Lupus anticoagulant-hypoprothrombinemia syndrome: report of two cases and review of the literature

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1 (2015) 24, CONCISE REPORT anticoagulant-hypoprothrombinemia syndrome: report of two cases and review of the literature SMN Mulliez 1, F De Keyser 2, C Verbist 2, A Vantilborgh 3, W Wijns 4, I Beukinga 4 and KMJ Devreese 1 1 Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium; 2 Department of Rheumatology, Ghent University Hospital, Ghent, Belgium; 3 Department of Hematology, Ghent University Hospital, Ghent, Belgium; and 4 Department of Hematobiology, Erasme Hospital, Brussels, Belgium anticoagulant-hypoprothrombinemia syndrome (LA-HPS) is a rare acquired disorder caused by prothrombin antibodies. The disease is most common in the pediatric age group (<16 years), and more prevalent in women. There are well-established clinical diseases associated with LA-HPS, most notably systemic lupus erythematosus (SLE) and viral infections. The clinical manifestation of LA-HPS varies greatly in severity and it may cause severe lifethreatening bleeding diathesis. LA-HPS is to be suspected when a patient presents with bleeding and a prolonged activated partial thromboplastin and prothrombin time, in combination with a lupus anticoagulant. The diagnosis is confirmed in the laboratory by identification of reduced prothrombin levels. There are no standardized recommendations for treatment of the hemorrhage associated with the syndrome; corticosteroids are used as first-line treatment. This review summarizes what is currently known about the pathogenesis, clinical features, diagnosis, treatment and prognosis of LA-HPS, and presents two case reports. (2015) 24, Key words: anticoagulant; hypoprothrombinemia; prothrombin; acquired hypoprothrombinemia; antiprothrombin antibodies; bleeding Introduction The presence of lupus anticoagulant (LA) has been associated with venous and arterial thrombosis and pregnancy complications. 1 However, LA can be associated with bleeding as a consequence of hypoprothrombinemia. Concomitant acute acquired hypoprothrombinemia and LA, the lupus anticoagulant-hypoprothrombinemia syndrome (LA- HPS), probably develops as a result of the presence of anti-factor II antibodies. The presence of these antibodies, unlike other prothrombic antiphospholipid antibodies, promotes bleeding. We describe two patients with hemorrhagic symptoms in combination with LA, one associated with systemic lupus erythematosus (SLE) and one preceded by an infection. In this article we report what is currently known about the pathogenesis, clinical features, diagnosis, treatment and Correspondance to: Katrien Devreese, Coagulation Laboratory, Laboratory for Clinical Biology, Ghent University Hospital, De Pintelaan, 185 (2P8), B-9000 Gent, Belgium. katrien.devreese@uzgent.be Received 28 May 2014; accepted 10 October 2014 prognosis of LA-HPS. We performed a literature search in PubMed using the following search terms with no limits: lupus anticoagulant hypoprothrombinemia syndrome, acquired hypoprothrombinemia, anti-prothrombin antibodies and bleeding. We included all articles published between 1960 and February The bibliographies of all retrieved publications were assessed for additional articles of relevance that were not identified in the initial search. We found 90 cases reported in the literature; we combined these data with the two new cases reported here to summarize the characteristics of LA-HPS. Case reports Case 1 A 21-year-old woman was admitted with a history of excessive menstrual bleeding during the recent few months, gingival bleeding and epistaxis. Three weeks prior to her presentation she was diagnosed with SLE. She suffered from increased fatigue, arthralgia and synovitis, especially of the proximal! The Author(s), Reprints and permissions: /

2 interphalangeal joints. Other notable symptoms included alopecia and Raynaud s phenomenon. She had no past history of bleeding disorders or thrombotic events, and her family history was not significant for any coagulation disorder. Her medication included meloxicam (since one month, 15 mg once daily), hydroxychloroquine sulfate (since two weeks, 200 mg twice daily), tranexamic acid and iron supplementation. At presentation, the complete blood count revealed a white blood cell (WBC) count of 5.02*10 9 /l (normal range, *10 9 /l), platelet count of 227*10 9 /l (normal range, *10 9 /l), and hemoglobin of 87 g/l (normal range, g/l). The initial coagulation screening showed a prolonged activated partial thromboplastin time (aptt) and prothrombin time (PT), and a normal fibrinogen level of 329 mg/dl (Table 1). In the diagnostic workup, we performed a mixing study of patient plasma and normal pooled plasma in a 1:1 proportion. The mixing study resulted in a correction of the PT, while the prolonged aptt with LAsensitive aptt reagent (PTT-LA, Diagnostica Stago, Asnie` res, France) did not improve, suggesting the presence of LA. This was confirmed by using the Staclot-LA Õ assay (Diagnostica Stago, Asnie` res, France). The dilute Russell s Viper Venom Test (drvvt) (LA screen, Life Diagnostics, DSRV, Clarkston, GA, USA), the mixing test, and the confirmation test (LA confirm, Life Diagnostics) were also positive and confirmed the presence of LA in the drvvt system (Table 1). Factor assays revealed a low prothrombin level (Factor II) and low factor (F) VIII, IX and XI levels. Clotting factor activities were measured in one-stage PT (II, V, X) or aptt (VIII, IX, XI) clotting assays using factor-deficient plasmas (Diagnostica Stago) in a standard 1:10 predilution of patient plasma. The nature of the decreased levels of coagulation factors was studied by repeated testing at increasing plasma dilution (1:40 and 1:100). FVIII, FIX and FXI levels increased toward normal at a 1:40 and 1:100 dilution, suggesting the presence of a non-specific inhibitor (typical pattern of LA). FII activity remained low even when high dilutions of the patient s plasma were tested. Further evaluation revealed the presence of immunoglobulin (Ig)G and IgM anticardiolipin antibodies (acl), IgG and IgM anti-b 2 -glycoprotein I (ab2gpi) (measured by HemosIL AcuStar, Instrumentation Laboratories, Bedford, MA, USA), and IgG and IgM antiphosphatidylserine-prothrombin (aps/ PT) antibodies (measured by enzyme-linked immunosorbent assay (ELISA) (Quanta Lite Õ, Table 1 Results of coagulation testing of Case 1, on admission, after one, two, and three months follow-up Assay Normal range After On one admission month After two months After three months PT (%) Control (%) 95 Mix 1:1 (%) 57 aptt (PTT-A) (sec) TT (sec) < Fibrinogen (mg/dl) aptt (PTT-LA) (sec) < Mix 1:1 (sec) < Staclot Õ aptt no PL (sec) > aptt PL (sec) ¼ aptt no PL <8 > aptt PL (sec) drvvt (LA screen) (sec) < LA screen mix 1:1 (sec) < LA confirm (sec) < Ratio LA screen/ < LA confirm FII (%) Dilution 1:40 (%) 18 Dilution 1:100 (%) 26 FV (%) FX (%) FVIII (%) Dilution 1:40 (%) 30.7 Dilution 1:100 (%) 86.5 FIX (%) Dilution 1:40 (%) 10.4 Dilution 1:100 (%) 65.6 FXI (%) Dilution 1:40 (%) 29 Dilution 1:100 (%) 50 acl IgG (U/ml) < IgM (U/ml) < ab2gp1 IgG (U/ml) < IgM (U/ml) < Antiprothrombin antibodies aps/pt IgG (U/ml) 30 >150 >150 >150 >150 aps/pt IgM (U/ml) 30 > >150 >150 Antiphospholipid 10 dot IgG and IgM Prothrombin Negative Positive Negative Negative Negative Phosphatidyl-serine Negative Positive Positive Positive Positive PT: prothrombin time; aptt: activated partial thromboplastin time; TT: thrombin time; PL: phospholipids; drvvt: dilute Russell s viper venom time; LA: lupus anticoagulant; F: factor; acl: anticardiolipin; ab2gp1: anti-b2-glycoprotein 1; aps/pt: antiphosphatidylserine/ prothrombin complex; IgG: immunoglobulin G; IgM: immunoglobulin M. INOVA Diagnostics, San Diego, CA, USA)). 2 The antiphospholipid 10 dot (Generic assays GmbH, Dahlewitz, Germany) showed IgG and IgM antiprothrombin antibodies (apt). Test results are shown in Table 1. Additionally, laboratory tests 737

3 738 showed the presence of anti-double-stranded DNA (anti-dsdna) (anti-dna antibody titer of 83 IU/ ml (normal range <7 IU/ml) (Farr-RIA, Trinity Biotech, Ireland)), anti-smb, anti-rnp-a, anti- RNP-C and anti-ribo-p antibodies (Inno-LIA TM ANA Update, Innogenetics, Belgium). Fresh frozen plasma and packed red blood cells were given to control menorrhagia, and high-dose corticosteroid therapy (methylprednisolone 125 mg) was immediately started because of a suspected autoantibody. Prednisolone therapy was slowly tapered and after one month of follow-up, both the PT and aptt and FII were normalized, prothrombin antibodies had disappeared, and no further bleeding episodes were seen (Figure 1). In addition, joint symptoms improved well on corticosteroid therapy. LA, acl, ab2gpi and aps/pt remained positive, even after three months of follow-up. Case 2 In March 2013, a 3.5-year-old boy was admitted for sudden macroscopic hematuria. On admission, he had no fever, no mictalgia, no abdominal pain, no edema, and no recent trauma. He suffered from symptoms of rhinitis for a few days. His medical history included left hydronephrosis due to fetomaternal infection that was successfully treated with antibiotics. The renal echography showed no malformations. He had no familial history of bleeding. Coagulation studies (Table 2) showed decreased PT (Thromborel S, Siemens, Marburg, Germany) of 40% (normal range, 70% 130%), prolonged aptt (Triniclot aptt-hs, Tcoag, Wicklow, Ireland) of 69.9 seconds (normal range, <35 sec) with decreased FII (20%) and FIX (48%), and normal FV, FVII, FX, FVIII and FXI. After repeating the factor assays (all deficient plasmas from Siemens, Marburg, Germany) at increasing Table 2 Results of coagulation of Case 2 s testing on admission Assay Normal range On admission PT (%) aptt (Triniclot aptt HS) (sec) < TT (s) < aptt (Actin FS) (sec) < Mix 1:1 (sec) 39.7 Mix 1:1 (after two hours incubation) 44.3 drvvt (LA1) (sec) < Mix 1:1 (sec) Confirm ratio < FII (%) Dilution 1:20 (%) 10 FV (%) FVII (%) FX (%) FVIII (%) Dilution 1:20 (%) 165 FIX (%) Dilution 1:20 (%) 58 FXI (%) Dilution 1:20(%) 89 Antiprothrombin antibodies aps/pt IgG (U/ml) 30 >150 aps/pt IgM (U/ml) 30 >150 Antiphospholipid 10 dot IgG and IgM Phosphatidyl-serine Negative Prothrombin Positive Cardiolipin Negative ab2gp1 Negative PT: prothrombin time; aptt: activated partial thromboplastin time; TT: thrombin time; drvvt: dilute Russell s viper venom time; F: factor; acl: anticardiolipin; aps/pt: antiphosphatidylserine/ prothrombin complex; IgG: immunoglobulin G; IgM: immunoglobulin M; ab2gp1: anti-b2-glycoprotein 1. Figure 1 Case 1: Response of the aptt and PT from diagnosis (December 27, 2013) up to one month of follow-up. Dotted lines represent the lower and upper range of aptt ( seconds) and PT ( seconds). aptt: activated partial thromboplastin time; PT: prothrombin time.

4 plasma dilution (1:20 dilution) FII activity remained low, while other coagulation factors (FVIII, FIX and FXI) increased to normal, suggesting the presence of a non-specific inhibitor. Additionally, aptt and drvvt (LA1, Siemens, Marburg, Germany) and mixing studies strongly suggested the manifestation of an anticoagulant inhibitor. The presence of LA was confirmed by drvvt confirmation assay (LA2, Siemens, Marburg, Germany). Further investigation revealed IgG and IgM aps/pt antibodies (measured by ELISA (Quanta Lite Õ, INOVA Diagnostics, San Diego, CA, USA)), and the antiphospholipid 10 dot (Generic Assays GmbH, Dahlewitz, Germany) confirmed the presence of IgG and IgM apt. acl and ab2gpi IgG and IgM antibodies were not demonstrated. Results of the laboratory tests are summarized in Table 2. No medical treatment was given. On day 2, hematuria spontaneously resolved and the patient was discharged from the hospital. Three months later, the patient s aptt and PT normalized. One year later, coagulation results were normal and LA had disappeared. Discussion Pathogenesis Antiphospholipid antibodies (apl) are a heterogeneous group of antibodies directed at plasma proteins with an affinity for anionic surfaces (e.g. phospholipids). The antibody-antigen complexes compete with the clotting factors for the phospholipids necessary in clotting assays. This so-called LA activity was one of the first assays to detect the apl. Besides the apl detected by clotting assays (LA), acl and ab2gpi are detected by solid-phase assays, 3 the latter measuring antibodies directed against the b2gpi protein that is the principal cofactor protein for apl. 4 aps/pt are apl bound by another cofactor protein, prothrombin. 5 In 1960, Rapaport et al. described a case of an 11-year-old girl with SLE and bleeding symptoms with LA associated with a profound acquired hypoprothrombinemia. 6 The authors suggested that the bleeding was due to disturbances in plasma coagulation caused by LA, and the result of a combination of profound hypoprothrombinemia and an inhibitor against prothrombinase. 6 About 15 years later it was shown that both prothrombin activity and prothrombin antigen concentrations decreased in LA-HPS. 7 In 1983, Bajaj et al. presented important information for understanding the mechanism of acquired LA-HPS. 8 Patient plasma contained antibodies that bound prothrombin but failed to neutralize its coagulant activity in vitro. Studies with cleavage products of prothrombin revealed that the antibodies of one LA-HPS patient bound to sites not essential for prothrombin activation, explaining why the PT was typically improving after mixing patient plasma with normal plasma, a phenomenon also seen in other factor deficiencies. The investigators proposed that hypoprothrombinemia results from the rapid clearance of prothrombin-antiprothrombin antibody complexes from the circulation, causing a factor II deficiency and hemorrhagic tendencies. 8 One year later, Edson et al. found apts in the plasma of LA patients with and without hypoprothrombinemia by using crossed immunoelectrophoresis. 9 These findings were confirmed by Fleck et al., who found apts in 74% of LA-positive patients (31 of 42 patients). 10 These studies demonstrated a strong association between the presence of LA and apts, and suggested a cross-reactivity between apl and epitopes on the prothrombin molecule. 11 apts are a heterogeneous group of antibodies with different immunological specificities. Two types of antibodies have been described: one with a high affinity for prothrombin alone, the other with minimal reactivity with prothrombin requiring phospholipids for elevated binding. 12,13 apt antibody complexes cause LA activity by competing for catalytic phospholipid surfaces with the binding of clotting factors, in a mechanism similar to that of ab2gpi. 14 However, while aps/pt has been established as a strong risk factor for thrombosis in antiphospholipid syndrome (APS), the role of apt remains to be determined. 5 Nonetheless, it was shown that clinically significant FII deficiency as a result of apts becomes apparent only if the clearance of the prothrombin-antiprothrombin antibody complex is accelerated. 8 Patient characteristics Age and sex The incidence of acquired hypoprothrombinemia associated with LA appears to be higher in the pediatric age group, as 55% of cases (49 of 89 cases) present cases in patients under the age of 16, with a median age at disease onset of 13 years (range 1 86 years). 6,8,9,11,15 70 This may be explained by the naturally faster hepatic clearance of the prothrombin/prothrombin antibody complex in children as compared to adults

5 740 The disease affects females more often than males, with an overall female:male ratio of 1.5:1 (54 women and 35 men). 6,8,9,11,15 70 The sex difference in disease prevalence in females is even greater in patients 16 years, with a female:male ratio of 2.5:1. 6,8,11,18 23,25,26,28,32 36,44 48,50,52 54,60,61,64,65,67 Underlying diagnosis In the two new cases of LA-HPS described in this paper, patients presented with severe bleeding diathesis with LA-HPS in combination with the two most frequently associated diseases: SLE (Case 1) and viral infection (Case 2). In 48 out of 87 cases (55%) LA-HPS was associated with an autoimmune disease, most frequently SLE (35 cases). 6,8,9,11,16,20,22,24,26,27,30,31, 33,34,38 41,44 46,49,51,55 58,60,62,64 68,71 Other associated autoimmune diseases were primary APS (six cases), incomplete SLE (<four criteria for SLE as proposed by the American College of Rheumatology 72 ) (four cases), discoid lupus (one case), celiac disease (one case), and autoimmune hepatitis (one case). 16,20,27,39,44,49,51 In 33% of the patients (29 out of 87 patients) bleeding was preceded by an infection (mostly viral, adenovirus in approximately half of these cases). 11,21,23,25,28,32,35,36,39,47,48,52 54,61,73 In three cases (3%) LA-HPS was associated with lymphoma, 17,40,63 in one case with multiple myeloma, 17 and in two cases LA-HPS was suspected to be drug induced (quinidine in one case and phenytoin in the other). 29,59 In 10% of cases (nine out of 87 cases) no underlying diagnosis was identified that could have been associated with the development of LA-HPS ( idiopathic ). 11,18,20,33,42,43,47,69 Three cases described patients presenting with both an autoimmune and an infectious disease at LA-HPS onset. Two cases of SLE patients presented with a pneumococcal septicemia and a viral infection, respectively. 8,11 One case report described a patient presenting with an autoimmune hepatitis who was admitted with symptoms of atypical pneumonia, which resolved after antibiotic therapy. 39 Except one case of a patient presenting with autoimmune hepatitis and atypical pneumonia described by de Larran aga et al., 39 all cases of LA-HPS associated with infection were found in children 12 years of age. 11,21,23,25,28,32,35,36,39,47,48,52 54,61,73 Clinical features In the cases reported, bleeding episodes varied in severity from easy bruising to life-threatening postoperative bleeding. In the new cases presented in Table 3 Clinical bleeding features in 72 patients with LA-HPS and bleeding Bleeding feature n (%) Epistaxis 27 (35%) Ecchymosis 34 (44%) Petechia 5 (6%) Gingival bleeding 10 (13%) Bleeding after tooth extraction 4 (5%) Gynecologic bleeding 11 (14%) Hematuria 12 (15%) Digestive tract hemorrhage a 9 (12%) Intracerebral hematoma/bleeding 5 (6%) Soft tissue bleeding b 7 (9%) Post-surgery bleeding 5 (6%) Post-surgery hematoma 2 (3%) Scrotal hematoma 1 (1%) Ulcer/cutaneous bleeding 3 (4%) Retinal or conjunctival bleeding 2 (3%) LA-HPS: lupus anticoagulant hypoprothrombinemia syndrome. a Includes melena, hematemesis, gastrointestinal bleeding, hemorrhagic diarrhea, and rectal bleeding. b Includes intramuscular hematoma. this paper, in Case 1 the patient suffered from severe menorrhagia and transfusion was required, whereas in Case 2 the patient presented with hematuria. Only six out of the 82 cases (7%) for whom sufficient information was reported did not show episodes of bleeding. Clinical bleeding features of 72 case reports (information lacking for four cases) are summarized in Table 3. Epistaxis and ecchymosis occurred in respectively 35% and 44% of the cases with available details. Other bleeding symptoms associated with LA-HPS include petechiae (6%), gingival bleeding (13%), bleeding after tooth extraction (5%), gynecologic bleeding (14%), hematuria (15%), digestive tract hemorrhages (including melena, hematemesis, gastrointestinal bleeding, hemorrhagic diarrhea, and rectal bleeding) (12%), intracerebral hematoma or bleeding (6%), soft tissue bleeding (9%), post-surgical bleeding or hematoma (9%), scrotal hematoma (1%), ulcerous or cutaneous bleeding (4%), and retinal or conjunctival bleeding (3%). 6,8,11,15 45,47 57,60,61,64,65,67 The elevated risk of recurrent miscarriages and venous and arterial thrombosis associated with LA is well known. Thrombosis was reported in 11 cases with LA-HPS (12%). 11,20,27,31,44,51,62,65,71 In two out of 11 cases the thrombotic event occurred prior to LA-HPS presentation. Both venous and arterial thrombosis were reported. In six of the cases describing a patient presenting with thrombosis, a single episode of thrombosis was reported, with multiple thrombotic events reported in the remaining five case reports. Three cases with

6 recurrent miscarriages were described, one with three miscarriages and two with four spontaneous abortions. 20,57,66 One case of a patient with a miscarriage at 1.5 months gestation and two pregnancies complicated by pre-eclampsia resulting in early labor at eight months and six months of gestation, respectively, was described. 40 All cases describing patients with thrombosis or recurrent miscarriages had LA-HPS associated with SLE or APS. Diagnosis LA-HPS was most often diagnosed after patients presented with bleeding symptoms and a prolonged PT in association with the presence of an LA. Occasionally, patients without prior clinical evidence of bleeding were diagnosed based on coagulation abnormalities during routine blood screening. In 84 cases with sufficient data available, five cases showed no bleeding symptoms. 53,58,66,69 The laboratory features observed in the reported cases are summarized in Table 4. The most common laboratory finding was the combination of prolonged aptt and PT, normal thrombin time, fibrinogen and normal platelet count. In all cases where relevant data were available, aptt (in 76 cases) and PT (in 72 cases) were prolonged. 6,8 11,15 35,37 45,47 54,56,58,60,64 67,69 This prolongation of aptt and PT may be due to coagulation factor (FII, V, X) deficiency, or indicate the presence of an inhibitor, and a mixing study should be performed to clarify this, as mixing of patient plasma with normal pooled plasma in a ratio of 1:1 will normalize aptt and PT in factor-deficient patients. In contrast, in LA- HPS only PT will normalize after mixing, while Table 4 Laboratory features of 92 cases with LA-HPS Assay n Median (range) Positivity (%) PT (N of sec) ( ) aptt (N of sec) ( ) FII (%) (<1 49) anticoagulant (n) (99%) acl (n) (75%) acl IgG (N of titer) ( ) ab2gpi (n) (70%) ab2gpi (median (range)) ( ) Antiprothrombin antibodies (n) (91%) N: number of times the upper value of the normal range or if not available of the normal control; n: number of patients with available data. LA-HPS: lupus anticoagulant hypoprothrombinemia syndrome; PT: prothrombin time; aptt: activated partial thromboplastin time; F: factor; acl: anticardiolipin; IgG: immunoglobulin G; ab2gp1: antib2-glycoprotein 1. aptt remains prolonged. To further investigate the prolonged aptt, testing for LA could be performed, as LA interferes with clotting in phospholipid-dependent tests such as aptt and drvvt. 74 LA may occasionally prolong PT, and FII deficiency should always be considered if LA is associated with a prolonged PT. As a next diagnostic step, coagulation factor activity should be determined. In most cases FII levels will be severely decreased. The median FII level reported in case studies was 12% (range <1% 49%). 6,9 11,15,17,19 45,47 54,56,58 60,64 66,69,73 Activity of other coagulation factors may be artificially reduced, but repeat testing in increasing dilutions of plasma should elucidate the true level of these coagulation factors, while FII activity will remain low at all dilutions. Similarly, the Bethesda assay for quantifying a factor-specific inhibitor can be false positive because of interference with LA, and an immunoassay for identification of factor inhibitors could then be used to exclude inhibitors. When LA-HPS is diagnosed, apl other than LA should be tested. However, standardization of the assays to do so remains a problem. 75,76 Therefore, apt are not included in the current classification criteria to define APS. 1 Nevertheless, apt are major antigen targets for apl and are frequently found in patients with APS. Two types of antibodies are described: apt alone and those against the phosphatidylserin-prothrombin complex (aps/pt), which are strongly associated with APS. 5,77 There is a lack of standardization in the assays for aps/pt and low reproducibility of the results between laboratories. However, recent studies have shown good performance of a commercially available kit. 2,78 In the cases reported in the literature, data on the presence of apl other than LA are limited. acl and ab2gpi tested positive in respectively 39 of 52 (75%) and 14 of 19 cases (70%). 17,20,22,24 28,31 35,38 45,47 54,56,58 60,69,71 Presence of apt was evaluated in 51 cases and positive in 46 cases (90%). 8 10,17,18,20 25,27,29,33 37,39,40,42,45,46,48 54,56 Treatment Treatment reported in 77 cases of LA-HPS is summarized in Table 5. Currently, there are no standardized guidelines for the treatment of LA-HPS. The fundamental objectives are to control bleeding (if necessary) and initiate immunosuppression to eradicate the inhibitor. However, prothrombin deficiency associated with transient LA mostly resolves spontaneously, as in 16 out of 21 (76%) reports presenting 741

7 742 Table 5 Treatments administrated in 77 patients with LA-HPS Treatment n (%) Failure of treatment, n (%) Supportive treatment Fresh frozen plasma 24 (31%) Packed red blood cells 16 (21%) Platelet concentrate 1 (1%) Prothrombin complex concentrate 3 (4%) Recombinant factor VIIa 1 (1%) Vitamin K 8 (10%) Immunosuppression Corticosteroids Alone 24 (31%) 3 (13%) In combination with other immunosuppression 22 (29%) 3 (14%) Cyclophosphamide In combination with or after CS 9 (12%) 0 (0%) Azathioprine In combination with CS 11 (14%) 0 (0%) IVIg Alone 7 (9%) 0 (0%) In combination with CS 1 (1%) 0 (0%) Rituximab Alone 1 (1%) 1 (100%) Alone followed by CS 1 (1%) 0 (0%) In combination with or after CS 1 (1%) 0 (0%) Other Plasma exchange 2 (3%) Hydroxychloroquine 7 (9%) Danazol Õ 1 (1%) N: number of cases; CS: corticosteroids; LA-HPS: lupus anticoagulant hypoprothrombinemia syndrome; IVIg: intravenous immunoglobulin G. cases with infection-associated LA-HPS and available information about therapy. 25,28,32,47,48,50,52,53 Only three out of 21 cases (14%) needed supportive treatment (fresh frozen plasma, packed red blood cells and/or vitamin K), while two cases (10%) also received corticosteroids or intravenous immunoglobulin (IVIg). In the two cases describing patients with druginduced (phenytoin and quinidine, respectively) LA-HPS, termination of drug treatment sufficiently reduced apts and no additional treatment was necessary. 29,59 When antibodies persist, immunosuppression is recommended to eradicate the inhibitor. Corticosteroids are used as a first-line treatment, as they might decrease clearance of prothrombinantiprothrombin complexes. 8 In 41 of 77 cases reported (60%) corticosteroid treatment was initiated. 6,8,11,15 17,20 22,24,26,27,30,31,33,34,37 41,44,45,49, 51,54,55,57,58,60,63,65,69,70 Prednisone at an initial dose of 60 mg/day or 1 mg/kg/day is the most common treatment option. 15 In most cases treatment with corticosteroids resulted in normalization of both PT and FII, and improved bleeding symptoms. However, tapering of steroid treatment may result in a decrease of prothrombin levels and relapse (six cases described). 26,30,33,34,58 Cyclophosphamide was prescribed in nine cases, with four cases receiving cyclophosphamide after developing lupus nephritis. 20,26,38,56 In two cases describing children with LA-HPS, cyclophosphamide was initiated after treatment failure resulting from tapering of steroid treatment. 26 In six out of nine cases cyclophosphamide was combined with corticosteroid treatment, while in three cases cyclophosphamide treatment followed corticosteroid treatment in a single maintenance therapy. 20,22,24,26,30,38,56,58 Eleven cases received azathioprine, always in combination with corticosteroids, 8,11,20,24,26,30,33,38,60,63,64 and effectiveness of the treatment varied. 20 In all but one case, recipients were SLE patients, with the non-sle patient suffering from idiopathic lymphoma. In eight cases patients were treated with IVIg, 20 22,30,41,42,71 with IVIg incorporated into frontline treatment of LA-HPS in four. 21,22,30,41 In one case IVIg was given before an elective surgery, 20 and in one case after failure of corticosteroid treatment. It is difficult to evaluate the effectiveness of IVIg because all the cases except one concurrently received corticosteroids. In this one case a dose of IVIg (1 g/kg) was administered one week after diagnosis, after an incomplete

8 response to vitamin K and fresh frozen plasma, and it resulted in complete normalization of the laboratory parameters. 21 Rituximab, an anti-cd20 monoclonal antibody, is used in CD20-positive malignancies, rheumatoid arthritis and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. 79 The literature presents three cases of patients receiving rituximab, with no clear effectiveness. 15,20,27 The first case report presented an increase of the FII level from 20% to 30% after four weekly doses of 375 mg/m 2, 27 whereas a second case report presented a patient who, after two courses of rituximab 1 g, showed no improvement in either PT or FII level. 20 A third case presented a patient who relapsed after a first treatment with steroids, and was subsequently treated with prednisone 60 mg/day and four doses of daily IVIg at 1 mg/kg. Treatment did not improve FII levels, after which rituximab was added at 375 mg/m 2 weekly for four weeks. FII levels increased two months later up to 74%. 15 Based on this report, rituximab may therefore be effective in second-line treatment. Lastly, in addition to supportive and immunosuppressive therapies, other treatments such as plasma exchange, hydroxychloroquine, and androgen Danazol Õ have been used to treat LA-HPS. Therapeutic plasma exchange has been incorporated into multiagent regimens in two patients and resulted in improvement of the clinical and laboratory status. 27,30 However, is not known whether the improvement is due to the plasma exchange or to other agents. Hydroxychloroquine is a drug routinely used for the management of SLE, and because LA-HPS frequently occurs in the setting of SLE, hydroxychloroquine was initiated in seven cases, always in combination with corticosteroids, with good response in all the patients. 20,24,33,34,38,40 One case described a patient with LA-HPS who, after failure of corticosteroid therapy, was treated with the androgen Danazol Õ and showed improvements in prothrombin levels. 49 Relapse and outcome Relapse was not reported in cases describing patients with LA-HPS associated with infections. In contrast, relapses of bleeding were described in eight cases, three cases associated with SLE, one with autoimmune hepatitis, one with APS, one with incomplete lupus and two with idiopathic LA-HPS. 20,34,38,39,43,57,68 Fatal bleeding was presented in two case reports, 57,68 and one case presents a patient dying of an unrelated myocardial infarction. 51 Conclusion We introduced in this manuscript two case reports of patients with LA-HPS associated with SLE and a transient viral infection, the most frequently associated diseases. We then presented the results of an extensive literature search on case reports presenting patients with LA-HPS. LA-HPS is a rare disease, with only 92 patients reported in the literature so far. The nature of bleeding episodes presented in these case studies varies greatly in severity. The diagnosis for this acquired hemorrhagic disorder, both clinically and based on laboratory parameters, is difficult, but should be suspected when both aptt and PT are prolonged, in combination with presence of LA. There is no consensus on a treatment strategy, but corticosteroids are mostly used as first-line treatment. However, prothrombin deficiency associated with transient LA often resolves spontaneously without therapy. In the two new cases of LA-HPS described in this paper, patients presented with severe bleeding diathesis with LA- HPS in combination with the two most frequently associated diseases: SLE (Case 1) and viral infection (Case 2). Funding This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors. Conflict of interest statement The authors have no conflicts of interest to declare. References 1 Miyakis S, Lockshin MD, Atsumi T, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4: Sciascia S, Sanna G, Murru V, Khamashta MA, Bertolaccini ML. Validation of a commercially available kit to detect anti-phosphatidylserine/prothrombin antibodies in a cohort of systemic lupus erythematosus patients. Thromb Res 2014; 133: Devreese KM, Pierangeli SS, de Laat B, Tripodi A, Atsumi T, Ortel TL. Testing for antiphospholipid antibodies with solid phase assays: Recommendations from the Subcommittee on Anticoagulant/Phospholipid-Dependent Antibodies. J Thromb Haemost 2014; 12: Galli M, Comfurius P, Maassen C, et al. Anticardiolipin antibodies (ACA) directed not to cardiolipin but to a plasma protein cofactor. Lancet 1990; 335:

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