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Semin Thromb Hemost 2011; 37(1): 049-057
DOI: 10.1055/s-0030-1270071
© Thieme Medical Publishers

Antiphospholipid Syndrome: Endocrinologic Manifestations and Organ Involvement

Ali A. Mehdi1 , 4 , Ibrahim Salti2 , 4 , Imad Uthman3 , 4
  • 1Research fellow, Division of Rheumatology, American University of Beirut, Beirut, Lebanon
  • 2Professor, Division of Endocrinology, American University of Beirut, Beirut, Lebanon
  • 3Professor, Division of Rheumatology, American University of Beirut, Beirut, Lebanon
  • 4Faculty of Medicine, American University of Beirut, Beirut, Lebanon
Further Information

Publication History

Publication Date:
09 February 2011 (online)

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ABSTRACT

Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by thrombotic tendency that affects most organ systems in the human body. In this report, we present a review of the endocrinologic manifestations associated with APS by evaluating the medical literature from 1968 to 2009 using MEDLINE and these keywords: APS, antiphospholipid syndrome, antiphospholipid antibodies, anticardiolipin antibodies, lupus anticoagulant, anti β-2 glycoprotein I, pituitary, adrenal, thyroid, parathyroid, ovary, testes, diabetes mellitus, and diabetes insipidus. Adrenal insufficiency was found to be the most common endocrine manifestation associated with APS. Autoimmune thyroid disease was associated with increased titers of antiphospholipid antibodies (aPL) without any APS clinical manifestations. In addition, hypopituitarism and Sheehan syndrome are increasingly being reported in association with aPL. Data regarding the prevalence and significance of aPL in diabetic patients remains uncertain. Finally, only a few cases of ovarian and testicular derangements have been reported. APS should be considered in any patient with adrenal insufficiency even in the absence of other thrombotic manifestations. It is also advisable to assess aPL in the sera of patients presenting with pituitary insufficiency. Further studies are needed to clarify the relationship between aPL and thyroid disorders and diabetes mellitus.

KEYWORDS

Antiphospholipid syndrome - adrenal - pituitary - thyroid - diabetes

REFERENCES

  • 1 Miyakis S, Lockshin M D, Atsumi T et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS).  J Thromb Haemost. 2006;  4 (2) 295-306
    CrossrefPubMedGoogle Scholar
  • 2 Thomas R H. Hypercoagulability syndromes.  Arch Intern Med. 2001;  161 (20) 2433-2439
    CrossrefPubMedGoogle Scholar
  • 3 Wong R C, Favaloro E J. Clinical features, diagnosis, and management of the antiphospholipid syndrome.  Semin Thromb Hemost. 2008;  34 (3) 295-304
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Oelkers W. Adrenal insufficiency.  N Engl J Med. 1996;  335 (16) 1206-1212
    CrossrefPubMedGoogle Scholar
  • 5 Cervera R, Piette J C, Font J Euro-Phospholipid Project Group et al. Antiphospholipid syndrome: clinical and immunologic manifestations and patterns of disease expression in a cohort of 1,000 patients.  Arthritis Rheum. 2002;  46 (4) 1019-1027
    CrossrefPubMedGoogle Scholar
  • 6 Eichner H L, Schambelan M, Biglieri E G. Systemic lupus erythematosus with adrenal insufficiency.  Am J Med. 1973;  55 (5) 700-705
    CrossrefPubMedGoogle Scholar
  • 7 Grottolo A, Ferrari V, Mariano M, Zambruni A, Tincani A, Del Bono R. Primary adrenal insufficiency, circulating lupus anticoagulant and anticardiolipin antibodies in a patient with multiple abortions and recurrent thrombotic episodes.  Haematologica. 1988;  73 (6) 517-519
    PubMedGoogle Scholar
  • 8 Asherson R A, Hughes G R. Recurrent deep vein thrombosis and Addison's disease in “primary” antiphospholipid syndrome.  J Rheumatol. 1989;  16 (3) 378-380
    PubMedGoogle Scholar
  • 9 Carette S, Jobin F. Acute adrenal insufficiency as a manifestation of the anticardiolipin syndrome?.  Ann Rheum Dis. 1989;  48 (5) 430-431
    CrossrefPubMedGoogle Scholar
  • 10 Asherson R A, Hughes G R. Hypoadrenalism, Addison's disease and antiphospholipid antibodies.  J Rheumatol. 1991;  18 (1) 1-3
    PubMedGoogle Scholar
  • 11 Espinosa G, Santos E, Cervera R et al. Adrenal involvement in the antiphospholipid syndrome: clinical and immunologic characteristics of 86 patients.  Medicine (Baltimore). 2003;  82 (2) 106-118
    CrossrefPubMedGoogle Scholar
  • 12 Presotto F, Fornasini F, Betterle C, Federspil G, Rossato M. Acute adrenal failure as the heralding symptom of primary antiphospholipid syndrome: report of a case and review of the literature.  Eur J Endocrinol. 2005;  153 (4) 507-514
    CrossrefPubMedGoogle Scholar
  • 13 Gerner P, Heldmann M, Borusiak P, Bures V, Wirth S. Adrenal failure followed by status epilepticus and hemolytic anemia in primary antiphospholipid syndrome.  Thromb J. 2005;  3 (1) 6
    CrossrefPubMedGoogle Scholar
  • 14 Legendre G, Vauthier-Brouzes D, Cornet A et al. Maternal adrenal necrosis in the third trimester of pregnancy: a rare complication of antiphospholipid syndrome [in French].  Gynecol Obstet Fertil. 2008;  36 (4) 413-416
    CrossrefPubMedGoogle Scholar
  • 15 Bhattacharya M, Yeh B M, Qayyum A, Coakley F V. Case 81: antiphospholipid antibody syndrome with adrenal hemorrhage and Budd-Chiari syndrome.  Radiology. 2005;  235 (1) 53-55
    CrossrefPubMedGoogle Scholar
  • 16 Dierking E, Gogoi R, Adamcik S, Greene L W, Curtin J P. Adrenal insufficiency after laparoscopic hysterectomy in a patient with primary antiphospholipid syndrome.  Obstet Gynecol. 2008;  111 ((2 Pt 2)) 495-498
    CrossrefPubMedGoogle Scholar
  • 17 Blanc P L, Forel C, Jay S, Susset V. Acute adrenal insufficiency during unilateral adrenal hemorrhage secondary to the antiphospholipid syndrome [in French].  Rev Med Interne. 2006;  27 (12) 970-972
    CrossrefPubMedGoogle Scholar
  • 18 Fujishima N, Komatsuda A, Ohyagi H et al. Adrenal insufficiency complicated with antiphospholipid syndrome (APS).  Intern Med. 2006;  45 (16) 963-966
    CrossrefPubMedGoogle Scholar
  • 19 Zhang Z L, Wang Y, Zhou W, Hao Y J. Addison's disease secondary to connective tissue diseases: a report of six cases.  Rheumatol Int. 2009;  29 (6) 647-650
    CrossrefPubMedGoogle Scholar
  • 20 Kurtulmus N, Cikrikcioglu M A, Aksoy O, Tukek T. Primary antiphospholipid syndrome presenting as hyponatremic hypertensive syndrome and acute adrenal insufficiency following it: a rare case.  Rheumatol Int. 2009;  April 14 (Epub ahead of print)
    PubMedGoogle Scholar
  • 21 Starakis I, Mazokopakis E, Siagris D, Liossis S, Karatza C, Antonopoulos A. Catastrophic antiphospholipid syndrome presented with severe hypertension, adult respiratory distress syndrome and unilateral adrenal haemorrhagic infarction.  Rheumatol Int. 2007;  27 (8) 781-783
    CrossrefPubMedGoogle Scholar
  • 22 Asherson R A. Acute respiratory distress syndrome and other unusual manifestations of the catastrophic antiphospholipid (Asherson's) syndrome.  Isr Med Assoc J. 2004;  6 (6) 360-363
    PubMedGoogle Scholar
  • 23 Asherson R A, Cervera R, Piette J C et al. Catastrophic antiphospholipid syndrome. Clinical and laboratory features of 50 patients.  Medicine (Baltimore). 1998;  77 (3) 195-207
    CrossrefPubMedGoogle Scholar
  • 24 Asherson R A, Cervera R, Piette J C et al. Catastrophic antiphospholipid syndrome: clues to the pathogenesis from a series of 80 patients.  Medicine (Baltimore). 2001;  80 (6) 355-377
    CrossrefPubMedGoogle Scholar
  • 25 Rao R H, Vagnucci A H, Amico J A. Bilateral massive adrenal hemorrhage: early recognition and treatment.  Ann Intern Med. 1989;  110 (3) 227-235
    PubMedGoogle Scholar
  • 26 Fox B. Venous infarction of the adrenal glands.  J Pathol. 1976;  119 (2) 65-89
    CrossrefPubMedGoogle Scholar
  • 27 Papadopoulos K I, Jönsson A, Berntorp E, Törnquist C, Hulthén U L. Primary antiphospholipid syndrome associated with postoperative primary adrenal failure.  J Intern Med. 1995;  238 (2) 175-178
    CrossrefPubMedGoogle Scholar
  • 28 Walz B, Ho Ping Kong H, Silver R. Adrenal failure and the primary antiphospholipid syndrome.  J Rheumatol. 1990;  17 (6) 836-837
    PubMedGoogle Scholar
  • 29 Arnason J A, Graziano F M. Adrenal insufficiency in the antiphospholipid antibody syndrome.  Semin Arthritis Rheum. 1995;  25 (2) 109-116
    CrossrefPubMedGoogle Scholar
  • 30 Berneis K, Buitrago-Téllez C, Müller B, Keller U, Tsakiris D A. Antiphospholipid syndrome and endocrine damage: why bilateral adrenal thrombosis?.  Eur J Haematol. 2003;  71 (4) 299-302
    CrossrefPubMedGoogle Scholar
  • 31 Baethge B A, Levine S N, Wolf R E. Antibodies to nuclear antigens in Graves' disease.  J Clin Endocrinol Metab. 1988;  66 (3) 485-488
    CrossrefPubMedGoogle Scholar
  • 32 Hofbauer L C, Heufelder A E. Coagulation disorders in thyroid diseases.  Eur J Endocrinol. 1997;  136 (1) 1-7
    CrossrefPubMedGoogle Scholar
  • 33 Takahashi A, Tamura A, Ishikawa O. Antiphospholipid antibody syndrome complicated by Grave's disease.  J Dermatol. 2002;  29 (12) 776-780
    PubMedGoogle Scholar
  • 34 Hofbauer L C, Spitzweg C, Heufelder A E. Graves' disease associated with the primary antiphospholipid syndrome.  J Rheumatol. 1996;  23 (8) 1435-1437
    PubMedGoogle Scholar
  • 35 Nakayama T, Yamamoto T, Kanmatsuse K, Kokubun S. Graves' disease associated with anticardiolipin antibody positivity and acquired protein S deficiency.  Rheumatol Int. 2003;  23 (4) 198-200
    CrossrefPubMedGoogle Scholar
  • 36 Mouelhi L, Chaieb M, Debbeche R et al. Association Budd Chiari syndrome, antiphospholipid syndrome and Grave's disease [in French].  Tunis Med. 2009;  87 (2) 164-166
    PubMedGoogle Scholar
  • 37 Mayaudon H, Crozes P, Riveline J P, Boyer B, Simon P, Bauduceau B. Antiphospholipid antibodies in Basedow disease [in French].  Presse Med. 1994;  23 (32) 1496
    PubMedGoogle Scholar
  • 38 Marongiu F, Conti M, Murtas M L et al. Anticardiolipin antibodies in Grave's disease: relationship with thrombin activity in vivo.  Thromb Res. 1991;  64 (6) 745-749
    CrossrefPubMedGoogle Scholar
  • 39 Petri M, Karlson E W, Cooper D S, Ladenson P W. Autoantibody tests in autoimmune thyroid disease: a case-control study.  J Rheumatol. 1991;  18 (10) 1529-1531
    PubMedGoogle Scholar
  • 40 Díez J J, Doforno R A, Iglesias P, Sastre J, Gómez-Pan A, Borbujo J. Anticardiolipin antibodies in autoimmune thyroid disease.  J Clin Lab Immunol. 1993;  40 (3) 125-134
    PubMedGoogle Scholar
  • 41 Paggi A, Caccavo D, Ferri G M et al. Anti-cardiolipin antibodies in autoimmune thyroid diseases.  Clin Endocrinol (Oxf). 1994;  40 (3) 329-333
    CrossrefPubMedGoogle Scholar
  • 42 Nabriski D, Ellis M, Ness-Abramof R, Shapiro M, Shenkman L. Autoimmune thyroid disease and antiphospholipid antibodies.  Am J Hematol. 2000;  64 (1) 73-75
    CrossrefPubMedGoogle Scholar
  • 43 Osundeko O, Hasinski S, Rose L I. Anticardiolipin antibodies in Hashimoto's disease.  Endocr Pract. 2001;  7 (3) 181-183
    PubMedGoogle Scholar
  • 44 Tektonidou M G, Anapliotou M, Vlachoyiannopoulos P, Moutsopoulos H M. Presence of systemic autoimmune disorders in patients with autoimmune thyroid diseases.  Ann Rheum Dis. 2004;  63 (9) 1159-1161
    CrossrefPubMedGoogle Scholar
  • 45 Dagenais P, Urowitz M B, Gladman D D, Norman C S. A family study of the antiphospholipid syndrome associated with other autoimmune diseases.  J Rheumatol. 1992;  19 (9) 1393-1396
    PubMedGoogle Scholar
  • 46 Innocencio R M, Romaldini J H, Ward L S. Thyroid autoantibodies in autoimmune diseases.  Medicina (B Aires). 2004;  64 (3) 227-230
    PubMedGoogle Scholar
  • 47 Mavragani C P, Danielides S, Zintzaras E, Vlachoyiannopoulos P G, Moutsopoulos H M. Antithyroid antibodies in antiphospholipid syndrome: prevalence and clinical associations.  Lupus. 2009;  18 (12) 1096-1099
    CrossrefPubMedGoogle Scholar
  • 48 Traverse W, Tendler B, Galea C, Lakshminarayan S, Parke A. Neuroendocrine manifestations of phospholipid antibody disease identified by long-term follow-up study of patients with phospholipid antibodies.  Ann N Y Acad Sci. 2006;  1069 386-390
    CrossrefPubMedGoogle Scholar
  • 49 Bendon R W, Wilson J, Getahun B, van der Bel-Kahn J. A maternal death due to thrombotic disease associated with anticardiolipin antibody.  Arch Pathol Lab Med. 1987;  111 (4) 370-372
    PubMedGoogle Scholar
  • 50 Pandolfi C, Gianini A, Fregoni V, Nalli G, Faggi L. Hypopituitarism and antiphospholipid syndrome.  Minerva Endocrinol. 1997;  22 (4) 103-105
    PubMedGoogle Scholar
  • 51 André M, Aumaître O, Piette J C, Thiéblot P. Hypopituitarism in a woman with a severe primary antiphospholipid syndrome.  Ann Rheum Dis. 1998;  57 (4) 257-258
    CrossrefPubMedGoogle Scholar
  • 52 Ikeda K, Matsushita M, Ando S, Sekigawa I, Iida N, Hashimoto H. A case of hypopituitarism and primary hypothyroidism associated with antiphospholipid syndrome [in Japanese].  Nihon Rinsho Meneki Gakkai Kaishi. 2000;  23 (1) 37-42
    PubMedGoogle Scholar
  • 53 Essaïs O, Ouertani H, Bouzid C, Zidi B. Hypopituitarism and antiphospholipid syndrome [in French].  Ann Endocrinol (Paris). 2003;  64 (4) 305-308
    PubMedGoogle Scholar
  • 54 Galvin J A, Van Stavern G P. Ischemic pituitary apoplexy associated with the lupus anticoagulant.  J Neurol Sci. 2004;  221 ((1-2)) 89-90
    CrossrefPubMedGoogle Scholar
  • 55 Khochtali I, Kacem M, Kria S, Golli M, Mahjoub S. Pituitary necrosis and antiphospholipid syndrome [in French].  Ann Endocrinol (Paris). 2009;  70 (2) 126-128
    CrossrefPubMedGoogle Scholar
  • 56 Kengne F G, Decaux G. Inappropriate secretion of ADH and central diabetes insipidus are related to antiphospholipid antibodies in SLE—case report and review of the literature.  Nephrol Dial Transplant. 2006;  21 (11) 3311-3315
    CrossrefPubMedGoogle Scholar
  • 57 Ben Hmida M, Bunker D, Baumelou A, Deray G, Bletry O, Jacobs C. Inappropriate secretion of antidiuretic hormone (SIADH) in a patient with systemic lupus erythematosus (SLE): a case report.  Clin Nephrol. 1992;  37 (1) 34-35
    PubMedGoogle Scholar
  • 58 Leventhal L J, Kobrin S, Callegari P E. Systemic lupus erythematosus and the syndrome of inappropriate secretion of antidiuretic hormone.  J Rheumatol. 1991;  18 (4) 613-616
    PubMedGoogle Scholar
  • 59 Elisaf M S, Milionis H J, Drosos A A. Hyponatremia due to inappropriate secretion of antidiuretic hormone in a patient with systemic lupus erythematosus.  Clin Exp Rheumatol. 1999;  17 (2) 223-226
    PubMedGoogle Scholar
  • 60 Tsai M H, Lu C S, Chen C J, Tsai W P, Liou L B. Extrapontine myelinolysis in a patient with systemic lupus erythematosus: a case report.  J Formos Med Assoc. 2002;  101 (7) 505-508
    PubMedGoogle Scholar
  • 61 Kajiyama H, Terai C, De Bellis A et al. Vasopressin cell antibodies and central diabetes insipidus in a patient with systemic lupus erythematosus and dermatomyositis.  J Rheumatol. 2004;  31 (6) 1218-1221
    PubMedGoogle Scholar
  • 62 Sánchez-Román J, Castillo-Palma M J, Ocaña Medina C, Villamil-Fernández F, Wichmann I. Neurogenic diabetes insipidus in patients with systemic lupus erythematosus.  Ann Rheum Dis. 1998;  57 (4) 261-262
    CrossrefPubMedGoogle Scholar
  • 63 Tekin N, Kural N, Koçak A K, Köse S. Diabetes insipidus in a pediatric patient with systemic lupus erythematosus. A case report.  Turk J Pediatr. 1997;  39 (2) 281-284
    PubMedGoogle Scholar
  • 64 Scolari F, Savoldi S, Zubani R, Maiorca R. Inappropriate ADH secretion: an unusual manifestation of antiphospholipid syndrome?.  Nephrol Dial Transplant. 1993;  8 (4) 382
    PubMedGoogle Scholar
  • 65 Hendra T J, Baguley E, Harris E N et al. Anticardiolipin antibody levels in diabetic subjects with and without coronary artery disease.  Postgrad Med J. 1989;  65 (761) 140-143
    CrossrefPubMedGoogle Scholar
  • 66 Triolo G, Giardina E, Scarantino G, Seddio G, Bompiani G. Detection of anti-phospholipid (cardiolipin, phosphatidylserine) antibodies in the serum of patients with non insulin-dependent (type 2) diabetes mellitus and macroangiopathy. Coexistence of anti-platelet reactivity.  Diabetes Res. 1989;  10 (2) 63-67
    PubMedGoogle Scholar
  • 67 Lorini R, d'Annunzio G, Montecucco C et al. Anticardiolipin antibodies in children and adolescents with insulin-dependent diabetes mellitus.  Eur J Pediatr. 1995;  154 (2) 105-108
    CrossrefPubMedGoogle Scholar
  • 68 Vinik A I, Leichter S B, Pittenger G L et al. Phospholipid and glutamic acid decarboxylase autoantibodies in diabetic neuropathy.  Diabetes Care. 1995;  18 (9) 1225-1232
    CrossrefPubMedGoogle Scholar
  • 69 Shigeta H, Yamaguchi M, Nakano K et al. Serum autoantibodies against sulfatide and phospholipid in NIDDM patients with diabetic neuropathy.  Diabetes Care. 1997;  20 (12) 1896-1899
    CrossrefPubMedGoogle Scholar
  • 70 d'Annunzio G, Caporali R, Montecucco C et al. Anticardiolipin antibodies in first-degree relatives of type 1, insulin-dependent, diabetic patients.  J Pediatr Endocrinol Metab. 1998;  11 (1) 21-25
    CrossrefPubMedGoogle Scholar
  • 71 Galtier-Dereure F, Biron C, Vies M, Bourgeois V, Schved J F, Bringer J. Vascular complications of diabetes mellitus: what role for phospholipid-binding antibodies?.  Lupus. 1998;  7 (7) 469-474
    CrossrefPubMedGoogle Scholar
  • 72 Gargiulo P, Goldberg J, Romani B et al. Qualitative and quantitative studies of autoantibodies to phospholipids in diabetes mellitus.  Clin Exp Immunol. 1999;  118 (1) 30-34
    CrossrefPubMedGoogle Scholar
  • 73 Ciarla M V, Bocciarelli A, Di Gregorio S et al. Autoantibodies and endothelial dysfunction in well-controlled, uncomplicated insulin-dependent diabetes mellitus patients.  Atherosclerosis. 2001;  158 (1) 241-246
    CrossrefPubMedGoogle Scholar
  • 74 Alagözlü H, Bakici Z, Gültekin F, Yildirim B, Sezer H. Anticardiolipin antibody positivity in diabetic patients with and without diabetic foot.  J Diabetes Complications. 2002;  16 (2) 172-175
    CrossrefPubMedGoogle Scholar
  • 75 Mohamed S M, Abdou M O, Assem H M, Moustafa T M, Soghier L M. Anticardiolipin antibodies in children with insulin-dependent diabetes mellitus.  Metabolism. 2002;  51 (9) 1148-1152
    CrossrefPubMedGoogle Scholar
  • 76 Gin H, Vergnot V, Diakou V et al. Anti-phospholipid antibodies in diabetes mellitus.  Clin Chem Lab Med. 2002;  40 (6) 604-608
    CrossrefPubMedGoogle Scholar
  • 77 Kalousová M, Fialová L, Skrha J et al. Oxidative stress, inflammation and autoimmune reaction in type 1 and type 2 diabetes mellitus.  Prague Med Rep. 2004;  105 (1) 21-28
    PubMedGoogle Scholar
  • 78 Tarkun I, Hacihanefioğlu A, Tarkun P, Cetinarslan B, Cantürk Z. Anticardiolipin and anti-beta2 glycoprotein I antibody concentrations in patients with type 2 diabetes mellitus.  Diabetes Res Clin Pract. 2005;  68 (3) 181-187
    CrossrefPubMedGoogle Scholar
  • 79 Palomo I G, Mujica V E, Alarcón M L, Pereira J G, Vásquez M R. Prevalence of antiphospholipid antibodies is not different in Chilean diabetic patients and normal individuals.  J Diabetes Complications. 2005;  19 (3) 133-137
    CrossrefPubMedGoogle Scholar
  • 80 Laadhar L, Zitouni M, Kallel-Sellami M, Bouguerra R, Chaabouni H, Makni S. Spectrum of autoantibodies in Tunisian adult type 1 diabetes mellitus.  Ann N Y Acad Sci. 2007;  1107 356-362
    CrossrefPubMedGoogle Scholar
  • 81 Calvo-Romero J M, Lima-Rodríguez E M. Anticardiolipin antibodies in patients with type 2 diabetes mellitus.  Clin Med Res. 2009;  7 (3) 93-95
    CrossrefPubMedGoogle Scholar
  • 82 Benekli M, Savaş M C, Erdem Y et al. Primary hyperparathyroidism in a patient with systemic lupus erythematosus-antiphospholipid syndrome.  Nephron. 1998;  79 (2) 215-216
    CrossrefPubMedGoogle Scholar
  • 83 Sefer S, Trotić R, Degoricija V, Vrsalović M, Ratković-Gusić I, Kes P. Healing of skin necrosis and regression of anticardiolipin antibodies achieved by parathyroidectomy in a dialyzed woman with calcific uremic arteriolopathy.  Croat Med J. 2001;  42 (6) 679-682
    PubMedGoogle Scholar
  • 84 Carbone J, Dulin E, Sarmiento E, Micheloud D, Rodríguez A. Antiphospholipid syndrome, hyperhomocysteinaemia and normocalcemic hyperparathyroidism.  Thromb Haemost. 2006;  95 (5) 900-901
    PubMedGoogle Scholar
  • 85 Chernyshov V P, Radysh T V, Gura I V, Tatarchuk T P, Khominskaya Z B. Immune disorders in women with premature ovarian failure in initial period.  Am J Reprod Immunol. 2001;  46 (3) 220-225
    CrossrefPubMedGoogle Scholar
  • 86 André M, Delèvaux I, Amoura Z et al. Ovarian vein thrombosis in the antiphospholipid syndrome.  Arthritis Rheum. 2004;  50 (1) 183-186
    CrossrefPubMedGoogle Scholar
  • 87 Morales-Roselló J, Villa P, Amrani M. Postpartum ovarian vein thrombosis with positive lupus anticoagulant.  Int J Gynaecol Obstet. 2004;  87 (2) 163-164
    CrossrefPubMedGoogle Scholar
  • 88 Leder A N, Flansbaum B, Zandman-Goddard G, Asherson R, Shoenfeld Y. Antiphospholipid syndrome induced by HIV.  Lupus. 2001;  10 (5) 370-374
    CrossrefPubMedGoogle Scholar
  • 89 Göbel U, Kettritz R, Schneider W, Luft F C. A particularly private pain.  Nephrol Dial Transplant. 2002;  17 (3) 516-518
    CrossrefPubMedGoogle Scholar

Imad W UthmanM.D. M.P.H. 

Department of Internal Medicine, American University of Beirut Medical Center

PO Box 11-0236, Riad El-Solh 1107, 2020 Beirut, Lebanon

Email: iuthman@aub.edu.lb