Neonatal lupus erythematosus with a high anticardiolipin antibody titer. Unusual variant of neonatal lupus erythematosus or early-onset systemic lupus erythematosus?

Neonatal lupus erythematosus in identical twins, showing transient bullous lesions

One of identical twin girls was born with ulcers on her leg, and shortly after birth developed a flaccid blister on the leg. Subepidermal blister with vacuolar degeneration of basal cell layer and the heavy infiltration of mononuclear cells in the upper dermis were observed in the blister lesion. She also had generalized livedo. Her identical twin sister did not exhibit ulcers or blisters, but was born with milia on her limbs. Their mother was found to have lupus erythematosus with positive anti-Ro/SSA antibodies and developed Sjögren syndrome. We emphasize neonatal blistering and congenital milia unique manifestations of neonatal lupus erythematosus.

[Neonatal lupus erythematosus and neurologic involvement: an incidental association?]

Neonatal lupus erythematosus is a rare disorder characterized by cutaneous lesions of the face and/or congenital heart block. The transplacental transfer of maternal anti-Ro/SSA, anti-La/SSB, or anti-U1RNP antibodies is responsible for the development of the disease. Few cases of neonatal lupus erythematosus with neurological involvement were reported in the medical literature.

CASE REPORT

A 36-week GA female infant presented with neonatal lupus erythematosus comprising cutaneous, hematologic and hepatic disorders with a favorable outcome. However, cutaneous atrophy and hyperpigmentation persisted. Spastic paraparesis was diagnosed at the age of six months.

CONCLUSION

The neurological lesions in neonatal lupus erythematosus could either be related to the presence of anti-Ro/SSA antibodies of maternal origin, or of anticardiolipin antibodies.

Autoantibody responses to cardiolipin and DNA in infancy: association with lymphocytic panniculitis

We report an infant with anticardiolipin (aCL) antibodies who presented with erythematous nodular skin lesions and elevated liver enzyme levels. The cutaneous manifestation was histologically lymphocytic lobular panniculitis with vasculitic and hemorrhagic changes. The infant also had low levels of anti-double stranded DNA (dsDNA) and anti-single stranded DNA (ssDNA) antibodies. There were no detectable antibodies to small nuclear ribonucleoproteins including Ro/SSA and La/SSB. His mother was consistently seronegative for any of these antibodies. Without corticosteroid therapy, cutaneous lesions resolved and anticardiolipin antibodies, but not anti-dsDNA and ssDNA antibodies, normalized within 16 months after the onset of the disease. Our patient demonstrated an uncommon presentation of aCL related cutaneous manifestation, the presentation with panniculitis being only the third such patient reported in the literature. Of great interest was the appearance of aCL antibodies and skin lesions during very early infancy.

La (SS-B)-positive neonatal lupus erythematosus: report of a case with unusual features

Neonatal lupus erythematosus is most often associated with autoantibodies against Ro and La antigens. Rarely, neonatal lupus erythematosus occurs in the absence of Ro antibody. We present a case of La antibody-positive neonatal lupus erythematosus with unusual features.

Prevalence of anticardiolipin antibodies in subacute cutaneous lupus erythematosus

We examined the prevalence of the antibodies to cardiolipin measured by solid-phase enzyme immunoassay during a prospective study of patients with subacute cutaneous lupus erythematosus (SCLE). Seven of 44 (16%) consecutive patients with SCLE had positive anticardiolipin antibodies; of these only three satisfied the American Rheumatism Association's revised criteria for the classification of systemic lupus erythematosus. Clinical findings probably associated with the positive anticardiolipin antibodies were found in four cases, including clotting abnormalities, thrombocytopenia, hemolytic anemia, livedo reticularis, chilblain lupus erythematosus lesions, migraine, leg venous thrombosis and pulmonary embolism after surgery, and spontaneous abortion. Our data suggest that it is reasonable to screen SCLE patients for these antibodies to confirm the presence of the antiphospholipid syndrome.

Neonatal lupus erythematosus in Japan

BACKGROUND

Although more than 200 cases of neonatal lupus erythematosus (NLE) have been reported, the prognosis, clinical characteristics, and genetic background of the patients are still obscure. Their symptoms seem to vary in different races.

OBJECTIVE

We had an opportunity to see two clinically different types of NLE. It is important to define the clinical characteristics in Japanese cases and to compare them to caucasian NLE cases reported earlier.

METHODS

Sixty Japanese infants with NLE and their mothers reported in Japan were investigated and compared with cases reported from other countries.

RESULTS

Japanese cases were highly associated with anti-SS-A/Ro, anti-SS-B/La, anti-ribonuclear protein, and anti-DNA antibodies. A low frequency of congenital heart block was noted but 8.3% of the cases progressed to systemic lupus erythematosus. HLA-DRw12 was a significantly relative risk in NLE.

CONCLUSION

The clinical characteristics of Japanese NLE patients were different from those of caucasian patients reported in the literature.

The 'antiphospholipid syndrome' and the 'lupus anticoagulant'

In recent years an association has been described between, on the one hand, an in vitro prolongation of phospholipid-dependent coagulation tests (the 'lupus anticoagulant') or the demonstration of antiphospholipid antibodies and, on the other, clinical events, particularly recurrent thrombosis (usually venous but sometimes arterial), thrombocytopenia, and also recurrent mid-term fetal loss. Other less well-documented associations with haemolytic anaemia, livedo reticularis, strokes and other neurological syndromes have been suggested. The antibodies are present temporarily in many infections, are usually of IgM isotype and thrombosis does not occur. However, they are persistently present and mainly of IgG isotype in a number of auto-immune disorders associated with thrombosis, in particular systemic lupus erythematosus, in which 50% of patients will show antibody of one isotype or another. The strongest association is with antinuclear factor-negative lupus and 'lupus-like' disorders in which a full diagnosis of classical lupus cannot be made. The clotting test abnormality and antiphospholipid antibodies may be found also in otherwise normal individuals suffering thrombosis or fetal loss--the so-called primary antiphospholipid syndrome. These data raise important questions for management, but many details are controversial despite a decade's work; this review examines the present position and outlines some of the difficulties, particularly from the point of view of nephrology and paediatrics.