Systemic sclerosis complicated by procainamide-induced lupus and antiphospholipid syndrome

In order to estimate the effect of the long term administration of cyclosporine (CsA) on the shape change of erythrocytes, erythrocyte shapes which are observed with a scanning electron microscope were classified according to the nomenclature of Bessis for stomatocyte-echinocyte shape transformation. As a result of observing the erythrocyte shape of fifty-six patients with kidney transplantation treated with CsA, the morphological index of the erythrocytes of patients significantly increased to 0.0835+/-0.0085*** in comparison with 0.0004+/-0.0051 of those from healthy volunteers (control) (***: p<0.001, ANOVA). Such transformations had no relation to the subjects' sex or age. On the other hand, the erythrocytes of patients administered more than 100 ng/ml of CsA and posttransplanted within less than two years were transformed by CsA from the state of discocyte to echinocyte. In rats, the morphological index of erythrocytes of rats treated with 3 mg/kg/d or 5 mg/kg/d of CsA significantly increased in comparison with rats treated with saline (control). Furthermore, the erythrocytes of two patients were observed in terms of shape before the treatment with CsA. In both patients, the echinocyte type of erythrocyte increased by treatment with CsA. In vitro, the morphological index of the erythrocytes incubated with plasma containing CsA significantly increased, to 0.459+/-0.066*** in comparison with 0.064+/-0.029 of the control. It is suggested from these results that CsA treatment induces the echinocyte type of erythrocyte.     

Monitoring of oral anticoagulant therapy in lupus anticoagulant positive patients with the anti-phospholipid syndrome

Introduction of the International Normalized Ratio (INR) has improved the standardization of laboratory control of oral anticoagulant therapy (OAT). However, it has been reported that misleading INR results can be obtained from OAT patients with lupus anticoagulant (LA). To investigate this claim, we studied 35 OAT patients, 14 of whom had anti-phospholipid syndrome (APS) with a documented LA. Attainment of anticoagulation was confirmed by chromogenic assay of factor VII and factor X. Prothrombin times were performed using eight thromboplastins (five derived from rabbit brain, two recombinant human tissue factor and one made from human placenta) with an International Sensitivity Index (ISI) of <1.40. When using the thromboplastin manufacturers' ISI there was a significant difference (ANOVA, P<0.0001) between INR results obtained with the eight reagents for both APS (average CV = 12.4%) and non-APS (average CV = 12.5%) patient groups. Variation using the eight thromboplastins was assessed by calculating the CV for each sample; these values were then pooled for each patient group to give the average CV for all samples with all reagents for the two patient groups. Results for both patient groups exhibited markedly reduced variation (APS group average CV = 6.5%, non-APS group average CV = 5.8%) when locally assigned ISI values were employed in the calculation of INRs. Our data does not support the suggestion that the INR may not reflect the true level of anticoagulation in the long-term warfarin-treated patient, in whom lupus anticoagulant was detected. However, there was strong evidence that thromboplastin use should be restricted to those clot detection systems for which the reagent's manufacturer has assigned an ISI, or local ISI assignment must be undertaken. The inappropriate use of a generic (i.e. optical or mechanical clot detection system without regard to specific analyser type) ISI value can lead to ambiguous results.     

Procainamide-induced agranulocytosis differs serologically and clinically from procainamide-induced lupus

Agranulocytosis is a well recognized but uncommon complication of procainamide (PA) therapy, whereas a lupus-like syndrome occurs in approximately 20% of patients treated chronically with PA. In order to gain insight into the immunopathogenic relationships among these conditions, we compared the humoral immune abnormalities in these patient groups as well as in asymptomatic PA-treated patients. A relatively uniform profile of IgM but not IgG autoantibody reactivity with a set of chromatin-related antigens was observed in eight elderly men who developed agranulocytosis after treatment with PA. In contrast PA-induced lupus patients had predominant reactivity with [(H2A-H2B)-DNA] in both IgM and IgG classes. Five of eight patients with agranulocytosis had elevated levels of neutrophil-reactive IgG which appeared to be due to immune complexes based on Fc gamma receptor blocking studies. However, 12 of 15 patients with PA-induced lupus, none of whom had neutropenia, had similar levels of neutrophil-reactive IgG, suggesting that this reactivity was not causally related to agranulocytosis. Agranulocytosis developed after less than 3 months treatment with PA in six of eight patients. This time course was similar to that seen in 77 PA-induced agranulocytosis patients reported in the literature plus 127 patients reported to the U.S. Food and Drug Administration in whom 90% developed agranulocytosis within 3 months of starting PA. In contrast, the mode duration of treatment with PA before lupus-like symptoms develop is 10-12 months. These findings, together with the different profiles of autoantibodies and clinical presentations, suggest that agranulocytosis arises from a different mechanism than that underlying PA-induced lupus.     

Transient lupus anticoagulants associated with hemorrhage rather than thrombosis: the hemorrhagic lupus anticoagulant syndrome

Lupus anticoagulants (LAs) represent a diverse group of antibodies directed against phospholipids. Patients with LAs may be free of symptoms but can have thrombotic complications including stroke, placental infarction, and fetal loss. Rarely hemorrhagic symptoms have been reported. We describe six previously healthy children who were first seen with clinical bleeding and prolonged activated partial thromboplastin time. Laboratory evaluation revealed positive results on mixing studies and evidence of phospholipid dependence of the anticoagulant, suggesting LAs. Four of six patients had anticardiolipin antibodies, and all four who were tested had reduced factor II activity levels. In all patients, bleeding symptoms resolved spontaneously within 3 months, and laboratory findings returned to normal within 6 months. The hemorrhagic LA syndrome should be considered in previously healthy children with new-onset bleeding and prolonged activated partial thromboplastin time. This clinical entity probably represents pathogenic mechanism distinct from thrombotic LA syndromes.     

The lupus anticoagulant

The clinical and laboratory experience with the lupus anticoagulant was reviewed in 37 patients. The anti-coagulant is thought to act by blocking the activation of prothrombin by the prothrombin activator comlex of factors Xa, V, and phospholipid. Although the anticoagulant has been principally associated with diseases of immune origin, 14 of the present patients had disorders not thought to be immune in nature. Eighteen patients underwent twenty-one operative procedures with only a single episode of excessive bleeding. In the author's experience, the lupus anticoagulant is a rare cause of bleeding.     

Circulating interleukin-16 in systemic lupus erythematosus

OBJECTIVE: To investigate the relationship between interleukin (IL)-16 and systemic lupus erythematosus (SLE). METHODS: Serum levels of IL-16 were examined in SLE patients using an enzyme-linked immunosorbent assay (ELISA). RESULTS: The serum level of IL-16 in the patients was much higher than that in healthy volunteers (P < 0.001). An increase in IL-16 was observed in proportion to the activity of SLE assessed by the SLE Disease Activity Index (SLEDAI) score (P < 0.0001). CONCLUSIONS: Our observations suggest an interaction between disease activity and the production of IL-16 in SLE, and reveal that IL-16 is a useful indicator of disease activity. This is the first report describing the relationship between IL-16 and SLE.     

Circulating lupus coagulants. A paradox in vascular pathology]

Lupus anticoagulants (LA) are acquired inhibitors of coagulation related to the antiphospholipid antibodies. Paradoxically, these anticoagulants do not expose patients to the risk of hemorrhage but, on the contrary, to a thrombotic risk. The association in a patient of an antiphospholipid antibody and a clinical manifestation (thrombosis or equivalent) defines the antiphospholipid syndrome. This syndrome is termed primary or secondary according to whether it appears as an isolated disorder or is associated with an identified disease, frequently autoimmune (systemic lupus erythematous or lupus related syndrome). Clinical complications of LA are arterial or venous thrombosis at various sites. They are frequently recurrent, and deep venous thrombosis of leg, oculo-cerebral ischemic lesions and heart valve complications have all been well documented. Thrombosis of the microcirculation can cause tissue or organ disfunction, the most characteristic effect being repeated abortions. Laboratory demonstration of LA is difficult when the inhibitor is weak, and this should be completed by tests for other antiphospholipid antibodies. Clinical studies are necessary to assess the thrombotic risk of the LA in different clinical conditions and to evaluate the need and type of antithrombotic treatment. The LA are heterogeneous and only a small proportion of patients with LA will develop thrombosis. New tests capable of predicting the thrombotic risk, bases on the physiopathological mechanisms with which LA interfere in vivo, are currently being investigated.     

Localization of the apoptosis-inducing activity of lupus anticoagulant in an annexin V-binding antibody subset

Lupus anticoagulant (LAC) is associated with arterial and venous thrombosis, thrombocytopenia, and recurrent fetal loss. We have reported previously that plasma with LAC activity induces apoptosis in endothelial cells and binds annexin V (Nakamura, N., Y. Shidara, N. Kawaguchi, C. Azuma, N. Mitsuda, S. Onishi, K. Yamaji, and Y. Wada. 1994. Biochem. Biophys. Res. Commun. 205:1488-1493). In this study, we separated two IgG antibody fractions, one with and one without affinity for annexin V, from 10 patients with LAC. LAC and apoptotic activities were localized in the annexin V-binding fraction in all 10 patients. DNA fragmentation was dose-dependent, paralleling the amount of IgG added to the human umbilical vein endothelial cell culture medium, and was inhibited by preincubation with annexin V. Removal of the antiphospholipid antibodies from patient IgG with phospholipid liposomes did not abolish the apoptosis-inducing activities or binding to annexin V. These results imply that patients with LAC often have antibodies that do not bind phospholipids and are responsible for the induction of apoptosis in endothelial cells.     

A quantitative, semi-automated and computer-assisted test for lupus anticoagulant

A previously unreported example of perineuronal satellitosis in the medial CA1 and adjacent subiculum in the human hippocampal formation is described. This phenomenon is characterized by a clustering of glial cells in relation to the perikarya of a subpopulation of neurons in the deep pyramidal layer and around most neurons scattered in the stratum oriens and subcortical white matter. Most of the perineuronal satellite glia were identified as oligodendrocytes based on their nuclear chromatin patterns and antigenic properties. Satellite oligodendrocytes were mostly of the medium dense variety. A type of satellite glia with nuclear features of the dark oligodendrocyte could not be identified unequivocally using the antigenic criteria employed in this study.     

Phosphatidyl serine-dependent antiprothrombin antibody is exclusive to patients with lupus anticoagulant

In attempt to develop a new chemotherapeutic regimen including carboplatin (CBDCA), epirubicin (EPI), and VP-16 in extensive small cell lung cancer, with a higher dose intensity compared with previous experience of our group, we determined the maximum tolerated dose (MTD) of VP-16 when administered in association with CBDCA (300 mg/ m2, i.v., day 1) and EPI (75 mg/m2, i.v., day 1), recycling chemotherapy every 3 weeks, with the support of granulocyte-colony-stimulating factor (G-CSF). A total of 15 patients received three dose levels of VP-16 (mg/m2, i.v., daily on days 1-3): 100 (three patients), 120 (six), and 140 (six). G-CSF was administered subcutaneously at the dose of 5 micrograms/kg/day on days 6-15 of each chemotherapy course. The MTD was established at 140 mg/m2 and myelotoxicity, grade 4 neutropenia with death for sepsis in one case and grade 3 thrombocytopenia in three cases, was dose limiting. The recommended dose of VP-16 for a phase II study is 140 mg/m2.     

Antiphospholipid antibodies other than lupus anticoagulant and anticardiolipin antibodies in women with recurrent pregnancy loss, fertile controls, and antiphospholipid syndrome

OBJECTIVE: To determine whether antiphospholipid antibodies other than lupus anticoagulant and anticardiolipin are associated with recurrent pregnancy loss. METHODS: Sera from three groups of women were studied: 1) 147 women with recurrent pregnancy loss but no clinical signs or symptoms of autoimmune disease who tested negative for lupus anticoagulant and medium-to-high levels of immunoglobulin G anticardiolipin antibodies; 2) 104 healthy, fertile controls of similar age and gravidity; and 3) 43 women with well-characterized antiphospholipid syndrome. Serum antibody binding against six phospholipids (cardiolipin, phosphatidic acid, phosphatidylserine, phosphatidylcholine, phosphatidylethanolamine, and phosphatidylinositol) was determined using enzyme-linked immunoassays, and results were normalized using an anticardiolipin standard. RESULTS: Twenty-six (18%) women with recurrent pregnancy loss and nine (9%) controls tested positive (above the 99th percentile) for antiphospholipid antibodies. Sera from five (3.4%) women with recurrent pregnancy loss and four (3.8%) controls demonstrated binding to phospholipid antigens other than cardiolipin. In contrast, binding to phospholipid antigens was demonstrated in sera from more than 90% of women with antiphospholipid syndrome. Among women testing positive for antiphospholipid antibodies, the median positive value for women in the antiphospholipid syndrome group was significantly higher than for those with recurrent pregnancy loss or normal fertile controls. CONCLUSIONS: Women with recurrent pregnancy loss are no more likely than fertile controls to have elevated levels of antiphospholipid antibodies once lupus anticoagulant, anticardiolipin, and an obvious clinical history of autoimmune disease have been excluded. Testing for antiphospholipid antibodies other than lupus anticoagulant and anticardiolipin is not clinically useful in the evaluation of recurrent pregnancy loss.     

Transitions of each inhibitor in a patient with lupus anticoagulant and anti-prothrombin antibody

In a 2-year-old girl showing purpura on her legs after administration of antibiotics, marked prolongation of activated partial thromboplastin time(APTT) and prothrombin time was noted. Circulating anticoagulants were demonstrated by the failure to correct APTT on neutralization test. A lupus anticoagulant(LA), one of the circulating anticoagulants, was detected by rabbit brain phospholipid neutralization procedure and platelet neutralization procedure. On crossed immunoelectrophoresis, the abnormal prothrombin peaks with reduced electrophoretic mobilities were considered prothrombin/prothrombin-antibody complexes because pretreatment with anti-human IgG serum caused their disappearance. This prothrombin-antibody seemed to be another circulating anticoagulant. The anti-prothrombin-antibody reduced prothrombin activities in the circulating blood of the patient to 20 approximately 30% of normal and the condition persisted for two weeks resulting in the purpura which occurred during that period. After two months, APTT was restored to normal following the disappearance of LA.     

Use of elimination of plasma phospholipid membranes for detection of "lupus anticoagulant" effects

The coagulation activity of plasma phospholipid membranes (PM) was measured in plasma depleted for platelets (PDP) in 50 normal subjects and 33 patients with the antiphospholipid syndrome (APS) and the "lupus anticoagulant" in the plasma. The normal value for phospholipid activation of clotting was 99.8 +/- 3.5% (from 75 to 125%), whereas in patients with APS and lupus anticoagulant it was 42.1 +/- 8.2% (p < 0.001). Addition of PM from patients' PDP to normal plasma free from PM did not normalize clotting. Addition of PM from normal plasma to patients' PDP normalized the clotting time. Therapy with discrete plasmapheresis increased the phospholipid activation value in the patients from 42.1 to 73.3% (p < 0.01), which was due to removal of the PM-antiphospholipid antibody complex from PDP. The proposed microfiltration method can be used in the complex of tests for detecting the lupus anticoagulant in patient's plasma.