Frequency of Anticardiolipin Antibodies in Women with Recurrent Fetal Loss

Aim: To find out the frequency of Anticardiolipin Antibodies in women with recurrent fetal loss Study design & duration: One year descriptive study Methods: Seventy five females were included in the study with ages ranging from 20-40 years with minimum two miscarriages. Diabetic females and females with history of bacterial or viral diseases were excluded from the study. Results: In this group the mean age was 27.60±3.29 years. Mean number of fetal losses was 2.95±1.45 whereas mean duration of marriage was 5.79±4.11 years. Conclusion: It is suggested that the patient with history of recurrent miscarriages must be screened for Anticardiolipin Antibodies to bring them out of psychological and physical trauma. Keywords: Anticardiolipin Antibodies (aCL), Recurrent fetal loss (RFL), aPTT

The Interaction of Sickle Cell Trait and Anticardiolipin Antibodies in Venousthromboembolism

Introduction Among the risk factors for venous thromboembolism (VTE) are inheritance of the sickle cell gene and antiphospholipid syndrome. Antiphospholipid antibodies are elevated in sickle cell disease but there is little information on its levels in sickle cell trait. The prevalence of anticardiolipin antibodies and association with VTE is equally not known in the Nigerian population. Methods A case control study involving 50 consecutive patients with Doppler confirmed venous thromboembolism at the University College Hospital Ibadan and 50 apparently healthy individuals. Haemoglobin electrophoresis was carried out using cellulose acetate membrane. IgG and IgM anticardiolipin antibodies were assayed by ELISA. Results The mean age of the patients was 58.7±18.5years, range of 21-89 years, there were 21 males (42%). Majority of the patients (42 (84%)) had deep venous thrombosis while five (10%) patients presented with pulmonary embolism, one had both deep venous thrombosis and pulmonary embolism. A patient had portal vein thrombosis and another, an intracardiac clot. Sedentary lifestyles, hypertension and concomitant malignancy were the most prevalent risk factors (34% each) (figure I). Both sedentary lifestyle and cancer were significantly associated with VTE (p<0.001). Sickle cell trait (Hb AS) occurred in the same number of patients and controls (eleven each). Higher levels of both IgG and IgM anticardiolipin antibodies were found among the VTE patients with sickle cell trait than controls. (Table 1) The mean levels of IgG antibody in Hb AS patients was 31.7 ± 12.8 GPL compared to 25 ± 13.8 GPL in the controls (p= 0.254) and mean IgM anticardiolipin antibodies in Hb AS patients was 18.7 ± 6.2 GPL while that of the controls was 16.8 ± 11.6 GPL (p= 0.633). The global mean levels of IgG and IgM anticardiolipin antibodies in the patients with VTE were 29.7 ± 9.1 GPL and 24.8 ±16.7 GPL respectively versus 28.5 ±13.7 GPL and 25.2 ±16.2 GPL in the controls. A multivariable logistic regression showed age, sedentary lifestyle and anemia as independent risk factors while a positive IgM anticardiolipin antibody appeared protective for VTE. (Table 2) Conclusion The prevalence of sickle cell trait and anticardiolipin levels did not differ between VTE patients and healthy controls. Age, hypertension, sedentary lifestyle and malignancies were identified risk factors in our cohort of patients. Larger prospective studies may be helpful in determining the influence of sickle cell trait and antiphospholipid antibodies in venous thromboembolism. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Abundance of B Cell Receptors Harboring Elongated Polytyrosine and Polyserine Rich Motifs within Their Heavy Chain CDR3 Distinguishes Catastrophic and Antiphospholipid Syndrome

ACKGROUND: Antiphospholipid syndrome (APS) is defined by arterial and/or venous thrombosis and/or pregnancy morbidity along with persistent circulating antiphospholipid antibodies (aPL). Central to APS pathogenesis are B cells that generate autoreactive antibodies, including anticardiolipin antibodies (aCL), and anti-β2-glycoprotein-I antibodies (anti-B2GPI). Several studies have implicated specific germline and/or antigen-driven somatic hypermutations within the complementarity determining regions (CDRs) of pathogenic antibodies in APS, as well as other thrombotic disorders. Nevertheless, the B cell repertoire in thrombotic APS remains poorly characterized. Recently, autoreactive and platelet activating pathogenic antibodies harboring elongated tyrosine rich CDR3 motifs were reported in patients with heparin-induced thrombocytopenia (HIT) (Zhu et.al, Blood 2019, 2020). Whether such antibodies are present in APS and their potential role, if so, has not been determined. APPROACH : We leveraged single cell immunoprofiling to characterize the presence of antibodies harboring elongated tyrosine rich CDR3 motifs in the circulating B cell repertoire obtained from peripheral blood mononuclear cells (PBMC) from patients with thrombotic (n=4) and catastrophic APS (n=3) as well as healthy individuals (n=3). We also correlated the abundance of these antibodies with criteria aPL and inflammatory cytokines in plasma. The modified Ham (mHam) test was used to assess functional complement activation in plasma in plasma from all of the subjects studied (Chaturvedi et al. Blood 2020). RESULTS : B cell clones containing elongated polytyrosine rich CDR3 motifs were most abundant in patients with a diagnosis of catastrophic APS (n=3) , and were markedly elevated in patients with APS (n=4) compared to healthy counterparts (n=3) (Table 1). Elongated polytyrosine rich CDR3 motifs from CAPS patients contained penta-tyrosine (Y5), hexa-tyrosine (Y6), hepta-tyrosine (Y7), and octa-tyrosine (Y8) motifs (table 2) and contained more tyrosine residues than the penta-tyrosines previously reported in HIT. In addition, all of the polytyrosine containing motifs CDR3 motifs were present on the heavy chain and was followed by MDVW motif of IGHJ6. The presence of B cell clones containing elongated polytyrosine rich CDR3 motifs exhibited significant positive correlations with complement activation measured by mHAM test (r=0.728, p=0.0032), criteria aPLs including anticardiolipin antibodies (aCL) and anti-β2-glycoprotein-I antibodies (anti-B2GPI), as well as plasma inflammatory cytokines; TNFα (r=0.901, p=1.5x10 -5), IL-23 (r=0.780, p=0.0016), IL-17C cytokines (r=0.729, p=0.0033), sICAM1 (r=0.740, p=0.0025), sVCAM1 (r=0.764, p=0.0015), (Figure 1). The presence of elongated polytyrosine rich CDR3 motifs was also associated with the increase abundance of polyserine rich CDR3 motifs that were present predominantly in patients with CAPS. CONCLUSION : These preliminary studies provide the first characterization of the prevalence of B cell clones containing elongated polytyrosine rich CDR3 motifs, previously reported in HIT, in the B cell repertoire of APS patients. Notably, the abundance of these B cell clones is markedly elevated in patients with CAPS and is associated with elevated levels of inflammatory cytokines TNFa, IL-23, IL-17C, sICAM1, and sVCAM1. Validation studies in larger cohorts from APS patients and other thrombotic disorders are ongoing. Figure 1 Figure 1. Disclosures Chaturvedi: Alexion: Other: Advisory board member; Dova: Other: Advisory board member; Sanofi Genzyme: Other: Advisory board member; Argenx: Other: Advisory board member; UCB: Other: Advisory board participation. Khorana: Bristol Myers Squibb: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Anthos: Consultancy, Honoraria; Sanofi: Consultancy, Honoraria; Halozyme: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Bayer: Consultancy, Honoraria. McCrae: Sanofi, Novartis, Alexion, and Johnson & Johnson: Consultancy, Honoraria; Dova, Novartis, Rigel, and Sanofi Genzyme: Consultancy.

Schizophrenia Genetics and Neuropsychiatric Features in Childhood-Onset Systemic Lupus Erythematosus

Objective We examined the association between schizophrenia genetic susceptibility loci and neuropsychiatric systemic lupus erythematosus (NPSLE) features in childhood-onset SLE (cSLE) participants. Methods Study participants from the Lupus Clinic at the Hospital for Sick Children, Toronto, met ≥4 of the ACR and/or SLICC SLE classification criteria and were genotyped using the Illumina MEGA or GSA arrays. Ungenotyped SNPs were imputed, and ancestry was genetically inferred. We calculated two additive schizophrenia weighted polygenic risk scores (PRSs) using: 1) genome-wide significant SNPs (P<5×10-8) and 2) expanded list of SNPs with significance P<0.05. We defined two outcomes compared to absence of NPSLE features: 1) any NPSLE feature and 2) subtypes of NPSLE features: psychosis and non-psychosis NPSLE. We completed logistic and multinomial regressions, first adjusted for inferred ancestry only and second including variables significantly associated with NPSLE in our cohort (P<0.05). Results We included 513 participants with cSLE. Median age at diagnosis was 13.8 years (IQR, 11.2-15.6), 83% were female, and 31% were of European ancestry. An increasing schizophrenia GWAS PRS was not significantly associated with NPSLE (OR=1.04, [95%CI 0.87,1.26];P=0.62), nor with NPSLE subtypes: psychosis (OR=0.97, [95%CI 0.73,1.29];P=0.84) and other non-psychosis NPSLE (OR=1.08, [95%CI 0.88,1.34];v=0.44) in ancestry adjusted models. Results were similar for the model including covariates (ancestry, malar rash, oral/nasal ulcers, arthritis, lymphopenia, Coombs-positive hemolytic anemia, lupus anticoagulant and anticardiolipin antibodies), and for the expanded PRS estimates. Conclusion We did not observe an association between known risk loci for schizophrenia and NPSLE in a multiethnic cSLE cohort. This work warrants further validation.

Case Report: Cerebral venous thrombosis revealing celiac disease

Celiac disease (CD) is an autoimmune enteropathy resulting from intolerance of an individual genetically predisposed to gluten. It has a large clinical polymorphism ranging from a classic digestive clinical presentation due to the malabsorption syndrome to extra-intestinal symptoms. Among the hematologic abnormalities, venous thromboembolic disease (VTE) has been reported, and they are most often located in the abdomen or lower limbs, but the cerebral localization was exceptionally described. We report a case of CD revealed by cerebral thrombophlebitis. A 44-year-old patient with no medical history and no drug intake, presented with hemiplegia followed by a status epilepticus in a context of apyrexia, initially hospitalized in intensive care. Magnetic imaging resonance displayed a cerebral venous thrombosis of the sigmoid sinus requiring anticoagulant treatment, then transferred to our department for the etiological investigation. On questioning, the patient reported chronic diarrhea and weight loss with no other associated symptoms. The examination revealed an underweight patient with pale conjunctiva, improvement of her deficit symptoms, and no other abnormalities. Laboratory tests noted biological signs of malabsorption. The thrombophilia assessment revealed a protein C deficiency with a slight increase in anticardiolipin antibodies and anti-Beta 2 glycoprotein 1 antibodies. Immunological tests noted positives anti-transglutaminase and IgA anti-endomysium antibodies. Duodenal biopsy demonstrated villous atrophy. After ruling out the other causes of VTE, the diagnosis of cerebral venous thrombosis secondary to CD was retained. Early diagnosis and treatment of CD improves the quality-of-life for patients and may spare them various long-term or even fatal complications.

Case Report: Cerebral venous thrombosis revealing celiac disease

Celiac disease (CD) is an autoimmune enteropathy resulting from intolerance of an individual genetically predisposed to gluten. It has a large clinical polymorphism ranging from a classic digestive clinical presentation due to the malabsorption syndrome to extra-intestinal symptoms. Among the hematologic abnormalities, venous thromboembolic disease (VTE) has been reported, and they are most often located in the abdomen or lower limbs, but the cerebral localization was exceptionally described. We report a case of CD revealed by cerebral thrombophlebitis. A 44-year-old patient with no medical history and no drug intake, presented with hemiplegia followed by a status epilepticus in a context of apyrexia, initially hospitalized in intensive care. Magnetic imaging resonance displayed a cerebral venous thrombosis of the sigmoid sinus requiring anticoagulant treatment, then transferred to our department for the etiological investigation. On questioning, the patient reported chronic diarrhea and weight loss with no other associated symptoms. The examination revealed an underweight patient with pale conjunctiva, improvement of her deficit symptoms, and no other abnormalities. Laboratory tests noted biological signs of malabsorption. The thrombophilia assessment revealed a protein C deficiency with a slight increase in anticardiolipin antibodies and anti-Beta 2 glycoprotein 1 antibodies. Immunological tests noted positives anti-transglutaminase and IgA anti-endomysium antibodies. Duodenal biopsy demonstrated villous atrophy. After ruling out the other causes of VTE, the diagnosis of cerebral venous thrombosis secondary to CD was retained. Early diagnosis and treatment of CD improves the quality-of-life for patients and may spare them various long-term or even fatal complications.

Antiphospholipid Antibodies and Heart Failure with Preserved Ejection Fraction. The Multicenter ATHERO-APS Study

Background. The prevalence of heart failure with preserved ejection fraction (HFpEF) in patients with antiphospholipid syndrome (APS) is unknown. Methods. A prospective multicenter cohort study including 125 patients was conducted: 91 primary APS (PAPS), 18 APS-SLE, and 16 carriers. HFpEF was diagnosed according to the 2019 European Society of Cardiology criteria: patients with ≥5 points among major and minor functional and morphological criteria including NT-ProBNP > 220 pg/mL, left atrial (LA) enlargement, increased left ventricular filling pressure. Results. Overall, 18 (14.4%) patients were diagnosed with HFpEF; this prevalence increased from 6.3% in carriers to 13.2% in PAPS and 27.8% in APS-SLE. Patients with HFpEF were older and with a higher prevalence of hypertension and previous arterial events. At logistic regression analysis, age, arterial hypertension, anticardiolipin antibodies IgG > 40 GPL (odds ratio (OR) 3.43, 95% confidence interval (CI) 1.09–10.77, p = 0.035), anti β-2-glycoprotein-I IgG > 40 GPL (OR 5.28, 1.53–18.27, p = 0.009), lupus anticoagulants DRVVT > 1.25 (OR 5.20, 95% CI 1.10–24.68, p = 0.038), and triple positivity (OR 3.56, 95% CI 1.11–11.47, p = 0.033) were associated with HFpEF after adjustment for age and sex. By multivariate analysis, hypertension (OR 19.49, 95% CI 2.21–171.94, p = 0.008), age (OR 1.07, 95% CI 1.00–1.14, p = 0.044), and aβ2GPI IgG > 40 GPL (OR 8.62, 95% CI 1.23–60.44, p = 0.030) were associated with HFpEF. Conclusion. HFpEF is detectable in a relevant proportion of APS patients. The role of aPL in the pathogenesis and prognosis of HFpEF needs further investigation.

Antiphospholipid Antibodies in Patients with Covid-19: Trend Over Time

Purpose Aim of the study was to investigate whether aPL positivity correlated with thrombosis in COVID-19 patients and whether it was transient or persistent. Methods We enrolled COVID-19 patients who underwent aPL tests: Lupus Anticoagulant (LA); IgM, IgG, IgA anticardiolipin antibodies (aCL); and IgM, IgG anti-β2-Glycoprotein-I antibodies (aβ2GPI). Results Twenty-eight out of 73 (38.4%) patients resulted positive for at least one aPL assay: 32.8% for IgA aCL, 6.8% for IgM aCL and 4.1% for IgM aβ2GPI. No patients tested positive for IgG aPL or LA at the first determination. Seven (9.6%) patients developed thrombotic events during hospitalization, with 4 of them resulting positive for aPL. In patients with thrombotic events during hospitalization the risk of death was increased 9-fold (LR+8.9, p=0.003). Patients with double positivity for aCL and aβ2GPI IgM had a LR+ of 6.3 to have thrombotic events (p=0.012) and a LR+ of 4.9 to have elevated D-dimer levels (p=0.027). In 10 out of 28 positive patients, aPL was detected in a second occasion at least 12-weeks apart and two patients confirmed the positivity. Conclusion Results suggest that double positivity for aCL and aβ2GPI IgM increases the risk of thrombosis in COVID-19, unlike IgA aCL positivity. APL positivity may be persistent, and it is advisable to monitor it over time.

Antiphospholipid antibodies and anticoagulant therapy: capillaroscopic findings

Background Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by specific vascular and obstetric manifestations and by antiphospholipid antibodies (aPL) positivity. Microvascular damage in the course of APS and “aPL carrier” patients without symptoms is poorly investigated. Objectives This study aims to compare nailfold videocapillaroscopy (NVC) microvascular parameters in APS patients and non-symptomatic "aPL carriers" and to investigate their possible correlations with different aPL subtypes. Methods NVC was performed during standard evaluations in 18 APS patients (mean age 50 ± 13.8 years), 24 "aPL carriers" without symptoms (mean age 46.4 ± 16.4 years), and 18 control patients (CTR) (mean age 74 ± 12.5 years) taking oral anticoagulants for non-immunological indications (i.e., cardiovascular accidents). All patients were investigated for the presence of dilated capillaries, giant capillaries, microhemorrhages, capillary loss, and further non-specific/specific abnormalities (i.e., branched “bushy” capillaries, sign of neoangiogenesis) by NVC. Every alteration was also classified according to a semi-quantitative score. Lupus anticoagulant, anticardiolipin antibodies, and antibeta2 glycoprotein I antibodies were tested in each patient. Results APS patients showed at NVC increased frequency of microhemorrhages (p = 0.039)—particularly a “comb-like” pattern (parallel hemorrhages) (p = 0.002)—than "aPL carriers". Of note, there were no significant differences concerning the isolated number of microhemorrhages between APS and the CTR group (p = 0.314), but “comb-like” hemorrhages were significantly more frequent in the APS group (p = 0.034). Not any significant correlation was found between the aPL subtypes and NVC parameters. Conclusions APS patients showed significantly a greater number of non-specific NVC abnormalities than "aPL carriers", particularly the “comb-like” NVC pattern. Oral anticoagulants may represent a confounding factor for isolated microhemorrhages. Not any correlation was found between aPL subtypes and NVC parameters. Further investigations are needed to better characterize the microvascular endothelium damage induced by aPL.

Antiphospholipid antibodies and their clinical significance

Обзор посвящён антифосфолипидным антителам (аФЛ) и их клинико-диагностической ценности. Рассматриваются вопросы стандартизации методов исследования аФЛ, в частности твердофазных тест-систем, одним из представителей которых является хемилюминесцентый анализ. Обсуждаются патогенетические аспекты антифосфолипидного синдрома (АФС) и описываются пути влияния аФЛ на различные компоненты гемостаза. Дается подробная характеристика β2-гликопротеина 1 (β2-ГП1) с описанием доменов. Подробно изучены клинические проявления и взаимосвязь «экстра»-критериальных аФЛ: IgA антител к кардиолипину (IgA-аКЛ), IgA антител к β2-ГП1 (IgA-аβ2-ГП1), антител к домену I β2-ГП1 (аβ2-ГП1-DI), антител к комплексу фосфатидилсерин–протромбин и аФЛ, не входящих в Сиднейские диагностические критерии АФС. Antiphospholipid syndrome (APS) is an acquired autoimmune thrombophilia in which patients have clinical signs of recurrent thrombosis and morbidity during pregnancy and constantly test positive for antibodies against phospholipid (aPL). At least one clinical (vascular thrombosis or pregnancy) and one laboratory (positive test result for anticoagulant lupus, anticardiolipin antibodies and/or anti-β2-glycoprotein 1 antibodies) must be performed in order for the patient to be classified as having APS. However, the clinical and laboratory APS spectra cover additional manifestations. Research interest is increasingly focused on developing new assays that may be more specifi c to APS than current aPL tests. This review focuses on extra criterion antiphospholipid antibodies — IgA antibodies to cardiolipin (IgA-aCL), IgA antibodies to β2-glycoprotein 1 (IgA-aβ2-GP1), antibodies to phosphatidylserine-prothrombin complex. A detailed description of aβ2-GP1 with a description of domains is given. The questions of standardization of aPL research methods, in particular, solid-phase test systems, one of which is chemiluminescent analysis, are examined.