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    "titulo" => "Non-traumatic metatarsal fracture&#58; Uncommon complication of primary antiphospholipid syndrome"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p class="elsevierStylePara elsevierViewall">Antiphospholipid syndrome &#40;APS&#41; is an autoimmune disorder characterized by recurrent venous or arterial thrombosis and&#47;or pregnancy morbidity associated with persistently elevated levels of antiphospholipid antibodies &#40;aPL&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1"><span class="elsevierStyleSup">1</span></a></p><p class="elsevierStylePara elsevierViewall">A number of non-thrombotic manifestations are associated with APS&#44; including chorea&#44; epilepsy&#44; transverse myelitis&#44; multiple-sclerosis-like syndrome or cutaneous manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib2"><span class="elsevierStyleSup">2</span></a> Very few reports have described orthopaedic manifestations in APS patients&#46;<a class="elsevierStyleCrossRefs" href="#bib3"><span class="elsevierStyleSup">3&#44;4</span></a> Avascular necrosis is the most frequent orthopaedic complication described in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib3"><span class="elsevierStyleSup">3&#44;4</span></a> More exceptional complications include algodystrophy and bone marrow necrosis&#46;</p><p class="elsevierStylePara elsevierViewall">Stress fractures of the metatarsals occur as a result of repetitive&#44; long-term loading and are more common in military recruits&#44; athletes&#44; dancers and in patients with metabolic diseases such as osteoporosis or diabetes mellitus&#46; Metatarsal fractures have been reported in rheumatoid arthritis&#44; polymialgia rheumatica and chronic bronchitis&#46; Associated risk factors in these conditions were long term treatment with corticosteroids and low bone density&#46;<a class="elsevierStyleCrossRef" href="#bib5"><span class="elsevierStyleSup">5</span></a> Sangle el al&#46;<a class="elsevierStyleCrossRef" href="#bib6"><span class="elsevierStyleSup">6</span></a> reported on metatarsal fractures in 17 female SLE patients associated with aPL and in 2 patients with primary APS&#44; without history of trauma&#46; We here describe the case of a primary APS patient who developed spontaneous metatarsal fracture despite anticoagulation therapy&#46;</p><p class="elsevierStylePara elsevierViewall">A 43-year-old female was admitted at the Clinical Immunology Unit because of development of an episode of central retinal vein occlusion&#46; Thrombosis was confirmed by ophthalmic evaluation and fluorescein fundus angiography&#46; The patient did not have risk factors for thrombosis&#46; Family history&#58; the mother had polymyositis and a sister autoimmune thyroiditis&#46; Her physical exam was normal&#46; IgM aPL determined by a standardized commercial enzyme-linked immunosorbent assay &#91;anticardiolipin &#40;15&#44; 45 and 16<span class="elsevierStyleHsp" style=""></span>MPL<span class="elsevierStyleHsp" style=""></span>units&#47;ml&#41; and anti-beta-2-glycoprotein-I &#40;11&#44; 30 and 60<span class="elsevierStyleHsp" style=""></span>units&#47;ml&#41;&#93; were positive in more than 2 separated evaluations &#40;at least 12 weeks apart&#41;&#46; Lupus anticoagulant was negative&#46; Serum concentrations of glucose&#44; creatinine&#44; urea&#44; cholesterol&#44; HDL-cholesterol&#44; LDL cholesterol&#44; triglycerides&#44; protein C&#44; protein S&#44; homocysteine and coagulation factors were normal&#46; Platelet counts were normal&#46; APS was diagnosed and acenocoumarol therapy started to maintain an international normalized ratio between 2 and 3&#46; An extended immunological study revealed the presence of elevated antithyroid antibody titers &#40;869&#8211;1553<span class="elsevierStyleHsp" style=""></span>IU&#47;ml&#41; with normal T3&#44; T4 and TSH levels and without clinical manifestations&#46; Low titer positive antinuclear antibodies &#40;1&#47;80 homogenous pattern&#41; were observed on only one occasion with negative values in further studies&#46; Anti-DNA antibodies were persistently negative&#46; Complement factors and haemolytical activity of complement were within normal values&#46; During a 7-year clinical follow-up the patient did not show any clinical criteria of SLE or other autoimmune diseases that could be associated with APS&#46; There was no recurrence of ocular thrombosis during follow-up&#46;</p><p class="elsevierStylePara elsevierViewall">Two years after the diagnosis of APS&#44; the patient complained of foot pain without any other symptoms&#46; Foot X-rays disclosed the presence of a third metatarsal fracture on the right foot &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#41;&#46; Serum calcium levels&#44; phosphataemia&#44; alkaline phosphatase&#44; metabolic profile and her bone mineral density were within normal ranges&#46; The patient had no physical stress or repetitive-overuse injuries&#44; and she had never received steroid treatment&#46; There was no evidence of malignancies or haemoglobinopathies&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p class="elsevierStylePara elsevierViewall">aPL are associated with arterial and venous thrombosis&#44; but their role in the pathogenesis of orthopaedic complications is unknown&#46;<a class="elsevierStyleCrossRef" href="#bib7"><span class="elsevierStyleSup">7</span></a> It has been suggested that bone microinfarcts caused by reaction of the aPL with endothelium could lead to bone damage and fracture&#46;<a class="elsevierStyleCrossRef" href="#bib7"><span class="elsevierStyleSup">7</span></a> Several risk factors such as glucocorticoid therapy or osteoporosis might explain development of osteonecrosis or bone fractures&#46; The fact that our patient did not have these conditions supports the hypothesis that this complication might have been associated with APS&#44; as reported by Sangle et al&#46;<a class="elsevierStyleCrossRef" href="#bib6"><span class="elsevierStyleSup">6</span></a> in APS patients using warfarin&#46; A relationship between long-term warfarin therapy and osteoporotic fractures has been reported<a class="elsevierStyleCrossRef" href="#bib8"><span class="elsevierStyleSup">8</span></a> and a degree of deterioration of bone structure has been also associated with acenocoumarol and low molecular weight heparin therapy&#44;<a class="elsevierStyleCrossRef" href="#bib9"><span class="elsevierStyleSup">9</span></a> but it remains unclear whether the antithrombotic therapy plays a role in the development of metatarsal fractures&#46;</p><p class="elsevierStylePara elsevierViewall">Proper diagnosis of metatarsal fractures requires a thorough clinical evaluation&#44; and an early diagnosis is important since these fractures may require treatment such as nonweight-bearing immobilization coupled with therapy and often surgery&#46;<a class="elsevierStyleCrossRef" href="#bib10"><span class="elsevierStyleSup">10</span></a></p><p class="elsevierStylePara elsevierViewall">As orthopaedic involvement could be considered an under-recognized feature of APS&#44; physicians dealing with these patients should consider metatarsal fractures as a possible cause of foot pain&#46; The idea that these fractures could be the first manifestation of APS should also be taken into account&#46;</p></span>"
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Correspondence
Non-traumatic metatarsal fracture: Uncommon complication of primary antiphospholipid syndrome
Fractura metatarsiana no traumática: Una complicación rara del síndrome antifosfolípido primario
D. Alecsandru, E. Fernandez-Cruz, J. Carbone
Autor para correspondencia
jcarbone.hgugm@salud.madrid.org

Corresponding author.
Immunology Department, Hospital Gregorio Marañon, Madrid, Spain

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