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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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Zhao Y, Huang C, Zhou Y, Qi W, Cai B, Hu C, Song Y, Zhu T, Shi X, Liu X, Wang Q, Tian X, Zhao Y, Zeng X, Li M, Zhao J. Performance validation of the 2023 American College of Rheumatology/European League Against Rheumatism antiphospholipid syndrome classification criteria in an antiphospholipid syndrome cohort. J Thromb Haemost 2024; 22:1660-1674. [PMID: 38462219 DOI: 10.1016/j.jtha.2024.02.019] [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: 01/03/2024] [Revised: 02/18/2024] [Accepted: 02/25/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The 2023 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) antiphospholipid syndrome (APS) classification criteria were developed with higher specificity but lower sensitivity compared with the 2006 Sydney revised classification criteria. OBJECTIVES To validate the performance of the 2023 ACR/EULAR APS classification criteria in a large Chinese APS cohort. METHODS This was a single-center cohort study. Inclusion criteria aligned with the entry criteria of 2023 criteria. APS classification by "expert consensus panel" served as the gold standard. Sensitivity and specificity were compared between the 2023 and 2006 criteria. RESULTS A total of 526 patients with a mean age of 38.55 ± 12.67 years were enrolled, of whom 366 (69.58%) were female and 182 (34.60%) had systemic lupus erythematosus (SLE). Among them, 407 (77.38%) patients were classified as APS by experts. The 2023 criteria demonstrated higher overall specificity than the 2006 criteria (0.983 vs 0.950), while sensitivity was relatively lower (0.818 vs 0.853). The sensitivity of the 2023 criteria improved for patients with SLE (0.860 vs 0.825), microvascular manifestations (0.867 vs 0.786), cardiac valve disease (0.903 vs 0.774), and thrombocytopenia (0.811 vs 0.790). Reduced sensitivity of the 2023 criteria was linked to the omission of certain microvascular manifestations, a stricter definition of pregnancy morbidity, and the exclusion of isolated thrombocytopenia and isolated IgM isotype antiphospholipid antibodies from meeting clinical and laboratory criteria, respectively. CONCLUSION The 2023 criteria offer higher overall specificity and improved sensitivity in specific patient subsets, such as those with SLE, microvascular manifestations, cardiac valve disease, and thrombocytopenia when compared with the 2006 criteria.
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Affiliation(s)
- Yuan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; 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, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; 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, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Wanting Qi
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Bin Cai
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Chaojun Hu
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yijun Song
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tienan Zhu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohua Shi
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinyan Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; 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, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; 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, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, Beijing, China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
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Tanariyakul M, Nebrajas K, Saowapa S, Polpichai N. Extensive Thrombosis in Catastrophic Antiphospholipid Syndrome in a Newly Diagnosed Systemic Lupus Erythematosus: A Case Report. Cureus 2024; 16:e59542. [PMID: 38826875 PMCID: PMC11144058 DOI: 10.7759/cureus.59542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
In this case report, we present the development of catastrophic antiphospholipid syndrome (CAPS), a rare and potentially fatal consequence of systemic lupus erythematosus (SLE), in a 33-year-old Micronesian woman. CAPS is characterized by extensive arterial thrombosis and multiorgan failure. The patient first showed signs of neuropsychiatric symptoms, brain infarctions on imaging, and severe hypoxic respiratory failure brought into the hospital by diffuse alveolar hemorrhage (DAH) along with lupus nephritis (LN). Blood urea nitrogen (BUN) and creatinine (Cr) were progressively elevated to 102/4.1 mg/dL, respectively. A urinalysis revealed microscopic hematuria and proteinuria with a urine protein/creatinine ratio of 6052 mg/g. She was also found to have had microangiopathic hemolytic anemia (MAHA) and severe venous thrombosis, both of which were indicative of CAPS. An aggressive approach, including immunosuppressive medication, therapeutic plasma exchange, and anticoagulation, had positive results, including renal recovery and the cessation of thrombotic episodes. This instance highlights how crucial it is to identify CAPS patients early and take appropriate action to improve patient outcomes for this difficult and sometimes deadly disorder.
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Affiliation(s)
- Manasawee Tanariyakul
- Internal Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, USA
| | - Kevin Nebrajas
- Internal Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, USA
| | - Sakditad Saowapa
- Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
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4
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Suardi S, Croce J, Colato C, Rizzo PC, Friso S, Pizzolo F. Skin erythematous migrant lesions consistent with histologically confirmed dermal arteriolar thrombosis connected to APS. Lupus 2024; 33:532-535. [PMID: 38444066 DOI: 10.1177/09612033241238270] [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] [Indexed: 03/07/2024]
Abstract
Antiphospholipid syndrome (APS) is an acquired thrombophilic disorder related to the presence of antiphospholipid antibodies (LAC, anticardiolipin, anti Beta2-glycoprotein) known to cause venous and arterial thrombosis and recurrent pregnancy loss. Skin disorder is a frequent finding usually due to vascular thrombosis involving the dermal layer and can be either localized or widespread causing necrosis and ulceration of the skin, without histological evidence of vasculitis. We present a case of a woman with APS with both arterial and venous thrombotic involvement associated with an atypical dermatological manifestation histologically consistent with a pauci-inflammatory intermediate-deep dermal arteriolar platelet-mediated thrombosis that appeared despite anticoagulation with warfarin and responding to the addition of antiplatelet therapy.
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Affiliation(s)
- Silvia Suardi
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Jacopo Croce
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Chiara Colato
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Paola Chiara Rizzo
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Simonetta Friso
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
| | - Francesca Pizzolo
- Department of Medicine, Unit of Internal Medicine, University of Verona, Verona, Italy
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5
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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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Andrade D, Tektonidou MG. Assessing disease activity and damage in antiphospholipid syndrome. Clin Immunol 2023; 255:109727. [PMID: 37558149 DOI: 10.1016/j.clim.2023.109727] [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: 06/13/2023] [Revised: 07/13/2023] [Accepted: 07/16/2023] [Indexed: 08/11/2023]
Abstract
Antiphospholipid syndrome (APS) has been characterized by a variety of vascular and pregnancy manifestations related to an interplay between thrombotic and inflammatory mechanisms, a progressive accrual of irreversible organ damage and increased morbidity and mortality rates, supporting a high need of optimal treatment approach. The lack of standardized outcome measures is a significant barrier in the design of clinical studies in APS. Disease activity (in principle reversible) and its distinction from disease damage (in principle irreversible) needs to be evaluated by validated scores for use in clinical trials but also in daily clinical practice in APS. A disease damage score in APS, the DIAPS score, has been developed and validated in external cohorts. The development of a disease activity score that will provide an accurate and reproducible rating of each disease domain, can help clinicians and researchers to comprehensively assess the activity of disease and the response to treatment, in an attempt to prevent future damage.
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Affiliation(s)
- Danieli Andrade
- Rheumatology Department, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil.
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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8
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Naranjo L, Stojanovich L, Djokovic A, Andreoli L, Tincani A, Maślińska M, Sciascia S, Infantino M, Garcinuño S, Kostyra-Grabczak K, Manfredi M, Regola F, Stanisavljevic N, Milanovic M, Saponjski J, Roccatello D, Cecchi I, Radin M, Benucci M, Pleguezuelo D, Serrano M, Shoenfeld Y, Serrano A. Circulating immune-complexes of IgG/IgM bound to B2-glycoprotein-I associated with complement consumption and thrombocytopenia in antiphospholipid syndrome. Front Immunol 2022; 13:957201. [PMID: 36172349 PMCID: PMC9511106 DOI: 10.3389/fimmu.2022.957201] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022] Open
Abstract
Background Antiphospholipid syndrome (APS) is a multisystemic autoimmune disorder characterized by thrombotic events and/or gestational morbidity in patients with antiphospholipid antibodies (aPL). In a previous single center study, APS-related clinical manifestations that were not included in the classification criteria (livedo reticularis, thrombocytopenia, leukopenia) were associated with the presence of circulating immune-complexes (CIC) formed by beta-2-glycoprotein-I (B2GP1) and anti-B2GP1 antibodies (B2-CIC). We have performed a multicenter study on APS features associated with the presence of B2-CIC. Methods A multicenter, cross-sectional and observational study was conducted on 303 patients recruited from six European hospitals who fulfilled APS classification criteria: 165 patients had primary APS and 138 APS associated with other systemic autoimmune diseases (mainly systemic lupus erythematosus, N=112). Prevalence of B2-CIC (IgG/IgM isotypes) and its association with clinical manifestations and biomarkers related to the disease activity were evaluated. Results B2-CIC prevalence in APS patients was 39.3%. B2-CIC-positive patients with thrombotic APS presented a higher incidence of thrombocytopenia (OR: 2.32, p=0.007), heart valve thickening and dysfunction (OR: 9.06, p=0.015) and triple aPL positivity (OR: 1.83, p=0.027), as well as lower levels of C3, C4 and platelets (p-values: <0.001, <0.001 and 0.001) compared to B2-CIC-negative patients. B2-CIC of IgM isotype were significantly more prevalent in gestational than thrombotic APS. Conclusions Patients with thrombotic events and positive for B2-CIC had lower platelet count and complement levels than those who were negative, suggesting a greater degree of platelet activation.
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Affiliation(s)
- Laura Naranjo
- Immunology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Aleksandra Djokovic
- Cardiology Department, University Hospital Center Bezanijska Kosa, Belgrade, Serbia
- School of Medicine , University of Belgrade, Belgrade, Serbia
| | - Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Maślińska
- Early Arthritis Clinic, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Savino Sciascia
- Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, Torino, Italy
| | - Maria Infantino
- Immunology and Allergy Laboratory, San Giovanni di Dio Hospital, Florence, Italy
| | - Sara Garcinuño
- Immunology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Kinga Kostyra-Grabczak
- Early Arthritis Clinic, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Mariangela Manfredi
- Immunology and Allergy Laboratory, San Giovanni di Dio Hospital, Florence, Italy
| | - Francesca Regola
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Natasa Stanisavljevic
- Internal Medicine, University Hospital Center Bezanijska Kosa, Belgrade, Serbia
- School of Medicine , University of Belgrade, Belgrade, Serbia
| | - Milomir Milanovic
- Internal Medicine Department, Clinic for Infectious and Tropical Diseases, Military Medical Academy, Belgrade, Serbia
| | - Jovica Saponjski
- Cardiology Department, University Clinical Center of Serbia, Belgrade, Serbia
| | - Dario Roccatello
- Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, Torino, Italy
| | - Irene Cecchi
- Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, Torino, Italy
| | - Massimo Radin
- Nephrology and Dialysis Unit (ERK-net Member), Center of Research of Immunopathology and Rare Diseases, Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, San Giovanni Bosco Hospital, Torino, Italy
| | - Maurizio Benucci
- Rheumatology Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Daniel Pleguezuelo
- Immunology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Serrano
- Immunology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- *Correspondence: Manuel Serrano,
| | - Yehuda Shoenfeld
- Ariel University, Ariel, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Antonio Serrano
- Immunology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
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9
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Mengeot L, Marot L, Baeck M. Rapidly evolving necrotic skin lesions of the face. JAAD Case Rep 2022; 28:149-151. [PMID: 36274788 PMCID: PMC9579697 DOI: 10.1016/j.jdcr.2022.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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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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11
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Mitschang C, Ehrchen J, Görge T. Differentialdiagnose Vaskulitis und Vaskulopathie aus
dermatologischer Sicht. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1876-2616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
ZusammenfassungVaskulopathien und Vaskulitiden stellen diagnostisch und therapeutisch eine
interdisziplinäre Herausforderung dar. Zugrunde liegen unterschiedliche
pathophysiologische Mechanismen, die zu vielfältigen klinischen
Krankheitsbildern führen können und therapeutisch
unterschiedliche Ansätze erlauben. Sowohl Vaskulitiden als auch
Vaskulopathien müssen nicht zwangsläufig mit einer
Systembeteiligung einhergehen, sondern können auch als rein kutane
Varianten auftreten. Aufgrund mangelnder pathognomonischer Laborparameter ist
die Diagnose häufig klinisch zu stellen. Dieser Artikel soll den
differentialdiagnostischen Blick, insbesondere auf die kutanen
Manifestationsformen bei Vaskulopathien und Vaskulitiden, schärfen.
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Affiliation(s)
- Carolin Mitschang
- Abteilung für Wundheilung/Phlebologie,
Universitätsklinikum Münster Klinik für Hautkrankheiten,
Münster, Germany
| | - Jan Ehrchen
- Abteilung für Autoimmun-Dermatologie,
Universitätsklinikum Münster Klinik für Hautkrankheiten,
Münster, Germany
| | - Tobias Görge
- Abteilung für Wundheilung/Phlebologie,
Universitätsklinikum Münster Klinik für Hautkrankheiten,
Münster, Germany
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12
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Boggio F, Ciavarella A, Arcudi S, Gualtierotti R, Rossio R, Tafuri F, Artoni A, Peyvandi F. Plasma Exchange in a Patient with Immune Thrombocytopenia Associated with Antiphospholipid Syndrome Hospitalized for COVID-19. Rheumatol Ther 2022; 9:1213-1219. [PMID: 35704176 PMCID: PMC9199312 DOI: 10.1007/s40744-022-00469-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022] Open
Abstract
Thrombocytopenia is a common feature of antiphospholipid syndrome (APS) and rarely requires treatment. Here we present the case of a 71-year-old man hospitalized for severe immune thrombocytopenia (ITP) secondary to APS and concomitant SARS-CoV-2 infection. The patient was successfully treated with systemic corticosteroids, intravenous immunoglobulins, and plasma exchange (PEX). Few data are published on the use of plasma exchange in the treatment of thrombocytopenia in non-catastrophic APS. In the setting of acute infection when immunosuppressive therapies might be contraindicated, plasma exchange may be considered an effective therapeutic option. SARS-CoV-2 infection may be a trigger for a relapse of immune thrombocytopenia.
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Affiliation(s)
| | - Alessandro Ciavarella
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.,Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sara Arcudi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Roberta Gualtierotti
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Raffaella Rossio
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Tafuri
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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13
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Sevim E, Siddique S, Chalasani MLS, Chyou S, Shipman W, O'Shea O, Harp J, Alpan O, Zuily S, Lu T, Erkan D. Mammalian Target of Rapamycin Pathway Assessment in Antiphospholipid Antibody Positive Patients with Livedo. J Rheumatol Suppl 2022; 49:1026-1030. [PMID: 35649551 DOI: 10.3899/jrheum.220049] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In antiphospholipid antibody (aPL) nephropathy, activation of the mammalian target of rapamycin (mTOR) contributes to endothelial cell proliferation, a key finding of aPL microvascular disease. Here, we examined mTOR activation in the skin of aPL-positive patients with livedo. METHODS Three patient groups with livedo were studied: persistently aPL-positive with or without systemic lupus erythematosus (SLE), and aPL-negative SLE (control). After collecting aPL-related medical history, two 5-mm skin biopsies of livedo were performed on each patient: a) peripheral (erythematous-violaceous lesion), b) central (non-violaceous area). We stained specimens for phosphorylated protein kinase B (P-AKT) and S6 ribosomal protein (P-S6RP) as mTOR activity markers, CD31 to identify endothelial cells, and Ki-67 to show cellular proliferation. We counted cells in the epidermis and compared mTOR positive cell counts between peripheral and central samples, and between patient groups, using Freidman and Wilcoxon Rank tests. RESULTS Ten patients with livedo reticularis were enrolled (aPL-positive without SLE: 4 [APS classification met: 3], aPL-positive SLE: 4 [APS classification met: 3], and aPL-negative SLE [control]: 2). In all aPL-positive patients, epidermal P-AKT and P-S6RP staining were significantly increased in both peripheral and central skin samples when compared to aPL-negative SLE controls; both were more pronounced in the lower basal layers of epidermis. CONCLUSION Our study demonstrates increased mTOR activity in livedoid lesions of aPL-positive patients with or without SLE, compared to aPL-negative SLE patients, more profoundly in the lower basal layers of epidermis. These findings may serve as a basis for further investigating mTOR pathway in aPL-positive patients.
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Affiliation(s)
- Ecem Sevim
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
| | - Salma Siddique
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
| | - Madhavi Latha S Chalasani
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
| | - Susan Chyou
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
| | - William Shipman
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
| | - Orla O'Shea
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
| | - Joanna Harp
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
| | - Oral Alpan
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
| | - Stéphane Zuily
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
| | - Theresa Lu
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
| | - Doruk Erkan
- Department of Rheumatology, Hospital for Special Surgery, New York, NY USA; Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA; Pediatric Rheumatology, Hospital for Special Surgery, New York, NY USA; Autoimmunity and Inflammation Program, Hospital for Special Surgery Research Institute, New York, NY, USA; Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, USA; Weill Cornell Tri-Institutional MD-PhD Program, New York, NY, USA; Histology; Department of Dermatology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; O&O Alpan, LLC, Fairfax, VA, USA; CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases; Inserm U1116 at Lorraine University, Nancy, France. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA. Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA. Corresponding Author: Name: Ecem Sevim, MD, Address: 600 East 233rd Street, Bronx, NY 10466. E-mail:
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14
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Xie W, Ji L, Zhang Z. Sirolimus Monotherapy for Thrombocytopenia in Primary Antiphospholipid Syndrome: A Pilot Study From a Tertiary Referral Center. Front Immunol 2022; 13:857424. [PMID: 35401500 PMCID: PMC8989728 DOI: 10.3389/fimmu.2022.857424] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/25/2022] [Indexed: 01/20/2023] Open
Abstract
Background Thrombocytopenia (TP) is considered as a warning sign of high-risk antiphospholipid syndrome (APS) and sometimes a paradoxical sign of anti-thrombosis treatment. Currently, there is an extreme paucity of effective and safe drugs for long-term management of TP in primary APS patients; therefore, we explored the efficacy and safety of sirolimus monotherapy. Methods In this real-world study, we included 7 consecutive patients with primary APS who received sirolimus monotherapy for TP. Oral sirolimus was initiated at a dose of 1–2 mg once daily and then adjusted primarily based on clinical efficacy and tolerance, with consideration of the sirolimus trough concentration of ≤15 ng/ml. Results Of included patients, the median age was 58 years with a median disease course of 1.5 years and 4 patients were treatment-naïve. All patients completed 6 months of sirolimus therapy with a median follow-up of 6 months (range: 6–15). All patients received sirolimus monotherapy for TP during the entire follow-up, without any additional agents. Overall, the platelet count exhibited a substantially increasing trend after sirolimus administration during the first 6 months (p < 0.001) and stability later. Specifically, the median platelet count was significantly increased from 59 × 109/l before sirolimus to 90 × 109/l at month 1 (p = 0.028), 131 × 109/l at 3 months (p = 0.028), and 178 × 109/l at 6 months (p = 0.018). Overall and complete responses were respectively achieved in 6 (85.7%) and 5 (71.4%) patients at month 6. Importantly, overall response was achieved in all 4 treatment-naïve patients. Additionally, there were different extents of decline in the titers of antiphospholipid antibodies after sirolimus treatment. Regarding safety, only one patient experienced an elevated cholesterol level with recovery after atorvastatin treatment. Conclusion Sirolimus monotherapy confers good efficacy and tolerance for TP in primary APS patients and therefore may be considered as a first-line therapy.
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Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Lanlan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
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15
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Haraguchi Y, Nakamura K, Inoue M, Sasaki T, Minami K, Yoshimura S, Naito S. Antiphospholipid Syndrome Diagnosed as a Result of the Occurrence of an Ischemic Stroke After a Successful Catheter Ablation of Atrial Fibrillation and Continuous Direct Oral Anticoagulants. Int Heart J 2022; 63:153-158. [DOI: 10.1536/ihj.21-475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | | | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
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16
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Gamal S, Mohamed S, Moghazy A. Thrombocytopenia in a cohort of primary and secondary antiphospholipid syndrome patients: Relation to clinical, laboratory manifestations and damage index. Arch Rheumatol 2022; 37:252-260. [PMID: 36017208 PMCID: PMC9377168 DOI: 10.46497/archrheumatol.2022.9088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives
This study aims to evaluate the prevalence of thrombocytopenia in a cohort of patients with primary and secondary antiphospholipid syndrome (APS) and to examine the relation of thrombocytopenia to the clinical, laboratory findings, and damage index for antiphospholipid syndrome (DIAPS). Patients and methods
Between August 2018 and February 2019, a total of 168 patients (16 males, 152 females; mean age: 32.5±8.4 years; range, 18 to 59 years) who were followed in our clinic for APS were retrospectively analyzed. Medical records of the patients were screened and clinical data, laboratory investigations, and treatments applied were recorded. The DIAPS was calculated for all patients. The patients were divided into two groups according to the presence or absence of thrombocytopenia and both groups were compared regarding clinical, laboratory findings and DIAPS. Further subgroup analysis was done for patients with primary APS. Results
The most common clinical manifestations in our patients were obstetric manifestations (77.4% in pregnant women), musculoskeletal manifestations (69%) and peripheral vascular thrombosis (54.8%). The prevalence of thrombocytopenia in our study was 42.3%, and it was significantly associated with musculoskeletal manifestations (p=0.043), vascular thrombosis (p=0.043), neurological manifestations (p=0.030), cutaneous manifestations (p=0.006), and use of immunosuppressives (p=0.047). The DIAPS was significantly higher in the thrombocytopenia group (p=0.034). Further subgroup analysis of patients with primary APS revealed that neurological manifestations (p=0.010) were significantly higher in the thrombocytopenia group, while the DIAPS was higher in the thrombocytopenia group, but it did not reach statistical significance (p=0.082). Conclusion
Thrombocytopenia may be associated with a higher incidence of vascular thrombosis, neurological manifestations, musculoskeletal manifestations, use of immunosuppressive treatment, and DIAPS. In primary APS patients, thrombocytopenia may be a risk for neurological manifestations.
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Affiliation(s)
- Sherif Gamal
- Department of Rheumatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Samar Mohamed
- Department of Rheumatology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Abdelkawy Moghazy
- Department of Rheumatology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Jalili J, Pourghorban R, Mahmoudpour M, Akhavi Milani A. Partial Splenic Embolization for the Management of Severe Refractory Thrombocytopenia in Antiphospholipid Syndrome: A Case Report and Literature Review. Vasc Endovascular Surg 2022; 56:316-320. [PMID: 34978216 DOI: 10.1177/15385744211072682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Antiphospholipid syndrome is an autoimmune condition characterized by arteriovenous thromboembolic events. Thrombocytopenia is a common finding among these patients and is typically of mild severity not requiring any treatment. However, severe cases of thrombocytopenia should be treated. Steroids, intravenous immune globulin (IVIG), and immunomodulatory agents are the first-line treatment options, and surgical splenectomy is usually reserved for more severe and refractory cases of thrombocytopenia. Herein, we report the case of a 30-year-old man with primary antiphospholipid syndrome and severe thrombocytopenia. The patient's thrombocytopenia had been refractory to almost all the medical managements, and surgical splenectomy could not be an option due to the patient's high-risk condition for surgery. The patient was successfully managed by partial splenic embolization (PSE) which was a unique application of this technique.
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Affiliation(s)
- Javad Jalili
- Department of Interventional Radiology, Emam Reza Hospital, 48432Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ramin Pourghorban
- Department of Medical Imaging, 6488Nepean Hospital, Kingswood, NSW, Australia
| | - Masoud Mahmoudpour
- Department of Interventional Radiology, Emam Reza Hospital, 48432Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Akhavi Milani
- Department of Interventional Radiology, Emam Reza Hospital, 48432Tabriz University of Medical Sciences, Tabriz, Iran
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Cerebral Vein Thrombosis in the Antiphospholipid Syndrome: Analysis of a Series of 27 Patients and Review of the Literature. Brain Sci 2021; 11:brainsci11121641. [PMID: 34942943 PMCID: PMC8699363 DOI: 10.3390/brainsci11121641] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 02/02/2023] Open
Abstract
(1) Background: The Antiphospholipid Syndrome (APS) is a systemic autoimmune disorder characterized by arterial and/or venous thrombosis, pregnancy morbidity and raised titers of antiphospholipid antibodies. Cerebral vein thrombosis (CVT) is a rare form of cerebrovascular accident and an uncommon APS manifestation; the information in the literature about this feature consists of case reports and small case series. Our purpose is to describe the particular characteristics of CVT when occurs as part of the APS and compare our series with the patients published in the literature. (2) Methods: We conducted a retrospective observational study collecting data from medical records in three referral centers for APS and CVT, and a systematic review of the literature for CVT cases in APS patients. (3) Results: Twenty-seven APS patients with CVT were identified in our medical records, the majority of them diagnosed as primary APS and with the CVT being the first manifestation of the disease; additional risk factors for thrombosis were identified. The review of the literature yielded 86 cases, with similar characteristics as those of our retrospective series. (4) Conclusions: To our knowledge, our study is the largest CVT series in APS patients published to date, providing a unique point of view in this rare thrombotic manifestation.
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de Azevedo Lopes E, Balbi GGM, Tektonidou MG, Pengo V, Sciascia S, Ugarte A, Belmont HM, Gerosa M, Fortin PR, Lopez-Pedrera C, Ji L, Cohen H, de Jesús GR, Branch DW, Nalli C, Petri M, Rodriguez E, Kello N, Ríos-Garcés R, Knight JS, Atsumi T, Willis R, Bertolaccini ML, Erkan D, Andrade D. Clinical and laboratory characteristics of Brazilian versus non-Brazilian primary antiphospholipid syndrome patients in AntiPhospholipid Syndrome Alliance for Clinical Trials and InternatiOnal Networking (APS ACTION) clinical database and repository. Adv Rheumatol 2021; 61:64. [PMID: 34711275 DOI: 10.1186/s42358-021-00222-3] [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: 07/09/2021] [Accepted: 10/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is characterized by episodes of thrombosis, obstetric morbidity or both, associated with persistently positive antiphospholipid antibodies (aPL). Studying the profile of a rare disease in an admixed population is important as it can provide new insights for understanding an autoimmune disease. In this sense of miscegenation, Brazil is characterized by one of the most heterogeneous populations in the world, which is the result of five centuries of interethnic crosses of people from three continents. The objective of this study was to compare the clinical and laboratory characteristics of Brazilian vs. non-Brazilian primary antiphospholipid syndrome (PAPS) patients. METHODS We classified PAPS patients into 2 groups: Brazilian PAPS patients (BPAPS) and PAPS patients from other countries (non-BPAPS). They were compared regarding demographic characteristics, criteria and non-criteria APS manifestations, antiphospholipid antibody (aPL) profile, and the adjusted Global Antiphospholipid Syndrome Score (aGAPSS). RESULTS We included 415 PAPS patients (88 [21%] BPAPS and 327 [79%] non-BPAPS). Brazilian patients were significantly younger, more frequently female, sedentary, obese, non-white, and had a higher frequency of livedo (25% vs. 10%, p < 0.001), cognitive dysfunction (21% vs. 8%, p = 0.001) and seizures (16% vs. 7%, p = 0.007), and a lower frequency of thrombocytopenia (9% vs. 18%, p = 0.037). Additionally, they were more frequently positive for lupus anticoagulant (87.5% vs. 74.6%, p = 0.01), and less frequently positive to anticardiolipin (46.6% vs. 73.7%, p < 0.001) and anti-ß2-glycoprotein-I (13.6% vs. 62.7%, p < 0.001) antibodies. Triple aPL positivity was also less frequent (8% vs. 41.6%, p < 0.001) in Brazilian patients. Median aGAPSS was lower in the Brazilian group (8 vs. 10, p < 0.0001). In the multivariate analysis, BPAPS patients still presented more frequently with livedo, cognitive dysfunction and sedentary lifestyle, and less frequently with thrombocytopenia and triple positivity to aPL. They were also less often white. CONCLUSIONS Our study suggests a specific profile of PAPS in Brazil with higher frequency of selected non-criteria manifestations and lupus anticoagulant positivity. Lupus anticoagulant (not triple positivity) was the major aPL predictor of a classification criteria event.
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Affiliation(s)
| | - Gustavo Guimarães Moreira Balbi
- University of São Paulo, Av. Dr. Arnaldo 455, Third Floor, Room 3109, São Paulo, 01246903, Brazil.,Federal University of Juiz de Fora, Minas Gerais, Brazil
| | | | | | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, University of Turin, Turin, Italy
| | - Amaia Ugarte
- Hospital Universitario Cruces, Barakaldo, País Vasco, Spain
| | | | - Maria Gerosa
- Clinical Immunology and Rheumatology Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | | | - Chary Lopez-Pedrera
- Rheumatology Service, IMIBIC/Reina Sofia Hospital, University of Cordoba, Cordoba, Spain
| | - Lanlan Ji
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | | | - D Ware Branch
- University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | - Cecilia Nalli
- Rheumatology and Immunology Unit, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Roberto Ríos-Garcés
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Barcelona, Catalonia, Spain
| | - Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | | | - Rohan Willis
- Antiphospholipid Standardization Laboratory, University of Texas Medical Branch, Galveston, TX, USA
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, King's College London British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and Sciences, London, UK
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Disease, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Danieli Andrade
- University of São Paulo, Av. Dr. Arnaldo 455, Third Floor, Room 3109, São Paulo, 01246903, Brazil.
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A Novel Mutation in the VPS13B Gene in a Cohen Syndrome Patient with Positive Antiphospholipid Antibodies. Case Reports Immunol 2021; 2021:3143609. [PMID: 34484844 PMCID: PMC8413065 DOI: 10.1155/2021/3143609] [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: 07/02/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022] Open
Abstract
Cohen syndrome is an autosomal recessive disorder with the primary symptoms of mental deficiency, progressive retinopathy, hypotonia, microcephaly, obesity of midchildhood onset, intermittent neutropenia, and dysmorphic facial features. The syndrome has high phenotypic heterogeneity and is caused by loss-of-function mutations in the VPS13B gene. Here, we introduce a novel homozygous nonsense mutation (c.8698G > T, p.E2900X) in the VPS13B gene in an 11-year-old Iranian boy with major symptoms of Cohen syndrome. He also had mild anemia accompanied by positive antiphospholipid antibodies, the latter has never been previously reported in Cohen syndrome.
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21
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Thomas J, Philips G, Gladson CJ. Primary Antiphospholipid Antibody Syndrome-Associated Severe Thrombocytopenia and Thrombosis Treated Successfully With "Quadruple Therapy". J Clin Rheumatol 2021; 27:e208-e210. [PMID: 34431809 DOI: 10.1097/rhu.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Pardos-Gea J, Marques-Soares JR, Buján S, Ordi-Ros J, Alijotas-Reig J. Persistent thrombocytopenia predicts poor long-term survival in patients with antiphospholipid syndrome: a 38-year follow-up study. Rheumatology (Oxford) 2021; 61:1053-1061. [PMID: 34115832 DOI: 10.1093/rheumatology/keab475] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 05/25/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To investigate the impact of thrombocytopenia on survival in patients with antiphospholipid syndrome (APS). METHODS Thrombocytopenia and other predictors of outcome were retrospectively evaluated in an antiphospholipid-antibody (aPL)-positive and APS cohort with 38-year follow-up (1980-2018). Thrombocytopenia was defined as < 150 × 109 platelets/l. Hazard ratios (HR) of mortality were calculated using Cox-regression models. RESULTS Among 114 patients, 64% had primary APS, 25% secondary APS, and 10% asymptomatic aPL. Mean follow-up was 19 (5-38) years. ANA (HR 1.8, p= 0.10, 95%CI 0.8-3.6), arterial thrombotic events (HR 7.0, p= 0.016, 95%CI 1.4-3.5), myocardial infarction (HR 8.3, p= 0.03, 95%CI 1.1-59), intracardiac thrombosis (HR 17, p= 0.04, 95%CI 1-279), and thrombocytopenia (HR 2.9, p= 0.004, 95%CI 1.4-6.1) were risk factors for all-cause mortality but in multivariate analysis only thrombocytopenia (HR 2.7, p= 0.01, 95%CI 1.3-6.0) remained significant. Persistent (HR 4.4, p= 0.001, 95%CI 2.1-9.2) and low-moderate thrombocytopenia (HR 2.8, p= 0.01, 95%CI 1.2-6.4) were associated with a significant increase in mortality compared with acute (HR 1.6, p= 0.40, 95%CI 0.5-5.3) and severe forms (HR 2.1, p= 0.30, 95%CI 0.5-9.2). APS patients with vs without thrombocytopenia were more frequently male (58% vs 24%, p= 0.001) with arterial thrombosis (55% vs 32%, p= 0.04), LA positivity (100% vs 87%, p= 0.04), type I aPL profile (89% vs 71%, p= 0.05), and anticoagulant treatment (89% vs 63%, p= 0.01). Thrombosis caused 13% of deaths in thrombocytopenic patients and 1% in those without (p= 0.01). CONCLUSION Thrombocytopenia is an aPL-related manifestation that identifies patients with severe disease phenotype and high thrombotic risk. Persistent low-moderate thrombocytopenia is associated with a reduced long-term survival.
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Affiliation(s)
- José Pardos-Gea
- Universidad Autonoma de Barcelona, Vall d´Hebron University Hospital, Barcelona, Spain
| | | | - Segundo Buján
- Universidad Autonoma de Barcelona, Vall d´Hebron University Hospital, Barcelona, Spain
| | - José Ordi-Ros
- Universidad Autonoma de Barcelona, Vall d´Hebron University Hospital, Barcelona, Spain
| | - Jaume Alijotas-Reig
- Universidad Autonoma de Barcelona, Vall d´Hebron University Hospital, Barcelona, Spain
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23
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Incidental diagnosis of antiphospholipid antibody syndrome (APS) in a trauma patient with thrombocytopenia & its anesthetic management. Trauma Case Rep 2021; 33:100488. [PMID: 33997231 PMCID: PMC8100616 DOI: 10.1016/j.tcr.2021.100488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2021] [Indexed: 11/21/2022] Open
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24
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Gomez-Flores M, Herrera-Argaez G, Vazquez-Martinez O, Herz-Ruelas M, Ocampo-Candiani J, Villarreal-Martinez A, Galarza-Delgado DA, Hernandez-Galarza I, Chavez-Alvarez S. Cutaneous manifestations of antiphospholipid syndrome. Lupus 2021; 30:541-548. [PMID: 33583236 DOI: 10.1177/0961203321990100] [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: 11/17/2022]
Abstract
Antiphospholipid syndrome (APS) is an acquired thrombophilic disorder in which autoantibodies are produced against a variety of phospholipids and phospholipid-binding proteins. The purpose of this article is to review cutaneous findings in patients with APS diagnosis. An overview regarding prevalence, description, pathogenesis and histopathology, are described for cutaneous manifestations of APS.
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Affiliation(s)
- Minerva Gomez-Flores
- Servicio de Dermatología at Hospital Universitario "Dr. Jose Eleuterio Gonzalez" Universidad Autonoma de Nuevo León, Mexico, México
| | | | - Osvaldo Vazquez-Martinez
- Servicio de Dermatología at Hospital Universitario "Dr. Jose Eleuterio Gonzalez" Universidad Autonoma de Nuevo León, Mexico, México.,Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, México
| | - Maira Herz-Ruelas
- Servicio de Dermatología at Hospital Universitario "Dr. Jose Eleuterio Gonzalez" Universidad Autonoma de Nuevo León, Mexico, México
| | - Jorge Ocampo-Candiani
- Servicio de Dermatología at Hospital Universitario "Dr. Jose Eleuterio Gonzalez" Universidad Autonoma de Nuevo León, Mexico, México
| | - Alejandra Villarreal-Martinez
- Servicio de Dermatología at Hospital Universitario "Dr. Jose Eleuterio Gonzalez" Universidad Autonoma de Nuevo León, Mexico, México
| | | | - Ivan Hernandez-Galarza
- Servicio de Dermatología at Hospital Universitario "Dr. Jose Eleuterio Gonzalez" Universidad Autonoma de Nuevo León, Mexico, México
| | - Sonia Chavez-Alvarez
- Servicio de Dermatología at Hospital Universitario "Dr. Jose Eleuterio Gonzalez" Universidad Autonoma de Nuevo León, Mexico, México
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25
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Sayar Z, Moll R, Isenberg D, Cohen H. Thrombotic antiphospholipid syndrome: A practical guide to diagnosis and management. Thromb Res 2021; 198:213-221. [PMID: 33485122 PMCID: PMC7560059 DOI: 10.1016/j.thromres.2020.10.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/12/2020] [Accepted: 10/07/2020] [Indexed: 12/13/2022]
Abstract
Thrombotic antiphospholipid syndrome (APS) is characterised by venous, arterial and/or small vessel thrombosis in the context of persistently positive antiphospholipid antibodies (aPL). The diagnosis and management of thrombotic APS continues to prove challenging for clinicians. We provide a practical guide to the diagnosis of APS including who to test for aPL and which tests to do. We also consider clinical practice points on the management of venous, arterial and small vessel thrombosis, in the context of first and recurrent thrombotic events. Non-criteria manifestations of APS are reviewed. An approach to recurrent thrombosis and anticoagulant-refractory APS is discussed, with options including increasing the anticoagulation intensity of vitamin K antagonists, switching to low-molecular-weight-heparin, the use of fondaparinux and/or the addition of antiplatelet treatment. Adjunctive options such as vitamin D, hydroxychloroquine and statins are also addressed.
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Affiliation(s)
- Zara Sayar
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK; Department of Haematology, Whittington Health NHS Trust, London, UK.
| | - Rachel Moll
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK; Department of Rheumatology, University College London Hospitals NHS Foundation Trust, 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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26
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Yazıcı A. Definition and treatment approach of non-criteria clinical manifestations of antiphospholipid syndrome. Eur J Rheumatol 2020; 7:180-183. [PMID: 35929896 PMCID: PMC7574762 DOI: 10.5152/eurjrheum.2020.20099] [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: 05/23/2020] [Accepted: 08/11/2020] [Indexed: 03/27/2024] Open
Abstract
Antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy morbidity with persistently positive antiphospholipid antibodies. However, in APS, there are several non-thrombotic clinical manifestations such as thrombocytopenia, cardiac valve disease, microthrombotic nephropathy, skin ulcer, or cognitive dysfunction. These non-criteria manifestations are relatively common and usually are non-responsive to anticoagulation. Among the non-criteria manifestations, thrombocytopenia, skin ulcers, migraine, and heart valve lesions are the most frequent manifestations described in APS. Limited data are available on the treatment of non-criteria manifestations of APS, and most therapeutic options are based on case reports or retrospective non-randomized studies. Although there is no consensus on the treatment of non-criteria manifestations of APS, anticoagulant therapy and immunomodulatory drugs could be combined in most patients.
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Affiliation(s)
- Ayten Yazıcı
- Division of Rheumatology, Department of Internal Medicine, Kocaeli University School of Medicine, Kocaeli, Turkey
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27
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Markers of autoimmunity in immune thrombocytopenia: prevalence and prognostic significance. Blood Adv 2020; 3:3515-3521. [PMID: 31730698 DOI: 10.1182/bloodadvances.2019000400] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 10/29/2019] [Indexed: 01/19/2023] Open
Abstract
Prior studies have demonstrated an increased prevalence of autoimmune markers in patients with immune thrombocytopenia (ITP). Clinical experience has suggested that there may be an association between autoimmune markers and poor outcomes in ITP, but current guidelines do not encourage routine testing in these patients. We retrospectively assessed the prevalence of autoimmune markers in adult patients with ITP from our institutional database and used multiple logistic regression analyses to test for an association between autoimmune marker positivity and thrombotic events or clinical remission. We also assessed whether positivity for common autoimmune markers was associated with positivity for platelet autoantibodies. There was a high rate of autoimmune marker positivity in this population, with antinuclear antibody (65%), antithyroid peroxidase antibody (31%), and direct antiglobulin (29%) the most commonly found. Antithyroid peroxidase antibody positivity was associated with a lower probability of remission (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.09-0.79; P = .017). Lupus anticoagulant positivity was associated with a higher rate of thrombosis (OR, 8.92; 95% CI, 1.94-40.95; P = .005), and antinuclear antibody was strongly associated with thrombosis (P = .001). There was no relation between platelet autoantibody positivity and the presence of autoimmune markers. These results suggest that many patients with ITP have a state of immune dysregulation that extends beyond platelet autoantibodies and that certain autoimmune markers may be prognostically useful in this disorder.
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28
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He H, Wu N. A 75-year-old woman with primary antiphospholipid syndrome presenting with livedoid vasculopathy. Dermatol Ther 2020; 33:e13480. [PMID: 32359084 DOI: 10.1111/dth.13480] [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: 12/05/2019] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 11/30/2022]
Abstract
The clinical presentation of primary antiphospholipid syndrome (PAPS) can vary, often mimicking many other medical conditions. Therefore, it is difficult to diagnose at the first presentation because of the absence of classical symptoms. We described an unusual presentation of PAPS mimicking livedoid vasculopathy (LV), where the only diagnostic clue at the initial presentation was skin lesions in both lower legs. A 75-year-old Han Chinese woman presented with features mimicking LV, without clinically significant antiphospholipid syndrome (APS). After many relevant laboratory examinations and histopathological examination, the patient was finally diagnosed as having PAPS. LV should not be treated as an independent disease, but as a skin manifestation. A high degree of suspicion of APS is needed in patients presenting or diagnosed with LV. Early interventions are necessary to prevent and reduce the risk of thrombosis. This case presents a rare clinical manifestation and provides significant information on PAPS.
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Affiliation(s)
- Huinv He
- Department of Pathology, The central hospital of Xianyang City, Xianyang, Shaanxi, China
| | - Ning Wu
- Department of Dermatology, The central hospital of Xianyang City, Xianyang, Shaanxi, China
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29
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Abstract
Purpose of review Although antiphospholipid syndrome (APS) is best known for conveying increased risk of thrombotic events and pregnancy morbidity, thrombocytopenia is also recognized as a common association. In this review, we will explore the relationship between thrombocytopenia and APS, highlighting our evolving understanding – and persistent knowledge gaps – through clinically oriented questions and answers. Recent findings A history of thrombocytopenia likely portends a more severe APS phenotype (including increased risk of thrombosis). Although the pathophysiology underlying thrombocytopenia in APS has yet to be definitively revealed, mechanisms that play a role (at least in subsets of patients) include: immune thrombocytopenic purpura/ITP-like autoantibodies against platelet glycoproteins; antiphospholipid antibody (aPL)-mediated platelet activation and consumption; and potentially life threatening thrombotic microangiopathy. Although thrombocytopenia is often ‘mild’ in APS (and therefore, may not require specific therapy), there are causes of acute-onset thrombocytopenia that mandate emergent work-up and treatment. When APS-related thrombocytopenia does require therapy, the approach must be individualized (requiring an understanding of pathophysiology in the particular APS patient). For patients with ITP-like disease, rituximab is emerging as a popular approach to treatment; in contrast, there are hints that thrombopoietin mimetics may be associated with elevated thrombotic risk. Summary Thrombocytopenia is common in APS, and is likely associated with more severe disease. Improved understanding of thrombocytopenia in APS has the potential to improve risk stratification, reveal novel aspects of APS pathophysiology, and lead to treatments that are more individualized and holistic.
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30
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Retiform purpura: A diagnostic approach. J Am Acad Dermatol 2020; 82:783-796. [DOI: 10.1016/j.jaad.2019.07.112] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/15/2019] [Accepted: 07/28/2019] [Indexed: 12/28/2022]
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31
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Kim JW, Kim TW, Ryu KH, Park SG, Jeong CY, Park DH. Anaesthetic considerations for patients with antiphospholipid syndrome undergoing non-cardiac surgery. J Int Med Res 2020; 48:300060519896889. [PMID: 31937174 PMCID: PMC7113712 DOI: 10.1177/0300060519896889] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/02/2019] [Indexed: 12/30/2022] Open
Abstract
Antiphospholipid syndrome (APS) is an acquired thrombotic autoimmune disorder that is clinically characterized by the development of thrombosis and obstetric morbidities in patients with antiphospholipid antibodies. Due to hypercoagulability, the focus of management is anticoagulation for the prevention of thrombosis and its recurrence. When such patients undergo surgery, however, the underlying risk of thrombosis increases as a result of anticoagulant withdrawal, immobilization, and/or intimal injury. Conversely, there is also an increased risk of bleeding due to thrombocytopaenia, possible disseminated intravascular coagulation, or progression to catastrophic APS, as a result of excessive anticoagulation, surgery, and infection. Measures for appropriate perioperative anticoagulation are discussed in this review, as well as anaesthetic considerations for preventing perioperative complications in patients with APS undergoing non-cardiac surgery.
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Affiliation(s)
- Jae Won Kim
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Tae Woo Kim
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Keon Hee Ryu
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Sun Gyoo Park
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Chang Young Jeong
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
| | - Dong Ho Park
- Department of Anaesthesiology and Pain Medicine, Eulji University Medical Centre, Daejeon, Korea
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Sun Y, Zhao J, Zhang P, Wu C, Jiang N, Zhou J, Zhang S, Wu Q, Wang Q, Li M, Zeng X. Clinical characteristics and risk factors of microvascular involvement in primary antiphospholipid syndrome: a longitudinal single-center study in China. Lupus 2019; 28:1558-1565. [PMID: 31635555 DOI: 10.1177/0961203319882506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The objective of this study was to investigate risk factors of microvascular involvement and survival in Chinese patients with primary antiphospholipid syndrome. METHODS In this single-center, retrospective study, we enrolled 112 patients with a confirmed diagnosis of primary antiphospholipid syndrome who were admitted to Peking Union Medical College Hospital from January 2004 to December 2016. Demographic data, clinical characteristics, laboratory results, and follow-up records were collected. RESULTS A total of 112 patients with primary antiphospholipid syndrome were studied. Microvascular involvement was identified in 21 patients (18.75%). Patients with microvascular involvement experienced fewer episodes of arterial or venous thrombosis (28.6% vs. 84.6%) and a higher incidence of thrombocytopenia (85.7% vs. 54.9%), respectively. Low complement and elevated high-sensitivity CRP levels were observed more frequently in the microvascular group compared with the non-microvascular group (complement 38.1% vs. 18.7%; high-sensitivity CRP 71.4% vs. 31.9%, respectively). Anti-β2-glycoprotein I antibodies were more prevalent in patients with microvascular involvement than in patients without (66.7% vs. 33.0%, respectively). Multivariate logistic regression analysis revealed that thrombocytopenia (odds ratio = 4.523, 95% confidence interval 1.139-17.962), elevated high-sensitivity CRP levels (odds ratio = 6.385, 95% confidence interval 1.969-20.704), and anti-β2-glycoprotein I antibody positivity (odds ratio = 5.042, 95% confidence interval 1.555-16.352) were independent risk factors for microvascular involvement. A Kaplan-Meier analysis revealed that survival was significantly poorer in patients with microvascular involvement compared with patients without (p = 0.0278). CONCLUSIONS In addition to arterial and venous thrombosis, antiphospholipid syndrome can affect the microvasculature of select organs. It is thus important for clinicians to be aware that antiphospholipid syndrome-associated microvascular involvement has a unique pathogenesis and can be a life-threatening condition.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - X Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Artım-Esen B, Çene E, Şahinkaya Y, Erdugan M, Oğuz E, Gül A, Öcal L, İnanç M. Autoimmune haemolytic anaemia and thrombocytopaenia in a single-centre cohort of patients with systemic lupus erythematosus from Turkey: clinical associations and effect on disease damage and survival. Lupus 2019; 28:1480-1487. [DOI: 10.1177/0961203319877245] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction Thrombocytopaenia and autoimmune haemolytic anaemia (AIHA) have considerable impact on prognosis in systemic lupus erythematosus (SLE). We investigated the frequencies of these haemocytopaenias, along with their associations and effect on outcome in a single-centre cohort of patients with SLE. Methods Demographic characteristics, clinical features, autoantibody profiles, damage and mortality data were compared between patients with and without each haematological abnormality. Variables displaying significant differences between the groups were entered into logistic regression. Results Ninety-three patients had AIHA and 215 had thrombocytopaenia. Both were associated with neuropsychiatric (NP) involvement, with each other, leucopaenia, antiphospholipid syndrome (APS) and antiphospholipid antibodies. More patients in both groups had organ damage, and their damage scores were higher. Association to NP damage was discernible. In addition, cardiovascular and renal damage and diabetes were more pronounced in patients with thrombocytopaenia. At logistic regression analysis, younger age, anticardiolipin antibody IgM positivity, leucopaenia and thrombocytopaenia were associated with AIHA whilst lupus anticoagulant activity, AIHA, leucopaenia, APS and NP involvement were associated with thrombocytopaenia. Among damage items, peripheral vascular damage, diabetes, NP damage, renal and ocular damage displayed significant associations with thrombocytopaenia, whereas none of the items did with AIHA. Patients with AIHA had significantly reduced survival rates at 10 and 20 years. Conclusions We observed that AIHA and thrombocytopaenia were associated with severe lupus, affecting major organs and causing end organ damage. Thus, they may be considered as prognostic markers. Furthermore, AIHA and especially thrombocytopaenia may also be a marker for a subgroup of lupus patients who have or may develop APS.
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Affiliation(s)
- B Artım-Esen
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - E Çene
- Department of Statistics, Faculty of Arts and Sciences, Yıldız Technical University, Istanbul, Turkey
| | - Y Şahinkaya
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - M Erdugan
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - E Oğuz
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A Gül
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - L Öcal
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - M İnanç
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Affiliation(s)
- S Sciascia
- 1 Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Italy.,2 School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
| | - M Radin
- 1 Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Italy.,2 School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
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Pérez D, Stojanovich L, Naranjo L, Stanisavljevic N, Bogdanovic G, Serrano M, Serrano A. Presence of Immune Complexes of IgG/IgM Bound to B2-glycoprotein I Is Associated With Non-criteria Clinical Manifestations in Patients With Antiphospholipid Syndrome. Front Immunol 2018; 9:2644. [PMID: 30524428 PMCID: PMC6256181 DOI: 10.3389/fimmu.2018.02644] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/26/2018] [Indexed: 11/26/2022] Open
Abstract
Background: Antiphospholipid syndrome (APS) is an acquired autoimmune disorder defined by the presence of both clinical (thromboembolic events or pregnancy morbidity) and laboratory (antiphospholipid antibodies, aPL) manifestations. Despite their importance, several clinical manifestations strongly associated with APS such as livedo reticularis (LR), thrombocytopenia, sicca-ophthalmic(sicca), heart, or neurological manifestations are not included in the APS clinical classification criteria. Circulating immune complexes (CIC) formed by Beta-2-glycoprotein I (B2GPI) and aPL (B2-CIC) have been described and their presence has been related with thrombotic events. Methods: Cross-sectional and observational cohort study in APS patients with thrombotic symptomatology. Setting and Participants: Fifty-seven patients from the University Hospital Center Bezanijska Kosa (Belgrade, Serbia) who met the APS classification criteria (35 with primary APS and 22 with APS associated to systemic lupus erythematosus). This study aimed to determine the prevalence of B2-CIC in APS patients and to evaluate their association with clinical manifestations of APS not included in the classification criteria. Results: B2-CIC prevalence in APS patients was 19.3%. The presence of thrombocytopenia (OR:5.7), livedo reticularis (OR:5.6), sicca (OR:12.6), and leukopenia (OR:5.6) was significantly higher in patients with B2-CIC than in the rest of APS patients. C3 and C4 complement factor levels were significantly lower in B2-CIC positive patients, which suggests a greater consumption of complement. Patients with quadruple aPL positivity (triple aPL-positivity plus the presence of B2-CIC) showed a higher prevalence of thrombocytopenia, leucopenia and LR than those with single/double aPL-positivity. No significant differences were found in the frequencies observed in patients with triple-only vs. single/double aPL-positivity. There were no significant differences between patients with primary APS and lupus-associated APS regarding the prevalence of B2-CIC and outcomes. Conclusions: Presence of B2-CIC is strongly associated with several non-criteria clinical manifestations related to APS and to higher complement consumption. More studies are required to better understand the clinical significance of B2-CIC.
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Affiliation(s)
- Dolores Pérez
- Immunology Department, Hospital 12 de Octubre, Madrid, Spain
| | - Ljudmila Stojanovich
- Internal Medicine, "Bezanijska Kosa", University Medical Center, Belgrade, Serbia
| | - Laura Naranjo
- Immunology Department, Hospital 12 de Octubre, Madrid, Spain
| | | | - Gordana Bogdanovic
- Internal Medicine, "Bezanijska Kosa", University Medical Center, Belgrade, Serbia
| | - Manuel Serrano
- Immunology Department, Hospital 12 de Octubre, Madrid, Spain
| | - Antonio Serrano
- Immunology Department, Hospital 12 de Octubre, Madrid, Spain
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Paule R, Morel N, Le Guern V, Fredi M, Coutte L, Belhocine M, Mouthon L, le Jeunne C, Chauvin A, Piette JC, Costedoat-Chalumeau N. Classification of primary antiphospholipid syndrome as systemic lupus erythematosus: Analysis of a cohort of 214 patients. Autoimmun Rev 2018; 17:866-872. [DOI: 10.1016/j.autrev.2018.03.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/04/2018] [Indexed: 12/21/2022]
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Lusa A, Carlson A. Safety and efficacy of thrombopoeitin mimetics for refractory immune thrombocytopenia purpura in patients with systemic lupus erythematosus or antiphospholipid syndrome: a case series. Lupus 2018; 27:1723-1728. [DOI: 10.1177/0961203318770023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background While thrombopoeitin (TPO) agonists that act to simulate platelet production have been approved for use in steroid-refractory chronic immune thrombocytopenia purpura (ITP), there are few data on the safety and efficacy of these medications in patients with concurrent systemic lupus erythematosus (SLE) or antiphospholipid syndrome (APS). Given that these agents can increase all hematopoietic cell lineages, it is unclear if there is an increased risk for exacerbation of the underlying lymphocyte-driven autoimmune disease in this population. Case summaries This case series includes four patients with SLE, one with concurrent APS, who were treated for steroid-refractory ITP with TPO mimetics at the University of Virginia between 2005 and 2015. In three of the four cases the medication was successful in improving platelet counts and preventing bleeding events. In addition, none of the patients experienced thrombosis or worsening of their underlying autoimmune disease. Conclusions This case series suggests that TPO mimetics are safe and moderately effective in patients with ITP in the setting of SLE or APS and do not contribute to increased disease activity.
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Affiliation(s)
- A Lusa
- Fontaine Research Park, University of Virginia, USA
| | - A Carlson
- Fontaine Research Park, University of Virginia, USA
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Pontara E, Banzato A, Bison E, Cattini MG, Baroni G, Denas G, Calligaro A, Marson P, Tison T, Ruffatti A, Pengo V. Thrombocytopenia in high-risk patients with antiphospholipid syndrome. J Thromb Haemost 2018; 16:529-532. [PMID: 29316193 DOI: 10.1111/jth.13947] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Indexed: 01/08/2023]
Abstract
Essentials The prevalence of thrombocytopenia in patients with antiphospholipid syndrome is not well defined. We studied triple positive patients with antiphospholipid syndrome and its catastrophic variant. Prevalence of thrombocytopenia was 6% and 100% in patients who developed the catastrophic form. In triple positive patients thrombocytopenia is low and platelets drop during the catastrophic form. SUMMARY Background Thrombocytopenia is the most common non-criteria hematological feature in patients with antiphospholipid syndrome (APS). This condition is more common in patients with catastrophic APS (CAPS). Objectives To evaluate the prevalence of thrombocytopenia in a large series of high-risk patients with APS, and to assess the behavior of the platelet count during CAPS. Methods/Patients This was a cross-sectional study in which we analyzed the platelet counts of a homogeneous group of high-risk APS patients (triple-positive). Six of these patients developed a catastrophic phase of the disease, and the platelet count was recorded before the acute phase, during the acute phase, and at recovery. Results The mean platelet count in 119 high-risk triple-positive patients was 210 × 109 L-1 . With a cut-off value for thrombocytopenia of 100 × 109 L-1 , the prevalence of thrombocytopenia was 6% (seven patients). No difference between primary APS and secondary APS was found. In patients who suffered from CAPS, a significant decrease from the basal count (212 ± 51 × 109 L-1 ) to that at the time of diagnosis (60 ± 33 × 109 L-1 ) was observed. The platelet count became normal again at the time of complete remission (220 ± 57 × 109 L-1 ). A decrease in platelet count always preceded the full clinical picture. Conclusions This study shows that, in high-risk APS patients, the prevalence of thrombocytopenia is low. A decrease in platelet count was observed in all of the patients who developed the catastrophic form of the disease. A decrease in platelet count in high-risk APS patients should be considered a warning signal for disease progression to CAPS.
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Affiliation(s)
- E Pontara
- Department of Cardiac Thoracic and Vascular Sciences, Cardiology Clinic, Thrombosis Center, University of Padova, Padova, Italy
| | - A Banzato
- Department of Cardiac Thoracic and Vascular Sciences, Cardiology Clinic, Thrombosis Center, University of Padova, Padova, Italy
| | - E Bison
- Department of Cardiac Thoracic and Vascular Sciences, Cardiology Clinic, Thrombosis Center, University of Padova, Padova, Italy
| | - M G Cattini
- Department of Cardiac Thoracic and Vascular Sciences, Cardiology Clinic, Thrombosis Center, University of Padova, Padova, Italy
| | - G Baroni
- Department of Cardiac Thoracic and Vascular Sciences, Cardiology Clinic, Thrombosis Center, University of Padova, Padova, Italy
| | - G Denas
- Department of Cardiac Thoracic and Vascular Sciences, Cardiology Clinic, Thrombosis Center, University of Padova, Padova, Italy
| | - A Calligaro
- Department of Medicine, Clinical Rheumatology, University of Padova, Padova, Italy
| | - P Marson
- Apheresis Unit, Blood Transfusion Service, University of Padova, Padova, Italy
| | - T Tison
- Apheresis Unit, Blood Transfusion Service, University of Padova, Padova, Italy
| | - A Ruffatti
- Department of Medicine, Clinical Rheumatology, University of Padova, Padova, Italy
| | - V Pengo
- Department of Cardiac Thoracic and Vascular Sciences, Cardiology Clinic, Thrombosis Center, University of Padova, Padova, Italy
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Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of antiphospholipid antibodies, such as lupus anticoagulant, anticardiolipin antibodies and anti-β2-glycoprotein 1 antibodies. APS can present with a variety of clinical phenotypes, including thrombosis in the veins, arteries and microvasculature as well as obstetrical complications. The pathophysiological hallmark is thrombosis, but other factors such as complement activation might be important. Prevention of thrombotic manifestations associated with APS includes lifestyle changes and, in individuals at high risk, low-dose aspirin. Prevention and treatment of thrombotic events are dependent mainly on the use of vitamin K antagonists. Immunosuppression and anticomplement therapy have been used anecdotally but have not been adequately tested. Pregnancy morbidity includes unexplained recurrent early miscarriage, fetal death and late obstetrical manifestation such as pre-eclampsia, premature birth or fetal growth restriction associated with placental insufficiency. Current treatment to prevent obstetrical morbidity is based on low-dose aspirin and/or low-molecular-weight heparin and has improved pregnancy outcomes to achieve successful live birth in >70% of pregnancies. Although hydroxychloroquine and pravastatin might further improve pregnancy outcomes, prospective clinical trials are required to confirm these findings.
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Hisada R, Kato M, Sugawara E, Fujieda Y, Oku K, Bohgaki T, Amengual O, Yasuda S, Atsumi T. Thrombotic risk stratification by platelet count in patients with antiphospholipid antibodies: a longitudinal study. J Thromb Haemost 2017; 15:1782-1787. [PMID: 28662299 DOI: 10.1111/jth.13763] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Indexed: 08/30/2023]
Abstract
Essentials Thrombotic risk stratification is an unmet need in antiphospholipid antibody carriers. Platelet count and antiphospholipid score (aPL-S) were combined to predict thrombotic events. Patients with high aPL-S are at high thrombotic risk regardless of platelet count. If platelet count is low, patients with low aPL-S are also on high thrombotic risk. SUMMARY Background Thrombocytopenia is a non-criteria clinical manifestation of antiphospholipid syndrome. However, it remains to be elucidated whether thrombocytopenia increases thrombotic risk in antiphospholipid antibody (aPL) carriers. Objectives To investigate the impact of platelet count in terms of predicting thrombotic events in aPL carriers, and to stratify the thrombotic risk by combining platelet count and antiphospholipid score (aPL-S), which represents a quantification of aPL varieties and titers. Patients/methods A single-center, retrospective, longitudinal study comprising 953 consecutive patients who were suspected of having autoimmune disease between January 2002 and December 2006 was performed. Low platelet count was defined as a count of < 150 × 103 μL-1 at the time of aPL testing. Results A negative correlation was observed between aPL-S and platelet count (r = - 0.2477). Among aPL-positive patients, those with a low platelet count developed thrombosis more frequently than those without (hazard ratio [HR] 2.95, 95% confidence interval [CI] 1.11-7.88). Among aPL-negative patients, no difference was found in the predictive value of thrombosis regardless of platelet count. Patients with aPLs were further divided into two subgroups according to aPL-S. Among low-aPL-S patients, those with low platelet counts developed thrombosis more frequently than those without (HR 3.44, 95% CI 1.05-11.2). In contrast, high-aPL-S patients developed thrombosis frequently regardless of platelet count. Conclusions aPL carriers with low platelet counts are at high risk of developing thrombosis. In particular, 'low-aPL-S carriers' may be stratified by platelet count in terms of predicting future thrombotic events.
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Affiliation(s)
- R Hisada
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - M Kato
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - E Sugawara
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Y Fujieda
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - K Oku
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - T Bohgaki
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - O Amengual
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - S Yasuda
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - T Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine and Faculty of Medicine, Hokkaido University, Sapporo, Japan
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Foord A, Baca N, Buchbinder D, Mahajerin A. Lupus anticoagulant hypoprothrombinemia syndrome associated with severe thrombocytopenia in a child. Pediatr Blood Cancer 2017; 64. [PMID: 27862892 DOI: 10.1002/pbc.26357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/07/2016] [Accepted: 10/12/2016] [Indexed: 01/19/2023]
Abstract
Lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) comprises lupus anticoagulant, acquired hypoprothrombinemia, and often mild thrombocytopenia or normal platelets. It is usually associated with autoimmunity or postviral illness. We describe a case of a 10-year-old boy with oral bleeding and severe thrombocytopenia initially suggestive of immune thrombocytopenia. Secondary to bleeding, evaluation demonstrated prolonged coagulation tests and subsequently revealed the presence of lupus anticoagulant and hypoprothrombinemia, along with marked autoimmunity, suggestive of LAHPS. He was treated with intravenous immunoglobulin and hydroxychloroquine. This case report and discussion highlight the diagnostic and therapeutic challenges associated with LAHPS and coincident severe thrombocytopenia.
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Affiliation(s)
- Aimee Foord
- Hematology-Oncology Hospitalist Service, Division of Pediatrics, Seattle Children's Hospital, Seattle, Washington
| | - Nicole Baca
- Division of Hematology/Oncology, CHOC Children's Hospital, Orange, California
| | - David Buchbinder
- Division of Hematology/Bone Marrow Transplant, CHOC Children's Hospital, Orange, California
| | - Arash Mahajerin
- Division of Hematology, CHOC Children's Hospital, Orange, California
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Thrombocytopenia as a thrombotic risk factor in patients with antiphospholipid antibodies without disease criteria. Med Clin (Barc) 2017; 148:394-400. [PMID: 28153433 DOI: 10.1016/j.medcli.2016.11.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/04/2016] [Accepted: 11/03/2016] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The antiphospholipid syndrome (APS) is an acquired immune disorder defined by the presence of thrombosis (arterial and/or venous) and/or pregnancy morbidity along with the presence of positive antiphospholipid antibodies (aPL). There is a clear relationship between aPL and some events not included in the clinical criteria, including haematologic. OBJECTIVES a) to study the probability of developing clinical APS in patients with positive aPL and thrombopenia; b) to identify potential risk factors for thrombosis, and c) to study the association between thrombocytopenia and aPL. METHODS A retrospective study of 138 patients with positive aPL without fulfilling clinical criteria for APS. Thrombocytopenia was defined as a platelet count≤100,000/μl. Patients with other causes of thrombocytopenia were excluded. RESULTS Seventeen of the 138 (12%) patients in the study had thrombocytopenia. The mean platelet count was 60,000/μl. The risk of developing thrombocytopenia was higher in smokers (OR 2.8; P=.044), in those with lupus anticoagulant (OR 13.5; P<.001) and those with higher burden of aPL (OR 50.8; P<.001). After a mean follow-up of 146±60.3 months, 5 patients with thrombocytopenia (29.4%) developed thrombosis. CONCLUSIONS In our series, the incidence of thrombocytopenia is 12%. aPL-positive patients who develop thrombocytopenia have a potential risk of developing thrombosis. Tobacco could be a risk factor for thrombocytopenia. Autoantibodies load is a risk factor for the development of thrombocytopenia.
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Masiero A, Campos L, Vitor J, Nogueira T, Rosas A, Sztajnbok F, Rodrigues M, Fonseca A, Gasparello R, Diniz C, Oliveira S. TROMBOCITOPENIA COMO MANIFESTAÇÃO INICIAL DA SÍNDROME DO ANTICORPO ANTIFOSFOLIPÍDEO (SAF) PEDIÁTRICO E RESPOSTA AO RITUXIMABE: SÉRIE DE CASOS. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Treatment of Catastrophic Antiphospholipid Syndrome. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/b978-0-444-63655-3.00017-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Recurrent pulmonary embolism during dabigatran treatment in a patient with immune thrombocytopenic purpura. Thromb Res 2016; 148:23-24. [PMID: 27768935 DOI: 10.1016/j.thromres.2016.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 10/08/2016] [Accepted: 10/14/2016] [Indexed: 12/24/2022]
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Bizjak M, Bruck O, Kanduc D, Praprotnik S, Shoenfeld Y. Vaccinations and secondary immune thrombocytopenia with antiphospholipid antibodies by human papillomavirus vaccine. Semin Hematol 2016; 53 Suppl 1:S48-50. [PMID: 27312165 DOI: 10.1053/j.seminhematol.2016.04.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 13-year-old girl developed immune thrombocytopenic purpura (ITP) and concomitant positive antiphospholipid antibodies (aPL) following vaccination with a quadrivalent human papillomavirus (HPV) vaccine. During the course of a disease, she developed clinical manifestation with bleeding and she was treated with intravenous immunoglobulins. Consequently, the number of her platelets remained critically low and she was put on corticosteroids and rituximab. Since then, her platelet count remain within the normal range, but her aPL are still present.
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Affiliation(s)
- Mojca Bizjak
- The Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Or Bruck
- The Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Darja Kanduc
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, Italy
| | - Sonja Praprotnik
- Department of Rheumatology, University Medical Centre, Ljubljana, Slovenia
| | - Yehuda Shoenfeld
- The Zabludowicz Center for Autoimmune Diseases, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Incumbent of the Laura Schwarz-kipp chair for research of autoimmune diseases, Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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Rodriguez-Pintó I, Espinosa G, Cervera R. Catastrophic antiphospholipid syndrome: The current management approach. Best Pract Res Clin Rheumatol 2016; 30:239-249. [DOI: 10.1016/j.berh.2016.07.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 07/28/2016] [Accepted: 07/28/2016] [Indexed: 02/08/2023]
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Refractory Immunological Thrombocytopenia Purpura and Splenectomy in Pregnancy. Case Reports Immunol 2015; 2015:216362. [PMID: 26798527 PMCID: PMC4698536 DOI: 10.1155/2015/216362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/30/2015] [Accepted: 12/08/2015] [Indexed: 11/21/2022] Open
Abstract
Thrombocytopenia is defined as a platelet count of less than 100,000 platelets per microlitre (mcL). Thrombocytopenia develops in approximately 6-7% of women during pregnancy and at least 3% of these cases are caused by immunological platelet destruction. Herein, we present a pregnant woman who develops at the first trimester autoimmune thrombocytopenia purpura associated with positive antiphospholipid antibodies. The disease was refractory to pharmacological treatments but had a favourable response to splenectomy. The patient carried the pregnancy to term without complication and gave birth to a healthy baby girl.
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Abstract
The association between antiphospholipid antibodies (aPL) and clinical problems goes beyond what is stated in the antiphospholipid syndrome (APS) classification criteria, namely thrombosis and pregnancy morbidity, and thrombocytopenia is the most common non-criteria hematologic manifestation of aPL with a frequency ranging from 20 to 50 %. Thrombocytopenia is rarely severe, and hemorrhage is far less common than thrombosis. However, when anticoagulation is considered, it may constitute a clinical problem with increased bleeding risk. Furthermore, thrombocytopenia represents a risk factor for thrombosis in aPL-positive patients. Therefore, it is important to understand the pathogenesis and the clinical associations of thrombocytopenia to build the right medical approach in aPL-positive patients. In this paper, we review the literature on aPL/APS-associated thrombocytopenia and briefly discuss the other conditions that can result in thrombocytopenia as they have commonalities with APS and their recognition is important to establish the most appropriate treatment strategy.
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