Positive antiphospholipid antibodies and pulmonary embolism in a patient with adalimumab-induced lupus.

It is known that administration of tumor necrotic factor (TNF) inhibitors induces lupus. The case of a Crohn's disease patient who had been treated with adalimumab (ADA) and showed positive anti-DNA and antiphospholipid antibodies and developed pulmonary embolism is presented. Fortunately, early diagnosis and intervention helped her survive. Although ADA was withdrawn, the Crohn's disease did not recur, and the autoantibodies became negative without any steroid therapy. It is important to recognise that administration of TNF inhibitors may be associated with antiphospholipid syndrome. It is necessary to perform therapeutic interventions such as TNF inhibitor withdrawal and prompt anticoagulant therapy when such pathology is suspected.

Antiphospholipid antibody-activated NETs exacerbate trophoblast and endothelial cell injury in obstetric antiphospholipid syndrome.

Despite the widespread use of antiplatelets and anticoagulants, women with antiphospholipid syndrome (APS) may face pregnancy complications associated with placental dysplasia. Neutrophil extracellular traps (NETs) are involved in the pathogenesis of many autoimmune diseases, including vascular APS; however, their role in obstetric APS is unclear. Herein, we investigated the role of NETs by quantifying cell-free DNA and NET marker levels. Live-cell imaging was used to visualize NET formation, and MAPK signalling pathway proteins were analysed. Cell migration, invasion and tube formation assays were performed to observe the effects of NETs on trophoblasts and human umbilical vein endothelial cells (HUVECs). The concentrations of cell-free DNA and NETs in sera of pregnant patients with APS were elevated compared with that of healthy controls (HCs) matched to gestational week. APS neutrophils were predisposed to spontaneous NET release and IgG purified from the patients (APS-IgG) induced neutrophils from HCs to release NETs. Additionally, APS-IgG NET induction was abolished with inhibitors of reactive oxygen species, AKT, p38 MAPK and ERK1/2. Moreover, NETs were detrimental to trophoblasts and HUVECs. In summary, APS-IgG-induced NET formation deserves further investigation as a potential novel therapeutic target in obstetrical APS.

Hydroxychloroquine inhibits proinflammatory signalling pathways by targeting endosomal NADPH oxidase.

OBJECTIVES: Hydroxychloroquine (HCQ) has been used for decades to treat patients with rheumatic diseases, for example, systemic lupus erythematosus (SLE), rheumatoid arthritis or the antiphospholipid syndrome (APS). We hypothesise that HCQ might target endosomal NADPH oxidase (NOX), which is involved in the signal transduction of cytokines as well as antiphospholipid antibodies (aPL). METHODS: For in vitro experiments, monocytic cells were stimulated with tumour necrosis factor α (TNFα), interleukin-1ß (IL-1ß) or a human monoclonal aPL and the activity of NOX was determined by flow cytometry. The expression of genes known to be induced by these stimuli was quantified by quantitative reverse transcription PCR. Live cell imaging was performed by confocal laser scanning microscopy. Finally, the effects of HCQ on NOX-induced signal transduction were analysed in an in vivo model of venous thrombosis. RESULTS: HCQ strongly reduces or completely prevents the induction of endosomal NOX by TNFα, IL-1ß and aPL in human monocytes and MonoMac1 cells. As a consequence, induction of downstream genes by these stimuli is reduced or abrogated. This effect of HCQ is not mediated by direct interference with the agonists but by inhibiting the translocation of the catalytic subunit of NOX2 (gp91phox) into the endosome. In vivo, HCQ protects mice from aPL-induced and NOX2-mediated thrombus formation. CONCLUSIONS: We describe here a novel mechanism of action of HCQ, that is, interference with the assembly of endosomal NOX2. Since endosomal NOX2 is involved in many inflammatory and prothrombotic signalling pathways, this activity of HCQ might explain many of its beneficial effects in rheumatic diseases including the APS.

A possible coagulation-independent mechanism for pregnancy loss involving ß(2) glycoprotein 1-dependent antiphospholipid antibodies and CD1d.

PROBLEM ß(2) glycoprotein1 (ß(2) GP1)-dependent antiphospholipid antibodies (aPL) increase the risk for recurrent pregnancy loss. We address whether anti-ß(2) GP1 antibodies can interact with phosphatidylserine (PS)-bearing CD1d on trophoblast cells and induce local inflammation. METHODS CD1d-bearing choriocarcinoma cells were used in flow cytometry and immunoprecipitation experiments. CD1d-mediated cytokine induction was assessed using antibody cross-linking. Cytokine production during co-culture of decidual lymphocytes with CD1d-bearing cells was also examined. RESULTS Trophoblast surface-expressed CD1d forms a complex with PS-bound ß(2) GP1. Anti-ß(2) GP1 mAb cross-linking causes IL12p70 release from CD1d-bearing cells. IL12p70 release from CD1d-bearing trophoblast cells was also induced during co-culture with human decidual lymphocytes. The addition of anti-ß2GP1 mAb to co-cultures resulted in a three-fold increase in IL12p70 secretion. IFNγ secretion from decidual lymphocytes was also induced during co-culture with anti-ß2GP1 mAbs. CONCLUSIONS ß(2) GP1-dependent IL12 release from CD1d-bearing trophoblast in the presence of aPL may link the antiphospholipid syndrome to pregnancy loss via an inflammatory mechanism.

Modulation of trophoblast angiogenic factor secretion by antiphospholipid antibodies is not reversed by heparin.

PROBLEM Women with antiphospholipid antibodies (aPL) are at risk of miscarriage and pre-eclampsia, obstetrical disorders associated with reduced trophoblast invasion and spiral artery transformation. aPL target the placenta by binding beta(2) -glycoprotein I (ß(2) GPI) on the trophoblast. In this study, we determined whether aPL alter the trophoblast secretion of angiogenic factors and evaluated the effect of low molecular weight heparin (LMWH) on this response. METHOD OF STUDY First-trimester trophoblast was treated with anti-ß(2) GPI antibodies with or without LMWH. Angiogenic factor secretion was measured by enzyme-linked immunosorbent assay. RESULTS Trophoblast cells produced more vascular endothelial growth factor (VEGF), placenta growth factor (PlGF), and soluble endoglin following exposure to anti-ß(2) GPI Abs, and this occurred in both a MyD88-dependent and MyD88-independent manner. LMWH was unable to reverse the effects of the anti-ß(2) GPI Abs on trophoblast VEGF secretion, but enhanced PlGF. Strikingly, LMWH upregulated soluble fms-like tyrosine kinase receptor-1 (sFlt-1) secretion independently of aPL. CONCLUSION This study demonstrates that aPL perturb the secretion of trophoblast angiogenic factors. LMWH does not reverse this effect but exacerbates sFlt-1 secretion, a potent anti-angiogenic factor. These findings may help to explain why women with antiphospholipid syndrome, who are treated with heparin to prevent early pregnancy loss, remain at increased risk of developing late obstetrical complications, such as pre-eclampsia.

Neuroprotective effect of Fn14 deficiency is associated with induction of the granulocyte-colony stimulating factor (G-CSF) pathway in experimental stroke and enhanced by a pathogenic human antiphospholipid antibody.

Using a transgenic mouse model of ischemic stroke we checked for a possible interaction of antiphospholipid antibodies (aPL) which often cause thromboses as well as central nervous system (CNS) involvement under non-thrombotic conditions and the TWEAK/Fn14 pathway known to be adversely involved in inflammatory and ischemic brain disease. After 7 days, infarct volumes were reduced in Fn14 deficient mice and were further decreased by aPL treatment. This was associated with strongest increase of the endogenous neuroprotective G-CSF/G-CSF receptor system. This unexpected beneficial action of aPL is an example for a non-thrombogenic action and the double-edged nature of aPL.

Anti-endothelial antibodies interfere in apoptotic cell clearance and promote thrombosis in patients with antiphospholipid syndrome.

Antiphospholipid syndrome is an important cause of recurrent thrombotic events. The pathogenesis of the thrombosis remains unclear, but it has been suggested that anti-phospholipid Abs, which are laboratory markers for the disease and include species capable of binding to vascular endothelial cells, play an important role. We hypothesized that these anti-endothelial Abs promote thrombosis through interference with clearance of dying cells. We show that healthy endothelial cell monolayers effectively remove apoptotic endothelial cells, but this clearance is markedly inhibited by serum or IgG from patients with antiphospholipid syndrome and anti-endothelial Abs. In addition, patient sera or IgG opsonize apoptotic endothelial cells and cause enhanced Fc-mediated uptake by professional phagocytes. Importantly, the delayed clearance of apoptotic cells by healthy endothelial cells and the enhanced Fc-mediated macrophage uptake each result in procoagulant consequences, as judged by increased thrombin generation. The effects on apoptotic cell clearance were reproduced by a mAb derived from a patient with antiphospholipid syndrome, which binds to endothelial cells and is thrombogenic in experimental models. Taken together, our data support a novel, dual mechanism by which anti-endothelial Abs are prothrombotic in antiphospholipid syndrome by inhibiting removal of procoagulant apoptotic cells and by diverting their clearance to provoke inflammatory and prothrombotic changes in professional phagocytes.

Efeitos adversos materno-fetais associados às trombofilias e à síndrome do anticorpo antifosfolípide / Adverse maternal-fetal effects associated to thrombophilias and to the antiphospolipid syndrome

O feto representa um corpo estranho ao organismo materno, uma vez que traz antígenos paternos distintos daqueles de sua genitora, entretanto, durante a gestação, o organismo materno desenvolve uma resposta imune ao feto, levando à tolerância materno-fetal sem reações patogênicas. Quando ocorrem desequilíbrios nessa tolerância, pode haver complicações obstétricas (perdas fetais, abortamentos recorrentes, pré-eclâmpsia, descolamento prematuro de placenta e restrição no crescimento intra-uterino). A investigação dessas complicações requer análise da associação entre a presença de trombofilias e anticorpos antifosfolípides. Nas trombofilias são encontradas mutações genéticas (como a resistência à proteína C ativa - RCPA e mutação do Fator V Leiden), diminuição dos níveis séricos dos anticoagulantes naturais (proteína C, proteína S e antitrombina) e hiper-homocisteinemia, que levam a distúrbios hemostáticos, sugeridos como causa de eventos adversos na gravidez. A presença de anticorpo antifosfolípide pode inibir a secreção de gonadotrofina coriônica, afetando o desenvolvimento embrionário, inibir a proteína placentária anticoagulante, levando à trombose placentária e à perda fetal, aumentar a síntese de tromboxano, bem como reduzir a síntese de prostaciclinas nos vasos placentários. O objetivo da presente revisão é atualizar os gineco-obstetras em relação aos efeitos adversos obstétricos associados às trombofilias e à síndrome do anticorpo antifostolípide.

Treatment options for patients who have antiphospholipid syndromes.

The antiphospholipid thrombosis syndrome, associated with anticardiolipin (aCL) or subgroup antibodies, can be divided into one of six subgroups (I-VI). There is little overlap (about 10% or less) between these subtypes, and patients usually conveniently fit into only one of these clinical types. Although there appears to be no correlation with the type, or titer, of aCL antibody and type of syndrome, the subclassification of thrombosis and aCL antibody patients into these groups is important from the therapy standpoint. This article also reviews the clinical presentations associated with each of these six subgroups.

Síndrome de anticuerpos antifosfolípidos / Antiphospholipid antibody syndrome

La intención de esta publicación ha sido revisar una patología emergente y de impacto reproductivo como es el síndrome antifosfolípidos. Especialmente nuestro enfoque es hacia su relación con patología obstétrica y su enfrentamiento en el embarazo. Además se revisan sus nuevos criterios diagnósticos y las nuevas estrategias para su estudio y tratamiento los que han logrado modificar en forma considerable el pronóstico y consecuencias de la enfermedad durante la gestación y el puerperio.

Asociación entre anticuerpos antifosfolípidos y complicaciones de la gestación en mujeres de Costa Rica / Association between antibodies antiphospholipids and complications of the gestation in women of Costa Rica

Objetivo: Determinar asociación entre los anticuerpos antifosfolípidos y complicaciones de la gestación (aborto de cualquier tipo, preeclampsia, eclampsia, insuficiencia placentaria grave o parto antes de la semana 34 de gestación), tomando como base la población de pacientes del servicio de Obstetricia del Hospital México. Materiales y métodos: Estudio de casos y controles en la población de pacientes atendidas por el servicio de Obstetricia del Hospital México en el período comprendido entre enero de 2002 y diciembre de 2004. Se tomaron los datos del registro de egresos Hospitalarios, se hizo un análisis descriptivo, y un análisis univariado y multivariado de las principales variables registradas. Resultados: El promedio de edad de las pacientes en los casos y los controles no mostró diferencia significativa. La provincia de San José reporta el mayor porcentaje de casos con un 39.9 por ciento, seguido por Heredia con un 26.8 por ciento y Alajuela con un 24.6 por ciento. En cuanto al número de gestaciones, se determinó que no influyen significativamente en relación con el aborto y otras complicaciones de la gestación. El análisis univariado y multivariado mantiene asociación entre los antecedentes clínicos de las gestaciones anteriores, además de los anticuerpos antifosfolípidos respecto al aborto y otras complicaciones de la gestación. Conclusión: Los anticuerpos antifosfolípidos deberían ser tomados en cuenta como parte del seguimiento del embarazo en pacientes con historia de abortos y complicaciones de la gestación en embarazos previos.

Síndrome dos anticorpos antifosfolipídicos (SaAFLs) / Antiphospholipid antibodies syndrome

Os autores revisam a síndrome dos anticorpos antifosfolípides, condição mais comum dentre as causas hematológicas de trombose. São discutidos aspectos relacionados com a epidemiologia, etiopatogenia, associações, manifestações sistêmicas e cutâneas, critérios de diagnóstico clínico e laboratorial e tratamento desta entidade clínica. A experiência pessoal dos autores, baseada em 52 casos, é acrescentada quando se referem às manifestações dermatológicas. Segundo a literatura, estas são as primeiras manifestações em 41 por cento dos casos da síndrome.

Neuronal-binding antibodies from patients with antiphospholipid syndrome induce cognitive deficits following intrathecal passive transfer.

Antiphospholipid antibodies (aPL) have been suggested to play a role in causing cognitive and behavioral impairments. In the present study we investigated the pathogenic potential of aPL by intracerebro-ventricular (ICV) administration of immunoglobulins (IgG) from patients with antiphospholipid syndrome (APS). IgG, purified from the sera of four APS patients, was tested for binding to normal mouse brain by immunohistological staining. These IgG (7.5 microg) were injected ICV unilaterally to male C3H mice. Mice injected with IgG purified from pooled sera derived from healthy subjects served as controls. The mice were examined neurologically for motor function and coordination, and cognitively in a Morris water maze. The cognitive tests were performed with the experimenter blinded to the treatment. The performance of the mice in four separate experiments was compared by analysis of variance with repeated measures. IgG from one APS patient was found to bind best to neuronal structures in the hippocampus and cerebral cortex. Mice (n = 43) injected with this IgG performed worse in the water maze compared to the controls (n = 45) with significant effects of the aPL IgG on the overall performance of the mice (treatment, P < 0.03), on learning throughout the experiment (treatment x day, P < 0.02) and on short term memory (treatment x day xtrial, P < 0.002). IgG injected from two of the three other patients also bound specifically to mouse brain neurons and produced an impairment in performance of the water maze. These results support the hypothesis that aPL that gain access to the central nervous system may play a direct role in the pathogenesis of neurological manifestations of APS.

Thrombogenicity of beta 2-glycoprotein I-dependent antiphospholipid antibodies in a photochemically induced thrombosis model in the hamster.

We previously showed that beta(2)-glycoprotein I (beta(2)GPI)-dependent lupus anticoagulants (LAs) form bivalent antigen-antibody complexes with high affinity for phospholipids; these complexes are responsible for their in vitro anticoagulant effect. We now studied the role of these bivalent complexes in arterial thrombosis in the hamster. Three monoclonal antibodies (mAbs) raised against human beta(2)GPI were selected on the basis of their cross-reactivity with hamster beta(2)GPI. Two of these, one with LA activity, 5H2, and one with only anticardiolipin properties, 11E8, were infused at 0 to 10 mg/kg prior to photochemically induced vessel damage. 5H2 promoted thrombus formation dose dependently, raising the thrombus size from 6.0 arbitrary units (AU) in controls (n = 9) to 65.0 AU in the high-dose group (10 mg/kg, n = 6, P =.007). The LA(-) mAb 11E8 and mAb 27A8, reactive with human beta(2)GPI exclusively, did not significantly promote thrombus formation. In a second set of experiments, intact mAb 5H2 was compared to its fragments. Intact mAb 5H2 at 3.3 mg/kg and the equimolar dose of F(ab')(2) fragments (2.2 mg/kg) promoted thrombus formation equally well (55.8 AU, n = 8 and 62.5 AU, n = 7, respectively); mAb 5H2-derived Fab' fragments were inactive. Immunohistochemical analysis showed platelet-rich thrombi, with 5H2 or its F(ab')(2) fragments mainly bound to individual platelets. Our results indicate that bivalent immune complex formation plays an important role in the genesis of arterial thrombosis by certain antiphospholipid antibodies. Cellular activation via the Fc portion of these immune complexes, however, is not essential, because F(ab')(2) fragments of 5H2 still promote thrombus formation.

Anticuerpos antifosfolipidos y embarazo / Antiphospholipid antibodies and pregnancy

La frecuencia de los anticuerpos antifosfoslípidos durante el embarazo es variable y depende de los antecedentes maternos. La historia de perdidas fetales previas, es el mejor predictor de riesgo para nuevas pérdidas, principalmente en mujeres con lupus eritematoso sistémico. Estos anticuerpos ocasionan complicaciones fetales y maternas. El tratamiento médico de éste síndrome durante el embarazo es controvertido y debe ser individual. Por carencia de estudios controlados y aleatorizados, la combinación heparina y aspirina, continúa siendo la terapia de elección. Los corticoesteroides, los antimaláricos y la gamaglobulina endovenosa, se reservan para situaciones especiales. El cuidado y manejo de estos pacientes requiere de un equipo de expertos de diferentes disciplinas médicas

Estudo anatomopatologico de placentas de pacientes portadoras da sindrome antifosfolipide / Placental pathologic features in antiphospholipid syndrome

Objetivos: determinar as alteracoes placentarias mais frequentemente observadas em pacientes portadoras da sindrome antifosfolipide. Metodos: foram analisadas, macro e microscopicamente, as placentas de 15 pacientes portadoras da sindrome antifosfolipide, tratadas com heparina associada a aspirina. A ocorrencia de infartos vilosos, de trombose intervilosa ou subcorionica, de lesoes nos vasos de troncos vilosos, assim como as caracteristicas da arvore vilosa, foram pesquisadas. Resultados: macroscopicamente, o infarto placentario foi a lesao mais frequentemente observada (33,3 por cento). A analise microscopica, a presenca de lesoes nos vasos de troncos vilosos foi a principal alteracao constatada, sendo evidenciada hipertrofia da camada media em 93,3 por cento dos casos, edema da adventicia, em 73,3 por cento, e edema da intima, em 46,7 por cento, seguida pelo infarto placentario, observado em 46,7 por cento dos casos...

Retinopatia vascular associada à Síndrome Antifosfolípide / Vascular occlusive retinopathy associated with anti-phospholipid antibodies

Os autores descrevem 2 casos (4 olhos) de retinopatia vaso-oclusiva periférica severa associada à síndrome antifosfolípide e descrevem também a fisiopatologia e alternativas terapêuticas desta condiçäo especial