Plasma exchange and immunoadsorption effectively remove antiphospholipid antibodies in pregnant patients with antiphospholipid syndrome.

Conventional therapy with aspirin and/or heparin is at times incapable of preventing complications in high risk pregnancies of patients with antiphospholipid syndrome (APS). In those cases, a so-called second-line treatment protocol is used in addition to conventional therapy strategies. This manuscript is a report on three APS pregnant patients who were successfully treated with plasma exchange (PE) (two cases) or with immunoadsorption (IA) (one case) as a second-line treatment strategy. The efficacy of these procedures in removing anticardiolipin (aCL) and anti-ß(2)glycoprotein I (aß(2)GPI) antibodies from blood was evaluated. Serum samples were collected before and after 87 apheretic treatment sessions. Serum IgG/M aCL and IgG/M aß(2)GPI antibodies were determined using an "in-house" enzyme-linked immunosorbent assay and showed that all three patients had medium/high IgG aCL and aß(2)GPI titers. All three women had a successful pregnancy. A significant decrease in IgG aCL (P = 0.0001) and aß(2)GPI (P = 0.0001) antibody titers was observed after PE and IA sessions. There was moreover a significant, steady fall in serum IgG aCL pretreatment levels during the course of all three pregnancies (P = 0.0001, P = 0.0001, P = 0.001). The fall in IgG aß(2)GPI was significant in two of the patients (P = 0.0001, P = 0.0001) both with high antibody titers, but not in one with medium antibody titers, who was treated with PE (P = 0.17).

A case of myeloperoxidase-antineutrophil cytoplasmic antibody and anticardiolipin antibody-positive pyogenic arthritis, pyoderma gangrenosum, acne and hidradenitis suppurativa (PAPASH) syndrome with colitis.

A previous case report of colitis and serine proteinase 3-antineutrophil cytoplasmic antibody positivity in pyogenic arthritis, pyoderma gangrenosum (PG), acne and hidradenitis suppurativa (PAPASH) syndrome with colitis has been published. Herein, we report a similar case of myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) positivity. A 26-year-old man presented with recurrent aseptic pyogenic arthritis, acne, hidradenitis suppurativa and PG. Lower gastrointestinal endoscopy was performed, and colitis was observed. No PSTPIP1 gene mutation was found in the gene-sequencing test. Based on these findings and prior case reports, we diagnosed the patient with PAPASH syndrome, a PAPA spectrum disorder complicated by colitis. This patient had PAPASH syndrome with colitis and was MPO-ANCA and anticardiolipin antibodies-positive; it is unclear whether these antibodies play a role in this disease, but it may provide clues to further elucidate its pathogenesis.

Expression of human recombinant beta 2-glycoprotein I with anticardiolipin antibody cofactor activity.

To enable the synthesis of beta 2-glycoprotein I mutants we have established a stable Chinese hamster ovary cell line that expresses human beta 2-glycoprotein I up to 2.9 micrograms/10(6) cells/day. Recombinant beta 2-glycoprotein I is identical to the purified native protein with respect to cofactor activity revealed in a modified anti-cardiolipin ELISA. Autoimmune type anti-cardiolipin antibody requires recombinant beta 2-glycoprotein I in a dose-dependent manner to bind cardiolipin whilst binding of infectious type antibody is inhibited. The purified recombinant beta 2-glycoprotein I in serum free medium exists as two oligosaccharide species which upon deglycosylation have identical apparent molecular weight to the deglycosylated native protein.

Anticardiolipin antibodies block the inhibition by beta 2-glycoprotein I of the factor Xa generating activity of platelets.

Antiphospholipid antibodies, defined either by lupus anticoagulant (LA) activity or positive anticardiolipin immunoabsorbent assay (ACA) are associated with a predisposition to thromboses, recurrent fetal loss or thrombocytopenia. The mechanisms for these predispositions remain undefined. We have enriched immunoglobulin fractions from two patient plasmas to obtain antibodies with LA activity but no ACA, or conversely, with ACA positivity but no LA, in order to investigate in vitro characteristics which might explain a thrombotic propensity. beta 2-glycoprotein I (beta 2-GPI), the plasma cofactor required for ACA binding to negatively charged phospholipid, has previously been shown to inhibit prothrombinase generation in the presence of activated platelets (8). We now report that beta 2-GPI, at physiological concentrations, inhibits the generation of factor Xa in the presence of activated gel-filtered platelets. Further, ACA interferes with this inhibition, resulting in protracted, unopposed factor Xa generation. This interference with beta 2-GPI, a natural anticoagulant component of plasma, is potentially prothrombotic. LA immunoglobulins behave differently and inhibit factor Xa generation in a manner similar to beta 2-GPI. These findings provide the basis for a previously unsuspected mechanism for thrombosis in patients with aPL.

Effect of plasma from patients with primary antiphospholipid syndrome on platelet function in a collagen rich perfusion system.

The effect on platelet function of plasma from 9 patients with primary antiphospholipid syndrome (PAS) with previous thrombotic episodes was investigated under flow conditions. Five asymptomatic individuals with antiphospholipid antibodies (aPL) (A-aPL) and 14 normal controls were also studied. Patients and controls plasmas were added (1:20 v/v) to anticoagulated blood and perfused through annular chambers containing collagen rich vessel segments. The interaction of platelets with vessel subendothelium was morphometrically evaluated in thin sections. An increase in both covered surface and thrombi formation was observed in perfusions in the presence of PAS-plasma (mean +/- SD: 34.2% +/- 9.6% and 23.2% +/- 10.0% respectively) compared with control plasmas (21.4% +/- 7.3% and 10.1% +/- 7.7%, p < 0.01). Affinity purified anticardiolipin antibodies from one PAS patient showed a similar effect when added to normal blood. In contrast, A-aPL plasma had no effect on platelet-subendothelium interaction. In parallel studies, the same plasmas were incubated with isolated normal platelets before and after activation with ADP or collagen and the binding of immunoglobulins (Ig) was determined by flow cytometry. A significantly increased binding of Ig was observed in 8 out of 9 plasmas from PAS patients when platelets had been activated with collagen but not when resting or ADP activated platelets were used. No increased Ig binding to platelets was seen using A-aPL individuals plasma. These observations might help to explain the pathophysiology of the thrombotic events occurring in patients with PAS.

Immunoglobulin G from patients with antiphospholipid syndrome impairs the fibrin dissolution with plasmin.

Immunoglobulin G (IgG) isolated from normal human blood plasma stabilizes the structure of perfused crosslinked fibrin and prolongs the time for its dissolution with plasmin, when the fibrin surface is exposed to 500 s(-1) shear rate flow. The IgG from patients suffering in antiphospholipid syndrome with thrombotic complications exerts even stronger antifibrinolytic effect. A patient, whose IgG does not affect the fibrin dissolution with plasmin, displays a bleeding tendency. The shear stress-induced disassembly of the fibrin clots containing IgGs with antifibrinolytic potency occurs at a much more advanced stage of fibrin digestion, as evidenced by the electrophoretic pattern of the ureatreated samples. The antifibrinolytic effects are also produced under static conditions and these are caused by the variable portion of the IgG molecules (fragment Fab), whereas the constant part (fragment Fc) has no inhibitory effect. The IgGs with antifibrinolytic properties do not affect directly the plasmin activity in amidolytic assay, but the IgGs from APS patients obliterate the competition of the fibrin and the peptidyl-p-nitroanilide for the protease in the same assay system suggesting interference of the IgGs with the plasmin action on the fibrin substrate. Thus, the correlation of the clinical symptoms with the effect of the isolated IgG on the dissolution of perfused fibrin clots supports a physiological and a pathological role of IgG in the fibrinolytic process related to the variability of the cross-reactions of immunoglobulins with fibrin, fibrin degradation products or fibrin-plasmin complexes.

Comparison of the effects of anticardiolipin antibodies from patients with the antiphospholipid syndrome and with syphilis on platelet activation and aggregation.

Anticardiolipin antibodies (aCL) are induced both in the Antiphospholipid Syndrome (APS) and syphilis, but thrombosis, thrombocytopenia, and pregnancy loss occur only in the APS. Differences in specificity and function of aCL antibodies might explain clinical differences between APS and syphilis. This study compared the effects on platelet activation and aggregation of affinity purified IgG anticardiolipin antibodies from 6 patients with the APS (IgG-APS) and 5 patients with syphilis (IgG-syph). Platelet aggregation was studied by aggregometry and platelet activation by flow cytometry. In the presence of low concentrations of thrombin, ADP, or collagen, all 6 IgG-APS samples induced platelet aggregation and activation, but none of the IgG-syph samples had this effect. In the absence of platelet agonists, only 3 of 6 IgG-APS caused platelet aggregation and none caused platelet activation; IgG-syph had no effect. The IgG-APS samples but not IgG-syph bound phosphatidylserine by ELISA. We conclude that polyclonal antibodies specific for phosphatidylserine may induce platelet activation and aggregation in the presence of low concentrations of platelet agonists.

Immunoglobulin gene sequence analysis of anti-cardiolipin and anti-cardiolipin idiotype (H3) human monoclonal antibodies.

Heavy and light chain variable region nucleotide sequences were derived from 6 human hybridoma antibodies which bear characteristics of antibodies associated with the phospholipid antibody syndrome. All antibodies originated from non-autoimmune individuals and were polyspecific. Four of these reacted with cardiolipin (and other antigens) and three carried the H3 idiotype which is expressed on a high percentage of disease-associated anti-cardiolipin antibodies. This idiotype was localized to the lambda light chain of the H3 monoclonal antibody and found on two other antibodies which like H3 expressed V lambda 4 or the related V lambda 3 subgroup light chains. The H3 idiotype however did not define these subgroups nor was it required or sufficient for anti-cardiolipin activity. Anti-cardiolipin binding was found in VH1, VH3 and VH4 heavy chain families and in a V kappa 1 light chain. The D region was diverse in both length and gene usage. Although all cardiolipin binding antibodies showed little deviation from germline variable (V) gene sequences, where mutations occurred they tended to be replacement mutations and clustered in complementarity determining regions (CDR) suggesting these B cells were derived from antigen-driven responses. These results from our panel of hybridomas and their comparison to other human antibodies provide extensive information on the diversity of genetic elements which can be used by cardiolipin-binding antibodies. We also show gene sequences which encode the disease-associated H3 idiotype and its location on lambda light chains, which imply that some labda light chains may be preferentially utilized in auto-reactive hybridomas.

Elution of anticardiolipin antibodies and their cofactor beta 2-glycoprotein 1 from the placentae of patients with a poor obstetric history.

Anticardiolipin antibodies (aCL) were eluted from the placentae of four women with elevated serum levels of aCL, demonstrating that these antibodies are bound to affected placentae. Anticardiolipin antibodies bound to affected placentae were only of the IgG isotype and the level of aCL in placental eluates did not reflect serum levels. Anticardiolipin antibodies were not isolated from placental eluates of control normal pregnancies. beta 2-Glycoprotein 1, the anticardiolipin antibody cofactor, was present in the placental eluates from both control and antiphospholipid antibody (aPL) affected pregnancies and was localised in the syncytiotrophoblast by immunohistochemical analysis. Antinuclear antibodies were present in the placental eluates of 3 of the 4 patients with antiphospholipid antibody syndrome and were absent from the placental eluates of control pregnancies. The authors propose that anticardiolipin antibody binds directly to placental tissue, disrupting uteroplacental blood flow and/or transport through the villi.

The effect of human anticardiolipin antibodies on murine pregnancy.

Anticardiolipin antibodies (aCL) were affinity purified or isolated in the IgG fraction of serum from 6 patients with antiphospholipid antibody syndrome. Anticardiolipin antibodies from one patient consistently compromised murine pregnancy. However in 92% (45 of 49) of cases injection of human anticardiolipin antibodies had no adverse effect on murine pregnancy, regardless of whether affinity purified aCL or IgG fractions were used. It is concluded that in most cases human anticardiolipin antibodies alone do not induce murine fetal loss.

Isolation and purification of anticardiolipin antibody from plasma of a patient with antiphospholipid syndrome: induced generation of platelet thromboxane A2 synthesis.

Antiphospholipid antibodies, particularly anticardiolipin antibodies (aCL) are autoantibodies frequently detected in the serum of patients with systemic lupus erythematosus (SLE) and the primary antiphospholipid antibody syndrome (PAPS). These patients commonly suffer from thrombosis, recurrent fetal loss and thrombocytopenia. Since platelet aggregation is pivotal in the genesis of thrombosis, we tested the hypothesis that perturbation of platelet membrane by aCL/beta 2-glycoprotein (aCL/beta 2GP) complex could trigger the biosynthesis of TXA2, a proaggregatory metabolite of AA. The preincubation of 14C-arachidonic acid (14C-AA)-labeled platelet pellets (14C-PP) from normal individuals with aCL alone followed by incubation with thrombin, resulted in a moderate increase in platelet thromboxane B2 (14C-TXB2) biosynthesis when compared to controls (without aCL). Similar incubations with beta 2GP-I alone resulted in negligible 14C-TXB2 biosynthesis. In contrast, the preincubations of normal 14C-PP with aCL/beta 2GP-I complex resulted in marked thrombin-induced TXB2 biosynthesis, underscoring the requirement of beta 2GP-I in aCL-induced platelet TXB2 biosynthesis. Taken together, these results are consistent with the view that aCL/beta 2GP-I platelet interactions do play a role, at least in part, in platelet hyperactivity and thrombosis in antiphospholipid antibody syndrome.

Purification of anticardiolipin and lupus anticoagulant activities by using cardiolipin immobilized on agarose beads.

We describe a novel method for the purification of aPL, in which pure CL is immobilized on octyl-sepharose beads by hydrophobic interaction. No lipid contamination was present in eluates, and the system could be reutilized three times without loosing extracting capacity. Four patients with antiphospholipid syndrome were studied. A marked decrease in aCL and LA activities was found in all patient plasmas after the passage through a CL-octyl-sepharose column. Both activities were recovered in eluates which contained beta 2-GP-I and IgGs. beta 2-GP-I was also present in normal plasma eluates, which showed no aCL and slight LA activity. This method represents an improvement in the purification of aPL, and could be useful in explaining the mechanism of action of antibodies that are obtained using pure phospholipid as extracting matrix.

Binding of autoimmune cardiolipin-reactive antibodies to heparin: a mechanism of thrombosis?

Autoimmune CL-rA need a plasma protein, beta 2GPI, to bind anionic PL. While beta 2GPI could be the true antigen, beta 2GPI binding to solid phase heparin did not determine its recognition by CL-rA when using patient plasmas. We tested plasmas from four patients with antiphospholipid syndrome in this study and no CL-rA binding to heparin sepharose was obtained. On the contrary, when CL-rA were first purified from the plasmas by means of a CL-octyl sepharose column, the purified material bound to the heparin sepharose column. Thus, after recognizing beta 2 GPI, CL-rA bind heparin. 'In vivo' CL-rA binding to heparin like-substances could inhibit the anti-thrombotic properties of endothelial cells.

Primary antiphospholipid syndrome presented by total infarction of right kidney with nephrotic syndrome.

We report the case of a young woman with primary antiphospholipid syndrome (APS), which presented with acute renal failure, hypoproteinemia, hypoalbuminemia and nephrotic proteinuria. Investigations showed total infarction of right kidney by extensive arterial and vein thrombosis and presence of anticardiolipin antibodies IgG isotype (anti-beta2-glycoprotein I-positive). She was submitted to right nefrectomy and initiated anticoagulant therapy. After nefrectomy, the postoperative period was marked by the development of arterial hypertension and persistence of nephrotic syndrome. Hypertension was treated with antihypertensive drugs (IECA, beta-blocker and calcium antagonist). As the nephrotic syndrome persisted despite anticoagulant and antihypertensive therapy, the patient was treated with oral corticosteroids. Her renal function improved, hypoproteinemia and hypoalbuminemia corrected to normal values and proteinuria decreased to subnephrotic value. We discuss the unusual presentation of this case of primary antiphospholipid syndrome with total unilateral renal thrombosis and nephrotic syndrome that respond to anticoagulant, antihypertensive and corticosteroid therapy.

Venous dural sinus thrombosis in a middle-aged woman with anticardiolipin antibodies.

Anticardiolipin antibodies are circulating autoantibodies directed against phospholipids. They have been previously associated with systemic venous and arterial but not with cerebral venous thrombosis. We describe the case of a middle aged woman with circulating anticardiolipin antibodies who suffered from dural sinus transversus and jugular venous thrombosis documented by Nuclear Magnetic Resonance (NMR).

Sneddon's syndrome associated with anticardiolipin antibody: a case report.

We report the case of a young man suffering from the rare combination of livedo reticularis and recurrent ischemic cerebrovascular disease (Sneddon's syndrome). He also had a circulating anticardiolipin antibody. in the absence of systemic lupus erythematosus, we suggest the likelihood of a primary antiphospholipid syndrome.

[Sneddon syndrome: 9 cases]. / Syndrome de Sneddon: 9 cas.

We observed a series of 9 patients (1 male, 8 females, mean age 49 years) who had experienced cerebral vascular events with livedo racemosa (Sneddon's syndrome). Vascular dementia occurred in 3 patients and in the 6 others there was a single or several acute cerebral ischaemic events. Angiography of the brain revealed multiple distal arterial occlusions in 5 cases and a moya-moya type collateral network in 2. Positivity for anticardiolipid antibodies fluctuated in 4 cases and there was a lupic syndrome in 2. Systemic lupus erythemosus was diagnosed in the last patient. Mitral valve defects were seen in 5 patients, including 3 due to post-rhematitis sequelae which became symptomatic before the appearance of signs of neurocutaneous involvement. Among these three patients, laboratory tests revealed a lupus band in one, anticardilipid antibodies in another and obliterating fibrous endartiritis of the renal arteries in the third. Sneddon's syndrome presents with heterogeneous signs related to its complex pathophysiology.

Avascular necrosis of the medial femoral condyle in HIV-infected patients.

Avascular necrosis (AVN) of the femoral head has been described in the literature in patients infected with the human immunodeficiency virus. It has been associated with either a hypertriglyceridemic state or the presence of antiphospholipid antibodies. We describe a case of AVN of the medial femoral condyle in an HIV-infected patient associated with a hypertriglyceridemic state.

Anticardiolipin antibody in recurrent spontaneous aborting and fertile women.

OBJECTIVE: To determine the association between the presence of anticardiolipin antibody and a history of recurrent spontaneous abortion. STUDY DESIGN: Clinical controlled study. LOCATION: Department of Gynecology and Obstetrics-University of Campinas (UNICAMP). SUBJECTS: 52 individuals with recurrent spontaneous abortion were included in Group 1 and 104 individuals with at least one live born child in Group 2. Elapsed time from last delivery to blood sampling varied from six months to two years. METHOD: Between November 1993 and November 1994, patients' blood samples were screened for anticardiolipin antibody by ELISA, as described by Triplett, Barna and Unger (1993). ANALYSIS: Chi-square and Fisher's Exact tests were used for statistical analysis. Student's "t" test was used to compare the means. RESULTS: There was no statistical difference in the presence of the anticardiolipin antibody between Group 1 (zero and 2.9%) and Group 2 (7.7 and 5.8%). CONCLUSION: There was no association between the presence of anticardiolipin antibody and recurrent spontaneous abortion.

[Chorea and primary antiphospholipid syndrome]. / Chorea en het primaire antifosfolipidensyndroom.

Primary antiphospholipid syndrome or PAPS is characterised by antiphospholipid antibodies and arterial and/or venous thromboses. Numerous other clinical features have been shown to be related to this syndrome. Chorea is a well known but rare phenomenon in systemic lupus erythematosus; it has been shown to be strongly related to the presence of antiphospholipid antibodies. We describe two patients with chorea that appeared to be caused by the PAPS.