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    "textoCompleto" => "To the editor&#58; A case that may be of clear practical help for healthcare professionals treating similar patients because of some characteristics of its clinical course&#44; response to treatment&#44; and potential confusion for responsible <br></br>physicians is reported below&#46; <br></br><br></br>Case report&#58; A 24-year-old female patient who experienced generalized tonic-clonic seizures when she was 20&#46; Physical examination revealed postictal disorientation&#44; mild Raynaud&#191;s phenomenon&#44; and malar erythema&#46; She had severe autoimmune hemolytic anemia due to complement-fixing hot IgG antibodies and thrombocytopenia&#59; renal failure with serum Cr levels of 2&#46;2 mg&#47;dL and dysmorphic RBCs&#59; hypocomplementemia &#40;C3 80 mg&#47;dL&#44; C4 8 mg&#47;dL&#41;&#44; ANA 1&#47;640&#44; IgG anticardiolipin 57&#46;7 UGP&#47;mL &#40;negative &#60; 10&#41;&#44; IgM anticardiolipin 58&#46;2 UGP&#47;mL&#44; lupus anticoagulant DVV test 131 &#40;negative &#60; 45&#41;&#46; MRI of the brain showed cortical-subcortical vasculitic-ischemic lesions&#46; The only remarkable data in the patient history was that she smoked 20 cigarettes daily&#46; <br></br><br></br>Based on diagnosis of a primary antiphospholipid syndrome &#40;PAPS&#41; and because of persistent severe hemolysis and renal function impairment&#44; plasmapheresis &#40;4 sessions on alternate days&#41; was started&#44; but no improvement was obtained in thrombocytopenia&#44; serum creatinine&#44; or anticardiolipin levels&#46; Mycophenolate mofetil 500 mg&#47;12 h and methylprednisolone 120 mg&#47;day were started&#46; Due to lack of response to this second treatment&#44; mycophenolate was replaced by cyclophosphamide as an IV bolus &#40;750 mg&#47;day&#44; 4 doses&#41; and acetyl salicylic acid 100 mg&#47;day&#46; <br></br>ACEIs were also added&#46; Due to persistent severe hemolytic anemia and poor kidney function after the first <br></br>cyclophosphamide cycle&#44; it was decided to use as adjuvant the chimeric anti-CD2 antibody&#44; rituximab &#40;Mabthera&#44; <br></br>Roche&#44; two 1 g doses&#41;&#46; At the end of rituximab treatment&#44; hemolytic anemia had disappeared&#44; and a renal biopsy could be performed&#44; showing a pattern of occlusive arteriolar disease consistent with clinical diagnosis&#46; <br></br><br></br>Complement and anticardiolipin antibody levels normalized and renal function improved&#44; with serum creatinine <br></br>of 1 mg&#47;dL and creatinine clearance ranging from 80 and 100 mL&#47;min after 3 and a half years of follow-up&#46; BP was maintained between 80 and 100 mmHg with ACEIs and ARBs&#46; In a new MRI of the brain&#44; lesions detected in 2003 had disappeared&#46; Anticoagulation with Sintrom to maintain INR between 2 and 2&#46;5 was administered as maintenance treatment&#46; Immunological parameters remained negative in successive&#44; frequent measurements&#46; After completing 4 years of anticoagulation and because of the total absence of immunological activity&#44; discontinuation of anticoagulation was considered&#44; since PAPS was in complete remission&#46; The need for antihypertensives was <br></br>independent from this remission&#44; considering the type of arteriolar lesions found in the biopsy&#46; <br></br><br></br>In December 2007&#44; the patient experienced infection by type 1 human papilloma virus&#44; that caused lesions consistent with a high-grade squamous intraepithelial lesion &#40;HGSIL&#41;&#46; Lupus anticoagulant was negative&#44; and C3 and C4 levels were normal&#46; Antinuclear antibodies at a titer of 1&#47;320 were only detected&#46; A gynecological procedure for taking deep histological samples was decided&#44; for which Sintrom was replaced by enoxaparin at prophylactic doses &#40;40 mg&#47;day&#41;&#46; On the fourth day of treatment&#44; the patient reported blurred vision in her right eye&#44; that gradually <br></br>increased in the 3 following days&#46; An eye fundus examination revealed amaurosis in the right eye due to complete thrombosis of the central retinal vein&#44; with abundant retinal bleeding&#46; <br></br><br></br>Diagnostic criteria for PAPS were established in the Sapporo Conference in 1999 and revised in Sydney in 2005&#44; and classified catastrophic PAPS as a separate group&#46;1 <br></br><br></br>Though the pathogenetic mechanisms of the disease are now better understood&#44;2 its treatment is only based on prevention and treatment of arterial and venous thrombosis&#44; and there are hardly any data about measures directed to pathogenetic factors&#46; 3 Thrombosis is the most easily recognized sign of PAPS&#44; and may depend on endothelial activation&#46; This would involve local stimulation of adhesion molecules and procoagulant proteins&#44; which would in term induce thrombus formation&#46; However&#44; other manifestations of the disease&#44; such as livedo reticularis&#44; cardiac valve disease&#44; thrombotic microangiopathy&#44; hyperintense lesions in MRI&#44; or repeated fetal loss cannot be <br></br>explained by this mechanism&#46; <br></br><br></br>Risk of recurrent thrombosis in these patients is high&#44; up to more than 50&#37; per year depending on the series&#46;4 In long-term treatments&#44; it is not completely clear whether oral anticoagulation at doses to maintain an INR &#62; 3 is more effective that anticoagulation to achieve an INR of 2-3&#46; Lifetime anticoagulation is currently advocated in patients who have experienced any thrombotic event&#46;5 In view of such a favorable course and total negativization of immunological markers&#44; the possibility of discontinuing or decreasing the dose of permanent anticoagulation was considered&#46; <br></br><br></br>Since a treatment with a real chance of destroying the clone producing harmful antibodies had been administered&#44; <br></br>a possible cure was a logical consideration&#46; There are not&#44; however&#44; epidemiological criteria or data allowing to establish whether PAPS may be cured&#46; <br></br><br></br>However&#44; the disease itself dispelled this doubt&#58; the occurrence of a retinal venous thrombosis when anticoagulation <br></br>was decreased showed the existence of clinical activity&#46; <br></br><br></br>Use of combined chemotherapy may provide a long-term solution for an extremely severe disease such as PAPS&#46; In this case&#44; complete immunosuppression&#44; associated to rituximab&#44; was used as background treatment&#46; There are very few reports in the literature on the use of these drugs in PAPS&#46; Mycophenolate6 and rituximab7 have only been used for PAPS with hemolytic anemia refractory to standard treatment with high-dose corticosteroids&#46; Use of cyclophosphamide for this condition has not been reported&#46; <br></br><br></br>It should be noted that articles published report improvement in hemolytic anemia&#44; but do not provide information <br></br>about what happened to the other components of PAPS&#44; such as renal involvement and cerebral lesion&#46; This case again illustrates the possibility of inducing a prolonged inactivity of the disease by using first-line immunosuppressive treatment&#46; It should also be emphasized that&#44; as occurred in this case&#44; the greatest value of rituximab is that it causes a rapid decrease of antibodies with a high pathogenetic capacity&#44; such as those inducing <br></br>hemolytic anemia&#44; present in this patient in clinically and analytically high levels&#46; <br></br><br></br>As a general rule&#44; in the larger series systemic lupus erythematosus &#40;SLE&#41; was not developed by more than 80&#37; of patients with PAPS&#58; However&#44; it should be noted that the onset of the clinical picture of autoimmune hemolytic anemia and hypocomplementemia would define a subgroup of patients with a significant risk of subsequent occurrence of SLE&#46;8 <br></br><br></br>Other factors associated to late occurrence of SLE include the presence of a Raynaud&#191;s phenomenon&#44; migraine&#44; <br></br>psychiatric changes&#44; and syndromes such as multiple sclerosis&#46;9&#44;10 While this patient had several of these signs&#44; persistent negative results in immunological tests for SLE supported the possibility of a complete remission&#47;cure&#46; However&#44; clinical facts proved the opposite&#46; A history of retinal venous thrombosis in PAPS is rare&#44; and is usually found in patients with antiphospholipid antibody activity&#46; 11&#44;12 The reported patient had no such activity&#44; but the fact that certain immunological positivity was found&#44; e&#46;g&#46; antinuclear antibodies&#44; allows for speculating about the existence of some active procoagulant mechanism&#46; <br></br><br></br>Based on the foregoing&#44; it may be stated that while no evidence from a sufficient number of cases is available to support use of more intensive immunosuppressive therapy in these patients&#44; such treatment may provide long-term or indefinite disease-free periods in these patients&#46; However&#44; despite the risk involved in permanent anticoagulation&#44; this case is a particularly clear example of risk persistence in spite of a prolonged immunological <br></br>inactivity&#46; <br></br>"
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Primary antiphospholipid syndrome: dormant, not cured
Síndrome antifosfolípido primario: dormido, no curado
Carlos Carameloa, Ana Ramosa, Simona Alexandrua, Olga Sanchez Pernauteb
a Servicio de Nefrologia Fundacion Jimenez Dí­az-Capio. Universidad Autónoma, Madrid, Madrid, España,
b Servicio de Reumatologia, Fundacion Jimenez Dí­az-Capio. Universidad Autónoma, Madrid, Madrid, España,
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    "textoCompleto" => "To the editor&#58; A case that may be of clear practical help for healthcare professionals treating similar patients because of some characteristics of its clinical course&#44; response to treatment&#44; and potential confusion for responsible <br></br>physicians is reported below&#46; <br></br><br></br>Case report&#58; A 24-year-old female patient who experienced generalized tonic-clonic seizures when she was 20&#46; Physical examination revealed postictal disorientation&#44; mild Raynaud&#191;s phenomenon&#44; and malar erythema&#46; She had severe autoimmune hemolytic anemia due to complement-fixing hot IgG antibodies and thrombocytopenia&#59; renal failure with serum Cr levels of 2&#46;2 mg&#47;dL and dysmorphic RBCs&#59; hypocomplementemia &#40;C3 80 mg&#47;dL&#44; C4 8 mg&#47;dL&#41;&#44; ANA 1&#47;640&#44; IgG anticardiolipin 57&#46;7 UGP&#47;mL &#40;negative &#60; 10&#41;&#44; IgM anticardiolipin 58&#46;2 UGP&#47;mL&#44; lupus anticoagulant DVV test 131 &#40;negative &#60; 45&#41;&#46; MRI of the brain showed cortical-subcortical vasculitic-ischemic lesions&#46; The only remarkable data in the patient history was that she smoked 20 cigarettes daily&#46; <br></br><br></br>Based on diagnosis of a primary antiphospholipid syndrome &#40;PAPS&#41; and because of persistent severe hemolysis and renal function impairment&#44; plasmapheresis &#40;4 sessions on alternate days&#41; was started&#44; but no improvement was obtained in thrombocytopenia&#44; serum creatinine&#44; or anticardiolipin levels&#46; Mycophenolate mofetil 500 mg&#47;12 h and methylprednisolone 120 mg&#47;day were started&#46; Due to lack of response to this second treatment&#44; mycophenolate was replaced by cyclophosphamide as an IV bolus &#40;750 mg&#47;day&#44; 4 doses&#41; and acetyl salicylic acid 100 mg&#47;day&#46; <br></br>ACEIs were also added&#46; Due to persistent severe hemolytic anemia and poor kidney function after the first <br></br>cyclophosphamide cycle&#44; it was decided to use as adjuvant the chimeric anti-CD2 antibody&#44; rituximab &#40;Mabthera&#44; <br></br>Roche&#44; two 1 g doses&#41;&#46; At the end of rituximab treatment&#44; hemolytic anemia had disappeared&#44; and a renal biopsy could be performed&#44; showing a pattern of occlusive arteriolar disease consistent with clinical diagnosis&#46; <br></br><br></br>Complement and anticardiolipin antibody levels normalized and renal function improved&#44; with serum creatinine <br></br>of 1 mg&#47;dL and creatinine clearance ranging from 80 and 100 mL&#47;min after 3 and a half years of follow-up&#46; BP was maintained between 80 and 100 mmHg with ACEIs and ARBs&#46; In a new MRI of the brain&#44; lesions detected in 2003 had disappeared&#46; Anticoagulation with Sintrom to maintain INR between 2 and 2&#46;5 was administered as maintenance treatment&#46; Immunological parameters remained negative in successive&#44; frequent measurements&#46; After completing 4 years of anticoagulation and because of the total absence of immunological activity&#44; discontinuation of anticoagulation was considered&#44; since PAPS was in complete remission&#46; The need for antihypertensives was <br></br>independent from this remission&#44; considering the type of arteriolar lesions found in the biopsy&#46; <br></br><br></br>In December 2007&#44; the patient experienced infection by type 1 human papilloma virus&#44; that caused lesions consistent with a high-grade squamous intraepithelial lesion &#40;HGSIL&#41;&#46; Lupus anticoagulant was negative&#44; and C3 and C4 levels were normal&#46; Antinuclear antibodies at a titer of 1&#47;320 were only detected&#46; A gynecological procedure for taking deep histological samples was decided&#44; for which Sintrom was replaced by enoxaparin at prophylactic doses &#40;40 mg&#47;day&#41;&#46; On the fourth day of treatment&#44; the patient reported blurred vision in her right eye&#44; that gradually <br></br>increased in the 3 following days&#46; An eye fundus examination revealed amaurosis in the right eye due to complete thrombosis of the central retinal vein&#44; with abundant retinal bleeding&#46; <br></br><br></br>Diagnostic criteria for PAPS were established in the Sapporo Conference in 1999 and revised in Sydney in 2005&#44; and classified catastrophic PAPS as a separate group&#46;1 <br></br><br></br>Though the pathogenetic mechanisms of the disease are now better understood&#44;2 its treatment is only based on prevention and treatment of arterial and venous thrombosis&#44; and there are hardly any data about measures directed to pathogenetic factors&#46; 3 Thrombosis is the most easily recognized sign of PAPS&#44; and may depend on endothelial activation&#46; This would involve local stimulation of adhesion molecules and procoagulant proteins&#44; which would in term induce thrombus formation&#46; However&#44; other manifestations of the disease&#44; such as livedo reticularis&#44; cardiac valve disease&#44; thrombotic microangiopathy&#44; hyperintense lesions in MRI&#44; or repeated fetal loss cannot be <br></br>explained by this mechanism&#46; <br></br><br></br>Risk of recurrent thrombosis in these patients is high&#44; up to more than 50&#37; per year depending on the series&#46;4 In long-term treatments&#44; it is not completely clear whether oral anticoagulation at doses to maintain an INR &#62; 3 is more effective that anticoagulation to achieve an INR of 2-3&#46; Lifetime anticoagulation is currently advocated in patients who have experienced any thrombotic event&#46;5 In view of such a favorable course and total negativization of immunological markers&#44; the possibility of discontinuing or decreasing the dose of permanent anticoagulation was considered&#46; <br></br><br></br>Since a treatment with a real chance of destroying the clone producing harmful antibodies had been administered&#44; <br></br>a possible cure was a logical consideration&#46; There are not&#44; however&#44; epidemiological criteria or data allowing to establish whether PAPS may be cured&#46; <br></br><br></br>However&#44; the disease itself dispelled this doubt&#58; the occurrence of a retinal venous thrombosis when anticoagulation <br></br>was decreased showed the existence of clinical activity&#46; <br></br><br></br>Use of combined chemotherapy may provide a long-term solution for an extremely severe disease such as PAPS&#46; In this case&#44; complete immunosuppression&#44; associated to rituximab&#44; was used as background treatment&#46; There are very few reports in the literature on the use of these drugs in PAPS&#46; Mycophenolate6 and rituximab7 have only been used for PAPS with hemolytic anemia refractory to standard treatment with high-dose corticosteroids&#46; Use of cyclophosphamide for this condition has not been reported&#46; <br></br><br></br>It should be noted that articles published report improvement in hemolytic anemia&#44; but do not provide information <br></br>about what happened to the other components of PAPS&#44; such as renal involvement and cerebral lesion&#46; This case again illustrates the possibility of inducing a prolonged inactivity of the disease by using first-line immunosuppressive treatment&#46; It should also be emphasized that&#44; as occurred in this case&#44; the greatest value of rituximab is that it causes a rapid decrease of antibodies with a high pathogenetic capacity&#44; such as those inducing <br></br>hemolytic anemia&#44; present in this patient in clinically and analytically high levels&#46; <br></br><br></br>As a general rule&#44; in the larger series systemic lupus erythematosus &#40;SLE&#41; was not developed by more than 80&#37; of patients with PAPS&#58; However&#44; it should be noted that the onset of the clinical picture of autoimmune hemolytic anemia and hypocomplementemia would define a subgroup of patients with a significant risk of subsequent occurrence of SLE&#46;8 <br></br><br></br>Other factors associated to late occurrence of SLE include the presence of a Raynaud&#191;s phenomenon&#44; migraine&#44; <br></br>psychiatric changes&#44; and syndromes such as multiple sclerosis&#46;9&#44;10 While this patient had several of these signs&#44; persistent negative results in immunological tests for SLE supported the possibility of a complete remission&#47;cure&#46; However&#44; clinical facts proved the opposite&#46; A history of retinal venous thrombosis in PAPS is rare&#44; and is usually found in patients with antiphospholipid antibody activity&#46; 11&#44;12 The reported patient had no such activity&#44; but the fact that certain immunological positivity was found&#44; e&#46;g&#46; antinuclear antibodies&#44; allows for speculating about the existence of some active procoagulant mechanism&#46; <br></br><br></br>Based on the foregoing&#44; it may be stated that while no evidence from a sufficient number of cases is available to support use of more intensive immunosuppressive therapy in these patients&#44; such treatment may provide long-term or indefinite disease-free periods in these patients&#46; However&#44; despite the risk involved in permanent anticoagulation&#44; this case is a particularly clear example of risk persistence in spite of a prolonged immunological <br></br>inactivity&#46; <br></br>"
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        "resumen" => "Comunicamos este caso por qu&#233; algunas caracter&#237;&#173;sticas de su evoluci&#243;n cl&#237;&#173;nica&#44; respuesta terap&#233;utica y posible confusi&#243;n para los m&#233;dicos tratantes&#44; pueden ser de clara ayuda pr&#225;ctica para los profesionales que tratan enfermos similares&#46;"
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                  "referenciaCompleta" => "Miyakis S, Lockshin MD, Atsumi T y cols: International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 4: 295-306, 2006. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16420554" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "Lim W, Crowther MA, Eikelboom JW: Management of Antiphospholipid Antibody Syndrome, a Systematic Review. JAMA 295: 357-365, 2006."
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                  "referenciaCompleta" => "Appel GB, Waldman M, Radhakrishnan J: New approaches to the treatment of glomerular diseases. Kidney Int 70, S45; S50, 2006."
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                  "referenciaCompleta" => "Rottem M, Krause I, Fraser A, Stojanovich L, Rovensky J, Shoenfeld Y: Autoimmune hemolytic anaemia in the antiphospholipid syndrome. Lupus 15:473-7, 2006. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16898185" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "Miserocchi E; Baltatzis S; Foster CS: Ocular features associated with anticardiolipin antibodies: a descriptive study. Am J Ophthalmol; 131:451-6, 2001. <a href="http://www.ncbi.nlm.nih.gov/pubmed/25935101" target="_blank">[Pubmed]</a>"
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Article information
ISSN: 20132514
Original language: English
DOI:
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