Novel diagnostic and therapeutic frontiers in thrombotic anti-phospholipid syndrome.

The anti-phospholipid syndrome (APS) is an autoimmune disorder characterized by vascular thrombosis and/or pregnancy morbidity, associated with a persistent positivity for anti-phospholipid antibodies (aPL). The current classification criteria for APS include three laboratory tests: lupus anti-coagulant (LA), anti-cardiolipin (aCL), and anti-ß2 glycoprotein-I (ß2GPI). To date, the therapeutic approach for thrombotic APS mainly centers on long-term anti-coagulation with a vitamin K antagonist (VKA). APS management may represent a challenge for the treating physicians. Patients with different aPL profiles need a tailored risk-stratified approach. Moreover, in patients with recurrent thrombotic events despite therapy with VKA, or in those with microvascular involvement, new therapeutic options are highly needed. In this review, we aim to elucidate recent findings about new aPL specifities, available risk scoring models, and novel therapeutic approaches in APS management.

Pandemic influenza immunization in primary antiphospholipid syndrome (PAPS): a trigger to thrombosis and autoantibody production?

OBJECTIVE: The objective of this report is to conduct short- and long-term evaluation of a large panel of antiphospholipid (aPL) autoantibodies following pandemic influenza A/H1N1 non-adjuvant vaccine in primary antiphospholipid syndrome (PAPS) patients and healthy controls. METHODS: Forty-five PAPS and 33 healthy controls were immunized with H1N1 vaccine. They were prospectively assessed at pre-vaccination, and three weeks and six months after vaccination. aPL autoantibodies were determined by an enzyme-linked immunosorbent assay (ELISA) and included IgG/IgM: anticardiolipin (aCL), anti-beta2glycoprotein I (anti-ß2GPI); anti-annexin V, anti-phosphatidyl serine and anti-prothrombin antibodies. Anti-Sm was determined by ELISA and anti-double-stranded DNA (anti-dsDNA) by indirect immunofluorescence. Arterial and venous thrombosis were also clinically assessed. RESULTS: Pre-vaccination frequency of at least one aPL antibody was significantly higher in PAPS patients versus controls (58% vs. 24%, p = 0.0052). The overall frequencies of aPL antibody at pre-vaccination, and three weeks and six months after immunization remained unchanged in patients (p = 0.89) and controls (p = 0.83). The frequency of each antibody specificity for patients and controls remained stable in the three evaluated periods (p > 0.05). At three weeks, two PAPS patients developed a new but transient aPL antibody (aCL IgG and IgM), whereas at six months new aPL antibodies were observed in six PAPS patients and none had high titer. Anti-Sm and anti-dsDNA autoantibodies were uniformly negative and no new arterial or venous thrombosis were observed throughout the study. CONCLUSIONS: This is the first study to demonstrate that pandemic influenza vaccine in PAPS patients does not trigger short- and long-term thrombosis or a significant production of aPL-related antibodies (ClinicalTrials.gov, #NCT01151644).

The selective estrogen receptor modulator DT56a (Femarelle) does not affect platelet reactivity in normal or thrombophilic postmenopausal women.

OBJECTIVE: The purpose of this study was to assess the effect of DT56a (Femarelle), a selective estrogen receptor modulator, on platelet function in normal and thrombophilic women being treated for severe menopausal symptoms. METHODS: The Platelet Function Analyzer-100 (PFA-100) was used to asses platelet reactivity at baseline and after 8 weeks of treatment with Femarelle (644 mg/d in divided doses) in 25 symptomatic postmenopausal women with normal clotting times and seven symptomatic women with shortened clotting times (<61 s). The PFA-100 measure of closure time is considered equal to clotting time in assessing clotting function and platelet adhesion, aggregation, and blood coagulation factors. Closure times were measured after 3 and 8 weeks in all participants and at 1 year in the women with shortened clotting times. The nonparametric Wilcoxon signed rank test was used to assess the changes between baseline and each of the three subsequent measurements. RESULTS: Pretreatment study of all seven women with shortened closure times confirmed abnormalities associated with thrombophilia: four women were heterozygous for the factor V Leiden gene mutation, one was heterozygous for the prothrombin gene mutation, one was found to have protein S deficiency, and one had increased anticardiolipin antibodies. All participants reported improved symptoms during the treatment period. No significant change in closure times was found in the normally clotting participants after 3 or 8 weeks of Femarelle therapy (P > 0.26). No significant change in closure time was seen in the seven thrombophilic women after 3 or 8 weeks or 1 year of Femarelle treatment (P > 0.26). The regression curve for measures over time was not significant (P = 0.26). CONCLUSIONS: Femarelle, whose active ingredient is DT56a, did not adversely affect platelet reactivity as measured by PFA closure times in symptomatic thrombophilic postmenopausal women or normal controls. Femarelle, a novel selective estrogen receptor modulator that inhibits menopausal symptoms without thrombogenicity, may offer a new clinical choice for therapy of symptomatic postmenopausal women.

Hypertension with elevated levels of oxidized low-density lipoprotein and anticardiolipin antibody in the circulation of premenopausal Indian women chronically exposed to biomass smoke during cooking.

UNLABELLED: This study aims to investigate whether indoor air pollution (IAP) from biomass fuel use was associated with hypertension, platelet hyperactivity, and elevated levels of oxidized low-density lipoprotein (oxLDL) and anticardiolipin antibody (aCL). We enrolled 244 biomass fuel-using (median age 34 year) and 236 age-matched control women who cooked with liquefied petroleum gas (LPG). Enzyme-linked immunosorbent assay was used to measure oxLDL in plasma and aCL in serum, flow cytometry for P-selectin expression on platelet and reactive oxygen species (ROS) generation by leukocytes, aggregometry for platelet aggregation, spectrophotometry for superoxide dismutase (SOD) in erythrocytes, and laser photometer for particulate matter <10 and 2.5 µm in diameter (PM(10) and PM(2.5), respectively) in cooking areas. Biomass users had three times more particulate pollution in kitchen, had higher prevalence of hypertension (29.5 vs. 11.0% in control, P < 0.05), elevated oxLDL (170.6 vs. 45.9 U/l; P < 0.001), platelet P-selectin expression (9.1% vs. 2.4%), platelet aggregation (23.2 vs. 15.9 Ohm), raised aCL IgG (28.7% vs. 2.1%), IgM (8.6% of vs. 0.4%), and ROS (44%) but depleted (13%) SOD. After controlling potential confounders, the changes were positively associated with PM(10) and PM(2.5) in indoor air, suggesting a positive association between IAP and increased cardiovascular risk. PRACTICAL IMPLICATIONS: The study showing high risk of developing cardiovascular diseases (CVD) among poor, underprivileged women in their reproductive ages in rural India is important from public health perspectives. It may motivate the government and the regulatory agencies of the country to take a serious note of the indoor air pollution (IAP) from biomass fuel use as it threatens the health of millions of women, children, and the elderly who mostly stay indoor. We hope the findings will strengthen the demand for setting up a standard for indoor air quality in the country in the line of national ambient air quality standard. The findings may also inspire the authorities to take measures for the reduction in IAP by improving housing, kitchen ventilation, and cook stoves. Moreover, the parameters used in this study can be utilized for large, population-based studies to identify women at a higher risk of developing CVD so that medical intervention can be taken at the formative stage of a disease.

Differences in individual efficacy of two Sairei-to preparations (Sojyutu-Sairei-to and Byakujyutu-Sairei-to) on recurrent spontaneous abortions of autoimmune etiologies evaluated by antinuclear antibody and anticardiolipin antibody titers.

The differences in individual efficacy of two Sairei-to preparations (Sojyutu-Sairei-to and Byakujyutu-Sairei-to) on antinuclear antibody (ANA) and anticardiolipin antibody (ACLA) positive recurrent spontaneous abortion (RSA) was analyzed in 52 patients (a total of 61 treatment sessions). Patients who failed to respond to initial treatment with Sojyutu-Sairei-to were additionally treated with Byakujyutu- Sairei-to, and the time course of ANA and ACLA titers in these patients was analyzed. ACLA titers were decreased significantly by the treatment of Byakujyutu-Sairei-to, however, the percentage of successfully prevented abortion cases did not differ significantly between the Sojyutu-Sairei-to treatment group and the Byakujyutu-Sairei-to treatment group. ACLA titer was decreased in all 10 cases where abortion was successfully prevented by the treatment with Sojyutu-Sairei-to or Byakujyutu-Sairei-to. In the cases where both ANA and ACLA were decreased following treatment with Sojyutu-Sairei-to or Byakujyutu-Sairei-to, the percentage of cases rated as "Kyo" and "Rikan" were significantly higher in the Byakujyutu-Sairei-to group. These results indicate that Byakujyutu-Sairei-to is effective against ACLA positive RSA through the antibody-reducing activity, which differs from that of Sojyutu-Sairei-to in individual cases. On the basis of these results, Sairei-to therapy, which is superior to aspirin and heparin in terms of efficacy and safety, is recommended as the first-line therapy for RSA of autoimmune etiologies. Furthermore, to elevate the percentage of successfully prevented abortions, it is advisable to select one of the two Sairei-to preparations (Sojyutu-Sairei-to and Byakujyutu-Sairei-to) on the basis of differential diagnosis using the methods of Oriental medicine.

Graves' disease associated with anticardiolipin antibody positivity and acquired protein S deficiency.

A 33-year-old woman had experienced recurrent pregnancy loss. She had positive anticardiolipin antibody and protein S deficiency. Her pregnancy was managed with anticoagulant therapy and she delivered a healthy infant. Three years after delivery, she reported progressive sweating, tremor, tachycardia, and a 4-kg weight loss. She was diagnosed with Graves' disease. This is a rare case of combined anticardiolipin antibody positivity, acquired protein S deficiency, and Graves' disease.

[Clinical observation on effect of Chinese herbal medicine plus human chorionic gonadotropin and progesterone in treating anticardiolipin antibody-positive early recurrent spontaneous abortion].

OBJECTIVE: To find a method without corticosteroids, aspirin or heparin for treatment of anticardiolipin antibody-positive early recurrent spontaneous abortion (AARSA). METHODS: Twenty-three patients of AARSA in the treated group were treated with Chinese herbal medicine (CHM) plus human chorionic gonadotropin and progesterone, and 18 patiens in the control group were treated with multi-vitamin only. The change of anticardiolipin antibody was determined by enzyme linked immunoabsorbent assay (ELISA). RESULTS: After treatment, anticardiolipin antibody negative converted in 20 cases (86.9%) of the treated group. The cure rate of abortion in the treated group was 82.6% (19/23), which was raised to 95% (19/20) in those patients with antibody negative conversion, while in the control group, it was 16.7% (3/18) merely, comparison between the two groups in cure rate showed significant difference (P < 0.01). CONCLUSION: CHM plus human chorionic gonadotropin and progesterone could cure AARSA effectively.

Central nervous system involvement in a child with polyarteritis nodosa and severe atopic dermatitis.

Polyarteritis nodosa is a diffuse vasculitis of small- and medium-sized muscular arteries that can involve the vessels of one or several organ systems. We report an 11-year-old boy with severe atopic dermatitis further complicated with erythroderma and cerebellar symptoms. Laboratory studies showed negative antinuclear antibodies and antineutrophil cytoplasmic antibodies; increased serum complement, IgG cryoglobulins 96.8 mg/dL (0-80) and serum IgG 2,160 mg/dL (613-1,295), and positive alpha-cardiolipin test. The IgE value was high. Skin prick tests and RAST were positive for dust mites and casein. The viral profile was negative. Imaging studies disclosed tortuousity in the vessels and ischemic infarction in the cerebellum and thalamus. A diagnosis of polyarteritis nodosa with central nervous system involvement was made. The patient improved with immunosuppressive therapy and thalidomide. Currently, the patient is controlled and in a rehabilitation program. Other cases of polyarteritis nodosa associated with atopic dermatitis have not been reported.

Effect of Salvia miltiorrhiza Bunge injection on anticardiolipin antibody production induced by beta2 glycoprotein.

AIM: To explore the therapeutic effect and the mechanism of Chinese herbs on antiphospholipid syndrome (APS) by observing the effect of Salvia miltiorrhiza Bunge injectio (SmBI) on anticardiolipin antibody (aCL) induced by beta2 glycoprotein I (beta2-GP I). METHODS: Sixty female mice randomly fell into 6 groups: group A, B, C, D was injected through abdominal cavity with different dosage of SmBI daily; after 14 d, group A, B, C, E was immunized with 150 microg of purified human beta2-GP I in complete Freund's adjuvant subcutaneously; group F as control. The titre of aCL were detected by enzyme linked immunosorbent assay; subsets of T cell were grouped by streptavidin-biotin complex technique; and the activity of IL-2 was measured by MTT chromatometry. RESULTS: (1) Compared with group E, the absorbance (A) of aCL in group A, B, and C was decreased (P < 0.05 or P < 0.01). By linear correlation, the dosage is negatively correlated with the A values of aCL in 1, 2, and 3 weeks (P < 0.01). (2) Compared with group E, TH/TS ratio was reduced in group A, B, and C (P < 0.05 or P < 0.01); there is no significant differences between group D and F (P>0.05). By linear correlation, the dosage is negatively correlated with TH/TS ratio (P < 0.01). (3) Compared with E, the activity of IL-2 in group B and C decreased significantly (P < 0.01). By linear correlation, there is negative correlation between dosage and IL-2 activity (P < 0.01). There is no significant difference between D and F (P > 0.05). (4) There is positive correlation between TH/TS ratio and IL-2 activity in different dilutions (P<0.01). CONCLUSION: The mechanism of suppressive effect of SmBI on aCL induced by beta2-GP I may be realized by resuming the elevated TH/TS ratio and IL-2 activity. The state that SmBI have no effect on normal mice indicates that SmBI has selective immunoregulative functive.

Tissue factor activity in patients with systemic lupus erythematosus: association with disease activity.

OBJECTIVE: Tissue factor (TF) is the major intrinsic initiator of clotting. TF expression on monocytes has been associated with high titers of anticardiolipin antibodies (aCL) in patients with antiphospholipid syndrome (APS) with thrombosis. We investigated the influence of clinical factors on TF activity in blood from patients with systemic lupus erythematosus (SLE) and examined the relationship between aCL and TF. METHODS: In this cross sectional study, consecutive patients with SLE from one rheumatology clinic gave blood samples for measurement of TF activity, aCL, and Russell viper venom time. We assessed disease activity by measuring sedimentation rate, anti-dsDNA, and complement components C3 and C4, and measured clinical indices. Associations were investigated with the Wilcoxon rank-sum test and linear regression. RESULTS: Sixty-nine patients contributed blood samples. The median age was 38 years, and 10 of the SLE patients had a history of thrombosis. Patients with active arthritis had TF activity 1.3 times that in patients without arthritis (p = 0.028). Users of nonsteroidal antiinflammatory drugs (NSAID) had TF activity significantly lower than nonusers (p = 0.010). Patients with previous thrombosis had TF activity significantly lower than patients without thrombosis (p < 0.001). Overall, aCL and TF activity were not associated when we adjusted for these clinical factors. CONCLUSION: Arthritis, previous thrombosis, and use of NSAID significantly modified TF activity in patients with SLE. Unlike previous reports, we found no association between aCL titer and TF activity, which may be due to our adjusting for other important clinical factors.

Different dietary fats influence serum and tissue lipids and anti-cardiolipin antibody levels in autoimmune-prone NZB/W F1 mice.

To investigate the influence of different dietary fats on lipids and anti-cardiolipin antibody levels, autoimmune NZB/W F1 mice were fed on diets containing 200 g dietary fat as palm oil, lard-soyabean oil (1:1, w/w), soyabean oil, rapeseed oil or fish oil/kg. In addition, each dietary fat group was divided into an early-feeding group with feeding from 2 months of age, and a late-feeding group with feeding from 5 months of age. Serum levels of triacylglycerol, phospholipid, cholesterol and anti-cardiolipin antibody were measured at regular intervals, and mice were killed at the age of 7 months for analysis of hepatic lipid and fatty acids. The results showed that hepatic triacylglycerol and cholesterol contents were lower in mice fed on fish oil than in those fed on palm oil. In contrast, hepatic phospholipid content was higher in mice of the fish oil group than in those of the other four dietary fat groups. Composition profiles for both hepatic and renal oleic acid (18: 1n-9), linoleic acid (18: 2n-6) and eicosapentaenoic acid (20: 5n-3) were similar to those of the dietary fats in mice of both early-feeding and late-feeding groups. Fish oil intake decreased arachidonic acid (20: 4n-6) concentration in kidney tissue but not in liver tissue. Serum triacylglycerol, cholesterol and phospholipid levels were lower in mice fed on fish oil than in those fed on palm oil. Immunoglobulin (Ig) M anti-cardiolipin antibody was lower for the fish oil group than for the other groups. The IgG anti-cardiolipin antibody level was significantly lower in mice fed on fish oil compared with that of the palm oil group only in the early-feeding group. There was a positive correlation between serum IgM anti-cardiolipin antibody and phospholipid levels (early-feeding group r 0.902, P < 0.05; late-feeding group r 0.894, P < 0.05). These findings suggest dietary fish oil may affect both lipid levels and anti-cardiolipin antibody, contributing to alleviation of the autoimmune process in autoimmune-prone NZB x NZW F1 mice.

Dietary polyunsaturated fatty acids decrease anti-dsDNA and anti-cardiolipin antibodies production in idiotype induced mouse model of systemic lupus erythematosus.

OBJECTIVE: To examine the effect of diets with different polyunsaturated fatty acid contents, including linseed oil which contains 70% omega-3 fatty acids, on autoantibody production in idiotype induced mouse model of systemic lupus erythematosus (SLE). METHODS: Five different fats were fed to mice with induced SLE and antibody titers to anti-DNA and anti-cardiolipin were determined and histological examination of kidneys were carried out. RESULTS: SLE mice fed linseed oil showed lower titers of antibodies to DNA and to cardiolipin and less severe kidney damage than mice fed other diets, including fish oil. CONCLUSION: Use of linseed oil may attenuate the severity of SLE and this diet may be recommended for other auto-immune diseases as well.

Primary antiphospholipid syndrome in stroke in the young.

Antiphospholipid syndrome is an uncommon cause of stroke. A 12 year old girl with this syndrome is reported who presented with thrombotic stroke and high titres of anticardiolipin (aCL) and lupus anticoagulant (LAC). The patient improved subsequently and was put on aspirin. The present report highlights the importance of screening for aCL and LAC in cases of stroke in young patients.