usually fatal. The authors report the rare case of a patient with primary APS and nonthrombotic PHT who has survived for twenty years after the onset of PHT. In this case, the patient's PHT resembled the primary idiopathic variety with clear lung fields and normal perfusion on the lung scan, and the combination therapy with nitrate, digoxin, and diuretics had been performed. During her clinical course over twenty years, she had not experienced any critical pulmonary thrombosis that influenced the progression of nonthrombotic PHT or any other severe systemic involvement of APS.

Clinicopathologic correlations of the antiphospholipid syndrome

Since the original description and definition of the antiphospholipid syndrome (APS), a number of distinct clinical manifestations related to it have appeared in the literature. These include vascular obstruction of both veins and arteries, thrombus formation on the endocardium and its consequences, as well as a group of other conditions where vascular obstructive mechanisms are either incompletely understood or unproven, eg, chorea, avascular necrosis, and pulmonary hypertension. Single vessel (large/medium) involvement or multiple vascular occlusions may cause a wide variety of presentations. Any combination of vascular occlusive events may occur in the same individual, and the time interval between them also varies considerably from weeks to months or even years. Rapid chronological occlusive events occurring over days to weeks have been termed the "catastrophic" APS. Most of these complications may be ascribed to the hypercoagulable state of which antiphospholipid antibodies appear either to be "markers" or intimately connected with the highly complex coagulation mechanisms resulting in thrombotic occlusions.

Lupus anticoagulant and cardiac manifestations in systemic lupus erythematosus

The occurrence of cardiac manifestations and their relationship with the lupus anticoagulant (LA) in SLE was studied in 74 patients who were followed up for 22 years (median), of which 16 years were after the initial LA testing. Pericarditis was the most common cardiac event occurring in 16 (22%) patients but it did not correlate with LA. Valvular heart disease, coronary artery disease, left ventricular failure and/or cor pulmonale were observed in 16 (22%) patients. Taken together, their occurrence was associated with a history of leg ulcers (odds 3.8, P = 0.028) but not with LA or other common clinical manifestations of the antiphospholipid syndrome. Valvular heart disease in five patients was significantly associated with LA (P = 0.05). Cor pulmonale due to chronic pulmonary embolism was present in two patients with LA. Myocardial infarctions in five patients occurred late in the course of disease but in relatively young patients (mean 43 years). Fatal myocardial infarction in the absence of atherosclerosis in two LA-positive patients supports a pathogenetic role for LA in these cases. In conclusion, of the various cardiac complications in SLE, valvular heart disease and cor pulmonale appear to be connected with the antiphospholipid syndrome. Both conditions should be actively sought in patients with LA to decrease possible adverse events (arterial emboli and right ventricular failure) affecting the patients' prognosis.

Cutaneous necrosis resulting from protein S deficiency and increased antiphospholipid antibody in a patient with systemic lupus erythematosus

A 23-year-old woman with widespread cutaneous necrosis resulting from protein S deficiency and increased antiphospholipid antibody in the setting of systemic lupus erythematosus is described. Our report illustrates the complex nature of evaluation of skin lesions in patients with active systemic lupus erythematosus.

Primary antiphospholipid syndrome (PAPS). Two case reports and therapeutic implications

Antiphospholipid antibodies (aPL) interfere with the coagulation system and can cause thrombosis and other clotting disorders. The combination of recurrent venous thrombosis, arterial embolism and recurrent fetal loss is nowadays considered to be primary antiphospholipid syndrome (PAPS), provided an underlying systemic lupus erythematosus (SLE) has been excluded and aPL have been detected. We report on two patients with PAPs, and show the course of their IgG- and IgM-anticardiolipin antibody (aCL) titers during immunosuppressive therapy with prednisone and azathioprine or cyclophosphamide. Over a period of 18 months this therapy was effective in preventing relapses of thrombo-embolism and other complications. Therapy with cyclophosphamide resulted in normalization of the aCL titers in one of the two reported cases. Azathioprine treatment reduced the aCL titer in the other patient, without fully normalizing it. Based on our observation, we propose to treat PAPS-associated severe and recurrent thrombo-embolic complications by aggressive immunosuppression, including azathioprine and cyclophosphamide.

Recurrent adverse pregnancy outcome and antiphospholipid antibodies

Antiphospholipid antibodies, which include lupus-like anticoagulant and anticardiolipin antibody, have been linked to a number of adverse pregnancy outcomes, although their exact pathogenic mechanisms remain poorly defined. The relative risk of complications such as intrauterine growth retardation, spontaneous abortions, and stillbirth in patients with antiphospholipid antibodies also remains undetermined. Heightened attention has been focused on the association, leading to investigations into the pathogenesis. Uncontrolled studies have also explored therapeutic regimens such as aspirin, steroids, and heparin, and clinical trials have used various treatment protocols. Although knowledge into the association of antiphospholipid antibodies and recurrent adverse pregnancy outcome is limited and continues to evolve, this association provides new insights into the disease and offers promise for pharmacologic prophylaxis. In this article, current concepts on pathogenesis, diagnosis, and therapy are reviewed and recommendations are made for clinical care of these patients.

Cutaneous thrombosis, cerebrovascular thrombosis, and lupus anticoagulant--the Sneddon syndrome. Report of 10 cases

Ten patients with circulating lupus anticoagulant who presented with cutaneous vascular disease and cerebrovascular disease are presented. Cutaneous manifestations were gangrene, thrombophlebitis, ulcers, and livedo reticularis. All 10 patients had cerebral infarction. The relationship between the cerebral and cutaneous vascular changes and the presence of lupus anticoagulant is supported by a common noninflammatory vascular thrombosis histologically in these patients and by the presence of similar pathologic and clinical findings in patients with the lupus anticoagulant syndrome.

IGM-containing immune complexes and antiphospholipid antibodies in patients with Sneddon's syndrome

We report three patients with a Sneddon syndrome in whom predominantly small (500-900 kD) IgM-containing serum immune complexes were detectable. Furthermore, antiphospholipid antibodies and increased von Willebrand factor antigen were found in the sera of two cases. Especially the data demonstrating small circulating immune complex as suggest that Sneddon's syndrome, a rare vasculitis disorder, might immunologically be characterized by circulating IgM-containing immune complexes which, in addition, could play a role in the pathogenesis of this disease entity. The elevated antiphospholipid antibodies as well as the increased von Willebrand factor antigen in the sera of the investigated patients have to be considered as nonspecific vasculitis-associated phenomena.

Skin lesions associated with circulating lupus anticoagulant

This retrospective study of 295 patients extends the earlier findings of an association between lupus anticoagulation and thrombosis by demonstrating the occurrence of cutaneous lesions related to the coagulation defect in 70 patients. The most frequent cutaneous associations were thrombophlebitis, skin ulcer, gangrene, haemorrhage, and cutaneous necrosis. Of the patients with skin lesions, 41% had the skin lesion as the first sign of the disease. It is important to recognize this association because nearly 40% of the patients with skin lesions have multisystem thrombotic phenomena in the course of the disease.

[Pulmonary arterial hypertension and systemic lupus erythematosus. Apropos of 2 cases. Review of the literature]

Pulmonary arterial hypertension may develop in patients with systemic lupus erythematosus (SLE) in the absence of lung tissue lesion or embolism in the pulmonary circulation. Its mechanisms and prognosis are imperfectly known, although various suggestions have been made concerning the possible role of pulmonary arterial spasm, immune complex arteritis or arterial wall fibrosis. We report two cases of SLE in female patients who presented with clinical signs of pulmonary arterial hypertension. The fact that pulmonary arterial hypertension regressed completely in one patient and resulted in death in the other points to different pathogenic mechanisms. In the first patient the dramatic therapeutic effectiveness of a calcium inhibitor suggests that an arterial spasm was involved, whereas the anatomical lesions found in the second patient are in favour of a fibrotic inflammatory arteritis. This pathogenic heterogeneity of pulmonary arterial hypertension in SLE, which may correspond to different evolutive stages of the disease, is documented by a review of the literature with special attention to the frequency and to the clinical biochemical, haemodynamic and histological aspects of this complication of SLE.

Pulmonary hypertension in hydralazine induced systemic lupus erythematosus: association with C4 null allele

A patient who developed pulmonary hypertension and systemic lupus erythematosus as a complication of hydralazine therapy is reported. She was a slow acetylator and in addition was found to have a null allele at the C4A locus.

Central retinal artery occlusion in Sneddon's disease associated with antiphospholipid antibodies

A 33-year-old woman with retinal artery occlusion also had Sneddon's disease (livedo reticularis, neurologic abnormalities, and labile hypertension). While retinal artery occlusive disease obviously must be added to the symptomatic spectrum of this rare disorder, the detection of antiphospholipid antibodies in this patient has pathogenetic implications.