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Di Ludovico A, Rinaldi M, Mainieri F, Di Michele S, Girlando V, Ciarelli F, La Bella S, Chiarelli F, Attanasi M, Mauro A, Bizzi E, Brucato A, Breda L. Molecular Mechanisms of Fetal and Neonatal Lupus: A Narrative Review of an Autoimmune Disease Transferal across the Placenta. Int J Mol Sci 2024; 25:5224. [PMID: 38791261 PMCID: PMC11120786 DOI: 10.3390/ijms25105224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
This study, conducted by searching keywords such as "maternal lupus", "neonatal lupus", and "congenital heart block" in databases including PubMed and Scopus, provides a detailed narrative review on fetal and neonatal lupus. Autoantibodies like anti-Ro/SSA and anti-La/SSB may cross the placenta and cause complications in neonates, such as congenital heart block (CHB). Management options involve hydroxychloroquine, which is able to counteract some of the adverse events, although the drug needs to be used carefully because of its impact on the QTc interval. Advanced pacing strategies for neonates with CHB, especially in severe forms like hydrops, are also assessed. This review emphasizes the need for interdisciplinary care by rheumatologists, obstetricians, and pediatricians in order to achieve the best maternal and neonatal health in lupus pregnancies. This multidisciplinary approach seeks to improve the outcomes and management of the disease, decreasing the burden on mothers and their infants.
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Affiliation(s)
- Armando Di Ludovico
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Marta Rinaldi
- Paediatric Department, Buckinghamshire Healthcare NHS Trust, Aylesbury-Thames Valley Deanery, Aylesbury HP21 8AL, UK;
| | - Francesca Mainieri
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Stefano Di Michele
- Department of Surgical Science, Division of Obstetrics and Gynecology, University of Cagliari, Cittadella Universitaria Blocco I, Asse didattico Medicina P2, Monserrato, 09042 Cagliari, Italy;
| | - Virginia Girlando
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Francesca Ciarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Saverio La Bella
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Francesco Chiarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Marina Attanasi
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
| | - Angela Mauro
- Pediatric Rheumatology Unit, Department of Childhood and Developmental Medicine, Fatebenefratelli—Sacco Hospital, Piazzale Principessa Clotilde, 20121 Milan, Italy
| | - Emanuele Bizzi
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, 20121 Milan, Italy; (E.B.); (A.B.)
| | - Antonio Brucato
- Division of Internal Medicine, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, University of Milan, 20121 Milan, Italy; (E.B.); (A.B.)
- Department of Biomedical and Clinical Sciences “Sacco”, University of Milano, Ospedale Fatebenefratelli, 20121 Milan, Italy
| | - Luciana Breda
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.); (F.M.); (V.G.); (F.C.); (S.L.B.); (F.C.); (M.A.)
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Rani V, Sharma R, Dalal JS, Saxena A, Lohchab SS, Dalal M. Newborns with congenital complete heart block: Advice for perinatal care providers. Trop Doct 2024; 54:167-171. [PMID: 38380895 DOI: 10.1177/00494755241231324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Congenital complete heart block (CCHB) is a rare, but a potentially life-threatening manifestation of autoimmune diseases in neonates. Bradycardia in CCHB can be misdiagnosed as foetal distress in utero and thus precipitating a Caesarean section. We report a case series of three neonates with bradycardia without any electrolyte abnormalities and structurally normal hearts with favourable outcomes.
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Affiliation(s)
- Vijay Rani
- Resident, Department of Pediatrics, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Renu Sharma
- Resident, Department of Pediatrics, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Jagjit Singh Dalal
- Senior Professor and Head, Department of Neonatology, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Anita Saxena
- Vice-Chancellor, Pt B D Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Shamsher Singh Lohchab
- Senior Professor, Department of Cardiothoracic and Vascular Surgery, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Monika Dalal
- Professor, Department of Obstetrics and Gynecology, Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
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Temporary pacemaker implantation through umbilical vein in a low birth weight neonate with congenital complete heart block. Cardiol Young 2021; 31:1687-1689. [PMID: 33888171 DOI: 10.1017/s1047951121001220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Congenital heart block is a rare and lethal condition in paediatric population associated with maternal connective tissue disorders and rarely with structural cardiac disease like atrioventricular canal defects with or without left isomerism and congenitally corrected transposition of great arteries. Pacing in neonate if indicated is generally accomplished by epicardial pacing systems. However, in cases of significant bradycardia and haemodynamic instability, temporary pacemaker implantation via transvenous approach remains as a suitable option. Despite the advances in percutaneous catheter interventions, use of transvenous pacing in newborn is extremely challenging due to inadvertent risk of vessel injury, thrombus formation and mortality, and most of the time technical inability to place the lead within the right ventricular cavity. We report a case of congenital complete atrioventricular block in a premature male with birth weight of 1.51 kg who was managed with temporary pacemaker implantation through umbilical vein.
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Ju YT, Wei YJ, Hsieh ML, Wang JN, Wu JM. Transient Congenital Complete Heart Block: A Case Report. CHILDREN 2021; 8:children8090790. [PMID: 34572222 PMCID: PMC8467866 DOI: 10.3390/children8090790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 12/27/2022]
Abstract
Congenital complete heart block is defined as a complete atrioventricular block occurring prenatally, at birth, or within the first month of life. Congenital complete heart block has a high mortality rate, and in infants with normal heart morphology, it is often associated with maternal connective tissue disease. In these latter cases, neonatal congenital complete heart block is usually irreversible. We present a rare case of a female neonate who had bradycardia noted at a gestational age of 37 weeks. Her mother had no autoimmune disease history. She had no structural heart disease, and the serology surveys for autoantibodies including SSA/Ro and SSB/La were all negative. Without intervention or medication, her congenital complete heart block completely recovered to a normal sinus rhythm within 5 days. The cause of the transient congenital complete heart block was unknown in this case.
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Affiliation(s)
| | | | | | | | - Jing-Ming Wu
- Correspondence: ; Tel.: +886-6-2353535 (ext. 5641)
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Gegieckienė R, Vankevičienė R, Kinčinienė O, Liubšys A. Challenges in the diagnosis and management of isolated congenital complete atrioventricular block in premature newborns. Clin Case Rep 2019; 7:1197-1203. [PMID: 31183093 PMCID: PMC6552935 DOI: 10.1002/ccr3.2190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 04/13/2019] [Accepted: 04/22/2019] [Indexed: 12/02/2022] Open
Abstract
Diagnostic and treatment challenges of congenital complete atrioventricular block in two premature newborn babies are presented. Timely recognition of this fetal condition, appropriate antenatal care, and treatment at a tertiary level care hospital as well as prompt postnatal management of the newborn baby are the key factors for good outcome. Prematurity is also associated with an additional risk of poor outcome and complications.
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Affiliation(s)
- Rūta Gegieckienė
- Vilnius University, Faculty of MedicineInstitute of Clinical Medicine, Clinic of Children's DiseasesVilniusLithuania
| | - Ramunė Vankevičienė
- Vilnius University, Faculty of MedicineInstitute of Clinical Medicine, Clinic of Children's DiseasesVilniusLithuania
| | - Odeta Kinčinienė
- Vilnius University, Faculty of MedicineInstitute of Clinical Medicine, Clinic of Children's DiseasesVilniusLithuania
| | - Arūnas Liubšys
- Vilnius University, Faculty of MedicineInstitute of Clinical Medicine, Clinic of Children's DiseasesVilniusLithuania
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Abstract
RATIONALE Neonatal lupus erythematosus (NLE) is an infrequent disease caused by transplacental maternal autoantibodies. The most common effects of NLE include cutaneous involvement and congenital heart block (CHB), although it might involve multiple organs, such as the liver, lungs, blood, and nervous or digestive systems. Izmirly PM1 and Tonello et al recently reported cutaneous manifestations of neonatal lupus and risk of subsequent CHB. The most serious complication of NLE is complete atrioventricular (AV) block. PATIENT CONCERNS We experienced 2 cases of NLE that were diagnosed in the past year in our Neonatal Intensive Care Unit. These cases showed 2 different clinical spectrums (CHB, multisystemic effects). One case was a 32-week pregnant woman with combined liver damage and fever, and her fetus was premature due to bradycardia and pericardial effusion. The second case was a young pregnant woman who had systemic lupus erythematosus for 2 years and had been taking methylprednisolone and hydroxychloroquine for a long time since her illness. When prenatal testing at 28 weeks of pregnancy showed that the fetus had CHB, the mother began taking dexamethasone. DIAGNOSIS The first case was diagnosed as NLE with CHB after birth, while the second was diagnosed as NLE with CHB, ductus arteriosus, and atrial septal defect when she was born at 34 weeks. INTERVENTIONS Both of 2 cases were treated with steroids, intravenous immunoglobulin, and a diuretic. But the second case was treated with isoprenaline in addition to the above. OUTCOMES Both of the infants was followed up and found to be clinically normal. During the clinic follow-up of the first case, the 8-month-old infant was still asymptomatic with normal growth and development. Her heart rate fluctuated from 40 to 90 beats/minute. LESSONS Autoimmune CHB is a severe, potentially life-threatening disorder associated with passive transfer of maternal anti-Sjogren's syndrome A/Ro and anti-Sjogren's syndrome B/La autoantibodies. Mothers who are positive for these autoantibodies are recommended to have serial echocardiography and obstetric ultrasonography from the early second trimester. Newborns should be delivered at an early stage of gestation if there is evidence of pericardial effusion, ascites, increasing ventricular ectopy, reduced ventricular shortening fraction, or AV valve regurgitation. Aggressive medical management after birth should be coupled with pacemaker implantation in infants who do not respond to medical therapies alone.
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Affiliation(s)
- Xiaoxia Li
- Department of Neonatal Intensive Care Unit
| | - Xianmei Huang
- Department of Pediatrics, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Abstract
Prenatal diagnosis has changed perinatal medicine dramatically, allowing for additional fetal monitoring, referral and counseling, delivery planning, the option of fetal intervention, and targeted postnatal management. Teams participating in the delivery room care of infants with known anomalies should be knowledgeable about specific needs and expectations but also ready for unexpected complications. A small number of neonates will need rapid access to postnatal interventions, such as surgery, but most can be stabilized with appropriate neonatal care. These targeted perinatal interventions have been shown to improve outcome in selected diagnoses.
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Affiliation(s)
- Elizabeth K Sewell
- Emory Children's Center Neonatalogy Offices, 2015 Uppergate Drive-3(rd) floor, Atlanta, GA 30322, USA
| | - Sarah Keene
- Emory Children's Center Neonatalogy Offices, 2015 Uppergate Drive-3(rd) floor, Atlanta, GA 30322, USA.
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Murakami K, Yamamoto Y, Fukunaga H, Matsushita M, Hirai C, Makino S, Shimizu T, Itakura A, Takeda S. Predictive markers and prenatal management of isolated fetal complete atrioventricular block: A retrospective review at a single institution. J Obstet Gynaecol Res 2017; 44:228-233. [PMID: 29160028 DOI: 10.1111/jog.13511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 08/12/2017] [Indexed: 11/30/2022]
Abstract
AIM The study was conducted to determine an effective method for identifying patients at high risk of developing isolated complete atrioventricular block (CAVB) and to review the efficacy of prenatal anti-inflammatory treatment. METHODS Fourteen CAVB cases and 76 anti-Ro-positive cases without CAVB were included in the study. Anti-Ro/La titers by double immunodiffusion and the prevalence of anti-52 kDa/60 kDa-Ro/48 kDa-La by Western blotting were compared between anti-Ro-positive women with and without CAVB. Outcomes of anti-Ro-positive CAVB cases were compared based on active prenatal anti-inflammatory treatment (plasma exchange or transplacental betamethasone). We evaluated the outcomes of five pregnancies from three women who had an affected child and underwent prophylactic plasma exchange (PEX) during subsequent pregnancy. RESULTS Ten out of 14 patients with CAVB were positive for anti-Ro. Anti-Ro titers were significantly higher in patients with CAVB (CAVB median 64; without CAVB median 16; P < 0.01). All cases with CAVB showed high titers of anti-Ro (≥ 32×), whereas only 42% of cases without CAVB showed high titers (≥ 32×) (P < 0.001). The survival rate at one year was 80% in anti-Ro-positive CAVB cases with active prenatal anti-inflammatory treatment, but only 40% in cases that did not receive treatment. Recurrence was not observed in cases treated with prophylactic PEX. CONCLUSIONS An anti-Ro level of 32× could be the threshold value for CAVB development. Prenatal anti-inflammatory treatment in patients with CAVB and prophylactic PEX in patients who had an affected child may have the potential to improve pregnancy outcomes.
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Affiliation(s)
- Keisuke Murakami
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yuka Yamamoto
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hideo Fukunaga
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Masakazu Matsushita
- Department of Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Chihiro Hirai
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Toshiaki Shimizu
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Satoru Takeda
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
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Pallangyo P, Mawenya I, Nicholaus P, Mayala H, Kalombola A, Sharau G, Majani N, Janabi M. Isolated congenital complete heart block in a five-year-old seronegative girl born to a woman seropositive for human immunodeficiency virus: a case report. J Med Case Rep 2016; 10:288. [PMID: 27756424 PMCID: PMC5070073 DOI: 10.1186/s13256-016-1082-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/29/2016] [Indexed: 11/24/2022] Open
Abstract
Background Congenital complete heart block is a life-threatening condition which is highly associated with autoimmune and connective tissue disorders. Presence of maternal autoantibodies for associated conditions increases the risk of delivering a child with congenital complete heart block, however, less than a half of all women with such antibodies are symptomatic even after delivery. Mortality rate is highest during the neonatal period (45 %) and about two-thirds of all cases will require permanent pacing at some point in their lives. Case presentation We report a case of isolated complete heart block in a 5-year-old HIV-free girl of African descent born to an HIV-infected woman with no prior history of autoimmune disorders. She was referred to us with chief complaints of recurrent syncopal attacks and effort intolerance since birth. A physical examination was unremarkable except for her being small for her age (body mass index 16.3 kg/m2) and bradycardia. Her vital signs were within acceptable range with the exception of her pulse rate, which ranged between 22 and 34 beats/minute. An echocardiogram revealed a sinus bradycardia, otherwise a structurally normal heart. An electrocardiogram showed atrioventricular dissociation in keeping with third-degree atrioventricular block. The child underwent a permanent epicardial pacemaker insertion and has been symptom-free following pacing. Conclusions Despite its infrequency and life-threatening potential, patients with congenital complete heart block have an excellent survival rate with timely diagnosis and intervention. An incidental detection of bradycardia in a fetus during routine obstetrical ultrasound examination should increase the index of suspicion for congenital complete heart block and warrant a screening for associated maternal autoantibodies.
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Affiliation(s)
- Pedro Pallangyo
- Department of Cardiovascular Medicine, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania.
| | - Isaac Mawenya
- Department of Cardiovascular Medicine, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
| | - Paulina Nicholaus
- Department of Cardiovascular Medicine, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
| | - Henry Mayala
- Department of Cardiovascular Medicine, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
| | - Amida Kalombola
- Department of Pediatric and Child Health, Muhimbili National Hospital, P.O Box 65000, Dar es Salaam, Tanzania
| | - Godwin Sharau
- Department of Pediatric Cardiology, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
| | - Naiz Majani
- Department of Pediatric Cardiology, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
| | - Mohamed Janabi
- Department of Cardiovascular Medicine, The Jakaya Kikwete Cardiac Institute, P.O Box 65141, Dar es Salaam, Tanzania
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Arai H, Nakajima H, Ogino N, Ito T, Goto R, Kameta Y, Ono N, Hosoya N, Sanada H, Takahashi T. A case of neonatal lupus erythematosus in a very low-birth-weight infant that suffered intraventricular hemorrhage at birth. Mod Rheumatol 2016; 28:721-723. [DOI: 10.3109/14397595.2016.1153181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Hirokazu Arai
- Department of Neonatology, Akita Red Cross Hospital, Akita, Japan,
| | | | - Nao Ogino
- Department of Pediatrics, Akita University Graduate School of Medicine, Akita, Japan, and
| | - Tomoo Ito
- Department of Neonatology, Akita Red Cross Hospital, Akita, Japan,
| | - Ryoji Goto
- Department of Neonatology, Akita Red Cross Hospital, Akita, Japan,
| | - Yurina Kameta
- Department of Obstetrics, Akita Red Cross Hospital, Akita, Japan
| | - Natsuki Ono
- Department of Obstetrics, Akita Red Cross Hospital, Akita, Japan
| | - Naoko Hosoya
- Department of Obstetrics, Akita Red Cross Hospital, Akita, Japan
| | - Hiroyuki Sanada
- Department of Obstetrics, Akita Red Cross Hospital, Akita, Japan
| | - Tsutomu Takahashi
- Department of Pediatrics, Akita University Graduate School of Medicine, Akita, Japan, and
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Ngo ST, Steyn FJ, McCombe PA. Gender differences in autoimmune disease. Front Neuroendocrinol 2014; 35:347-69. [PMID: 24793874 DOI: 10.1016/j.yfrne.2014.04.004] [Citation(s) in RCA: 590] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 04/20/2014] [Accepted: 04/22/2014] [Indexed: 12/21/2022]
Abstract
Autoimmune diseases are a range of diseases in which the immune response to self-antigens results in damage or dysfunction of tissues. Autoimmune diseases can be systemic or can affect specific organs or body systems. For most autoimmune diseases there is a clear sex difference in prevalence, whereby females are generally more frequently affected than males. In this review, we consider gender differences in systemic and organ-specific autoimmune diseases, and we summarize human data that outlines the prevalence of common autoimmune diseases specific to adult males and females in countries commonly surveyed. We discuss possible mechanisms for sex specific differences including gender differences in immune response and organ vulnerability, reproductive capacity including pregnancy, sex hormones, genetic predisposition, parental inheritance, and epigenetics. Evidence demonstrates that gender has a significant influence on the development of autoimmune disease. Thus, considerations of gender should be at the forefront of all studies that attempt to define mechanisms that underpin autoimmune disease.
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Affiliation(s)
- S T Ngo
- School of Biomedical Sciences, University of Queensland, St Lucia, Queensland, Australia; University of Queensland Centre for Clinical Research, University of Queensland, Herston, Queensland, Australia
| | - F J Steyn
- School of Biomedical Sciences, University of Queensland, St Lucia, Queensland, Australia
| | - P A McCombe
- University of Queensland Centre for Clinical Research, University of Queensland, Herston, Queensland, Australia; Department of Neurology, Royal Brisbane & Women's Hospital, Herston, Queensland, Australia.
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