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Howley L, Eyerly-Webb S, Killen SAS, Paul E, Krishnan A, Gropler MRF, Drewes B, Dion E, Lund A, Buyon JP, Cuneo BF. Variation in prenatal surveillance and management of anti-SSA/Ro autoantibody positive pregnancies. J Matern Fetal Neonatal Med 2024; 37:2323623. [PMID: 38443062 PMCID: PMC11005667 DOI: 10.1080/14767058.2024.2323623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/21/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE To describe international surveillance and treatment strategies for managing anti-SSA/Ro autoantibody positive pregnancies. STUDY DESIGN An electronic REDCap questionnaire was distributed to Fetal Heart Society and North American Fetal Therapy Network members which queried institution-based risk stratification, surveillance methods/frequency, conduction abnormality treatments, and postnatal anti-SSA/Ro pregnancy assessment. RESULTS 101 responses from 59 centers (59% US, 17% international) were collected. Most (79%) do not risk stratify pregnancies by anti-SSA/Ro titer; those that do use varied cutoff values. Many pregnant rheumatology patients are monitored for cardiac abnormalities regardless of maternal anti-SSA/Ro status. Surveillance strategies were based on maternal factors (anti-SSA/Ro status 85%, titer 25%, prior affected child 79%) and monitoring durations varied. Most respondents treat 2° and 3° fetal atrioventricular block, commonly with dexamethasone and/or IVIG. CONCLUSIONS Wide variation exists in current fetal cardiac surveillance and treatment for anti-SSA/Ro autoantibody positive pregnancies, highlighting the need for evidence-based protocols to optimize care.
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Affiliation(s)
- Lisa Howley
- Midwest Fetal Care Center, Children’s Minnesota, Minneapolis, MN, USA
- The Children’s Heart Clinic, Children’s Minnesota, Minneapolis, MN USA
| | | | - Stacy A. S. Killen
- Vanderbilt University Medical Center, Monroe Carell Jr. Children’s Hospital, Nashville, TN, USA
| | - Erin Paul
- Icahn School of Medicine, Mount Sinai Children’s Heart Center, New York, NY, USA
| | | | | | - Bailey Drewes
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Eric Dion
- Midwest Fetal Care Center, Children’s Minnesota, Minneapolis, MN, USA
| | - Amy Lund
- Midwest Fetal Care Center, Children’s Minnesota, Minneapolis, MN, USA
- The Children’s Heart Clinic, Children’s Minnesota, Minneapolis, MN USA
| | - Jill P. Buyon
- New York University Grossman School of Medicine, NYU Langone Medical Center, New York, NY, USA
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Cue LV, Rosenn B. "An update on the approach to treatment of Sjogren's Disease in pregnancy". J Matern Fetal Neonatal Med 2024; 37:2411583. [PMID: 39362796 DOI: 10.1080/14767058.2024.2411583] [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: 07/11/2024] [Revised: 09/14/2024] [Accepted: 09/26/2024] [Indexed: 10/05/2024]
Abstract
BACKGROUND Women with Sjögren's Disease are more likely to experience pregnancy complications compared to their counterparts without the disease. Attention to detail and familiarity with the most recent research and guidelines in this field are required to achieve optimal maternal and fetal outcomes. Such complications include pregnancy induced hypertension, fetal growth restriction, thromboembolic events, and preterm delivery. Among the most life-threatening sequela of maternal Sjogren's Disease is fetal autoimmune congenital heart block (ACHB), which has high potential to cause intrauterine fetal death, neonatal mortality, developmental delay, and other long-term pediatric complications. Currently, surveillance with weekly echocardiograms and obstetric sonograms in the second trimester are recommended to screen for ACHB with the goal of early detection and intervention before progression from first- or second- of heart block to complete heart block. OBJECTIVE We describe a case of maternal Sjogren's Disease, which prompted us to raise questions regarding the optimal frequency of obtaining fetal echocardiograms, and the ideal management in case a prolonged PR interval was to be found. We use this case to provide a springboard for discussion on updated antenatal management strategies for ACHB prevention. METHODS To conduct this analysis, we searched PubMed for articles published over the last 10 years, with attention focused on articles written since 2016. Additionally, updated guidelines by other specialties such as Rheumatology, Cardiology and Pediatrics on this issue were reviewed. RESULTS Thorough search of the literature yielded several meta-analyses concurring that the mothers with Sjogren's Disease had increased rates of premature birth, pregnancy induced hypertension, increased risks of delivering infants with intrauterine growth restriction (IUGR), with the most life-threatening risk being that of congenital heart block. Literature supporting prophylactic hydroxychloroquine and the use of steroids to reverse or halt the progression of congenital heart block at the time of diagnoses appeared at the forefront of search results. CONCLUSION Pregnant women with SS have an increased risk for complications such as intrauterine growth restriction, thromboembolic events, pregnancy-induced hypertension, preterm delivery, and cesarean delivery and should prioritize obtaining pre- or peri-conceptional counseling. In women with anti SSA/SSB antibodies, a medication regimen should be considered with the object of decreasing the concentration of these antibodies, and hence decrease the risks of ACHB. Current literature supports the inclusion of hydroxychloroquine for this purpose, even prior to conception. Although the most recent studies recommend against prophylactic use of steroids, their potential to prevent progression to complete block should be weighed against their potential negative effects. Short and long-term treatment with corticosteroids has been associated with increased maternal risk of infection, weight gain, osteonecrosis, hypertension and bone mineral density disorders. Intrauterine growth restriction, oligohydramnios, and adrenal suppression have been among the fetal risks associated with steroids while improved infant survival or decreased need for pacing have not been demonstrated. Management of these pregnancies is complex and should include a multidisciplinary approach involving a maternal-fetal medicine sub-specialist, a rheumatologist, a pediatrician, a neonatologist, and the patient herself with her family in a model of shared decision-making.
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Affiliation(s)
- Lauren V Cue
- Jersey City Medical Center, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Barak Rosenn
- Jersey City Medical Center, Rutgers New Jersey Medical School, Newark, NJ, USA
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Shao S, Liao H, Zhou S, Li Y, Yu H, Dai X, Zhu Q, Hua Y, Wang C, Zhou K. Isolated non-immune-mediated second-degree atrioventricular block in the fetus: natural history and predictive factors for spontaneous recovery. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:486-492. [PMID: 38642334 DOI: 10.1002/uog.27662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVES To determine the clinical course of fetal isolated non-immune-mediated second-degree atrioventricular block (AVB) and the factors associated with spontaneous recovery in these cases. METHODS Fetuses with isolated non-immune-mediated second-degree AVB were recruited prospectively between 2014 and 2022. These fetuses were divided into two groups: those which recovered spontaneously and those which did not. Maternal and fetal characteristics and intrauterine and postnatal outcomes were compared between the two groups. RESULTS The study cohort included 20 fetuses with isolated non-immune-mediated second-degree AVB, diagnosed at a median gestational age of 22.0 (range, 17.0-35.0) weeks. In 12 fetuses, 1:1 atrioventricular conduction was restored spontaneously in utero and there was no recurrence during the postnatal follow-up period. In the remaining eight fetuses, second-degree AVB was maintained and, in six of these, the pregnancy was terminated on parental request. Of the two liveborn children who had persistent second-degree AVB prenatally, one had progressed to complete AVB at the latest follow-up, at the age of 34 months, but was asymptomatic, without heart enlargement or dysfunction. The other child progressed to complete AVB after delivery and was diagnosed with type-2 long QT syndrome. This infant died aged 2 months. Fetuses in the group that recovered spontaneously had earlier gestational age at diagnosis (median, 20.0 (range, 17.0-26.0) vs 24.5 (range, 18.0-35.0) weeks; P = 0.004) and higher atrial rate at diagnosis (median, 147 (range, 130-160) vs 138 (range, 125-149) bpm; P = 0.006) in comparison with the group that did not recover spontaneously. The best cut-off values for prediction of failure to recover spontaneously were 22.5 weeks' gestational age at diagnosis and 144 bpm atrial rate at diagnosis, with sensitivities of 87.5% and 75.0%, respectively, and specificities of 92.0% and 87.5%, respectively. CONCLUSIONS The outcome of 60% of fetuses with isolated non-immune-mediated second-degree AVB was favorable. Earlier gestational age and higher atrial rate at diagnosis were associated with spontaneous reversion to normal sinus rhythm. Prenatal genetic testing should be performed in cases with persistent AVB, to exclude heritable disorders including long QT syndrome. These findings provide important information for clinical management and prenatal counseling in these cases. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Shao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - H Liao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - S Zhou
- Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Y Li
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - H Yu
- Department of Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - X Dai
- Department of Ultrasound, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Q Zhu
- Department of Ultrasound, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Y Hua
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - C Wang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - K Zhou
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
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Demirci O, Gezer M, Tosun Ö. Fetal bradyarrhythmias: classification, monitoring and outcomes of 40 cases at a single center. J Perinat Med 2024; 52:759-768. [PMID: 38917319 DOI: 10.1515/jpm-2024-0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/31/2024] [Indexed: 06/27/2024]
Abstract
OBJECTIVES To assess congenital fetal bradyarrhythmias with regard to etiological causes, features, risk factors, and prognosis. METHODS This retrospective study involved fetuses with fetal bradyarrhythmias. All fetuses were evaluated by ultrasonography. Parental ECGs and family histories were obtained, and maternal autoantibodies were measured. Gestational age at diagnosis, fetal atrial and ventricular rates at presentation, type of bradyarrhythmias, the presence or absence of a congenital heart defect (CHD), fetal hydrops, fetal myocardial dysfunction, extra-cardiac abnormalities, maternal autoimmune diseases, maternal autoantibodies as well as prenatal treatment, and neonatal outcome were collected. RESULTS Of the 40 fetuses included in the study, 11 had maternal rheumatologic disease, 16 had complex cardiac anomalies such as left and right isomerism. Fetuses with CHD significantly differed from those without CHD with increased rates of extra-cardiac anomalies, hydrops, fetal deaths and shorter survival after 28 days (p<0.05). Survival was significantly better in fetuses with maternal rheumatic disease as compared with those with no maternal rheumatic disease (p<0.05). Maternal anti-arrhythmic therapy was administered in 11 fetuses. In utero maternal treatment resulted in no significant difference in the course of arrhythmia or hydrops in fetuses with or without maternal rheumatic disease (p<0.05). In regression analysis, the absence of fetal hydrops was the only independent factor associated with survival (p=0.04). CONCLUSIONS The course of bradyarrhythmias, along with survival, seems to be more favorable in fetuses with maternal rheumatic disease than in those with CHD, especially left and right isomerism. Hydrops was the sole independent factor associated with poor survival.
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Affiliation(s)
- Oya Demirci
- Department of Perinatology, University of Health Sciences Zeynep Kâmil Women's and Children's Disease Training and Research Hospital, Istanbul, Türkiye
| | - Murad Gezer
- Department of Perinatology, University of Health Sciences Zeynep Kâmil Women's and Children's Disease Training and Research Hospital, Istanbul, Türkiye
| | - Öykü Tosun
- Department of Pediatric Cardiology, Medeniyet University Faculty of Medicine, Istanbul, Türkiye
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Walcott SE, Tan CH, Wicker J, Litovsky S. Subclinical maternal autoimmune disease leading to congenital high degree atrioventricular block: Case report and review of the literature. Cardiovasc Pathol 2024; 72:107634. [PMID: 38508435 DOI: 10.1016/j.carpath.2024.107634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 03/08/2024] [Accepted: 03/13/2024] [Indexed: 03/22/2024] Open
Abstract
Maternal autoimmune disease is the most common cause of congenital heart block (CHB), a rare illness characterized by fibrosis and calcification of the fetal atrioventricular (AV) node due to maternal autoantibodies anti-SSA/Ro and anti-SSB/La. We report the full autopsy and clinical information on a female neonate with high degree AV block and calcification in the AV node, atrial approaches to the AV node, and both right and left bundle branches, born to a 27-year-old female with subclinical autoimmune disease.
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Affiliation(s)
- Shelby E Walcott
- University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL
| | - Christian H Tan
- Department of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, AL.
| | - Jason Wicker
- Department of Pathology, Children's of Alabama, Birmingham, AL
| | - Silvio Litovsky
- Division of Anatomic Pathology, Department of Pathology, University of Alabama at Birmingham, Birmingham, AL
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Ben-Shabat N, Krasun A, Fisher L, Patt YS, Balassiano Strosberg I, Watad A, Beinart R, Cohen AD, Amital H. Anti-Ro and anti-La seropositivity is associated with increased rates of ischemic heart disease in adults: Results from a large population-based study. Atherosclerosis 2024; 396:117626. [PMID: 39002391 DOI: 10.1016/j.atherosclerosis.2024.117626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND AND AIMS Emerging evidence suggests an arrhythmogenic effect of Anti-Ro/SSA (anti-Ro) and anti-La/SSB (anti-La) antibodies in adults, potentially involving a subclinical intracardiac inflammatory process. Despite the established association between inflammation and ischemic heart disease (IHD), it is noteworthy that as of now no study has delved into the potential link between these antibodies and IHD. This population-based study aimed to examine the association between anti-Ro/La seropositivity and IHD in the general adult population. METHODS We conducted a retrospective study using electronic medical records from the largest health maintenance organization in Israel. Patients with positive serology for either or both anti-Ro and anti-La antibodies were included, along with matched controls. Multivariate logistic regression models were utilized to assess the odds of IHD in seropositive patients compared to controls. RESULTS Among 17,231 seropositive patients and 84,368 controls, the rate of IHD was significantly higher in the seropositive group (9.7 % vs. 8.1 %,OR = 1.23; 95%CI 1.14-1.31; p<0.001). The association was more pronounced in younger patients [<40 years old (OR = 3.36; 95%CI 1.66-6.82; p<0.001), 40-49 years old (OR = 1.85; 95%CI 1.26-2.73; p<0.01), 50-59 years old (OR = 1.87; 95%CI 1.55-2.26; p<0.001), 60-69 years old (OR = 1.26; 95%CI 1.11-1.42; p<0.001), ≥70 years old (OR = 1.11; 95%CI 1.03-1.20; p<0.01)], as well as in patients with fewer traditional cardiovascular risk-factors (none:OR = 1.29; 95 % CI 1.09 to 1.77; p<0.01, 1-2:OR = 1.30; 95 % CI 1.19 to 1.41; p<0.001, ≥3:OR = 1.09; 95 % CI 0.99 to 1.21; p=0.076). CONCLUSIONS Our study demonstrates for the first time a positive association between anti-Ro/La seropositivity and IHD in the general adult population, especially among younger individuals with fewer traditional cardiovascular risk factors.
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Affiliation(s)
- Niv Ben-Shabat
- Department of Medicine B, Sheba Medical Center, Tel Hashomer, Israel; Faculty of Medicine, Tel-Aviv University, Israel
| | - Anna Krasun
- Department of Geriatric Medicine C, Sheba Medical Center, Tel Hashomer, Israel
| | - Lior Fisher
- Department of Medicine B, Sheba Medical Center, Tel Hashomer, Israel; Faculty of Medicine, Tel-Aviv University, Israel
| | - Yonatan Shneor Patt
- Department of Medicine B, Sheba Medical Center, Tel Hashomer, Israel; Faculty of Medicine, Tel-Aviv University, Israel
| | | | - Abdulla Watad
- Department of Medicine B, Sheba Medical Center, Tel Hashomer, Israel; Faculty of Medicine, Tel-Aviv University, Israel; Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds, UK
| | - Roy Beinart
- Faculty of Medicine, Tel-Aviv University, Israel; Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel; Davidai Arrhythmia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Arnon D Cohen
- Chief Physician's Office, Clalit Health Services, Tel-Aviv, Israel; Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Howard Amital
- Department of Medicine B, Sheba Medical Center, Tel Hashomer, Israel; Faculty of Medicine, Tel-Aviv University, Israel.
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Wasuwanich P, Wen TS, Egerman RS, Karnsakul W. Epidemiology and Outcomes of Hepatitis E Virus-Associated Hospitalisations in the United States With a Focus on Pregnancy: A Nationwide Population Study, 1998-2020. J Viral Hepat 2024. [PMID: 39129263 DOI: 10.1111/jvh.13994] [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] [Received: 06/10/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/13/2024]
Abstract
Hepatitis E virus (HEV) is typically asymptomatic in developed countries but can be more severe in certain populations. We aim to describe the epidemiology of HEV-associated hospitalisations from 1998 to 2020 in the United States, investigate risk factors for inpatient mortality and describe outcomes in pregnant women. We utilised the National Inpatient Sample and extracted cases of HEV-associated hospitalisations using ICD-9/10 diagnostic codes. Demographic, clinical and pregnancy data were extracted and analysed by chi-square and logistic regression. We identified 3354 cases of HEV-associated hospitalisations; 1689 (50.4%) were female and 1425 (42.5%) were non-Hispanic White. The median age was 50 (IQR: 37-59) years. Hospitalisation rates for HEV ranged from 2.5 per 10,000,000 in 2008 to a peak of 9.6 per 10,000,000 people in the general U.S. population in 2004. The mortality rate was 5.2%. Age ≥ 40 years (OR: 7.73; 95% CI: 1.57-38.09; p = 0.012), HIV infection (OR: 4.63; 95% CI: 1.26-16.97; p = 0.021), and coagulopathy (OR: 7.22; 95% CI: 2.81-18.57; p < 0.001) were associated with increased odds of mortality within the HEV cohort. There were 226 pregnant women with HEV. Rates of maternal death, stillbirth and preterm birth were similar between HEV and non-HEV pregnant cohorts. Hepatitis B and hepatitis C co-infection were significantly more common in the HEV pregnant cohort (p < 0.05). HEV-associated hospitalisations are uncommon in the United States, but likely underdiagnosed. Certain risk factors can be used to predict prognosis of these hospitalised patients. Pregnant women with HEV appear to have favourable maternal and fetal outcomes despite hepatitis B and C co-infection.
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Affiliation(s)
- Paul Wasuwanich
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Tony S Wen
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Robert S Egerman
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Paladugu V, Teja N, Menon R, Ramachandran R. Fetal and Maternal Outcomes in a Cohort of Patients With Primary Sjogren's Syndrome: An Observational Study. Cureus 2024; 16:e66926. [PMID: 39280504 PMCID: PMC11401627 DOI: 10.7759/cureus.66926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 08/15/2024] [Indexed: 09/18/2024] Open
Abstract
Background Pregnant women with primary Sjogren's syndrome (PSS) have a high incidence of maternal and fetal complications due to immunological variations caused by maternal antibodies (anti-Sjogren's-syndrome-related antigen A (SSA) and anti-anti-Sjogren's-syndrome-related antigen B (SSB) crossing the placenta from the 12th week of gestation, mediating the tissue damage. A multidisciplinary approach is required in the management of such patients. Data regarding the effects of PSS on pregnancy are deficient in the Indian context. Methods This was a retrospective observational study on the maternal and fetal outcomes of PSS on a cohort of pregnant women treated at our tertiary care center between 2011 and 2020. Patients who satisfied the criteria for PSS were included, and patients with other associated autoimmune disorders were excluded. Maternal age, number of miscarriages, prior obstetric history, and maternal and fetal complications were recorded and statistically analyzed. Results There were 16 pregnancies in 10 women with PSS (incidence: 1/1,000 pregnancies/year) in our study. The mean gestational age of the mother at presentation was 31 ± 9.0 weeks. Oligohydramnios in five (11.8), intrauterine fetal demise (IUFD) in two (11.8), and first-trimester medical termination of pregnancy (MTP) in four (23.5) were noted. The weight of neonates was 2.3 ± 0.8 kg, and the mean duration of neonatal intensive care (NICU) stay was seven days. Fetal echo revealed congenital heart block (CHB), with six (50.0%) complete and one (8.3%) incomplete (p = 0.004). One baby needed a permanent pacemaker. Conclusion Maternal and fetal complications are high in our set of mothers with PSS. Early detection, regular follow-up, and a multidisciplinary approach may improve the outcome.
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Affiliation(s)
- Vinya Paladugu
- Obstetrics and Gynaecology, Amrita Institute of Medical Sciences and Hospital, Kochi, IND
| | - Nikhil Teja
- Internal Medicine, Amrita Institute of Medical Sciences and Hospital, Kochi, IND
| | - Rajashree Menon
- Obstetrics and Gynaecology, Amrita Institute of Medical Sciences and Hospital, Kochi, IND
| | - Riju Ramachandran
- General Surgery, Amrita Institute of Medical Sciences and Hospital, Kochi, IND
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Bankole A, Nwaonu J. A review of neonatal lupus syndrome. Sci Prog 2024; 107:368504241278476. [PMID: 39285783 PMCID: PMC11418246 DOI: 10.1177/00368504241278476] [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: 09/25/2024]
Abstract
This review article discusses neonatal lupus syndrome (NLS), an immune-mediated disease caused by maternal antibodies. Maternal antibodies in the fetal circulation are mostly but not always protective. NLS is a disease caused by pathogenic maternal autoantibodies in the fetal circulation. The passive immunization of the fetus by NLS-causing maternal antibodies may occur in the absence of a previously known maternal systemic autoimmune rheumatic disease (SARD). Screening for NLS-related antibodies in patients with related SARD or those in whom there is a risk of NLS including first-degree relatives should occur before pregnancy. This screening is best performed as part of a collaborative relationship between obstetrics and rheumatology. Pregnancy preparations in those with SARD include transitioning to pregnancy-safe medications. The symptoms of NLS range from minor skin rashes to fetal demise from heart block. Fetal screening allows for maternal therapeutic interventions that may be beneficial, as well as the use of fetal pacemakers in the more severe cases that include cardiac NLS.
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Affiliation(s)
- Adegbenga Bankole
- Internal Medicine/Rheumatology, Virginia Tech Carilion School of Medicine (VTCSOM), Roanoke, VA, USA
| | - Jane Nwaonu
- Internal Medicine/Rheumatology, Virginia Tech Carilion School of Medicine (VTCSOM), Roanoke, VA, USA
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Gamazo-Herrero J, Medina-Luezas JA, Cusacovich I, Martín-Asenjo M, González-Montagut-Gómez C, Sánchez-González MD, Aramburu-Muñoz F, Janta I, García-Morán E, Veras-Burgos CM, Corral-Gudino L, Abad-Molina C, González-Fuentes R. Should Physicians Be Aware of Rhythm Disturbances in Adults with Systemic Autoimmune Diseases and Anti-Ro52 Antibodies? A Cross-Sectional Study. J Clin Med 2024; 13:3510. [PMID: 38930039 PMCID: PMC11204400 DOI: 10.3390/jcm13123510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/28/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
Objectives: The association between anti-Ro/SSA antibodies and the appearance of cardiac rhythm disorders in adults is discussed. We aim to study this relationship, together with active treatments and comorbidities, and its impact on daily clinical practice in adults with systemic autoimmune diseases (SADs). Methods: This cross-sectional single-center study was conducted in a tertiary hospital between January 2021 and March 2022. A sample of adult patients followed up in the SAD Unit with a diagnosis of a SAD and previously tested for anti-Ro/SSA and anti-La/SSB were recruited. All of them underwent a 12-lead electrocardiogram. Results: 167 patients were included. 90 (53.9%) were positive for anti-Ro60, 101 (60.5%) for anti-Ro52, and 45 (26.9%) for anti-La/SSB; 52 (31.3%) were triple-negative. 84% were women, and the mean age was 59 years (standard deviation 12.8). The most common SAD was primary Sjögren's syndrome (34.8%), followed by systemic lupus erythematosus (24.6%) and rheumatoid arthritis (22.8%). A statistically significant relationship was found between anti-Ro52 positivity and cardiac rhythm disorders (relative risk = 2.007 [1.197-3.366]), specifically QTc prolongation (relative risk = 4.248 [1.553-11.615]). Multivariate regressions showed a significant association, with diabetes mellitus being the most related comorbidity. The association between anti-Ro52 antibodies and atrioventricular conduction disorders was not significant. Conclusions: The presence of anti-Ro52 antibodies in adult patients with SADs is associated with an increased risk of QTc prolongation. Electrocardiographic screening of patients with SAD, anti-Ro52 antibodies, and other risk factors, like diabetes mellitus or QT-prolonging drugs, seems advisable. Those with baseline electrocardiogram abnormalities or additional risk factors should undergo electrocardiographic monitoring.
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Affiliation(s)
- Javier Gamazo-Herrero
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain; (J.G.-H.)
| | - Julio Antonio Medina-Luezas
- Systemic Autoimmune Diseases Unit, Department of Rheumatology, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain
| | - Ivan Cusacovich
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain; (J.G.-H.)
- Department of Medicine, Dermatology and Toxicology, Medicine College, University of Valladolid, Avda. Ramón y Cajal 7, 47003 Valladolid, Spain
| | - Miguel Martín-Asenjo
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain; (J.G.-H.)
- Department of Medicine, Dermatology and Toxicology, Medicine College, University of Valladolid, Avda. Ramón y Cajal 7, 47003 Valladolid, Spain
| | - Carmen González-Montagut-Gómez
- Systemic Autoimmune Diseases Unit, Department of Rheumatology, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain
| | - María Dolores Sánchez-González
- Systemic Autoimmune Diseases Unit, Department of Rheumatology, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain
| | - Francisco Aramburu-Muñoz
- Systemic Autoimmune Diseases Unit, Department of Rheumatology, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain
| | - Iustina Janta
- Systemic Autoimmune Diseases Unit, Department of Rheumatology, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain
| | - Emilio García-Morán
- Electrophysiology Unit, Department of Cardiology, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain
| | - Carlos Miguel Veras-Burgos
- Electrophysiology Unit, Department of Cardiology, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain
| | - Luis Corral-Gudino
- Department of Medicine, Dermatology and Toxicology, Medicine College, University of Valladolid, Avda. Ramón y Cajal 7, 47003 Valladolid, Spain
- Department of Internal Medicine, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y Leon (SACYL), C/Dulzaina n°2, 47012 Valladolid, Spain
| | - Cristina Abad-Molina
- Immunology Laboratory, Department of Microbiology, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y Leon (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain
| | - Roberto González-Fuentes
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud de Castilla y León (SACYL), Avda. Ramón y Cajal nº3, 47003 Valladolid, Spain; (J.G.-H.)
- Department of Medicine, Dermatology and Toxicology, Medicine College, University of Valladolid, Avda. Ramón y Cajal 7, 47003 Valladolid, Spain
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11
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Gamba A, Zen M, Depascale R, Calligaro A, Gatto M, Iaccarino L, Doria A. Modern Management of Pregnancy in Systemic Lupus Erythematosus: From Prenatal Counseling to Postpartum Support. J Clin Med 2024; 13:3454. [PMID: 38929983 PMCID: PMC11204490 DOI: 10.3390/jcm13123454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/05/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that predominantly affects women of childbearing age. Pregnancy in SLE patients poses unique challenges due to the potential impact on maternal and fetal outcomes. We provide an overview of the management of SLE during pregnancy, including preconception risk stratification and counseling, treatment, and disease activity monitoring. These assessments are critical to minimize maternal and fetal adverse events in pregnant patients with SLE. Disease flares, preeclampsia, antiphospholipid syndrome complications, and maternal mortality are the major risks for a woman with SLE during gestation. Timely treatment of SLE relapse, differentiation of preeclampsia from lupus nephritis, and tailored management for antiphospholipid syndrome are essential for a successful pregnancy. Fetal outcomes include neonatal lupus (NL), preterm birth, cesarean delivery, fetal growth restriction (FGR), and small-for-gestational-age (SGA) infants. We focused on NL, linked to maternal anti-Ro/SS-A and anti-La/SS-B antibodies, which can lead to various manifestations, particularly cardiac abnormalities, in newborns. While there is a common consensus regarding the preventive effect of hydroxychloroquine, the role of echocardiographic monitoring and fluorinated steroid treatment is still debated. Finally, close postpartum monitoring and counseling for subsequent pregnancies are crucial aspects of care.
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Affiliation(s)
- Anna Gamba
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Margherita Zen
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Roberto Depascale
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Antonia Calligaro
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Mariele Gatto
- Academic Rheumatology Centre, Department of Clinical and Biological Sciences, University of Turin, AO Mauriziano di Torino, 10128 Turin, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
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12
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Kukla P, Podlejska B, Wiliński J. Congenital Complete Heart Block-To Stimulate (When?) or Not to Stimulate? Healthcare (Basel) 2024; 12:1158. [PMID: 38921273 PMCID: PMC11203115 DOI: 10.3390/healthcare12121158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/02/2024] [Accepted: 06/05/2024] [Indexed: 06/27/2024] Open
Abstract
This article presents the case of a 27-year-old female patient with idiopathic congenital complete heart block who does not consent to the implantation of a cardiac pacemaker but was referred by her primary care physician for cardiological evaluation. The conduction disturbance was recognized at the age of 6 and was asymptomatic. The professional disqualification from pacemaker implantation included a detailed history of a patient's symptoms, an echocardiographic assessment of the heart, exercise testing and ECG Holter monitoring. The aid of salbutamol administered orally was also useful.
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Affiliation(s)
- Piotr Kukla
- Department of Internal Medicine and Cardiology, Specialist Hospital H. Klimontowicza, 38-300 Gorlice, Poland;
| | - Beata Podlejska
- Department of Internal Medicine and Cardiology, Specialist Hospital H. Klimontowicza, 38-300 Gorlice, Poland;
| | - Jerzy Wiliński
- Center for Invasive Cardiology, Electrotherapy and Angiology, 33-300 Nowy Sącz, Poland;
- Department of Internal Medicine with Cardiology Subdivision, Blessed Marta Wiecka District Hospital, 32-700 Bochnia, Poland
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13
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Tan Z, Shao M, Zhou Y, Wang L, Ma Y, Xiang N, Yuan X, Wang B, Xie X, Zhou M, Wang Y, Li S, Li X. Increased risk of adverse gestational outcomes in pregnant women with primary Sjögren's syndrome. RMD Open 2024; 10:e003616. [PMID: 38806189 PMCID: PMC11138269 DOI: 10.1136/rmdopen-2023-003616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 05/16/2024] [Indexed: 05/30/2024] Open
Abstract
OBJECTIVES This study aimed to identify risk factors contributing to diverse pregnancy outcomes in primary Sjögren's syndrome (pSS) cases. METHODS A retrospective analysis was conducted on pregnant individuals with pSS, who received outpatient or inpatient care across multiple hospitals in Anhui Province, China, from January 2015 to December 2022. RESULTS This study included 164 pregnant women with pSS and 328 control subjects, with no statistically significant difference in average age between the two groups. Analysis of pregnancy outcomes revealed that, compared with the control group, pregnant women in the pSS group were more likely to experience miscarriages, both spontaneous (12.80% vs 1.52%, p<0.001) and therapeutic (6.10% vs 0.91%, p<0.05). The proportion of placental abnormalities detected during prenatal ultrasound in women from the pSS group was higher (14.63% vs 6.40%, p<0.05). In the analysis of pregnancy outcomes for live-born neonates, a higher incidence of congenital heart abnormalities was observed in the pSS group (27.34% vs 12.03%, p<0.05). While there were no significant differences between the pSS pregnancies in terms of both normal and adverse pregnancy outcomes, a comparison of fetal survival and fetal loss in pSS pregnancies revealed a greater use of prophylactic anticoagulant therapy in the fetal survival group. Notably, the application of low molecular weight heparin (LMWH) emerged as an independent protective factor for fetal survival. CONCLUSIONS Compared with non-autoimmune controls, pregnancy in women with pSS presents more challenges. Importantly, we observed that the use of LMWH as anticoagulant therapy is an independent protective measure for fetal survival.
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Affiliation(s)
- Zhen Tan
- The First Affiliated Hospital of USTC, Hefei, Anhui, China
| | - Meilin Shao
- The First Affiliated Hospital of USTC, Hefei, Anhui, China
- Department of Physiology, Anhui Medical College, Hefei, Anhui, China
| | - Yingbo Zhou
- The First Affiliated Hospital of USTC, Hefei, Anhui, China
| | - Li Wang
- The First Affiliated Hospital of USTC, Hefei, Anhui, China
| | - Yan Ma
- The First Affiliated Hospital of USTC, Hefei, Anhui, China
| | - Nan Xiang
- The First Affiliated Hospital of USTC, Hefei, Anhui, China
| | - Xiang Yuan
- The First Affiliated Hospital of USTC, Hefei, Anhui, China
| | - Bin Wang
- Huainan First People's Hospital, Huainan, Anhui, China
| | | | - Mingtao Zhou
- People's Hospital of Chizhou, Chizhou, Anhui, China
| | - Yumin Wang
- Huangshan City People's Hospital, Huangshan, Anhui, China
| | - Sidong Li
- University of Science and Technology, Hefei, Anhui, China
| | - Xiaomei Li
- The First Affiliated Hospital of USTC, Hefei, Anhui, China
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14
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Killen SAS, Strasburger JF. Diagnosis and Management of Fetal Arrhythmias in the Current Era. J Cardiovasc Dev Dis 2024; 11:163. [PMID: 38921663 PMCID: PMC11204159 DOI: 10.3390/jcdd11060163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 06/27/2024] Open
Abstract
Diagnosis and management of fetal arrhythmias have changed over the past 40-50 years since propranolol was first used to treat fetal tachycardia in 1975 and when first attempts were made at in utero pacing for complete heart block in 1986. Ongoing clinical trials, including the FAST therapy trial for fetal tachycardia and the STOP-BLOQ trial for anti-Ro-mediated fetal heart block, are working to improve diagnosis and management of fetal arrhythmias for both mother and fetus. We are also learning more about how "silent arrhythmias", like long QT syndrome and other inherited channelopathies, may be identified by recognizing "subtle" abnormalities in fetal heart rate, and while echocardiography yet remains the primary tool for diagnosing fetal arrhythmias, research efforts continue to advance the clinical envelope for fetal electrocardiography and fetal magnetocardiography. Pharmacologic management of fetal arrhythmias remains one of the most successful achievements of fetal intervention. Patience, vigilance, and multidisciplinary collaboration are key to successful diagnosis and treatment.
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Affiliation(s)
- Stacy A. S. Killen
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Monroe Carell Jr. Children’s Hospital at Vanderbilt, 2200 Children’s Way, Suite 5230, Nashville, TN 37232, USA
| | - Janette F. Strasburger
- Division of Cardiology, Departments of Pediatrics and Biomedical Engineering, Children’s Wisconsin, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, WI 53226, USA;
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15
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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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16
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Price EJ, Benjamin S, Bombardieri M, Bowman S, Carty S, Ciurtin C, Crampton B, Dawson A, Fisher BA, Giles I, Glennon P, Gupta M, Hackett KL, Larkin G, Ng WF, Ramanan AV, Rassam S, Rauz S, Smith G, Sutcliffe N, Tappuni A, Walsh SB. British Society for Rheumatology guideline on management of adult and juvenile onset Sjögren disease. Rheumatology (Oxford) 2024:keae152. [PMID: 38621708 DOI: 10.1093/rheumatology/keae152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/02/2024] [Indexed: 04/17/2024] Open
Abstract
Sjögren disease (SD) is a chronic, autoimmune disease of unknown aetiology with significant impact on quality of life. Although dryness (sicca) of the eyes and mouth are the classically described features, dryness of other mucosal surfaces and systemic manifestations are common. The key management aim should be to empower the individual to manage their condition-conserving, replacing and stimulating secretions; and preventing damage and suppressing systemic disease activity. This guideline builds on and widens the recommendations developed for the first guideline published in 2017. We have included advice on the management of children and adolescents where appropriate to provide a comprehensive guideline for UK-based rheumatology teams.
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Affiliation(s)
- Elizabeth J Price
- Department of Rheumatology, Great Western Hospital NHS Foundation Trust, Swindon, UK
| | - Stuart Benjamin
- The Academy Library and Information Service, Great Western Hospital NHS Foundation Trust, Swindon, UK
| | - Michele Bombardieri
- Department of Rheumatology, Barts and The London School of Medicine and Dentistry, Barts Health NHS Trust, London, UK
- Centre for Experimental Medicine and Rheumatology, The William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Simon Bowman
- Department of Rheumatology, Milton Keynes University Hospital, Milton Keynes, UK
- Department of Rheumatology, University Hospitals Birmingham NHSFT, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Sara Carty
- Department of Rheumatology, Great Western Hospital NHS Foundation Trust, Swindon, UK
| | - Coziana Ciurtin
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Bridget Crampton
- Patient Representative, Sjogren's UK Helpline Lead, Sjogren's UK (British Sjögren's Syndrome Association), Birmingham, UK
| | - Annabel Dawson
- Patient Representative, Sjogren's UK (British Sjögren's Syndrome Association), Birmingham, UK
| | - Benjamin A Fisher
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre and Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Peter Glennon
- General Practice, NHS Staffordshire & Stoke on Trent ICB, Stafford, UK
| | - Monica Gupta
- Department of Rheumatology, Gartnavel General Hospital, Glasgow, UK
| | - Katie L Hackett
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | | | - Wan-Fai Ng
- Translational and Clinical Research Institute & Newcastle NIHR Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
- Department of Rheumatology, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Saad Rassam
- Haematology and Haemato-Oncology, KIMS Hospital, Maidstone, Kent, UK
| | - Saaeha Rauz
- Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Guy Smith
- Department of Ophthalmology, Great Western Hospital NHS Foundation Trust, Swindon, UK
| | | | - Anwar Tappuni
- Institute of Dentistry, Queen Mary University of London, London, UK
| | - Stephen B Walsh
- London Tubular Centre, University College London, London, UK
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17
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Yang Y, Huang XX, Huo RX, Lin JY. Impact of Sjögren's syndrome on maternal and fetal outcomes following pregnancy: a systematic review and meta-analysis of studies published between years 2007-2022. Arch Gynecol Obstet 2024; 309:1135-1149. [PMID: 37921880 DOI: 10.1007/s00404-023-07259-3] [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: 03/04/2023] [Accepted: 10/06/2023] [Indexed: 11/05/2023]
Abstract
OBJECTIVE To show the impact of Sjögren's syndrome (SS) on maternal and fetal outcomes following pregnancy. METHODS We performed a literature search based on PubMed, Web of science, Wan fang, China National Knowledge Infrastructure and ProQuest databases from 1 January 2007 to 6 November 2022. Grading of Recommendations, Assessment, Development, and Evaluations approach was used to assess the certainty of the evidence. Systematic reviews and meta-analyses were performed using RevMan 5.3 software. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird. Trial sequential analyses were performed by TSA 0.9. RESULTS Nine studies with 2341 patients and 2472 pregnancies with SS were included in our analysis. This current analysis showed pregnancy hypertension and preeclampsia/eclampsia to be significantly higher in pregnant women with SS compared to pregnant women without SS (OR: 1.65, 95% CI: 1.04-2.63; P = 0.03), (OR: 2.06, 95% CI: 1.16-3.65; P = 0.01) respectively. Cesarean section, thromboembolic disease, premature rupture of membranes, and spontaneous abortion were also significantly higher in the SS women with OR: 2.07, 95% CI: 1.48-2.88; P < 0.0001, OR: 9.45, 95% CI: 1.99-44.87; P = 0.005, OR: 1.36, 95% CI: 1.13-1.64; P = 0.001, OR: 9.30, 95% CI: 4.13-20.93; P < 0.00001, respectively. Significantly higher premature births were observed with infants who were born from SS mothers (OR: 2.19, 95% CI: 1.54-3.12; P < 0.0001). Infants defined as 'small for gestational age/intrauterine growth restriction' and 'weighing < 2500 g' were also significantly higher in patients suffering from SS (OR: 2.26, 95% CI: 1.38-3.70; P = 0.001), (OR: 3.84, 95% CI: 1.39-10.61; P = 0.009) respectively. In addition, live birth significantly favored infants who were born from mothers without SS (OR: 21.53, 95% CI: 8.36-55.44; P < 0.00001). Subgroup analysis by sample size revealed that pregnancy hypertension risk has significantly increased in small cohort (OR: 2.74, 95%CI: 1.45-5.18), and a slight increase was found in population-based studies (OR: 1.14, 95%CI: 0.91-1.43). In both small cohorts and population-based researches, cesarean section was significantly higher in SS (OR: 2.13, 95% CI: 1.29, 3.52; OR: 1.85, 95% CI: 1.29-2.64, respectively). The number of infants with intrauterine growth restriction did not grow in the population-based researches (OR: 2.07, 95%CI: 0.92-4.66) although there has been an increase in small reports (OR: 2.53, 95%CI: 1.16-5.51). Subgroup analysis was conducted on the basis of study location (not Asian vs. Asian countries) indicated that cesarean section was significantly higher in SS in both countries (OR: 1.69, 95% CI: 1.31-2.18; OR: 3.37, 95% CI: 2.39-4.77, respectively). CONCLUSION This meta-analysis has shown SS to have a high impact on maternal and fetal outcomes following pregnancy.
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Affiliation(s)
- Yang Yang
- Department of Rheumatology and Immunology, Guangxi Academy of Medical Sciences, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530016, China
| | - Xin-Xiang Huang
- Department of Rheumatology and Immunology, Guangxi Academy of Medical Sciences, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530016, China
| | - Rong-Xiu Huo
- Department of Rheumatology and Immunology, Guangxi Academy of Medical Sciences, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530016, China
| | - Jin-Ying Lin
- Department of Rheumatology and Immunology, Guangxi Academy of Medical Sciences, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530016, China.
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18
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Buyon JP, Masson M, Izmirly CG, Phoon C, Acherman R, Sinkovskaya E, Abuhamad A, Makhoul M, Satou G, Hogan W, Pinto N, Moon-Grady A, Howley L, Donofrio M, Krishnan A, Ahmadzia H, Levasseur S, Paul E, Owens S, Cumbermack K, Matta J, Joffe G, Lindblade C, Haxel C, Kohari K, Copel J, Strainic J, Doan T, Bermudez-Wagner K, Holloman C, Sheth SS, Killen S, Tacy T, Kaplinski M, Hornberger L, Carlucci PM, Izmirly P, Fraser N, Clancy RM, Cuneo BF. Prospective Evaluation of High Titer Autoantibodies and Fetal Home Monitoring in the Detection of Atrioventricular Block Among Anti-SSA/Ro Pregnancies. Arthritis Rheumatol 2024; 76:411-420. [PMID: 37947364 PMCID: PMC11095662 DOI: 10.1002/art.42733] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE This prospective study of pregnant patients, Surveillance To Prevent AV Block Likely to Occur Quickly (STOP BLOQ), addresses the impact of anti-SSA/Ro titers and utility of ambulatory monitoring in the detection of fetal second-degree atrioventricular block (AVB). METHODS Women with anti-SSA/Ro autoantibodies by commercial testing were stratified into high and low anti-52-kD and/or 60-kD SSA/Ro titers applying at-risk thresholds defined by previous evaluation of AVB pregnancies. The high-titer group performed fetal heart rate and rhythm monitoring (FHRM) thrice daily and weekly/biweekly echocardiography from 17-26 weeks. Abnormal FHRM prompted urgent echocardiography to identify AVB. RESULTS Anti-52-kD and/or 60-kD SSA/Ro met thresholds for monitoring in 261 of 413 participants (63%); for those, AVB frequency was 3.8%. No cases occurred with low titers. The incidence of AVB increased with higher levels, reaching 7.7% for those in the top quartile for anti-60-kD SSA/Ro, which increased to 27.3% in those with a previous child who had AVB. Based on levels from 15 participants with paired samples from both an AVB and a non-AVB pregnancy, healthy pregnancies were not explained by decreased titers. FHRM was considered abnormal in 45 of 30,920 recordings, 10 confirmed AVB by urgent echocardiogram, 7 being second-degree AVB, all <12 hours from normal FHRM and within another 0.75 to 4 hours to echocardiogram. The one participant with second/third-degree and two participants with third-degree AVB were diagnosed by urgent echocardiogram >17 to 72 hours from an FHRM. Surveillance echocardiograms detected no AVB when the preceding interval FHRM recordings were normal. CONCLUSION High-titer antibodies are associated with an increased incidence of AVB. Anti-SSA/Ro titers remain stable over time and do not explain the discordant recurrence rates, suggesting that other factors are required. Fetal heart rate and rhythm (FHRM) with results confirmed by a pediatric cardiologist reliably detects conduction abnormalities, which may reduce the need for serial echocardiograms.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gary Satou
- University of California, Los Angeles, California
| | | | | | | | - Lisa Howley
- Midwest Fetal Care Center, Children's Minnesota/Allina Health, Minneapolis, Minnesota
| | | | | | | | | | - Erin Paul
- Mount Sinai Hospital, New York City, New York
| | | | | | | | - Gary Joffe
- Perinatal Associates of New Mexico, Rio Rancho, New Mexico
| | | | - Caitlin Haxel
- University of Vermont Children's Hospital, Burlington, Vermont
| | | | | | - James Strainic
- UH Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Tam Doan
- Baylor School of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Conisha Holloman
- Baylor School of Medicine, Baylor College of Medicine, Houston, Texas
| | - Shreya S Sheth
- Baylor School of Medicine, Baylor College of Medicine, Houston, Texas
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19
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Bedei IA, Kniess D, Keil C, Wolter A, Schenk J, Sachs UJ, Axt-Fliedner R. Monitoring of Women with Anti-Ro/SSA and Anti-La/SSB Antibodies in Germany-Status Quo and Intensified Monitoring Concepts. J Clin Med 2024; 13:1142. [PMID: 38398455 PMCID: PMC10889801 DOI: 10.3390/jcm13041142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Background: The fetuses of pregnant women affected by anti-Ro/anti-La antibodies are at risk of developing complete atrioventricular heart block (CAVB) and other potentially life-threatening cardiac affections. CAVB can develop in less than 24 h. Treatment with anti-inflammatory drugs and immunoglobulins (IVIG) can restore the normal rhythm if applied in the transition period. Routine weekly echocardiography, as often recommended, will rarely detect emergent AVB. The surveillance of these pregnancies is controversial. Home-monitoring using a hand-held Doppler is a promising new approach. Methods: To obtain an overview of the current practice in Germany, we developed a web-based survey sent by the DEGUM (German Society of Ultrasound in Medicine) to ultrasound specialists. With the intention to evaluate practicability of home-monitoring, we instructed at-risk pregnant women to use a hand-held Doppler in the vulnerable period between 18 and 26 weeks at our university center. Results: There are trends but no clear consensus on surveillance, prophylaxis, and treatment of anti-Ro/La positive pregnant between specialists in Germany. Currently most experts do not offer home-monitoring but have a positive attitude towards its prospective use. Intensified fetal monitoring using a hand-held Doppler is feasible for pregnant women at risk and does not lead to frequent and unnecessary contact with the center. Conclusion: Evidence-based guidelines are needed to optimize the care of anti-Ro/La-positive pregnant women. Individual risk stratification could help pregnancy care of women at risk and is welcmed by most experts. Hand-held doppler monitoring is accepted by patients and prenatal medicine specialists as an option for intensified monitoring and can be included in an algorithm for surveillance.
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Affiliation(s)
- Ivonne Alexandra Bedei
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - David Kniess
- Department of Prenatal Diagnosis and Fetal Therapy, Philipps-University Marburg, 35041 Marburg, Germany; (D.K.)
| | - Corinna Keil
- Department of Prenatal Diagnosis and Fetal Therapy, Philipps-University Marburg, 35041 Marburg, Germany; (D.K.)
| | - Aline Wolter
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - Johanna Schenk
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
| | - Ulrich J. Sachs
- Institute for Clinical Immunology and Transfusion Medicine, Justus-Liebig University, 35392 Giessen, Germany;
- Center for Transfusion Medicine and Hemotherapy, University Hospital Giessen and Marburg, 35041 Marburg, Germany
- German Center for Fetomaternal Incompatibility (DZFI), University Hospital Giessen and Marburg, 35392 Giessen, Germany
| | - Roland Axt-Fliedner
- Department of Prenatal Diagnosis and Fetal Therapy, Justus-Liebig University Giessen, 35392 Giessen, Germany; (A.W.); (J.S.); (R.A.-F.)
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20
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Dharmagadda A, Tambolkar S, Chavan S, Garlapati S. Late-Onset Dilated Cardiomyopathy in Auto Immune-Mediated Complete Congenital Heart Block: A Case Report. Cureus 2024; 16:e54222. [PMID: 38496172 PMCID: PMC10943330 DOI: 10.7759/cureus.54222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
Complete congenital heart block (CHB), a rare and fatal bradyarrhythmia observed in children, carries significant mortality and morbidity. When congenital heart block occurs in isolation with a structurally normal heart, it prompts suspicion of an autoimmune etiology, wherein maternal antibodies are transmitted transplacentally, impacting the fetal conducting system. The manifestation of congenital complete atrioventricular block (CCAVB) can lead to complications such as dilated cardiomyopathies, arrhythmias, and fibroelastosis in certain cases. Notably, dilated cardiomyopathy is a significant prognostic factor in children diagnosed with congenital heart block. Pathological investigations have revealed the presence of antibodies, complements, and indicators of inflammation or fibrosis across the myocardium, emphasizing the shared molecular mechanisms between CCAVB and the development of dilated cardiomyopathy (DCM). This article presents the case of a one-year-old female child who presented with signs of dilated cardiomyopathy, later identified through retrospective evaluation as having autoimmune congenital heart block. The mother of the child was diagnosed with Sjogren's syndrome, characterized by positive anti-RO titers. Remarkably, the child remained asymptomatic for a year without the need for pacing intervention. The child's condition was successfully stabilized with appropriate treatment, and plans for pacemaker insertion will be considered once specific criteria are met. The onset of cardiomyopathy in a known case of CCAVB should serve as a crucial alert for prognostic considerations and the potential necessity for early-pacing intervention.
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Affiliation(s)
- Amulya Dharmagadda
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Sampada Tambolkar
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Sanjay Chavan
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Srinija Garlapati
- Pediatrics, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
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21
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Duman D, Tunca Sahin G, Stuart G, Walsh M, Caputo M, Parry A, Beattie B, Conner C, Uzun O. Influence of improved antenatal detection on the outcomes of complete atrioventricular block diagnosed in fetal-neonatal life and childhood periods - a single-centre experience in South Wales for 55 years. Cardiol Young 2024; 34:412-420. [PMID: 38149337 DOI: 10.1017/s1047951123003967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
OBJECTIVE This study aimed to analyse the influence of improved antenatal detection on the course, contemporary outcomes, and mortality risk factors of the complete atrioventricular block during fetal-neonatal and childhood periods in South Wales. METHODS The clinical characteristics and outcomes of complete atrioventricular block in patients without structural heart disease at the University Hospital of Wales from January 1966 to April 2021 were studied. Patients were divided into two groups according to their age at diagnosis: I-fetal-neonatal and II-childhood. Contemporary outcomes during the post-2001 era were compared with historical data preceding fetal service development and hence earlier detection. RESULTS There were 64 patients: 26 were identified in the fetal-neonatal period and the remaining 38 in the childhood period. Maternal antibodies/systemic lupus erythematosus disease (anti-Ro/Sjögren's-syndrome-related Antigen A and/or anti-La/Sjögren's-syndrome-related Antigen B) were present in 15 (57.7%) of the fetal-neonatal. Fetal/neonatal and early diagnosis increased after 2001 with an incidence of 1:25000 pregnancies. Pacemaker implantation was required in 34 patients, of whom 13 were diagnosed in the fetal-neonatal group. Survival rates in cases identified before 2001 were at 96.3% (26/27), whereas it was 83.8% (31/37) in patients diagnosed after 2001 (P > 0.05). Other mortality risk factors comprised a lower gestational week at birth, maternal antibodies, and an average ventricular heart rate of < 55 bpm. CONCLUSIONS Fetal diagnosis of complete atrioventricular block is still portends high fetal and neonatal mortality and morbidity despite significantly improved antenatal detection after 2001. Pacemaker intervention is needed earlier in the fetal-neonatal group. Whether routine antenatal medical treatment might alter this outcome calls for further prospective multicentre studies.
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Affiliation(s)
| | | | | | - Mark Walsh
- Bristol Royal Children's Hospital, Bristol, UK
| | | | | | | | | | - Orhan Uzun
- University Hospital of Wales, Cardiff, UK
- Cardiff University, School of Medicine, Cardiff, UK
- Swansea University, School of Engineering and Sport Sciences, Swansea, UK
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22
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Limquiaco KNY, Salido EO. Complete Congenital Heart Block in the Offspring of an Asymptomatic Woman with Isolated High Titer Anti-Ro Antibody. ACTA MEDICA PHILIPPINA 2024; 58:84-89. [PMID: 38939855 PMCID: PMC11199349 DOI: 10.47895/amp.vi0.6358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Among pregnant women, 1-2% are anti-Ro positive and while half of them have symptoms of connective tissue disease, the rest are asymptomatic. The presence of anti-Ro is of concern because of the risk of congenital heart block in the child. We report the case of an asymptomatic 27-year-old G2P1(1001) woman, who presented with persistent fetal bradycardia in her 21st week of gestation (AOG) and was found to have elevated titers for anti-Ro (>320 U/ml). Hydroxychloroquine 200 mg/day and prednisone 10 mg/day were given from the 33rd week of gestation up until the delivery. At 37 weeks AOG, she delivered a live male neonate with a complete heart block. On the 6th day of life, the infant remained bradycardic, hence a pacemaker was inserted and heart rate maintained at 100-120 bpm. On subsequent follow-ups, the mother and child did not develop any systemic manifestations and the infant was thriving well. While a diseased condition may not be apparent in a pregnant anti-Ro positive woman, the risk of neonatal lupus (NL) is demonstrated in this patient's case. This report illustrates how prenatal care of an asymptomatic woman led to the discovery of a fetal abnormality and served to prepare the family and the medical team to ably handle the birth and subsequent care of a neonate with NL.
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Affiliation(s)
- Kristine Niña Y Limquiaco
- Division of Rheumatology, Department of Medicine, Philippine General Hospital, University of the Philippines Manila
| | - Evelyn O Salido
- Division of Rheumatology, Department of Medicine, Philippine General Hospital, University of the Philippines Manila
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23
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González-Zambrano H, Orozco-Barocio G, Franco-Ramos MC. Prevalence of neonatal lupus in a small group of antibody-carrying mothers and frequency of complete atrioventricular block. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2024; 94:33-38. [PMID: 38507328 PMCID: PMC11160526 DOI: 10.24875/acm.22000233] [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: 09/29/2022] [Accepted: 05/10/2023] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Neonatal lupus (NL) is extremely rare and is caused by the transplacental passage of maternal IgG autoantibodies against Ro, La, and/or RNP proteins into the fetal circulation, which can cause congenital complete atrioventricular block (CCAB), permanent skin lesions, and liver involvement. OBJECTIVE To know the prevalence of NL in patients with CCAB and the clinical course in long-term follow-up. METHODS From January 1992 to December 2017, patients with CCAB were included. The presence of anti-SSA/Ro and anti-SSB/La antinuclear antibodies in maternal serum confirmed NL. RESULTS Eight patients were included with a follow-up of 10 ± 6 years; NL was concluded in 62.5%; two were male. One of them was diagnosed in utero, two at birth, and a pacemaker was implanted in them, one at 12 years of age and another at 15. The other two cases were diagnosed at 18 and 26 years of age, and permanent pacemakers were implanted 8 and 5 years later, respectively. In one case, a definitive pacemaker was not implanted in a newborn with only 1 year of follow-up. At delivery, 60% of the mothers were free of rheumatic disease, and altogether, they all had 19 children; none of them presented NL manifestations. CONCLUSIONS CCAB is rare and frequently associated with a maternal autoimmune disease, practically all of them will require a definitive pacemaker at some point in their lives.
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Affiliation(s)
- Héctor González-Zambrano
- Cardiology Service, Hospital General de Occidente, Ministry of Health
- National Institutes of Health, Ministry of Health
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24
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李 宇, 闫 亚, 靳 家, 李 春, 裴 秋. [Clinical characteristics of fetal cardiac disease in patients with anti-SSA antibody positive]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2023; 55:1053-1057. [PMID: 38101788 PMCID: PMC10723988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To investigate the clinical manifestations and laboratory indicators of anti-Sjögren's-syndrome-related antigen A (SSA) antibody associated fetal cardiac disease. METHODS Pregnant women hospitalized at Peking University People's Hospital from January 2013 to July 2023 were included. Eleven patients with anti-SSA antibody positive were eventually diagnosed with fetal cardiac di-sease. And patients with anti-SSA antibody positive without fetal cardiac disease were selected as controls. Clinical manifestations, laboratory indications and drug usage were compared between the two groups. RESULTS Among these 11 patients, congenital heart block was confirmed in seven, which was the most common manifestations of fetal cardiac malformation. The proportion of the patients diagnosed with autoimmune disease before pregnancy in fetal cardiac malformation group was significantly lower than that in the control group (P=0.032), while most of the patients in the fetal cardiac malformation group received immune-related examinations for the first time because of this time's fetal cardiac diagnosis. While most of the patients in the control group received routine examinations because of autoimmune diseases diagnosed before pregnancy. During pregnancy, the white blood cell level [(9.29±2.58)×109/L vs. (7.10±1.90×109/L, t=3.052, P=0.004], erythrocyte sedimentation rate [(49.50 (48.00, 51.00) mm/h vs. 23.00 (15.00, 30.25) mm/h, Z=-2.251, P=0.024], IgA level [3.46 (2.30, 5.06) g/L vs. 2.13 (1.77, 2.77) g/L, Z=-2.181, P=0.029], and antinuclear antibody (ANA) titers [1∶320 (1∶160, 1∶320) vs. 1∶80 (1∶40, 1∶160), Z=-3.022, P=0.003] were significantly higher in fetal cardiac malformation group than in the control group. The proportion of positive anti-SSB antibody during pregnancy did not show a statistically significant difference between the two groups (37.5% vs. 7.7%, P=0.053). There was no significant difference in hydroxychloroquine dosage and initiation time between the two groups. The dosage of prednisone in the second and third trimesters was significantly higher in the cardiac malformation group than that in the control group, but there was no significant difference in the first trimester. CONCLUSION Fetal cardiac disease is rare in pregnant women with anti-SSA antibody. White blood cell, erythrocyte sedimentation rate, IgA, the titer of ANA positivity were higher in the fetal heart disease group during pregnancy. Since congenital heart block is difficult to reverse, its prevention and monitoring are more important than remedial treatment.
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Affiliation(s)
- 宇菲 李
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People' s Hospital, Beijing 100044, China
| | - 亚妮 闫
- 北京大学人民医院妇产科,北京 100044Department of Obstetrics & Gynecology, Peking University People' s Hospital, Beijing 100044, China
| | - 家扬 靳
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People' s Hospital, Beijing 100044, China
| | - 春 李
- 北京大学人民医院风湿免疫科,北京 100044Department of Rheumatology and Immunology, Peking University People' s Hospital, Beijing 100044, China
| | - 秋艳 裴
- 北京大学人民医院妇产科,北京 100044Department of Obstetrics & Gynecology, Peking University People' s Hospital, Beijing 100044, China
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25
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Zucchi D, Fischer-Betz R, Tani C. Pregnancy in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2023; 37:101860. [PMID: 37596173 DOI: 10.1016/j.berh.2023.101860] [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: 05/18/2023] [Accepted: 07/25/2023] [Indexed: 08/20/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease which frequently affects women of childbearing age. Nowadays, pregnancy is not contraindicated in cases of well-controlled disease activity, but pregnancies are still at higher risk of maternal and fetal complications compared to the general population. During pregnancy and puerperium patients are at risk of disease flare, and obstetric complications are more frequent in cases of active disease at conception/beginning of pregnancy, a history of lupus nephritis, and concomitant presence of antiphospholipid syndrome. To improve pregnancy outcomes in SLE patients, appropriate preconception counseling with changes in medication, if necessary, and close rheumatological and obstetrical monitoring are fundamental. This review aims to summarize the risk factors for adverse pregnancy outcomes and provide an update on developments in medical care for pregnancy in SLE patients.
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Affiliation(s)
- Dina Zucchi
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Italy; Department of Medical Biotechnologies, University of Siena, Italy
| | - Rebecca Fischer-Betz
- Medical Faculty, Department Rheumatology & Hiller-Research Unit Rheumatology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Italy.
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Song L, Meng Q, Liu C, Wang G, Wang H, Zhou G, Feng Z. Experience of treating congenital complete atrioventricular block with epicardial pacemaker in infants and young children: a retrospective study. BMC Cardiovasc Disord 2023; 23:575. [PMID: 37990158 PMCID: PMC10664347 DOI: 10.1186/s12872-023-03620-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 11/16/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND This article summarizes the treatment experience for congenital complete atrioventricular block (CCAVB) in newborns and infants, and discusses the necessity and feasibility of treating CCAVB with permanent pacemaker implantation in this population. METHODS In this study, the clinical data and follow-up results of nine children admitted at our center with CCAVB from January 2005 to March 2023 were retrospectively analyzed. Among them, two children received early implantation of permanent pacemakers (within 1 year of age), two children received non-early implantation (1 year or older), and the remaining five children received no pacemaker implantation. CCAVB diagnosis was confirmed by clinical symptoms and clinical examinations, including electrocardiography and echocardiography before surgery. After surgery, the pacing and sensing functions of the pacemaker were observed using electrocardiography, echocardiography, and pacing threshold monitoring. A comprehensive assessment of the treatment efficacy was conducted, encompassing improvements in clinical symptoms, growth and development, as well as the absence of any additional potential complications. The children who did not receive pacemaker implantation were followed up. RESULTS Among the four children who successfully received pacemaker implantation, one child who received non-early implantation died. For the remaining three children, the threshold level, amplitude, impedance, and minute ventilation sensor function of the pacemaker were good during the follow-up period, with a heart rate at the pacing rate. The growth and development of the aforementioned patients who received pacemaker implantation demonstrated adherence to the percentile curve, and their motor and cognitive development remained unaffected. However, among the children who did not undergo pacemaker implantation, two experienced death, while three were lost to follow-up, thereby limiting the evaluation of their long-term outcomes. CONCLUSIONS Early implantation of an epicardial pacemaker at an early stage in newborns and infants diagnosed with CCAVB can significantly improve clinical symptoms without affecting their growth and development. These data are in line with current literature and suggest that early implantation of an epicardial pacemaker in newborns and infants diagnosed with CCAVB but further studies are needed.
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Affiliation(s)
- Linhong Song
- Department of Pediatric Cardiology, Faculty of Pediatrics, The Seventh Medical Center of Chinese PLA General Hospital, NO. 5 Nanmencang, Dongcheng District, Beijing, 100700, China
| | - Qiang Meng
- Department of Pediatric Cardiology, Faculty of Pediatrics, The Seventh Medical Center of Chinese PLA General Hospital, NO. 5 Nanmencang, Dongcheng District, Beijing, 100700, China
| | - Changgen Liu
- Department of Pediatric Cardiology, Faculty of Pediatrics, The Seventh Medical Center of Chinese PLA General Hospital, NO. 5 Nanmencang, Dongcheng District, Beijing, 100700, China
- Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Gang Wang
- Department of Pediatric Cardiology, Faculty of Pediatrics, The Seventh Medical Center of Chinese PLA General Hospital, NO. 5 Nanmencang, Dongcheng District, Beijing, 100700, China
| | - Hui Wang
- Department of Pediatric Cardiology, Faculty of Pediatrics, The Seventh Medical Center of Chinese PLA General Hospital, NO. 5 Nanmencang, Dongcheng District, Beijing, 100700, China
| | - Gengxu Zhou
- Department of Pediatric Cardiology, Faculty of Pediatrics, The Seventh Medical Center of Chinese PLA General Hospital, NO. 5 Nanmencang, Dongcheng District, Beijing, 100700, China.
| | - Zhichun Feng
- Department of Pediatric Cardiology, Faculty of Pediatrics, The Seventh Medical Center of Chinese PLA General Hospital, NO. 5 Nanmencang, Dongcheng District, Beijing, 100700, China.
- Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
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27
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Barsalou J, Jaeggi E, Grosse-Wortmann L, Laskin CA, Adeli K, Silverman ED. High-sensitivity cardiac troponin T in infants exposed to anti-Ro antibodies. Rheumatology (Oxford) 2023; 62:3416-3420. [PMID: 36912668 DOI: 10.1093/rheumatology/kead105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/29/2023] [Accepted: 02/24/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVES Cardiac involvement in neonatal lupus erythematosis (NLE) can present as myocarditis/endocardial fibroelastosis (EFE). It is unknown whether high-sensitivity cardiac troponin T (hs-cTnT) is useful in identifying subclinical myocardial inflammation in infants exposed prenatally to anti-Ro antibodies. This study reports hs-cTnT levels in infants exposed to anti-Ro antibodies with/without cardiac NLE and reports cardiac MRI (CMR) findings in a subset of these children. METHODS The study included 45 consecutive infants exposed prenatally to anti-Ro antibodies with (n = 7) or without (n = 38) cardiac NLE, who were seen at the SickKids NLE Clinic between 2012 and 2014. Hs-cTnT levels were measured at least once, and those infants with values of ≥30 ng/l were offered the opportunity to undergo CMR. Descriptive statistics were performed. RESULTS Of 38 infants without cardiac NLE, 25 had a hs-cTnT level of ≥30 ng/l (including 1 of >113 ng/l); of these, 8 underwent CMR (all without myocarditis/EFE). All 7 infants with cardiac NLE had at least one hs-cTnT level of ≥30 ng/l, but only 2/7 had a level of >113 ng/l; 4/7 infants with cardiac NLE had CMR (all without myocarditis/EFE); 6/7 infants with cardiac NLE had their steroid treatment adjusted based on the trend in their hs-cTnT levels. CONCLUSION Only 3/45 anti-Ro antibodies-exposed infants had hs-cTnT values outside the reference range reported in healthy infants. None of 12 infants who had CMR had subclinical myocarditis/EFE. Routine measurement of hs-cTnT in every anti-Ro antibody-exposed infant is not indicated. Further studies are needed to define the role of hs-cTnT as a biomarker for cardiac NLE.
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Affiliation(s)
- Julie Barsalou
- Division of Pediatric Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Edgar Jaeggi
- Division of Pediatric Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, SickKids Hospital Research Institute, Toronto, Canada
| | - Lars Grosse-Wortmann
- Division of Pediatric Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, SickKids Hospital Research Institute, Toronto, Canada
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Carl A Laskin
- Department of Medicine, Obstetrics and Gynecology, University of Toronto, TRIO Fertility, Toronto, Canada
| | - Khosrow Adeli
- Division of Clinical Biochemistry, Department of Laboratory Medicine and Pathobiology, The Hospital for Sick Children, University of Toronto, SickKids Hospital Research Institute, Toronto, Canada
| | - Earl D Silverman
- Division of Pediatric Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, SickKids Hospital Research Institute, Toronto, Canada
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Tian X, Zhao J, Song Y, Wang Q, Li M, Liu J, Zeng X. 2022 Chinese guideline for the management of pregnancy and reproduction in systemic lupus erythematosus. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:115-138. [PMID: 37781682 PMCID: PMC10538620 DOI: 10.2478/rir-2023-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/19/2023] [Indexed: 10/03/2023]
Abstract
Systemic lupus erythematosus (SLE), a prevalent autoimmune disease predominantly affecting women of childbearing age, presents ongoing challenges despite notable advances in diagnosis and treatment. Although survival rates for SLE patients have significantly improved, pregnancy continues to pose a considerable obstacle. Addressing this critical need for enhanced reproductive and prenatal care, there is a pressing imperative to establish standardized protocols for peri-gestational monitoring and treatment in SLE patients. This guideline is jointly sponsored by the National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), the Chinese Systemic Lupus Erythematosus Treatment and Research Group (CSTAR), and the Chinese Research Committee of Pregnancy and Reproduction in Autoimmune Rheumatic Diseases (CHOPARD). Thirteen pertinent clinical questions have been generated through several rounds of rigorous clinical and methodological expert discussions and selections for a comprehensive understanding of key aspects in this domain. Guided by thorough examination of research evidence and expert perspectives, the formulated recommendations aim to optimize pregnancy success rates, reduce maternal and infant mortality rates, and ultimately enhance the overall well-being of SLE patients.
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Affiliation(s)
- Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Yijun Song
- Department of Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Juntao Liu
- Department of Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
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Liu CM, Chen YC, Hu YF. Harnessing cell reprogramming for cardiac biological pacing. J Biomed Sci 2023; 30:74. [PMID: 37633890 PMCID: PMC10463311 DOI: 10.1186/s12929-023-00970-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 08/22/2023] [Indexed: 08/28/2023] Open
Abstract
Electrical impulses from cardiac pacemaker cardiomyocytes initiate cardiac contraction and blood pumping and maintain life. Abnormal electrical impulses bring patients with low heart rates to cardiac arrest. The current therapy is to implant electronic devices to generate backup electricity. However, complications inherent to electronic devices remain unbearable suffering. Therefore, cardiac biological pacing has been developed as a hardware-free alternative. The approaches to generating biological pacing have evolved recently using cell reprogramming technology to generate pacemaker cardiomyocytes in-vivo or in-vitro. Different from conventional methods by electrical re-engineering, reprogramming-based biological pacing recapitulates various phenotypes of de novo pacemaker cardiomyocytes and is more physiological, efficient, and easy for clinical implementation. This article reviews the present state of the art in reprogramming-based biological pacing. We begin with the rationale for this new approach and review its advances in creating a biological pacemaker to treat bradyarrhythmia.
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Affiliation(s)
- Chih-Min Liu
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Chun Chen
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
- Institute of Biopharmaceutical Sciences, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.
- Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan.
- Institute of Biopharmaceutical Sciences, College of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Naito R, Ohmura K, Higuchi S, Nakai W, Kohyama M, Mimori T, Morinobu A, Arase H. Positive and negative regulation of the Fcγ receptor-stimulating activity of RNA-containing immune complexes by RNase. JCI Insight 2023; 8:e167799. [PMID: 37432743 PMCID: PMC10543717 DOI: 10.1172/jci.insight.167799] [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: 12/20/2022] [Accepted: 07/06/2023] [Indexed: 07/12/2023] Open
Abstract
The U1RNP complex, Ro/SSA, and La/SSB are major RNA-containing autoantigens. Immune complexes (ICs) composed of RNA-containing autoantigens and autoantibodies are suspected to be involved in the pathogenesis of some systemic autoimmune diseases. Therefore, RNase treatment, which degrades RNA in ICs, has been tested in clinical trials as a potential therapeutic agent. However, no studies to our knowledge have specifically evaluated the effect of RNase treatment on the Fcγ receptor-stimulating (FcγR-stimulating) activity of RNA-containing ICs. In this study, using a reporter system that specifically detects FcγR-stimulating capacity, we investigated the effect of RNase treatment on the FcγR-stimulating activity of RNA-containing ICs composed of autoantigens and autoantibodies from patients with systemic autoimmune diseases such as systemic lupus erythematosus. We found that RNase enhanced the FcγR-stimulating activity of Ro/SSA- and La/SSB-containing ICs, but attenuated that of the U1RNP complex-containing ICs. RNase decreased autoantibody binding to the U1RNP complex, but increased autoantibody binding to Ro/SSA and La/SSB. Our results suggest that RNase enhances FcγR activation by promoting the formation of ICs containing Ro/SSA or La/SSB. Our study provides insights into the pathophysiology of autoimmune diseases involving anti-Ro/SSA and anti-La/SSB autoantibodies, and into the therapeutic application of RNase treatment for systemic autoimmune diseases.
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Affiliation(s)
- Ryota Naito
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto, Japan
- Laboratory of Immunochemistry, World Premier International (WPI) Immunology Frontier Research Center, and
- Department of Immunochemistry, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Koichiro Ohmura
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto, Japan
- Department of Rheumatology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shuhei Higuchi
- Laboratory of Immunochemistry, World Premier International (WPI) Immunology Frontier Research Center, and
- Department of Immunochemistry, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Wataru Nakai
- Laboratory of Immunochemistry, World Premier International (WPI) Immunology Frontier Research Center, and
- Department of Immunochemistry, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Masako Kohyama
- Laboratory of Immunochemistry, World Premier International (WPI) Immunology Frontier Research Center, and
- Department of Immunochemistry, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
- Center for Infectious Diseases for Education and Research (CiDER), and
| | - Tsuneyo Mimori
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Sakyo-ku, Kyoto, Japan
| | - Hisashi Arase
- Laboratory of Immunochemistry, World Premier International (WPI) Immunology Frontier Research Center, and
- Department of Immunochemistry, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
- Center for Infectious Diseases for Education and Research (CiDER), and
- Center for Advanced Modalities and DDS (CAMaD), Osaka University, Osaka, Japan
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Lazzerini PE, Murthy Ginjupalli VK, Srivastava U, Bertolozzi I, Bacarelli MR, Verrengia D, Salvini V, Accioli R, Carbone SF, Santoro A, Cartocci A, Cevenini G, Cantara S, Cantore A, Bisogno S, Brucato A, Laghi-Pasini F, Acampa M, Capecchi PL, Boutjdir M. Anti-Ro/SSA Antibodies Blocking Calcium Channels as a Potentially Reversible Cause of Atrioventricular Block in Adults. JACC Clin Electrophysiol 2023; 9:1631-1648. [PMID: 37227349 DOI: 10.1016/j.jacep.2023.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND In ∼50% of severe atrioventricular blocks (AVBs) occurring in adults <50 years, the underlying etiology remains unknown. Preliminary evidence from case reports suggests that autoimmunity, specifically the presence of circulating anti-Ro/SSA antibodies in the patient (acquired form), in the patient's mother (late-progressive congenital form), or in both (mixed form), could be involved in a fraction of idiopathic AVBs in adults by possibly targeting the L-type calcium channel (Cav1.2) and inhibiting the related current (ICaL). OBJECTIVES The purpose of this study was to evaluate whether anti-Ro/SSA antibodies are causally implicated in the development of isolated AVBs in adults. METHODS Thirty-four consecutive patients with isolated AVB of unknown origin and 17 available mothers were prospectively enrolled in a cross-sectional study. Anti-Ro/SSA antibodies were assessed by fluoroenzyme-immunoassay, immuno-Western blotting, and line-blot immunoassay. Purified immunoglobulin-G (IgG) from anti-Ro/SSA-positive and anti-Ro/SSA-negative subjects were tested on ICaL and Cav1.2 expression using tSA201 and HEK293 cells, respectively. Moreover, in 13 AVB patients, the impact of a short course of steroid therapy on AV conduction was evaluated. RESULTS Anti-Ro/SSA antibodies, particularly anti-Ro/SSA-52kD, were found in 53% of AVB-patients and/or in their mothers, most commonly an acquired or mixed form (two-thirds of cases) without history of autoimmune diseases. Purified IgG from anti-Ro/SSA-positive but not anti-Ro/SSA-negative AVB patients acutely inhibited ICaL and chronically down-regulated Cav1.2 expression. Moreover, anti-Ro/SSA-positive sera showed high reactivity with peptides corresponding to the Cav1.2 channel pore-forming region. Finally, steroid therapy rapidly improved AV conduction in AVB-patients with circulating anti-Ro/SSA antibodies but not in those without. CONCLUSIONS Our study points to anti-Ro/SSA antibodies as a novel, epidemiologically relevant and potentially reversible cause of isolated AVB in adults, via an autoimmune-mediated functional interference with the L-type calcium channels. These findings have significant impact on antiarrhythmic therapies by avoiding or delaying pacemaker implantation.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy.
| | | | - Ujala Srivastava
- VA New York Harbor Healthcare System, SUNY Downstate Health Science University, New York, New York, USA
| | - Iacopo Bertolozzi
- Cardiology Intensive Therapy Unit, Department of Internal Medicine, Nuovo Ospedale San Giovanni di Dio, Florence, Italy
| | - Maria Romana Bacarelli
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Decoroso Verrengia
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Viola Salvini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Riccardo Accioli
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | | | - Amato Santoro
- Cardio-thoracic Department, University Hospital of Siena, Siena, Italy
| | | | - Gabriele Cevenini
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Silvia Cantara
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy; Laboratory of Clinical and Translational Research, University Hospital of Siena, Siena, Italy
| | - Anna Cantore
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Stefania Bisogno
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | | | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Mohamed Boutjdir
- VA New York Harbor Healthcare System, SUNY Downstate Health Science University, New York, New York, USA; NYU Grossman School of Medicine, New York, New York, USA
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Fierro JJ, Prins JR, Verstappen GM, Bootsma H, Westra J, de Leeuw K. Preconception clinical factors related to adverse pregnancy outcomes in patients with systemic lupus erythematosus or primary Sjögren's syndrome: a retrospective cohort study. RMD Open 2023; 9:e003439. [PMID: 37652559 PMCID: PMC10476138 DOI: 10.1136/rmdopen-2023-003439] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVE To identify preconception clinical factors associated with adverse pregnancy outcomes (APO) in patients with systemic lupus erythematosus (SLE) or primary Sjögren's syndrome (pSS). METHODS A single-centre, retrospective cohort study was conducted, which included pregnant women treated at the University Medical Center Groningen between January 2010 and August 2021 who fulfilled classification criteria for SLE or pSS. Demographic data, relevant comorbidities, disease duration, disease activity before and during pregnancy, APO, laboratory parameters and treatment regimens were recorded. Associations between the presence of APO and preconception characteristics were evaluated. RESULTS Our study population included 48 (70%) SLE and 21 (30%) pSS pregnancies concerning 70 fetuses (one twin). Preterm birth (n=9, 19%) was the most frequent APO in SLE pregnancies, while in pSS pregnancies this was miscarriages (n=3, 14%). There were no associations between the presence of APO in SLE pregnancies and clinical parameters, laboratory parameters or medication use prior to conception. In the pSS group, significant associations were found between the presence of APO and body mass index (p=0.010), parity (p=0.046), C4 (p=0.021) and low C4 levels (p=0.002). CONCLUSIONS No preconception risk factors related to APO were found in SLE pregnancies, whereas preconception complement levels were associated with APO development in patients with pSS.
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Affiliation(s)
- Juan J Fierro
- Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
- Microbiología y Parasitología, Grupo Reproduccion, Universidad de Antioquia UdeA, Medellin, Antioquia, Colombia
| | - Jelmer R Prins
- Obstetrics and Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Gwenny M Verstappen
- Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Hendrika Bootsma
- Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Johanna Westra
- Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
| | - Karina de Leeuw
- Rheumatology and Clinical Immunology, University Medical Center Groningen, Groningen, The Netherlands
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Abstract
Congenital complete heart block (CCHB) defines atrioventricular conduction abnormalities diagnosed in utero or within the first 27 days of life. Maternal autoimmune disease and congenital heart defects are most commonly responsible. Recent genetic discoveries have highlighted our understanding of the underlying mechanism. Hydroxychloroquine shows promise in preventing autoimmune CCHB. Patients may develop symptomatic bradycardia and cardiomyopathy. The presence of these and other specific findings warrants placement of a permanent pacemaker to relieve symptoms and prevent catastrophic events. The mechanisms, natural history, evaluation, and treatment of patients with or at risk for CCHB are reviewed.
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Affiliation(s)
- Leonard Steinberg
- Pediatric Cardiology, Children's Heart Center, Ascension St. Vincent, 8333 Naab Rd, Ste 320, Indianapolis, IN 46260, USA.
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Kumthekar RN, Opfermann JD, Mass P, Contento JM, Berul CI. Percutaneous epicardial pacing in infants using direct visualization: A feasibility animal study. J Cardiovasc Electrophysiol 2023; 34:1452-1458. [PMID: 37172303 DOI: 10.1111/jce.15926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/20/2023] [Accepted: 04/29/2023] [Indexed: 05/14/2023]
Abstract
BACKGROUND Pacemaker implantation in infants and small children is limited to epicardial lead placement via open chest surgery. We propose a minimally invasive solution using a novel percutaneous access kit. OBJECTIVE To evaluate the acute safety and feasibility of a novel percutaneous pericardial access tool kit to implant pacemaker leads on the epicardium under direct visualization. METHODS A custom sheath with optical fiber lining the inside wall was built to provide intrathoracic illumination. A Veress needle inside the illumination sheath was inserted through a skin nick just to the left of the xiphoid process and angled toward the thorax. A needle containing a fiberscope within the lumen was inserted through the sheath and used to access the pericardium under direct visualization. A custom dilator and peel-away sheath with pre-tunneled fiberscope was passed over a guidewire into the pericardial space via modified Seldinger technique. A side-biting multipolar pacemaker lead was inserted through the sheath and affixed against the epicardium. RESULTS Six piglets (weight 3.7-4.0 kg) had successful lead implantation. The pericardial space could be visualized and entered in all animals. Median time from skin nick to sheath access of the pericardium was 9.5 (interquartile range [IQR] 8-11) min. Median total procedure time was 16 (IQR 14-19) min. Median R wave sensing was 5.4 (IQR 4.0-7.3) mV. Median capture threshold was 2.1 (IQR 1.7-2.4) V at 0.4 ms and 1.3 (IQR 1.2-2.0) V at 1.0 ms. There were no complications. CONCLUSION Percutaneous epicardial lead implantation under direct visualization was successful in six piglets of neonatal size and weight with clinically acceptable acute pacing parameters.
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Affiliation(s)
- Rohan N Kumthekar
- Division of Cardiology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Justin D Opfermann
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Paige Mass
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, District of Columbia, USA
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Jacqueline M Contento
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Washington, District of Columbia, USA
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
| | - Charles I Berul
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia, USA
- Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia, USA
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Kotecha MK, Merchant K, Chan CJ, Choo JTL, Gopagondanahalli KR, Zhang DZ, Tan TH, Sundararaghavan S. Endocardial Fibroelastosis as an Independent Predictor of Atrioventricular Valve Rupture in Maternal Autoimmune Antibody Exposed Fetus: A Systematic Review with Clinicopathologic Analysis. Diagnostics (Basel) 2023; 13:diagnostics13081481. [PMID: 37189582 DOI: 10.3390/diagnostics13081481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Neonatal lupus (NL) is a clinical syndrome that develops in the fetus as a result of maternal autoimmune antibodies. Congenital complete heart block (CHB) is the most common manifestation, while extranodal cardiac manifestations of NL, such as endocardial fibroelastosis (EFE) and myocarditis, are rare but more serious. Less is known about this atrioventricular valve rupture due to valvulitis as a consequence of maternal autoantibodies. We have described a case of cardiac neonatal lupus with an antenatally detected CHB patient who developed mitral and tricuspid valve chordal rupture at 45 days of age. We compared the cardiac histopathology and the fetal cardiac echocardiographic findings of this case with another fetus that was aborted after being antenatally diagnosed with CHB but without valvar rupture. A narrative analysis after a systematic review of the literature regarding atrioventricular valve apparatus rupture due to autoimmune etiology along with maternal characteristics, presentation, treatment, and outcome have been discussed in this article. OBJECTIVES To describe published data on atrioventricular valve rupture in neonatal lupus, including clinical presentation, diagnostic evaluation, management, and outcomes. METHODS We conducted a PRISMA-compliant descriptive systematic examination of case reports that included accounts of lupus during pregnancy or in the newborn period that resulted in an atrioventricular valve rupture. We gathered information on the patient's demographics, the details of the valve rupture and other comorbidities, the maternal therapy, the clinical course, and the results. We also used a standardized method to evaluate the cases' quality. A total of 12 cases were investigated, with 11 cases drawn from 10 case reports or case series and 1 from our own experience. RESULTS Tricuspid valve rupture (50%) is more common than mitral valve rupture (17%). Unlike mitral valve rupture, which occurs postnatally, the timing of tricuspid valve rupture is perinatal. A total of 33% of the patients had concomitant complete heart block, while 75% of the patients had endocardial fibroelastosis on an antenatal ultrasound. Antenatal changes pertaining to endocardial fibroelastosis can be seen as early as 19 weeks of gestation. Patients with both valve ruptures generally have a poor prognosis, especially if they occur at close intervals. CONCLUSION Atrioventricular valve rupture in neonatal lupus is rare. A majority of patients with valve rupture had antenatally detected endocardial fibroelastosis in the valvar apparatus. Appropriate and expedited surgical repair of ruptured atrioventricular valves is feasible and has a low mortality risk. Rupture of both atrioventricular valves occurring at close intervals carries a high mortality risk.
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Affiliation(s)
- Monika Kantilal Kotecha
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Khurshid Merchant
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Charmaine Jiahui Chan
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Jonathan Tze Liang Choo
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | | | - Dyan Zhewei Zhang
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Teng Hong Tan
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Sreekanthan Sundararaghavan
- Department of Paediatric Subspecialties, Cardiology Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
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Makadia L, Izmirly P, Buyon JP, Phoon CKL. Autoimmune Congenital Complete Heart Block: How Late Can It Occur? AJP Rep 2023; 13:e29-e34. [PMID: 37168107 PMCID: PMC10166639 DOI: 10.1055/s-0043-1768708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
Objective Maternal anti-Ro (SSA) and/or anti-La (SSB) antibodies are a risk factor for congenital complete heart block (CHB). Because detailed analysis of the incidence of CHB after 24 weeks of gestational age (GA) is lacking, we aimed to ascertain the risk of "later-onset" CHB among offspring of SSA/SSB-positive mothers in the published literature. Study Design Using search terms "neonatal lupus heart block" and "autoimmune congenital heart block" on PubMed and Ovid, we gathered prospective studies of SSA/SSB-positive mothers with fetal echo surveillance starting from before CHB diagnosis and retrospective cases of fetal CHB diagnosis after 24 weeks of GA (if there was prior normal heart rate) or after birth. Results Ten prospective studies included 1,248 SSA/SSB-positive pregnancies with 24 cases of CHB diagnosed during pregnancy (1.9%). Among these, three (12.5%) were after 24 weeks-at weeks 25, 26, and 28. Our retrospective studies revealed 50 patients with CHB diagnosis in late fetal life and neonatal period and 34 in the nonneonatal childhood period. An additional four cases were diagnosed after age 18 years. Conclusion Later-onset autoimmune CHB in offspring of SSA/SSB-positive mothers does occur. Our analysis suggests that prenatal surveillance should continue beyond 24 weeks of GA but is limited by inconsistent published surveillance data.
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Affiliation(s)
- Luv Makadia
- Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine, New York, New York
| | - Peter Izmirly
- Division of Rheumatology, Department of Medicine, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Jill P. Buyon
- Division of Rheumatology, Department of Medicine, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Colin K. L. Phoon
- Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine, New York, New York
- Address for correspondence Colin K. L. Phoon, MPhil, MD Division of Pediatric Cardiology, Department of Pediatrics, Hassenfeld Children's Hospital at NYU Langone and NYU Grossman School of Medicine150-160 East 32nd Street, New York, NY 10016
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Sheng X, Song X, Xiong Y, Ren T, Chang X, Wu J, Cao J, Cheng T, Wang M. Maternal and infant outcomes of pregnancy associated with anti-SSA/RO antibodies: a systematic review and meta-analysis. Pediatr Rheumatol Online J 2023; 21:22. [PMID: 36870970 PMCID: PMC9985242 DOI: 10.1186/s12969-023-00803-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/26/2023] [Indexed: 03/06/2023] Open
Abstract
OBJECTIVE The relationship between anti-SSA/RO antibodies and pregnancy has been reported previously, and we aim to visualize the rates of maternal and infant outcomes with anti-SSA/RO. METHODS We systematically searched records from Pubmed, Cochrane, Embase, and Web of Science databases, pooled incidence rates of adverse outcomes of pregnancy, and 95% confidence intervals (CIs) were performed with RStudio. RESULTS A total of 890 records comprising 1675 patients and 1920 pregnancies were searched from the electronic databases. For maternal outcomes, the pooled estimate rates were 4% for termination of pregnancy, 5% for spontaneous abortion, 26% for preterm labor, and 50% for cesarean operation. While for fetal outcomes, the pooled estimate rates were 4% for perinatal death, 3% for intrauterine growth retardation, 6% for endocardial fibroelastosis, 6% for dilated cardiomyopathy, 7% for congenital heart block, 12% for congenital heart block recurrence, 19% for cutaneous neonatal lupus erythematosus, 12% for hepatobiliary disease and 16% for hematological manifestations. A subgroup analysis of congenital heart block prevalence was performed, diagnostic method and study region were found to affect heterogeneity to some extent. CONCLUSION Cumulative analysis of data from real-world studies confirmed adverse pregnancy outcomes of women with anti-SSA/RO, serves as a reference and a guide for the diagnosis and subsequent treatment of these women, thereby enhancing maternal and infant health. Additional studies with real-world cohorts are required to validate these results.
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Affiliation(s)
- Xiangrui Sheng
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Xiaohui Song
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Yue Xiong
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Tian Ren
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Xin Chang
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Jian Wu
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Jing Cao
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China.
| | - Tao Cheng
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China.
| | - Mingjun Wang
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China.
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Andreoli L, Chighizola CB, Iaccarino L, Botta A, Gerosa M, Ramoni V, Tani C, Bermas B, Brucato A, Buyon J, Cetin I, Chambers CD, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, De Carolis S, Dolhain R, Fazzi EM, Förger F, Giles I, Haase I, Khamashta M, Levy RA, Meroni PL, Mosca M, Nelson-Piercy C, Raio L, Salmon J, Villiger P, Wahren-Herlenius M, Wallenius M, Zanardini C, Shoenfeld Y, Tincani A. Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11 th International Conference on Reproduction, Pregnancy and Rheumatic Diseases. Autoimmun Rev 2023; 22:103259. [PMID: 36549355 DOI: 10.1016/j.autrev.2022.103259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Autoimmune rheumatic diseases (ARD) can affect women and men during fertile age, therefore reproductive health is a priority issue in rheumatology. Many topics need to be considered during preconception counselling: fertility, the impact of disease-related factors on pregnancy outcomes, the influence of pregnancy on disease activity, the compatibility of medications with pregnancy and breastfeeding. Risk stratification and individualized treatment approach elaborated by a multidisciplinary team minimize the risk of adverse pregnancy outcomes (APO). Research has been focused on identifying biomarkers that can be predictive of APO. Specifically, preeclampsia and hypertensive disorders of pregnancy tend to develop more frequently in women with ARD. Placental insufficiency can lead to intrauterine growth restriction and small-for-gestational age newborns. Such APO have been shown to be associated with maternal disease activity in different ARD. Therefore, a key message to be addressed to the woman wishing for a pregnancy and to her family is that treatment with compatible drugs is the best way to ensure maternal and fetal wellbeing. An increasing number of medications have entered the management of ARD, but data about their use in pregnancy and lactation are scarce. More information is needed for most biologic drugs and their biosimilars, and for the so-called small molecules, while there is sufficient evidence to recommend the use of TNF inhibitors if needed for keeping maternal disease under control. Other issues related to the reproductive journey have emerged as "unmet needs", such as sexual dysfunction, contraception, medically assisted reproduction techniques, long-term outcome of children, and they will be addressed in this review paper. Collaborative research has been instrumental to reach current knowledge and the future will bring novel insights thanks to pregnancy registries and prospective studies that have been established in several Countries and to their joint efforts in merging data.
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Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia B Chighizola
- Paediatric Rheumatology Unit, ASST G. Pini & CTO, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Angela Botta
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO, Research Center for Adult and Pediatric Rheumatic Diseases, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Véronique Ramoni
- Medicina Generale Lodi, ASST Lodi-Ospedale Maggiore, Lodi, Italy
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Jill Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Irene Cetin
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy; Department of Woman, Mother and Child, Luigi Sacco and Vittore Buzzi Children Hospitals, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Christina D Chambers
- Department of Pediatrics, University of California, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, La Jolla, CA, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, Cochin Hospital, Referral center for rare autoimmune and systemic diseases, Université de Paris, CRESS, INSERM, INRA, Paris, France
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal M edicine, University of Genoa, IRCSS San Martino Polyclinic, Genoa, Italy
| | - Sara De Carolis
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elisa M Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, Department of rheumatology, University College London Hospital, London, UK
| | - Isabell Haase
- Department for Rheumatology and Hiller Research Institute, Heinrich-Heine-University, Düsseldorf, Germany
| | - Munther Khamashta
- Women & Children's Health, King's College, London, UK; GlaxoSmithKline Global Medical Expert, Dubai, United Arab Emirates
| | - Roger A Levy
- Universidade do Estado de Rio de Janeiro, Rio de Janeiro, Brazil; GlaxoSmithKline Global Medical Expert, Collegeville, PA, USA
| | - Pier Luigi Meroni
- IRCCS Istituto Auxologico Italiano, Immunorheumatology Research Laboratory, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Jane Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA
| | - Peter Villiger
- Rheumatology and Clinical Immunology, Medical Center Monbijou, Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases, St Olavs Hospital, Trondheim, University Hospital and Institute of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cristina Zanardini
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Ariel University, Ariel, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
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Reversal of Fetal Heart Block in Antibody-Positive Mother After Hydroxychloroquine and Dexamethasone. Pediatr Cardiol 2023; 44:727-731. [PMID: 35699754 DOI: 10.1007/s00246-022-02945-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 05/31/2022] [Indexed: 10/18/2022]
Abstract
Maternal autoantibody-related complete heart block in the fetus is considered irreversible. During prenatal care for a 25-year-old nulliparous Hispanic woman with newly diagnosed nephrotic-range proteinuria and positive anti-nuclear antigen antibody, complete fetal heart block with a ventricular rate of 60 beats per minute was detected on a fetal echocardiogram at 28-week gestation. A small pericardial effusion and ascites were noted consistent with fetal hydrops. Dexamethasone and hydroxychloroquine were initiated. Fetal rhythm improved to Mobitz type 1 second-degree heart block, with a ventricular rate of 91 beats per minute. The fetus was born prematurely at 34-week gestation with second-degree heart block which improved to first-degree heart block prior to hospital discharge. First-degree heart block persisted at 2 years of age with a P-R interval of 185 ms. Transplacental treatment with dexamethasone and hydroxychloroquine was associated with sustained reversal of complete heart block to sinus rhythm.
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40
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Zhang L, Huang H, Yang S, Yin H, Chen D, Lu L. An Intravenous Immunoglobulin Scheme Successfully Preventing Recurrent Congenital Heart Block in Fetuses of Anti-SSA/SSB-Positive Mothers. JACC Clin Electrophysiol 2023. [DOI: 10.1016/j.jacep.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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41
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Pu Y, Zhang L. Application of dermatoscopy, reflectance confocal microscopy, and high-frequency ultrasound for diagnosing neonatal lupus erythematosus: A case report. Skin Res Technol 2023; 29:e13291. [PMID: 36823514 PMCID: PMC10155786 DOI: 10.1111/srt.13291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/28/2023] [Indexed: 02/20/2023]
Affiliation(s)
- Yunjing Pu
- Department of Dermatology, Kunming Children's HospitalYunnan Key Laboratory of Children's Major Disease ResearchKunmingChina
| | - Li Zhang
- Department of Dermatology, Kunming Children's HospitalYunnan Key Laboratory of Children's Major Disease ResearchKunmingChina
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Akuka A, Ben-Shabat N, Watad A, Tsur AM, Ehrenberg S, McGonagle D, Comaneshter D, Beinart R, Cohen AD, Amital H. Association of anti-Ro seropositivity with cardiac rhythm and conduction disturbances. Eur Heart J 2022; 43:4912-4919. [PMID: 36148481 DOI: 10.1093/eurheartj/ehac516] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 07/09/2022] [Accepted: 09/07/2022] [Indexed: 01/12/2023] Open
Abstract
AIMS Anti-Ro/La autoantibodies are especially prevalent in autoimmune diseases but are also relatively frequent in healthy adults. Their arrhythmogenic effect on the immature cardiac conductive system is well established, with substantial evidence demonstrating an increased risk for congenital atrioventricular block in neonates of seropositive mothers. Despite their wide distribution and their arrhythmogenic potential effect, there are no large population studies conducted in seropositive adults. Thus, this is the first large population-based study to examine the association of anti-Ro/La seropositivity with cardiac rhythm and conduction disturbances. METHODS AND RESULTS This cross-sectional designed study involved the electronic health records of the largest health maintenance organization in Israel. All subjects that were tested positive for anti-Ro/anti-La antibodies between the years 2002 and 2019 were included and were matched by age, gender, and place of residence, with controls. Rates of different cardiac rhythm and conduction disturbances were compared between groups. Sensitivity analyses were performed using propensity score matching. The study population included 17 231 anti-Ro/La seropositive subjects and 84 368 controls. Anti-Ro seropositive patients had higher rates of conduction disturbances (3.0 vs. 1.7%, P < 0.001) and rhythm disturbances (10.5 vs. 7.0%, P < 0.001). Patients who tested positive for anti-La alone did not demonstrate a significant association with arrhythmias. Multivariate logistic regression analysis, controlling for possible confounders, showed an increased risk for cardiac conduction disturbances [odds ratio (OR) 1.44, 95% confidence interval (CI) 1.25-1.66, P < 0.001], as well as for cardiac rhythm disturbances (OR 1.21, 95% CI 1.11-1.31, P < 0.001) among anti-Ro seropositive patients. However, the association with rhythm disturbances was more robust in certain subgroup analyses. CONCLUSIONS Anti-Ro seropositivity is positively associated with adult cardiac conduction disturbances and, to a lesser extent, cardiac rhythm disturbances, regardless of the presence of concurrent autoimmune disease.
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Affiliation(s)
- Aviram Akuka
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer 5262100, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Ramat-Aviv 69978, Israel
| | - Niv Ben-Shabat
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer 5262100, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Ramat-Aviv 69978, Israel
| | - Abdulla Watad
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer 5262100, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Ramat-Aviv 69978, Israel.,Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds LS2 9JT, UK
| | - Avishai M Tsur
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer 5262100, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Ramat-Aviv 69978, Israel.,Israel Defence Forces, Medical Corps, Tel Hashomer, Ramat Gan 52620, Israel.,Faculty of Medicine, Department of Military Medicine, Hebrew University of Jerusalem, Jerusalem 9190401, Israel
| | - Scott Ehrenberg
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer 5262100, Israel
| | - Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds LS2 9JT, UK
| | - Doron Comaneshter
- Chief Physician's Office, Faculty of Health Sciences, Clalit Health Services Tel Aviv, Ben Gurion University of the Negev, Beer Sheva 8410501, Israel
| | - Roy Beinart
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Ramat-Aviv 69978, Israel.,Heart Institute, Chaim Sheba Medical Center, Tel Hashomer 52620, Israel.,Davidai Arrhythmia Center, Sheba Medical Center, Tel Hashomer 52620, Israel
| | - Arnon D Cohen
- Chief Physician's Office, Faculty of Health Sciences, Clalit Health Services Tel Aviv, Ben Gurion University of the Negev, Beer Sheva 8410501, Israel.,Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva 8410501, Israel
| | - Howard Amital
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer 5262100, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Ramat-Aviv 69978, Israel
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Neonatal lupus erythematosus - prevention is better than cure. Postepy Dermatol Alergol 2022; 39:1021-1026. [PMID: 36686025 PMCID: PMC9837598 DOI: 10.5114/ada.2022.122601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/07/2022] [Indexed: 12/24/2022] Open
Abstract
Neonatal lupus erythematosus (NLE) is a congenital autoimmune condition in which the transplacental passage of immunoglobulin G (IgG) directed against auto-antigens causes clinical symptoms in the foetus or neonate. Anti-Ro/SS-A, anti-La/SS-B, and to a lesser extent, anti-U1RNP autoantibodies (aAbs) have the strongest association with NLE. However, ~ 50% of affected mothers are asymptomatic despite carrying those aAbs. The clinical picture of the disease is very diverse. Cardiac manifestations are the most severe, including congenital heart block (CHB), with a mortality rate of ~18%. Preventative therapy with hydroxychloroquine (HCQ) reduces the recurrence rate of CHB in subsequent pregnancies by ~50%.
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Fernández-Buhigas I. Obstetric management of the most common autoimmune diseases: A narrative review. Front Glob Womens Health 2022; 3:1031190. [PMID: 36505012 PMCID: PMC9728613 DOI: 10.3389/fgwh.2022.1031190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/10/2022] [Indexed: 11/24/2022] Open
Abstract
Historically, women with an autoimmune disease (AD) could not get pregnant due to infertility frequently linked to the medical condition or because the pregnancy was contraindicated, as it could harm the mother and the future child. Sometimes, pregnancy was contraindicated because the medication needed to control the AD could not be given during pregnancy. All these items are no longer true nowadays. Fertility treatments have advanced, obstetric care is better, and the medical treatments of autoimmune diseases have progressed, so women with any kind of AD are encouraged to get pregnant, and their presence in obstetric clinics is arising. This is challenging for the obstetricians, as to be sure that these pregnancies are safe for the mother and the future child, the obstetricians need to know the natural evolution of these conditions, the impact of pregnancy and postpartum on the illness, and the impact of the AD in the pregnancy. In this narrative review, we aim to make a brief resume of the obstetric management of the most common diseases (Systemic lupus erythematosus, antiphospholipid syndrome, the Anti-Ro/SSA and Anti-La/SSB antigen-antibody systems, rheumatoid arthritis, Sjögren's syndrome and Undifferentiated systemic rheumatic disease and overlap syndromes).
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Affiliation(s)
- Irene Fernández-Buhigas
- Obstetrics and Gynecology Department, Hospital Universitario de Torrejón, Madrid, Spain,School of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain,Correspondence: Irene Fernández-Buhigas
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Kaizer AM, Lindblade C, Clancy R, Tebo AE, Drewes B, Masson M, Chang M, Fraser N, Buyon JP, Cuneo BF. Reducing the burden of surveillance in pregnant women with no history of fetal atrioventricular block using the negative predictive value of anti-Ro/SSA antibody titers. Am J Obstet Gynecol 2022; 227:761.e1-761.e10. [PMID: 35690080 PMCID: PMC10871557 DOI: 10.1016/j.ajog.2022.05.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND The risk of fetal atrioventricular block in anti-Ro/SSA antibody-exposed pregnancies with no previous affected offspring is approximately 2%. A high antibody titer is necessary but not sufficient for atrioventricular block, and specific antibody titers do not predict risk. However, there are no data on the negative predictive value of antibody titer to identify pregnancies at low risk of fetal atrioventricular block, and may not require surveillance. OBJECTIVE This study aimed to define anti-Ro52 and anti-Ro60 antibody thresholds for the identification of fetuses unlikely to develop atrioventricular block using clinically validated and research laboratory tests. STUDY DESIGN This study performed a multicenter review of pregnant subjects who tested positive in their local commercial laboratories for anti-Ro/SSA antibodies at the University of Colorado Children's Hospital (2014-2021) and Phoenix Children's Hospital (2014-2021) and enrolled in the Research Registry for Neonatal Lupus (RRNL) at New York University Langone Medical Center (2002-2021). The subjects were referred on the basis of rheumatologic symptoms or history of atrioventricular block in a previous pregnancy and were retrospectively grouped on the basis of pregnancy outcome. Group 1 indicated no fetal atrioventricular block in current or past pregnancies; group 2 indicated fetal atrioventricular block in the current pregnancy; and group 3 indicated normal current pregnancy but with fetal atrioventricular block in a previous pregnancy. Maternal sera were analyzed for anti-Ro52 and anti-Ro60 antibodies using a clinically validated multiplex bead assay (Associated Regional and University Pathologists Laboratories, Salt Lake City, UT) and a research enzyme-linked immunosorbent immunoassay (New York University). This study calculated the negative predictive value separately for anti-Ro52 and anti-Ro60 antibodies and for the 2 combined using a logistic regression model and a parallel testing strategy. RESULTS This study recruited 270 subjects (141 in group 1, 66 in group 2, and 63 in group 3). Of note, 89 subjects in group 1 had data on hydroxychloroquine treatment: anti-Ro/SSA antibody titers were no different between those treated (n=46) and untreated (n=43). Mean anti-Ro52 and anti-Ro60 titers were the lowest in group 1 and not different between groups 2 and 3. No case of fetal atrioventricular block developed among subjects with anti-Ro52 and anti-Ro60 titers of <110 arbitrary units per milliliter using the multiplex bead assay of the Associated Regional and University Pathologists Laboratories (n=141). No case of fetal atrioventricular block developed among subjects with research laboratory anti-Ro52 titers of <650 and anti-Ro60 of <4060 enzyme-linked immunosorbent immunoassay units (n=94). Using these 100% negative predictive value thresholds, more than 50% of the anti-Ro/SSA antibody pregnancies that ultimately had no fetal atrioventricular block could be excluded from surveillance based on clinical and research titers, respectively. CONCLUSION Study data suggested that there is a clinical immunoassay level of maternal anti-Ro/SSA antibodies below which the pregnancy is at low risk of fetal atrioventricular block. This study speculated that prospectively applying these data may avert the costly serial echocardiograms currently recommended for all anti-Ro/SSA-antibody positive pregnancies and guide future management.
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Affiliation(s)
- Alexander M Kaizer
- Department of Biostatistics and Informatics, University of Colorado Boulder, Aurora, CO
| | | | - Robert Clancy
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Anne E Tebo
- Department of Pathology, Associated Regional University Pathologists, Institute for Clinical and Experimental Pathology, University of Utah School of Medicine, Salt Lake City, UT
| | - Bailey Drewes
- Division of Cardiology, Department of Pediatrics and Obstetrics, University of Colorado School of Medicine, Aurora, CO
| | - Mala Masson
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Miao Chang
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Nicola Fraser
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Bettina F Cuneo
- Division of Cardiology, Department of Pediatrics and Obstetrics, University of Colorado School of Medicine, Aurora, CO.
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Mannarino S, Santacesaria S, Raso I, Fini G, Pozzi E, Cocuccio C, Calcaterra V, Zuccotti G. Atrioventricular Block in Celiac Disease: An Unusual Clinical Presentation in a Child. A Case-Based Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1627. [PMID: 36360355 PMCID: PMC9688162 DOI: 10.3390/children9111627] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/10/2022] [Accepted: 10/24/2022] [Indexed: 09/09/2023]
Abstract
Congenital or acquired atrioventricular block (AVB) is a rare disorder in the pediatric population, while celiac disease (CeD) is a common multisystemic autoimmune disorder that is characterized by intestinal manifestations as they are the typical clinical presentation. Sometimes CeD presents more complex multisystemic involvement which includes the heart. Cardiac involvement, such as dilated cardiomyopathy, myocarditis or conduction disease, have been mainly described in untreated adult patients with or without gastro-intestinal symptoms; rare cases of AVB and CeD have been also reported, particularly in association with extra-cardiac manifestations. We describe a case of a progressive acquired AVB block in a 4-year-old child, in which CeD was later diagnosed. A rapid and significantly improvement of the AVB grade has been obtained after the child started a strict gluten-free diet, and so we suggest including diagnostic exams for CeD in all of the children with acquired AVB.
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Affiliation(s)
- Savina Mannarino
- Pediatric Cardiology Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Sara Santacesaria
- Pediatric Cardiology Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Irene Raso
- Pediatric Cardiology Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Giulia Fini
- Pediatric Cardiology Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Elena Pozzi
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Cristina Cocuccio
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
| | - Valeria Calcaterra
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
| | - Gianvincenzo Zuccotti
- Pediatric Department, “Vittore Buzzi” Children’s Hospital, 20154 Milan, Italy
- Department of Biomedical and Clinical Science, University of Milano, 20157 Milano, Italy
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Kayser C, Dutra LA, Dos Reis-Neto ET, Castro CHDM, Fritzler MJ, Andrade LEC. The Role of Autoantibody Testing in Modern Personalized Medicine. Clin Rev Allergy Immunol 2022; 63:251-288. [PMID: 35244870 DOI: 10.1007/s12016-021-08918-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 02/08/2023]
Abstract
Personalized medicine (PM) aims individualized approach to prevention, diagnosis, and treatment. Precision Medicine applies the paradigm of PM by defining groups of individuals with akin characteristics. Often the two terms have been used interchangeably. The quest for PM has been advancing for centuries as traditional nosology classification defines groups of clinical conditions with relatively similar prognoses and treatment options. However, any individual is characterized by a unique set of multiple characteristics and therefore the achievement of PM implies the determination of myriad demographic, epidemiological, clinical, laboratory, and imaging parameters. The accelerated identification of numerous biological variables associated with diverse health conditions contributes to the fulfillment of one of the pre-requisites for PM. The advent of multiplex analytical platforms contributes to the determination of thousands of biological parameters using minute amounts of serum or other biological matrixes. Finally, big data analysis and machine learning contribute to the processing and integration of the multiplexed data at the individual level, allowing for the personalized definition of susceptibility, diagnosis, prognosis, prevention, and treatment. Autoantibodies are traditional biomarkers for autoimmune diseases and can contribute to PM in many aspects, including identification of individuals at risk, early diagnosis, disease sub-phenotyping, definition of prognosis, and treatment, as well as monitoring disease activity. Herein we address how autoantibodies can promote PM in autoimmune diseases using the examples of systemic lupus erythematosus, antiphospholipid syndrome, rheumatoid arthritis, Sjögren syndrome, systemic sclerosis, idiopathic inflammatory myopathies, autoimmune hepatitis, primary biliary cholangitis, and autoimmune neurologic diseases.
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Affiliation(s)
- Cristiane Kayser
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | - Marvin J Fritzler
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Luis Eduardo C Andrade
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil. .,Immunology Division, Fleury Medicine and Health Laboratories, São Paulo, Brazil.
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Short and long-term outcomes of children with autoimmune congenital heart block treated with a combined maternal-neonatal therapy. A comparison study. J Perinatol 2022; 42:1161-1168. [PMID: 35717457 DOI: 10.1038/s41372-022-01431-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/18/2022] [Accepted: 06/08/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The short and long-term outcomes of children with anti-Ro/La-related congenital heart block treated with a combined maternal-neonatal therapy protocol were compared with those of controls treated with other therapies. STUDY DESIGN Sixteen mothers were treated during pregnancy with a therapy consisting of daily oral fluorinated steroids, weekly plasma exchange and fortnightly intravenous immunoglobulins and their neonates with intravenous immunoglobulins (study group); 19 mothers were treated with fluorinated steroids alone or associated to intravenous immunoglobulins or plasma exchange (control group). RESULT The combined-therapy children showed a significantly lower progression rate from 2nd to 3rd degree block at birth, a significant increase in heart rate at birth and a significantly lower number of pacemaker implants during post-natal follow-up with respect to those treated with the other therapies. CONCLUSION The combined therapy produced better short and long term outcomes with respect to the other therapies studied.
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Bhatia S, Aggarwal N, Vaidya A, Puri RD. Fetal Endocardial Valvular and Supravalvular Calcification as a Manifestation of Anti-Ro/SSA-La/SSB Antibody Mediated Cardiac Phenotype. JOURNAL OF FETAL MEDICINE 2022. [DOI: 10.1007/s40556-022-00351-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Favourable outcome of a severe bradyarrhythmia in a neonate: a case report. Cardiol Young 2022; 33:663-665. [PMID: 35938296 DOI: 10.1017/s1047951122002554] [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: 11/06/2022]
Abstract
We report the case of a term neonate with severe fetal bradycardia with an unusually benign clinical course with follow-up till infancy.
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