Factores de predicción relevantes en la supervivencia de pacientes con síndrome antifosfolípido / Relevants predictions factors in the survival of patients with antiphospholipid syndrome

Introducción: Los pacientes con síndrome antifosfolípido desarrollan morbilidad y mortalidad significativas a pesar del tratamiento actual. Es imperativo, identificar factores pronósticos y medidas terapéuticas para prevenir estas complicaciones. Objetivo: Determinar los factores relevantes en la predicción de la supervivencia en los pacientes con síndrome antifosfolípido. Métodos: Se realizó un estudio longitudinal analítico de una cohorte histórica de personas con síndrome antifosfolípido, diagnosticados, según los criterios de Sapporo/Sydney y colaboradores en la consulta de enfermedades autoinmunes sistémicas del Hospital Universitario Clínico-Quirúrgico «Arnaldo Milián Castro», Villa Clara, del año 2000 al 2015. Se estudiaron variables demográficas y clínicas. En cada caso se determinó el tiempo de supervivencia con relación al evento muerte. Se aplicó el método de Kaplan Meier para calcular la supervivencia global y determinar las variables predictoras de la mortalidad. Según el estudio de los estadígrafos de comparación interestratos(Log-Rank) se demostró la significación estadística con la prueba de Chi cuadrado de homogeneidad. Resultados: De los 128 pacientes estudiados, 118 fueron femeninos y 10 masculinos (111 de piel blanca y 17 no blancos). La supervivencia global fue de 67,1 % con una media de 13,37 años. Las variables más relevantes que aportaron a la mortalidad en relación con menor supervivencia fueron: leucopenia, linfopenia, color de la piel no blanca, y el no uso de aspirina, con medias de supervivencia de 8,83; 8,17; 10,72; 12,10 años, respectivamente. Conclusiones: La identificación temprana de los factores pronósticos de supervivencia permite implementar estrategias oportunas e individualizadas en pacientes con síndrome antifosfolípido.

Introduction: patients with antiphospholipid syndrome develop significant morbidity and mortality despite current treatment. Identifying prognostic factors and therapeutic measures to prevent these complications is indispensable. Objective: to determine relevant factors in the prediction of survival in patients with antiphospholipid syndrome. Methods: a longitudinal analytical study was carried out on cohorts with antiphospholipid syndrome who were diagnosed according to the Sapporo-Sydney criteria and collaborators in the systemic autoimmune disease consultation at "Arnaldo Milián Castro" Clinical and Surgical University Hospital in Villa Clara from 2000 to 2015. Demographic and clinical variables were studied. The survival time in relation to the death event was determined in each case. The Kaplan - Meier method was applied to calculate overall survival and determine the predictor variables for mortality. According to the study of inter-strata comparison statistics (Log-Rank), statistical significance was demonstrated with the Chi-square test of homogeneity. Results: a number of 118 patients were female and 10 male from the 128 studied (111 white-skinned and 17 non-white). Overall survival was 67.1% with a mean of 13.37 years. The most relevant variables that contributed to mortality in relation to lower survival were leukopenia, lymphopenia, non-white skin color and non-use of aspirin, with mean survival of 8.83; 8.17; 10.72; 12.10 years, respectively. Conclusions: the early identification of survival prognostic factors allows us the implementation of timely and individualized strategies in patients with antiphospholipid syndrome.

Climatério e lúpus eritematoso sistêmico / Climacteric and systemic lupus erythematosus

O lúpus eritematoso sistêmico é uma doença crônica, complexa e multifatorial que apresenta manifestações em vários órgãos. O seu acometimento ocorre 10 vezes mais no sexo feminino do que no masculino. É uma doença com uma clínica variada e com graus variados de gravidade, causando fadiga, manifestações cutâneas, como rash malar, fotossensibilidade, queda de cabelo e manifestações musculoesqueléticas, como artralgia, mialgia e atrite. Podem ocorrer flares (crises), que se caracterizam por aumento mensurável na atividade da doença. No climatério, no período da pré-menopausa, o lúpus eritematoso sistêmico ocorre com mais frequência, podendo ocorrer também na pós-menopausa. Algumas doenças são mais frequentes na fase do climatério, e a presença do lúpus pode influenciar na sua evolução, como a doença cardiovascular, osteoporose e tromboembolismo venoso. A terapia hormonal oral determina aumento do risco de tromboembolismo venoso no climatério, e na paciente com lúpus eritematoso sistêmico há aumento dos riscos de flares e de trombose. Em vista disso, a terapia hormonal é recomendada apenas para pacientes com lúpus eritematoso sistêmico estável ou inativo, sem história de síndrome antifosfolípides e com anticorpos antifosfolípides negativa, devendo-se dar preferência para a terapia estrogênica transdérmica, em menor dose e de uso contínuo. Na paciente com lúpus eritematoso sistêmico ativo ou com história de síndrome antifosfolípides ou com anticorpos antifosfolípides positiva, recomenda-se a terapia não hormonal, como os antidepressivos. (AU)

Systemic lupus erythematosus is a chronic, complex, multifactorial disease that manifests in several organs. Its involvement occurs 10 times more in females than in males. It is a disease with a varied clinic and varying degrees of severity, causing fatigue, skin manifestations such as malar rash, photosensitivity, hair loss and musculoskeletal manifestations such as arthralgia, myalgia and arthritis. Flare may occur, which are characterized by measurable increase in disease activity. In the climacteric, in the premenopausal period, systemic lupus erythematosus occurs more frequently, and may also occur in the postmenopausal period. Some diseases are more frequent in the Climacteric phase and the presence of lupus can influence its evolution, such as cardiovascular disease, osteoporosis and venous thromboembolism. Oral hormone therapy determines an increased risk of venous thromboembolism in the climacteric and in patients with systemic lupus erythematosus there is an increased risk of flares and thrombosis. In view of this, hormone therapy is only recommended for patients with stable or inactive systemic lupus erythematosus, without a history of antiphospholipid syndrome and with antiphospholipid antibodies, giving preference to transdermal estrogen therapy, at a lower dose and for continuous use. In patients with active systemic lupus erythematosus or with a history of antiphospholipid syndrome or positive antiphospholipid antibodies, non-hormonal therapy, such as antidepressants, is recommended. (AU)

Application progress of high-throughput sequencing in antiphospholipid syndrome / 中华预防医学杂志

Antiphospholipid syndrome (APS) is characterized by arterial and venous thrombosis and(or) morbid pregnancy, accompanied by persistent antiphospholipid antibody (aPL) positivity. However, due to the complex pathogenesis of APS and the large individual differences in the expression of aPL profiles of patients, the problem of APS diagnosis, prognosis judgment and risk assessment may not be solved only from antibody level. It is necessary to use new technologies and multiple dimensions to explore novel APS biomarkers. The application of next generation sequencing (NGS) technology in diseases with high incidence of somatic mutations, such as genetic diseases and tumors, has been very mature. Thus, gradually understanding the research and application progress of APS by NGS technology from genome, transcriptome, epigenome and other aspects is meaningful. This article reviews the related research of NGS technology in APS, and provide more reference for the deep understanding of the APS-related screening markers and disease pathogenesis.

Avaliação da transferência materno-infantil de anticorpos em pacientes com síndrome antifosfolípide / Evaluation of maternal-child antibody transfer of patients with antiphospholipid syndrome

Introdução: a síndrome antifosfolípide (SAF) é caracterizada por eventos trombóticos e perdas gestacionais de repetição sendo considerada a trombofilia adquirida mais comum. Objetivo: realizar uma revisão narrativa da passagem transplacentária de anticorpos em pacientes com SAF. Metodologia: revisão narrativa da literatura. Resultados: quando não está associada a alguma doença do tecido conectivo é dita primária e quando em associação com lúpus eritematosos sistêmico é dita secundária. A morbidade gestacional é frequente e torna-se de importância avaliar a passagem desses anticorpos transplacentariamente, desde que existem modelos animais da síndrome com transferência passiva desses anticorpos. A passagem transplacentária de anticorpos específicos já foi determinada em estudos, os quais demonstraram baixos níveis destes anticorpos no soro materno, porém uma eficiente passagem transplacentária para o neonato. Conclusão: existem poucos estudos sobre essa passagem materno-infantil em pacientes com SAF, que são aqui revisados.

Introduction: a antiphospholipid syndrome (APS) is characterized by thrombotic events and recurrent pregnancy losses and is considered the most common acquired thrombophilia. Objective: to carry out a narrative review of the transplacental passage and antibodies in patients with APS. Methodology: narrative literature review Results: when it is not associated with any connective tissue disease, it is said to be primary and when in association with systemic lupus erythematosus it is said to be secondary. Gestational morbidity is frequent and it is important to evaluate the passage of these antibodies transplacentally, since there are animal models of the syndrome with passive transfer of these antibodies. The transplacental passage of specific antibodies has already been determined in studies, which demonstrated low levels of these antibodies in the maternal serum, but an efficient transplacental passage for the newborn. Conclusion: there are few studies on this maternal-infant passage in patients with APS, which are reviewed here.

Additional risk factors associated with thrombosis and pregnancy morbidity in a unique cohort of antiphospholipid antibody-positive patients / 中华医学杂志(英文版)

BACKGROUND@#Antiphospholipid syndrome (APS) is an autoimmune prothrombotic condition with significant morbidity. The objective of this study was to identify additional clinical and epidemiological risks of arterial thrombosis, venous thrombosis, and pregnancy morbidities in a large cohort of persistent antiphospholipid antibodies (aPLs)-positive carriers.@*METHODS@#This was a cross-sectional cohort study of 453 consecutive patients with a documented positive aPL who attended Peking University People's Hospital. Among 453 patients screened, 297 patients had persistent positive aPL. We compared asymptomatic aPL carriers with thrombotic and obstetric APS patients. And the univariate analysis and multivariable logistic regression were used to evaluate the association between different risk factors and APS clinical manifestations. The levels of circulating markers of neutrophil extracellular traps (NETs) (cell-free DNA and citrullinated histone H3 [Cit-H3]) were assessed and compared among aPL-positive carriers with or without autoimmune disease and APS patients.@*RESULTS@#Additional risk factors associated with arterial thrombosis among aPL-positive carriers included: smoking (odds ratio [OR] = 6.137, 95% confidence interval [CI] = 2.408-15.637, P  = 0.0001), hypertension (OR = 2.368, 95% CI = 1.249-4.491, P  = 0.008), and the presence of underlying autoimmune disease (OR = 4.401, 95% CI = 2.387-8.113, P < 0.001). Additional risks associated with venous thrombosis among aPL carriers included: smoking (OR = 4.594, 95% CI = 1.681-12.553, P  = 0.029) and the presence of underlying autoimmune disease (OR = 6.330, 95% CI = 3.355-11.940, P < 0.001). The presence of underlying autoimmune disease (OR = 3.301, 95% CI = 1.407-7.744, P  = 0.006) is the additional risk, which demonstrated a significant association with APS pregnancy morbidity. Higher circulating levels of cell-free DNA and Cit-H3 were observed among APS patients and aPL patients with autoimmune diseases compared with those aPL carriers without underlying autoimmune diseases. Furthermore, control neutrophils that are conditioned with APS patients'sera have more pronounced NET release compared with those treated with aPL carriers'sera without underlying autoimmune diseases.@*CONCLUSIONS@#We identified several potential additional risk factors for APS clinical manifestations among a large cohort of Chinese aPL carriers. Our data may help physicians to risk stratify aPL-positive Asian patients.

Antiphospholipid antibody role in Acute Ischemic Stroke patients with COVID-19: A narrative review

@#Antiphospholipid antibodies (aPL) are commonly found in humans after an infection. Its action can promote thrombosis via the activation of endothelial cells, platelets, and neutrophils. This autoantibody is the leading cause of antiphospholipid antibody syndrome (APS), characterized by widespread thrombosis in various vascular beds. COVID-19 also causes acute ischemic stroke (AIS) in the younger demographic, who previously was not considered a population at risk for AIS, which may be related to APS. This narrative review will discuss the role of aPL in COVID-19 patients who experienced AIS during infection.

Recurrent epistaxis with coagulation disorders in a boy aged 2 years / 中国当代儿科杂志

A boy, aged 2 years and 5 months, had recurrent epistaxis, and the coagulation function examination showed that activated partial thromboplastin time (APTT) was significantly prolonged. Further laboratory examinations showed that the prolonged APTT was not immediately corrected in the APTT correction test, with positive lupus anticoagulant and low prothrombin activity. The boy was diagnosed with hypoprothrombinemia-lupus anticoagulant syndrome. The condition was improved after treatment with glucocorticoid, immunoglobulin, and vitamin K1. The boy has been followed up for 6 months, and no epistaxis was observed. Prothrombin activity returned to normal, and lupus anticoagulant remained positive. This is a relatively rare disease, and for patients with bleeding symptoms and coagulation disorders, it is recommended to perform the tests such as APTT correction test, lupus anticoagulant testing, and coagulation factor dilution test, which can improve the detection rate of this disease, so as to achieve early diagnosis, provide rational treatment in the early stage, and improve the prognosis.

Catastrophic antiphospholipid syndrome / Síndrome antifosfolípido catastrófico

ABSTRACT The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by the development of thrombotic events and/or obstetric morbidity in the presence of antiphospholipid antibodies (aPL), such as the lupus anticoagulant (LA), anticardiolipin antibodies (aCL) or anti- β 2-glycoprotein I antibodies (a β2 GPI). In 1992, Ronald A. Asherson described a very aggressive clinical variant of this syndrome characterized by the development of multiple thrombotic manifestations, simultaneously or in a short period of time. The term catastrophic APS was proposed and since then it is known by this name.

RESUMEN El síndrome antifosfolípido (SAF) es una enfermedad sistêmica autoinmune, caracterizada por el desarrollo de eventos trombóticos y/o morbilidad obstétrica en presencia de anticuerpos antifosfolípidos (aPL), tales como el anticoagulante lúpico (AL), los anticuerpos anticardiolipina (aCL) o anticuerpos anti- β2-glicoproteína I (aβ2GPI). En 1992, Ronald A. Asherson describió una variante clínica muy agresiva de este síndrome, caracterizada por el desarrollo de múltiples manifestaciones trombóticas, de manera simultánea o dentro de un corto periodo de tiempo. Se propuso entonces el término SAF catastrófico y desde entonces se le ha conocido por ese nombre.

Síndrome antifosfolipídico en pediatría: a propósito de un caso / The antiphospholipid antibody syndrome in pediatrics: a case repor

El síndrome antifosfolipídico (SAF) es infrecuente en la edad pediátrica (3 %) y se presenta como eventos trombóticos de lechos vasculares y/o abortos espontáneos, asociado a la presencia de anticuerpos antifosfolipídicos (aFL). Este síndrome puede ser primario o asociado a alguna enfermedad sistémica subyacente. Se presenta el caso de una niña de 12 años con hemiparesia faciobraquiocrural derecha y alteración en la marcha de aparición aguda, en la cual se confirma un accidente cerebrovascular (ACV) isquémico por trombosis de la arteria cerebral media asociado a aFL positivos (anticuerpo anticardiolipina, anticoagulante lúpico y anticuerpo anti-ß2-glicoproteína). Cumple con los criterios para realizar diagnóstico de síndrome antifosfolipídico. Luego de iniciar el tratamiento, la paciente evoluciona de manera favorable. Se trata de una patología infrecuente y de presentación variable, por lo que requiere un alto sentido de alerta por parte del equipo de salud para evitar retrasos en el diagnóstico y el tratamiento, y disminuir su morbimortalidad

Antiphospholipid syndrome (APS) is infrequent at pediatric age (3 %) and is characterized by venous or arterial thrombosis and/or spontaneous abortions. APS occurs either as a primary condition or in the setting of an underlying disease. This is a case of a 12-year-old girl with a right hemiparesis and acute disturbance in gait, in which an ischemic cerebrovascular accident (CVA) due to middle cerebral artery thrombosis associated with positive antiphospholipid antibodies is confirmed (anticardiolipin antibody, lupus anticoagulant and anti-ß2-glycoprotein antibody), fulfilling the criteria for the diagnosis of antiphospholipid syndrome . After starting treatment accordingly, the patient evolves favorably. As this pathology is infrequent and of variable presentation, it requires a high sense of alert from the health team to avoid delays in diagnosis and treatment

Reativação da BCG após vacina contra COVID-19: relato de caso / BCG reactivation after COVID-19 vaccine: case report

A reativação da BCG pode ocorrer em diversos contextos: associada a quadros infecciosos, imunossupressão, autoimunidade e pós-vacinações. Além disso, especialmente em crianças abaixo de 5 anos de idade, deve ser valorizada como um achando presente em cerca de 50% dos casos de Doença de Kawasaki. Neste artigo, relatamos o primeiro caso publicado na literatura de uma paciente adulta jovem, a qual manifestou uma reativação de BCG após receber a primeira dose de vacina contra COVID-19 (AztraZeneca/Oxford/Biomanguinhos). Dentro das primeiras 24h após a administração da vacina, a paciente desenvolveu febre alta, sudorese, dor local, mialgia difusa e cefaleia. Após dois dias, iniciou eritema e enduração no local da cicatriz da vacina BCG. Ela tem como comorbidade a urticária crônica espontânea, porém estava assintomática sem crises há mais de 1 ano. Tem como antecedente familiar relevante o óbito materno por síndrome complexa de sobreposição de autoimunidade (lúpus eritematoso sistêmico, síndrome de Sjögren e síndrome do anticorpo antifosfolípide). Após ser medicada com anti-inflamatórios não esteroides (AINE) e corticoterapia tópica de moderada potência por 3 dias, houve resolução completa da reativação da BCG. A paciente, após 3 meses, recebeu a segunda dose da vacina e não manifestou nenhum sintoma. Acredita-se que a reativação da BCG ocorra devido a um mecanismo de reação cruzada entre HSP do indivíduo, elicitadas como mediadores da imunidade inata frente à inflamação vacinal, com alguns epítopos do M. bovis. Recomendase que seja investigada alguma condição imunossupressora ou autoimune nos pacientes que manifestem reativação da BCG, principalmente em adultos, na qual a doença de Kawasaki é bastante rara. As vacinas, incluindo as contra COVID-19, também podem desencadear o surgimento deste fenômeno imunológico ainda pouco compreendido.

BCG reactivation can occur in different contexts: associated with infectious conditions, immunosuppression, autoimmunity and post-vaccinations. Also, especially in children below of 5 years of age, should be valued as a finding present in about 50% of cases of Kawasaki disease. In this article, we report the first case published in the literature of a young adult patient, who manifested a reactivation of BCG after receiving the first dose of vaccine against COVID-19 (AztraZeneca/Oxford/Biomanguinhos). Within the first 24 hours after the administration of the vaccine, the patient developed high fever, sweating, local pain, diffuse myalgia and headache. After 2 days, erythema and induration at the site of the BCG vaccine scar began. she has how comorbidity to chronic spontaneous urticaria, but she was asymptomatic without crises for more than 1 year. The relevant family history is maternal death due to the complex syndrome of autoimmunity overlap (systemic lupus erythematosus, Sjögrens syndrome, and anti-phospholipid antibody). After being medicated with NSAID and moderate topical corticosteroid therapy potency for 3 days, there was complete resolution of BCG reactivation. The patient, after 3 months, received the 2nd dose of the vaccine and had no symptoms. It is believed that the reactivation of BCG occurs due to a cross-reaction mechanism between the individuals HSP, elicited as mediators of innate immunity against vaccine inflammation, with some epitopes of M. bovis. It is recommended that any immunosuppressive or autoimmune condition be investigated in patients that manifest BCG reactivation, especially in adults, in which Kawasaki disease is quite rare. Vaccines, including those against COVID-19, can also trigger of this immunological phenomenon still poorly understood.

Síndrome antifosfolípido (SAF): diferencias clínicas e inmunoserológicas entre SAF primario y secundario en una cohorte colombiana / Antiphospholipid syndrome (APS): Clinical and immunoserological differences between primary and secondary APS in a Colombian cohort

RESUMEN Introducción: El síndrome antifosfolípido (SAF) es una enfermedad autoinmune sistémica, caracterizada por trombosis recurrente, que puede afectar la circulación arterial y venosa. Objetivo: Analizar las diferencias inmunológicas y farmacológicas, así como los desenlaces clínicos de una cohorte de pacientes con SAF primario y secundario. Materiales y métodos: Estudio de corte transversal que incluyó 352 pacientes con diagnóstico de SAF atendidos entre los arios 2014 y 2018. Se analizaron variables sociodemográficas, clínicas e inmunológicas y se realizó un análisis univariado y un análisis bivariado mediante la prueba chi-cuadrado para determinar diferencias entre los pacientes con SAF primario y SAF secundario. Finalmente, se hizo un análisis multivariado para buscar asociaciones con los desenlaces clínicos trombóticos en los pacientes con SAF. Resultados: La edad promedio de la población fue de 42,4 ± 14 años; el 84,6% correspondió a sexo femenino. El 67,6% de los pacientes tenía diagnóstico de SAF primario y un 32,4% de SAF secundario, siendo el lupus eritematoso sistémico (LES) la enfermedad asociada en un 84%. Dentro de los eventos trombóticos, el más frecuente fue la trombosis venosa profunda (17,3%), seguida por el ataque cerebrovascular (9,9%). En los eventos obstétricos existió una prevalencia del 39,4% para abortos. No se encontraron diferencias en el perfil sociodemográfico ni en el perfil inmunoserológico entre los pacientes con diagnóstico de SAF primario y aquellos con SAF secundario. Los eventos trombóticos tuvieron mayor frecuencia en el grupo de SAF primario, pero solo la tromboembolia pulmonar alcanzó significación estadís tica. Eventos obstétricos como los abortos no fueron diferentes entre ambos grupos. Dentro de los factores asociados a los eventos trombóticos, se encontró que el sexo femenino tiene una probabilidad 5 veces mayor de accidente cerebrovascular y 3 veces mayor de trombosis venosa profunda. Los anti- β2GPI tipo IgM aumentaron alrededor de 3 veces la probabilidad de presentar abortos en mujeres con SAF. Conclusión: Se presenta una de las cohortes colombianas más grandes de pacientes con SAF reportadas hasta el momento en la literatura. La población es comparable clínica y sociodemográficamente con lo encontrado en otros estudios, aunque la prevalencia de SAF primario fue mayor y las complicaciones trombóticas fueron menores. La tromboembolia pulmonar fue significativamente mayor en el grupo de SAF primario.

ABSTRACT Introduction: Antiphospholipid syndrome (APS) is a systemic autoimmune disease charac terized by recurrent thrombosis that can affect the arterial and venous circulation. Objective: To analyze the immunological and pharmacological differences, as well as the clinical outcomes of a cohort of patients with primary APS and secondary APS. Materials and methods: A retrospective cohort study was conducted that included 352 records of patients diagnosed with APS and treated between 2014 and 2018. A description is pre sented of the sociodemographic, clinical, and immunological profile of the population. A bivariate analysis performed using the chi-squared test to determine differences between groups with primary APS and secondary APS, and finally a multivariate analysis to search for associations with thrombotic clinical outcomes in patients with APS. Results: The mean age was 42.4 ± 14 years, and 84.6% were females. Two-thirds (67.6%) of the patients had a diagnosis of primary APS, and 32.4% of secondary APS, of which 84% were associated with systemic lupus erythematosus (SLE). Among the thrombotic events, the most frequent were deep vein thrombosis (17.3%) and stroke (9.9%). Obstetric events were frequent, with a prevalence of 39.4% for miscarriages. No differences were found in the sociodemographic or immunoserological profile when comparing the group of primary vs. secondary APS. Thrombotic events were more frequent in the primary APS group, although only pulmonary embolism reached statistical significance. There were no differences bet ween the two groups as regards obstetric events, such as miscarriages. Women were found to be 5 times more likely to have a stroke and 3 times more to have deep vein thrombosis. The anti-β2GPI type IgM increased the probability of presenting miscarriages about 3 times in women with APS. Conclusion: The study contains one of the largest Colombian cohorts with APS reported so far, and although it is both clinically and sociodemographically similar to other cohorts, there is a higher prevalence of primary APS. There was a lower frequency of thrombotic complications compared to other cohorts. Patients with primary APS had a tendency to develop thrombosis, as has already been reported in the literature.

Cáncer de mama triple negativo, abortos a repetición e isquemia digital grave / Triple negative breast cancer, repeated abortions and severe digital ischemia

Resumen El presente caso corresponde a una mujer con antecedentes de tres abortos de menos de 10 semanas y cáncer de mama, que desarrolló isquemia digital grave luego del segundo ciclo de capecitabina. Se determinó la presencia de anticuerpos antifosfolipídicos positivos. Dado que las pacientes con síndrome antifosfolipídico obstétrico tienen incremento del riesgo de desarrollar neoplasia y que la isquemia digital grave puede ser la forma de presentación del síndrome antifosfolipídico en los pacientes con cáncer, se presenta el caso para remarcar el beneficio de pesquisar y realizar un diagnóstico temprano de estas características de la enfermedad.

Abstract The present case corresponds to a woman with history of three miscarrieges less than10 weeks and breast cancer, who develops severe digital ischemia after the second cycle of capecitabine. Positive antiphospholipid antibodies were determined. Patients with obstetric antiphospholipid syndrome have an increased risk of developing cancer, and severe digital ischemia could be an unusual form of presentation of the antiphospholipid syndrome in patients with cancer. This case is presented to highlight the benefit of researching and making an early diagnosis of these characteristics of the disease.

Síndrome do anticorpo antifosfolípide e trombocitopenia induzida por heparina: relato de caso / Antiphospholipid antibody syndrome and heparin-induced thrombocytopenia: a case report

RESUMO A Síndrome do Anticorpo Antifosfolípide (SAAF) é uma trombofilia mediada por autoanticorpos protrombóticos responsáveis por aumentar o risco de complicações cardiovasculares e obstétricas. O diagnóstico de SAAF requer elevação de pelo menos um dos autoanticorpos antifosfolipídeos acompanhado de pelo menos um evento de trombose vascular e/ou morbidade gestacional. A Trombocitopenia Induzida por Heparina (HIT) é uma reação medicamentosa adversa protrombótica na qual a heparina forma complexos com fator plaquetário 4, formando neoantígenos que são reconhecidos pelos autoanticorpos. Apresentamos um caso raro de HIT associado à SAAF com tromboembolismo venoso recorrente apesar de anticoagulação. PALAVRAS-CHAVE: Síndrome do anticorpo antifosfolípide, trombose, trombocitopenia induzida por heparina

ABSTRACT Antiphospholipid Antibody Syndrome (APS) is a thrombophilia mediated by prothrombotic autoantibodies responsible for increasing the risk of cardiovascular and obstetric complications. The diagnosis of APS requires elevation of at least one of the antiphospholipid autoantibodies accompanied by at least one event of vascular thrombosis and/or gestational morbidity. Heparin-Induced Thrombocytopenia (HIT) is a prothrombotic adverse drug reaction in which heparin forms complexes with platelet factor 4, forming neoantigens that are recognized by autoantibodies. We present a rare case of HIT associated with APS with recurrent venous thromboembolism despite anticoagulation. KEYWORDS: Antiphospholipid syndrome, thrombosis, heparin-induced thrombocytopenia

Síndrome de Sneddon não relacionada a anticorpos antifosfolípides / Sneddon's syndrome not related to antiphospholipid antibodies

RESUMO A Síndrome de Sneddon é uma vasculopatia trombótica não inflamatória rara, caracterizada por livedo reticular generalizado e eventos cerebrovasculares isquêmicos recorrentes. Sua forma idiopática, ou seja, aquela não relacionada a positividade de anticorpos ou presença de outras doenças, é a mais incomum. As inúmeras manifestações que podem se relacionar à síndrome refletem a heterogeneidade dos casos, ressaltando a importância da investigação clínica e seguimento desses pacientes. Relatamos um caso de Síndrome de Sneddon idiopática em paciente feminina a qual apresentou livedo reticular generalizado como manifestação inicial, seguido de acidentes vasculares cerebrais. PALAVRAS-CHAVE: Síndrome de Sneddon, anticorpos antifosfolípides, livedo reticular

ABSTRACT Sneddon Syndrome is a rare non-inflammatory thrombotic vasculopathy characterized by generalized reticular livedo and recurrent ischemic cerebrovascular events. Its idiopathic form, that is, that not related to antibody positivity or the presence of other diseases, is the most uncommon. The numerous manifestations that may be related to the syndrome reflect the heterogeneity of cases, highlighting the importance of clinical investigation and follow-up of these patients. We report a case of idiopathic Sneddon's Syndrome in a female patient who presented generalized livedo reticularis as the initial manifestation, followed by cerebrovascular accidents. KEYWORDS: Sneddon's Syndrome, antiphospholipid antibodies, livedo reticularis

Retinal ischemia as the first manifestation of antiphospholipid antibody syndrome / Isquemia retiniana como primeira manifestação da síndrome do anticorpo antifosfolipídio

ABSTRACT Antiphospholipid antibody syndrome (APS) is characterized by the development of venous and/or arterial thrombosis and by gestational morbidity (recurrent fetal losses) in the presence of antiphospholipid antibodies. We report the case of a 38-year-old woman who was diagnosed with primary APS from thromboembolic abnormalities in the retinal periphery that led to retinal ischemia. The aim of this study is to share with physicians and medical undergraduates an atypical manifestation of the syndrome that is the most common acquired thrombophilia, that should be part of the diagnostic routine of all clinical specialties.

RESUMO A síndrome do anticorpo antifosfolipídio (SAAF) caracteriza-se pelo desenvolvimento de tromboses venosas e/ou arteriais e pela morbidade gestacional (perdas fetais recorrentes) na presença de anticorpos antifosfolipídicos. Foi relatado o caso de uma paciente de 38 anos que foi diagnosticada com SAAF primária, a partir de alterações tromboembólicas na periferia da retina, que levaram à isquemia retiniana. O objetivo desse estudo é compartilhar com médicos e acadêmicos de medicina uma manifestação atípica da síndrome que é a trombofilia adquirida mais comum, devendo fazer parte da rotina diagnóstica de todas as especialidades clínicas.

Resultados obstétricos en gestantes diagnosticadas de síndrome antifosfolípido / Obstetric outcomes in pregnant women diagnosed of antiphospholipid syndrome

INTRODUCCIÓN: El síndrome antifosfolípido (SAF) es una enfermedad autoinmune caracterizada por la aparición de trombosis, complicaciones obstétricas y la presencia de anticuerpos antifosfolípidos. El objetivo de este estudio fue evaluar los resultados obstétricos en gestantes diagnosticadas de síndrome antifosfolípido, así como evaluar las condiciones que podrían influir en estos resultados. MATERIAL Y MÉTODOS: Se realizó un estudio retrospectivo de gestantes con diagnóstico previo de SAF, que fueron atendidas en nuestro centro entre los años 2007 y 2017. RESULTADOS: En el período de estudio se recogieron 35 gestantes con SAF, con un total de 50 gestaciones. Se empleó heparina en el 100% de las gestaciones y ácido acetilsalicílico en el 96%. La aparición de alguna complicación obstétrica ocurrió en el 34% de las gestaciones estudiadas. El perfil de anticuerpos triple positivo se asoció a mayor porcentaje de partos prematuros. La presencia de anticoagulante lúpico de forma aislada no se asoció a peores resultados obstétricos. DISCUSIÓN: La gestación en la mujer con SAF supone un importante reto, que precisa de un manejo multidisciplinar por parte del obstetra y el reumatólogo. Por otro lado, el perfil de anticuerpos antifosfolípidos podría detectar a las pacientes con mayor riesgo con el fin de adecuar el tratamiento y mejorar los resultados obstétricos.

INTRODUCTION: The antiphospholipid syndrome (APS) is an autoinmune disease characterized by the occurence of thrombosis, obstetric morbidity and the presence of antiphospholipid antibodies. The aim of this study was to evaluate the obstetric outcomes in pregnant women diagnosed of antiphospholipid syndrome, as well as examine the conditions which may influence in those results. MATERIALS AND METHODS: A retrospective study was undertaken with pregnant women diagnosed of APS, who were attended in our hospital between 2007 and 2017. RESULTS: During the period of study 35 patients with APS and a sum of 50 pregnancies were gathered. Heparin was used in all pregnancies and acetylsalicylic acid in 96%. Any adverse obstetric outcome occurred in 34% of the pregnancies in the study. The triple positivity of antiphospholipid antibodies was associated to higher percentage of premature deliveries. The lupus anticoagulant alone was not related to worse obstetric outcomes. CONCLUSIONS: Pregnancy in APS patients means a challenge, requiring a multidisciplinary management by Obstetricians and Rheumathologists. On the other hand, the antiphospholipid antibodies profile could help to recognize those patients at risk, in order to adequate treatment and improve obstetric results.