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Zermano S, Novak A, Vogrig E, Parisi N, Driul L. GALD: new diagnostic tip for early diagnosis - a case report and literature review. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1077304. [PMID: 37251532 PMCID: PMC10213929 DOI: 10.3389/frph.2023.1077304] [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] [Received: 10/22/2022] [Accepted: 04/24/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Gestational alloimmune liver disease is a rare and serious condition caused by a maternal-fetal alloimmune disorder. There are not many studies about the antenatal treatment (IVIG infusion) of affected fetuses as the diagnosis is generally made postnatally. The possibility of an early diagnosis by means of ultrasonography and a gynecologist's assesment can provide prompt treatment of this disease. Case report We report the case of 38-year-old pregnant woman referred to our centre in view of severe fetal hydrops seen by ultrasound at 31 weeks + 1 day gestation. A male infant was born and subsequently died after developing liver failure. Postmortem examination revealed the presence of diffuse hepatic fibrosis in the absence of hemosiderin deposits and no extrahepatic siderosis. Immunohistochemical analysis was also performed which showed diffuse hepatocyte positivity for the terminal complement complex (C5b-C9) confirming the suspicion of GALD. Methods A comprehensive literature search published from 2000 to 2022 was conducted on PubMed and Scopus. Paper selection was performed following the PRISMA guidelines. Fifteen retrospective studies were identified and selected. Results A total of 15 manuscripts describing 26 cases were finally included in our research. Twenty-two fetuses/newborns with suspected GALD were studied, of which 11 had a confirmed histopathological diagnosis of GALD. Prenatal diagnosis of gestational alloimmune liver disease is difficult because ultrasound findings may be absent or nonspecific. Only one case report described fetal hydrops similar to our clinical case. As highlighted by the current case, in fetuses presenting with hydrops, once the most common etiologies have been excluded, hepatobiliary complications and liver failure caused by GALD should be considered. Conclusions Global knowledge of this disorder and its wide spectrum of presentations may help to increase the number of cases that are diagnosed early and accurately. The recurrence rate of an infant being affected with GALD in another pregnancy is more that 90%. Recurrence however can be prevented by treatment with IVIG during pregnancy. This highlights the importance of having obstetricians and pediatricians familiar with gestational alloimmune liver disease.
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Affiliation(s)
- Silvia Zermano
- Department of Medicine, University of Udine, Udine, Italy
| | - Alice Novak
- Department of Medicine, University of Udine, Udine, Italy
| | - Emanuela Vogrig
- Department of Obstetrics, Gynecology and Pediatrics, Department of Medical Area DAME, Obstetrics and Gynecology Unit, Udine University Hospital, Udine, Italy
| | - Nadia Parisi
- Department of Medicine, University of Udine, Udine, Italy
| | - Lorenza Driul
- Department of Medicine, University of Udine, Udine, Italy
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Demetrian M, Botezatu R, Gică N, Safta V, Grecu G, Dima V, Binișor AD, Panaitescu A. Gestational Alloimune Liver Disease-Case Report. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010066. [PMID: 36670617 PMCID: PMC9857314 DOI: 10.3390/children10010066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 12/29/2022]
Abstract
We describe the case of a newborn with the antenatal onset of hepatic failure, which has been investigated for all etiologies that can cause liver damage: infectious, metabolic, genetic, and immune. The lack of a clear answer regarding the etiology and the response to immunoglobulin therapy led us to the diagnosis of gestational alloimmune liver disease. Gestational alloimunne liver disease is an uncommon and very severe cause of neonatal acute liver failure (NALF). Initially, the therapeutic approach aimed at correcting the effects produced by iron loading, respectively, iron chelators and antioxidants. Since all aspects of this case indicated characteristic features typical for GALD, therapy with intravenous immunoglobulins (IVIG) was introduced. If such therapy alters the prognosis of newborns with GALD, the etiology and pathophysiology remain uncertain. However, in cases regarding severe hepatic failure with the perinatal onset and apparently unknown etiology, immunoglobulin or exchange transfusion therapy should be taken into account even before finalizing all the etiological investigations. The prognosis is uncertain and varies between clinical resolution, chronic hepatitis/cirrhosis, and the need for a hepatic transplant, and overall survival depends on prompt therapeutic intervention.
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Affiliation(s)
| | - Radu Botezatu
- The Obstetrics and Gynecology Department, University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania
| | - Nicolae Gică
- The Obstetrics and Gynecology Department, University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania
| | | | - Georgeta Grecu
- Filantropia Clinical Hospital, 011132 Bucharest, Romania
| | - Vlad Dima
- The Obstetrics and Gynecology Department, University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania
- Correspondence:
| | | | - Anca Panaitescu
- The Obstetrics and Gynecology Department, University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania
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Last E, Ketteridge D, Moore D. Expanding the spectrum of gestational alloimmune liver disease. J Paediatr Child Health 2022; 58:1450-1451. [PMID: 34755414 DOI: 10.1111/jpc.15828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Eleanor Last
- Trainee Medical Officer Unit, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - David Ketteridge
- Metabolic Unit, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - David Moore
- Department of Gastroenterology, Women's and Children's Hospital, Adelaide, South Australia, Australia
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Chavhan GB, Kamath BM, Siddiqui I, Tomlinson C. Magnetic resonance imaging of neonatal hemochromatosis. Pediatr Radiol 2022; 52:334-339. [PMID: 33710405 DOI: 10.1007/s00247-021-05008-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/15/2020] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
Neonatal hemochromatosis is a rare condition that causes neonatal liver failure, frequently resulting in fetal loss or neonatal death. It is thought that most cases of neonatal hemochromatosis are caused by gestational alloimmune liver disease (GALD), with neonatal hemochromatosis being a phenotype of GALD rather than a disease process. Extrahepatic siderosis in the pancreas, myocardium, thyroid and minor salivary gland is a characteristic feature of neonatal hemochromatosis. There is also sparing of the reticuloendothelial system with no iron deposition in the spleen. Hepatic and extrahepatic siderosis seen in neonatal hemochromatosis is from iron dysregulation secondary to liver damage rather than iron deposition causing the liver damage. The presence of extrahepatic siderosis in the pancreas and thyroid is diagnostic of neonatal hemochromatosis and can be detected noninvasively by multi-echo gradient recalled echo (GRE) T2*-weighted sequence of MRI within hours of birth. This helps to expedite the treatment in the form of intravenous immunoglobulin and exchange transfusion, which improves the survival in these babies. The finding of hepatic siderosis is nonspecific and does not help in the diagnosis of neonatal hemochromatosis because it is seen with other causes of advanced liver disease.
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Affiliation(s)
- Govind B Chavhan
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada. .,Medical Imaging Department, University of Toronto, Toronto, ON, Canada.
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Iram Siddiqui
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christopher Tomlinson
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
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5
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Yeh PJ, Huang SF, Chiang MC, Wang CJ, Lai MW. Efficacy of Intravenous Immunoglobulin/Exchange Transfusion Therapy on Gestational Alloimmune Liver Disease. Front Pediatr 2021; 9:680730. [PMID: 34235125 PMCID: PMC8255369 DOI: 10.3389/fped.2021.680730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Gestational alloimmune liver disease (GALD) is a rare but critical cause of neonatal liver failure. After discovering the maternal-fetal alloimmune mechanism, intravenous immunoglobulin (IVIG) with or without exchange transfusion (ET) has gradually replaced antioxidant cocktails as the first-line therapy. Whether such therapy changes the outcome of neonates with GALD is yet to be defined. Method: We reported a pair of twins with discordant presentations, mild and self-limited in the older, whereas liver failure in the younger, who was successfully rescued by ET and IVIG. To investigate the outcome after therapeutic alteration, 39 cases between 2005 and 2020 from literature research were collected. Results: Half of the collected cases (47.1%) were preterm. Common presentations were ascites, jaundice, respiratory distress, hepatomegaly, and edema. Leading laboratory abnormalities were coagulopathy, hypoalbuminemia, and elevated serum ferritin. Salivary gland biopsy and magnetic resonance imaging detected extrahepatic siderosis in 70% (14/20) and 56% (14/25), respectively. IVIG, ET, and liver transplantation were performed in 19 (48.7%), 15 (38.5%), and 8 (20.5%) patients, respectively. The overall survival (OS) rate and native liver survival (NLS) rate were 64.1% (25/39) and 43.6% (17/39), respectively. Although the compiled results did not support a significant benefit, the OS and NLS were higher in the IVIG with/without ET group compared with those treated with conventional therapy [OS (70 vs. 57.9%) and NLS (55 vs. 31.6%), respectively]. Conclusion: A high index of suspicion for GALD is crucial when facing a neonate with liver failure. Despite no significant influence on the outcome over conventional therapy in such a rare and detrimental disease, IVIG with or without ET can be worth trying before resorting to liver transplantation, which is resource-demanding and technique-challenging in small infants.
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Affiliation(s)
- Pai-Jui Yeh
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shiu-Feng Huang
- Department of Pathology, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan.,Institute of Molecular and Genomic Medicine, National Health Research Institutes, Zhunan, Taiwan
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chao-Jan Wang
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Wei Lai
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan.,Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
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Fischer HS, Staufner C, Sallmon H, Henning S, Bührer C. Early Exchange Transfusion to Treat Neonates With Gestational Alloimmune Liver Disease: An 11-Year Cohort Study. J Pediatr Gastroenterol Nutr 2020; 70:444-449. [PMID: 31880662 DOI: 10.1097/mpg.0000000000002593] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Exchange transfusion (ET) and intravenous immunoglobulin are potentially life-saving treatment options in newborns with gestational alloimmune liver disease (GALD). Since 2008, early ET has been the standard of care for symptomatic neonates with suspected GALD in our unit. The present study's aim was to investigate the outcomes of this approach. METHODS From 2008 to 2018, all neonates who received ET for suspected GALD were identified, and their clinical course and outcomes were analyzed in a descriptive cohort study. In survivors, liver function parameters before ET and maximum values after ET and at discharge were compared. RESULTS During the 11-year period, 12 infants received ET for suspected GALD at a median (range) chronological age of 11 (1-23) days and gestational age of 38 (32-40) weeks. Signs of impaired liver function, most frequently postnatal hypoglycemia, hyperferritinemia, direct hyperbilirubinemia, and coagulopathy, were present in all infants. Survival without a liver transplant in the overall cohort was 10 of 12 (83.3%) and 7 of 9 (78%) in those fulfilling the criteria of acute liver failure. Two patients died, one of them after liver transplantation. Direct bilirubin typically increased after ET, even in survivors. All survivors recovered and were discharged from the pediatric hepatology outpatient clinic after 8 (3-11) months of follow-up. CONCLUSIONS In newborns with suspected GALD, a limited diagnostic work-up followed by early ET may lead to favorable outcomes. More data are required to develop an evidence-based clinical approach to GALD.
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Affiliation(s)
- Hendrik S Fischer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin
| | - Christian Staufner
- Department of General Pediatrics, Division of Neuropaediatrics and Metabolic Medicine, Universitätsklinikum Heidelberg, Heidelberg
| | - Hannes Sallmon
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin.,Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin
| | - Stephan Henning
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin
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Kumagai T, Terashima H, Uchida H, Fukuda A, Kasahara M, Kosuga M, Okuyama T, Tsunoda T, Inui A, Fujisawa T, Narita A, Eto Y, Kubota M. A case of Niemann-Pick disease type C with neonatal liver failure initially diagnosed as neonatal hemochromatosis. Brain Dev 2019; 41:460-464. [PMID: 30737051 DOI: 10.1016/j.braindev.2019.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/17/2018] [Accepted: 01/15/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Niemann-Pick type C (NPC) is a lysosomal lipid storage disease with mutation of NPC1/NPC2 genes, which transport lipids in the endosome and lysosome, and various neurological symptoms. NPC patients also develop hepatosplenomegaly or liver disorder in the neonatal period, and 10% suffer severe liver failure. Neonatal hemochromatosis (NH) is a liver disorder characterized by hepatic and extrahepatic siderosis. Although the etiology of NH is unclear, recent reports suggest that the gestational alloimmune mechanism is the cause of NH. Herein, we report a Japanese NPC patient initially diagnosed as NH. CASE REPORT A 5-day-old boy was transferred to our hospital with severe cholestatic liver failure. Congenital infections and metabolic screening were negative, and NH was suspected. However intra and extrahepatic siderosis were not found. As his liver deteriorated rapidly, liver transplantation was performed at 19 days old. The explanted liver showed cirrhosis, and strong C5b-9 complex staining of hepatocytes, so NH was diagnosed. From the age of one and a half years, he developed regression, vertical supranuclear gaze palsy and cataplexy. Fibroblast filipin staining was strong, blood oxysterol was high, and there were compound heterozygous mutations in NPC1,p.[(F288L)];[(K1206N)]. The patient was then diagnosed as NPC and started on miglustat. CONCLUSION Neonatal liver failure was initially diagnosed as NH. Later, the patient developed various neurological symptoms characteristic of NPC. Neurological follow-up of children who develop NH is required.
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Affiliation(s)
- Tadayuki Kumagai
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan; Department of Clinical Laboratory Medicine, National Center for Child Health and Development, Tokyo, Japan.
| | - Hiroshi Terashima
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Motomichi Kosuga
- Department of Clinical Laboratory Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Torayuki Okuyama
- Department of Clinical Laboratory Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Tomoyuki Tsunoda
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Tomoo Fujisawa
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Aya Narita
- Division of Child Neurology, Institute of Neurological Science, Tottori University, Faculty of Medicine, Yonago, Japan
| | - Yoshikatsu Eto
- Advanced Clinical Research Center, Southern TOHOKU Research Institute for Neuroscience, Fukushima, Japan
| | - Masaya Kubota
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
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Kasko O, Klose E, Rama G, Newberry D, Jnah A. Gestational Alloimmune Liver Disease: A Case Study. Neonatal Netw 2019; 37:271-280. [PMID: 30567809 DOI: 10.1891/0730-0832.37.5.271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Gestational alloimmune liver disease (GALD) is initiated by maternal antibodies that attack fetal hepatocytes. The fetal immune response to the antibodies causes liver damage. The incidence of GALD is four per 100,000 live births in the United States. Frequently, liver injury leads to fetal loss or neonatal demise; nonetheless, the presentation of GALD has a wide range of severity. Survival rates have increased from 20 to 80 percent changes in treatment and understanding of GALD. Current treatment is focused on supportive care with intravenous immunoglobulin (IVIG) and exchange transfusions. Mortality risk is positively associated with the timing of diagnosis. Although there has been an increase in understanding this disease, the discovery of the specific alloantigen is still needed. Relevant embryology, pathophysiology, clinical manifestations, diagnosis, medical treatment, and prognosis are discussed to aid health care professionals in the early identification and treatment for the neonate and family unit.
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Abstract
BACKGROUND There are limited data on utility of magnetic resonance imaging (MRI) in the assessment of suspected neonatal hemochromatosis (NH). OBJECTIVES The aim of the study was to present our experience with utilization of multi-echo sequence MRI technique in the evaluation of NH and to compare MRI findings in infants with and without NH. METHODS MRI performed for suspected NH were retrospectively reviewed to note the presence and severity of iron deposition (ID) in liver, spleen, pancreas, and kidneys on multi-echo sequences. Findings were compared in infants with and without NH. RESULTS Of 20 infants (9 boys and 11 girls; median age of 12.5 days) included in the study, 7 of 20 had NH and 13 of 20 were assigned to the non-NH group. Higher degree of pancreatic ID was seen in the NH group (P = 0.001) with 4 of 7 evaluable pancreas showing moderate-to-severe degree and 1 of 7 showing mild degree of ID whereas none of the 13 infants in non-NH group showed moderate or severe degree of pancreatic ID. Even though the severity of hepatic ID was higher in NH group (P = 0.033), variable severity of hepatic ID was seen in both groups with most infants in both groups showing moderate-to-severe degree of ID. The severity of splenic ID was not particularly associated with any group (P = 0.774) but there was no moderate or severe degree of ID in NH. Renal ID was seen in two infants in non-NH group. CONCLUSIONS A moderate-to-severe degree of pancreatic ID seen on MRI tends to be associated with NH and should be sought to establish a timely diagnosis of NH. Presence and severity of hepatic ID cannot be used for differentiation of NH from other causes of neonatal liver failure.
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Dubruc E, Nadaud B, Ruchelli E, Heissat S, Baruteau J, Broué P, Debray D, Cordier MP, Miossec P, Russo P, Collardeau-Frachon S. Relevance of C5b9 immunostaining in the diagnosis of neonatal hemochromatosis. Pediatr Res 2017; 81:712-721. [PMID: 28085791 DOI: 10.1038/pr.2017.8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 12/04/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Neonatal hemochromatosis caused by a gestational alloimmune mechanism or gestational alloimmune liver disease (GALD) is a rare perinatal disorder characterized by intra- and extrahepatic iron overload. It is believed to result from complement-mediated liver injury, in which the classical complement pathway is activated by maternal antibody/fetal antigen complexes, leading to hepatocyte lysis by the membrane attack complex C5b9. According to some authors, C5b9 expression in more than 75% of liver parenchyma is specific for GALD. METHODS We conducted a retrospective multicentric immunohistochemical study with anti-C5b9 in GALD cases (n = 25) and non-GALD cases with iron overload (n = 36) and without iron overload (n = 18). RESULTS C5b9 was expressed in 100% of GALD cases but involved more than 75% of the liver parenchyma in only 26% of the cases. C5b9 was detected in 26.75% of the non-GALD cases with more than 75% of positive parenchyma in maternal erythrocytic alloimmunization, herpes and enterovirus hepatitis, bile acid synthetic defect, DGUOK mutation, Gaucher disease, cystic fibrosis, and giant-cell hepatitis with autoimmune hemolytic anemia. CONCLUSION Diagnosis and therapeutic management of GALD cannot only be based on C5b9 expression in liver samples as it is not specific of this disease.
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Affiliation(s)
- Estelle Dubruc
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Béatrice Nadaud
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Eduardo Ruchelli
- Department of pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sophie Heissat
- Department of pediatrics, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Julien Baruteau
- Pediatric Hepatology and Inborn Metabolic Diseases Unit, University Children's Hospital, Toulouse, France
| | - Pierre Broué
- Pediatric Hepatology and Inborn Metabolic Diseases Unit, University Children's Hospital, Toulouse, France
| | - Dominique Debray
- Department of Pediatric Surgery, Hepatology, and Transplantation, Necker Enfants Malades Hospital, Paris, France
| | | | - Pierre Miossec
- Department of immunology, Hôpital Edouard Herriot, CHU de Lyon, France.,Université Claude Bernard Lyon 1, France
| | - Pierre Russo
- Department of pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sophie Collardeau-Frachon
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France.,Université Claude Bernard Lyon 1, France.,SOFFOET, Société Française de Foetopathologie, Paris, France
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