At this week’s Cox’s Conference, Dr. Nathalie Kolandjian preented a case of thrombotic thrombocytopenic purpura to expert discussant, Dr. Srikanth Nagalla. Continue reading Cox’s Conference: Acquired Thrombotic Thrombocytopenic Purpura
In today’s Cox’s Conference, Dr. Senthil Sukumar presented a case of Chikungunya to expert discussant Dr. James Luby. Continue reading Cox’s Conference: Chikungunya
At today’s Cox’s Conference, Dr. Apple Long presented a case of primary hyperparathyroidism with expert discussant, Dr. Biff Palmer. Continue reading Cox’s Conference: Primary Hyperparathyroidism
In today’s Cox’s Conference, Dr. Sarah Cossich presented a case of cutaneous lupus to expert discussant Dr. Salahuddin Kazi. Continue reading Cox’s Conference: Cutaneous Lupus
In today’s Cox’s Conference, Dr. Kevin Misner with expert discussant Dr. James Luby presented a case of chronic pulmonary aspergillosis. Continue reading Cox’s Conference: Chronic pulmonary aspergillosis
In today’s Cox’s Conference, Dr. Karl Gordon Patti presented a case of chronic effusive pericarditis to expert discussant, Dr. Justin Grodin. Continue reading Cox’s Conference: Chronic Pericarditis
In today’s Cox’s Conference, Dr. Jan Ramesh with expert discussant Dr. Biff Palmer presented a case of recurrent hypokalemia in the setting of lifelong hypertension that ultimately was diagnosed as Liddle Syndrome.
During today’s Cox’s Conference, Dr. Shreya Rao along with expert discussants, Dr. Zahid Ahmad and Dr. Naim Maalouf, presented a case of hypertriglyceridemia.
At today’s Cox’s Conference, Dr. Josephine Harrington with expert discussant Dr. Srikanth Nagalla of antiphospholipid antibody syndrome.
-Antiphospholipid antibody syndrome should be suspected in a patient with unprovoked venous and arterial thromboses, especially in a young patient without provocation. Testing can also be considered in women with histories of pregnancy loss, intrauterine growth restriction, preeclampsia, and abruption in settings in which antiphospholipid syndrome is suspected (testing should be limited to lupus anticoagulant, anticardiolipin Ab, and beta 2 glycoprotein Ab)
-Diagnosis is based on clinical criteria of thromboses or pregnancy morbidity in the presence of antiphospholipid antibodies. The antiphospholipid antibodies used in the Sapporo classification are anticardiolipin (IgG and IgM), anti-beta2-glycoprotein (IgG or IgM), and lupus anticoagulant. Repeat confirmatory laboratory testing of the above antiphospholipid antibodies should be confirmed >= 12 weeks apart
-Remember that you need clinical features and laboratory features to diagnosis antiphospholipid antibody syndrome. Thus, there is no value in testing asymptomatic patients
-Multiple positive antiphospholipid antibodies, particularly triple positive (anticardiolipin, anti beta2 glycoprotein, and lupus anticoagulant) are at higher risk of thrombosis
Q: What is the importance of diagnosing antiphospholipid antibody syndrome, particularly in men, who will not have the pregnancy related complications?
A: Antiphospholipid antibody syndrome, due to its high risk of recurrence, typically requires indefinite anticoagulation. This is in contrast to unprovoked or provoked venous thromboses, for which discontinuation can be entertained. However, patient risk factors for bleeding, patient preference, and antibody positivity (e.g. triple positive vs single positive) should be taken into consideration. Moreover, the diagnosis of antiphospholipid antibody syndrome has implications on choice of anticoagulation. The evidence for the use of direct acting anticoagulants is scant, partially due to the rarity of disease limiting feasibility of large scale trials. The RAPS trial demonstrated non-inferiority of rivaroxaban when compared to warfarin; however, surrogate markers of thrombogenicity were used and long-term studies examining the actual thrombosis event rate of rivaroxaban vs warfarin are lacking. Thus, there is a general bias towards vitamin K antagonists in the treatment of antiphospholipid antibody syndrome. Additionally, the knowledge that antiphospholipid syndrome is driving thrombosis may yield additional treatment considerations for recurrent thrombosis while therapeutic on vitamin K antagonists. Hydroxycholroquine has been suggested to decrease the risk of thrombotic events and may be considered as add-on therapy to anticoagulation in such patients.
Q: Can anticoagulation be discontinued based on falling titers of antiphospholipid antibody titers later in life?
A: This is a great question whose answer is waiting to be discovered.
At today’s Cox’s Conference, Dr. Elizabeth McGehee with expert discussant Dr. James Luby presented a case of infective prosthetic valve endocarditis. Continue reading Cox’s Conference: Infective prosthetic valve endocarditis