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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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2
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Zhang S, Han X, Liu W, Wen Q, Wang J. Pregnancy in patients with systemic lupus erythematosus: a systematic review. Arch Gynecol Obstet 2022; 308:63-71. [PMID: 35913558 DOI: 10.1007/s00404-022-06718-7] [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: 06/26/2022] [Accepted: 07/18/2022] [Indexed: 11/28/2022]
Abstract
Systemic lupus erythematosus (SLE)-a most common disorder in women of reproductive age-has been described to be associated with adverse pregnancy outcomes. Despite the increased health risks for the mother (preeclampsia, lupus flare, arterial hypertension, gestational diabetes mellitus and thrombotic risk when antiphospholipid antibodies are present) and fetus (miscarriage, stillbirth, premature birth, intrauterine growth restriction and neonatal lupus), the majority of patients can deliver healthy neonates. With appropriate management by a multidisciplinary team, composing rheumatologists, obstetricians and neonatologists, women with SLE can achieve better pregnancy outcomes by monitoring associated predictive indicators, raising major concern for severe complications and somewhat early delivery if necessary. In this review, we summarize the latest advances in secondary infertility and pregnancy-related risk perception for lupus patients, with an emphasis on the safety of biological agents (mainly belimumab and rituximab) and traditional therapeutic regimens.
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Affiliation(s)
- Shumin Zhang
- Department of Rheumatiod and Immunology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China
| | - Xiao Han
- Department of Rheumatiod and Immunology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China
| | - Wenping Liu
- Department of Rheumatiod and Immunology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China
| | - Qiong Wen
- Department of Rheumatiod and Immunology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China
| | - Jibo Wang
- Department of Rheumatiod and Immunology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, China.
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3
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Carvalho JF, Viana VS, Leon EP, Bonfa E, Pasoto SG, Martins VR. RETRACTED: Antibodies to cellular prion protein and its cognate ligand stress-inducible protein 1 in systemic lupus erythematosus. Lupus 2020; 29:NP1-NP7. [PMID: 32588733 DOI: 10.1177/0961203320935987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jozélio F Carvalho
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vilma St Viana
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Elaine P Leon
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eloisa Bonfa
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Sandra G Pasoto
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vilma R Martins
- Ludwig Institute for Cancer Research, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
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4
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De Carolis S, Garufi C, Garufi E, De Carolis MP, Botta A, Tabacco S, Salvi S. Autoimmune Congenital Heart Block: A Review of Biomarkers and Management of Pregnancy. Front Pediatr 2020; 8:607515. [PMID: 33415090 PMCID: PMC7784711 DOI: 10.3389/fped.2020.607515] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/30/2020] [Indexed: 11/13/2022] Open
Abstract
Autoimmune Congenital Heart Block (CHB) is an immune-mediated disease due to transplacental passage of circulating anti-Ro/SSA and anti-La/SSB autoantibodies. It occurs in 2% of anti-Ro/SSA-exposed pregnancies, and recurrence rate is nine times higher in subsequent pregnancies. Aim of this review is to identify biomarkers of CHB and treatment strategies. The Ro-system is constituted by two polypeptides targeted by the anti-Ro52 and anti-Ro60 autoantibodies. The central portion of Ro52 (p200), more than the full amino-acid sequence of Ro-52, is recognized to be the fine specificity of anti-Ro associated to the highest risk of cardiac damage. If anti-p200 antibody should be tested, as biomarker of CHB, over standard commercial ELISAs is still debated. Recent studies indicate that type I-Interferon (IFN) can activate fibroblasts in fetal heart. In the mother the anti-Ro/La antibodies activate the type I IFN-signature, and maternal IFN-regulated genes correlate with a similar neonatal IFN-gene expression. Evaluation of maternal IFN-signature could be used as novel biomarker of CHB. The measurement of "mechanical" PR interval with weekly fetal echocardiogram (ECHO) from 16 to at least 24 weeks of gestation is strongly recommended for CHB prenatal diagnosis. However, ECHO screening presents some limitations due to difficult identification of first-degree block and possible occurrence of a complete block from a normal rhythm in few days. Maternal administration of Hydroxychloroquine from the tenth week of gestation, modulating toll-like receptor and autoantibody-dependent type I IFN activation on the fetus, has an important role in preventing CHB in pregnant women with high risk for recurrent CHB.
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Affiliation(s)
- Sara De Carolis
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
| | - Cristina Garufi
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, UOC Reumatologia, Sapienza University of Rome, Rome, Italy
| | - Ester Garufi
- Medical School, University of Florence, Florence, Italy
| | - Maria Pia De Carolis
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
| | - Angela Botta
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
| | - Sara Tabacco
- Department of Gynecological Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Salvi
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Department of Obstetrics, Gynaecology and Pediatrics, Rome, Italy
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5
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Clancy RM, Halushka M, Rasmussen SE, Lhakhang T, Chang M, Buyon JP. Siglec-1 Macrophages and the Contribution of IFN to the Development of Autoimmune Congenital Heart Block. THE JOURNAL OF IMMUNOLOGY 2018; 202:48-55. [PMID: 30518570 DOI: 10.4049/jimmunol.1800357] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 10/08/2018] [Indexed: 11/19/2022]
Abstract
Given that diseases associated with anti-SSA/Ro autoantibodies, such as systemic lupus erythematosus and Sjögren syndrome, are linked with an upregulation of IFN and type I IFN-stimulated genes, including sialic acid-binding Ig-like lectin 1 (Siglec-1), a receptor on monocytes/macrophages, recent attention has focused on a potential role for IFN and IFN-stimulated genes in the pathogenesis of congenital heart block (CHB). Accordingly, three approaches were leveraged to address the association of IFN, IFN-stimulated genes, and the phenotype of macrophages in affected fetal cardiac tissue: 1) cultured healthy human macrophages transfected with hY3, an anti-SSA/Ro-associated ssRNA, 2) RNA isolated from freshly sorted human leukocytes/macrophages after Langendorff perfusion of three fetal hearts dying with CHB and three healthy gestational age-matched hearts, and 3) autopsy tissue from three additional human CHB hearts and one healthy heart. TLR ligation of macrophages with hY3 led to the upregulation of a panel of IFN transcripts, including SIGLEC1, a result corroborated using quantitative PCR. Using independent and agnostic bioinformatics approaches, CD45+CD11c+ and CD45+CD11c- human leukocytes flow sorted from the CHB hearts highly expressed type I IFN response genes inclusive of SIGLEC1. Furthermore, Siglec-1 expression was identified in the septal region of several affected fetal hearts. These data now provide a link between IFN, IFN-stimulated genes, and the inflammatory and possibly fibrosing components of CHB, positioning Siglec-1-positive macrophages as integral to the process.
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Affiliation(s)
- Robert M Clancy
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY 10016;
| | - Marc Halushka
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21205; and
| | - Sara E Rasmussen
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY 10016
| | - Tenzin Lhakhang
- Applied Bioinformatics Laboratories, New York University School of Medicine, New York, NY 10016
| | - Miao Chang
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY 10016
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY 10016
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6
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Nahal SK, Selmi C, Gershwin ME. Safety issues and recommendations for successful pregnancy outcome in systemic lupus erythematosus. J Autoimmun 2018; 93:16-23. [PMID: 30056945 DOI: 10.1016/j.jaut.2018.07.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 07/19/2018] [Accepted: 07/19/2018] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) primarily affects women of childbearing age. One of the major changes in SLE focuses on the timing of a successful pregnancy. In the past, pregnancy was strongly discouraged in SLE, especially in the presence of risk factors such as nephritis, use of immunosuppressive therapies, or positivity of specific autoantibodies such as anti-phospholipids and anti-Ro/SSA, La/SSBA. Thanks to our better knowledge on the disease and management, pregnancy success rates in SLE patients have significantly improved care by the a multidisciplinary team which fosters a successful pregnancy with minimal complications for the mother and fetus when the disease is inactive or in remission. This approach is based on a counseling phase before pregnancy, to assess SLE activity phase, specific medications, risk factors, and continues through pregnancy and lactation with significantly improved pregnancy outcomes. Further, we can now better define the risk of disease flares during pregnancy based on a better understanding of the changes in maternal immunity and its relationship with SLE-associated autoimmunity and chronic inflammation. There is wide consensus that women with SLE can have successful pregnancies as long as conception is planned in a phase of inactive disease, and when the patient is closely managed by a rheumatologist, high-risk OB/GYN, neonatologist, and other medical specialists as indicated. Preconception counseling is essential to assess the risk of both fetal and maternal complications as well as identify life-threatening contraindications. Particular attention should be used in those SLE cases that have nephritis, APS or positivity for aPL, pulmonary hypertension, and positive anti-Ro/SSA or anti-La/SSB antibodies. In conclusion, the use of specific guidelines on the management of SLE before and during pregnancy and lactation, and a better understanding of the use of immunosuppressive therapies have significantly increased pregnancy success.
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Affiliation(s)
- Simran Kaur Nahal
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, CA, USA
| | - Carlo Selmi
- Division of Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Science and Translational Medicine, University of Milan, Italy.
| | - M Eric Gershwin
- Division of Rheumatology, Allergy, and Clinical Immunology, University of California, Davis, CA, USA.
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7
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Abstract
Fetal cardiac abnormalities are some of the commonest congenital disorders seen in prenatal life. They can be anatomical or functional and can develop de novo or as a consequence of either maternal or fetal disease. Untreated, morbidity and mortality rates are high for hypoplastic left heart disorders and for some fetal tachy and bradyarrhythmias. Optimum management strategies are often not clear because of the lack of knowledge about the precise natural history of some of these conditions. Prenatal therapy ranges from invasive fetal cardiac intervention to maternal administration of drugs for transplacental transfer to the fetus. This comprehensive review covers many fetal cardiac disorders and various prenatal therapeutic options that are available.
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Affiliation(s)
- Sailesh Kumar
- a Mater Research Institute / University of Queensland , Brisbane , Australia.,b Mater Centre for Maternal Fetal Medicine , Mater Mothers' Hospital , Brisbane , Australia.,c Faculty of Medicine , the University of Queensland , Brisbane , Australia
| | - Jade Lodge
- b Mater Centre for Maternal Fetal Medicine , Mater Mothers' Hospital , Brisbane , Australia
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8
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Clancy RM, Markham AJ, Jackson T, Rasmussen SE, Blumenberg M, Buyon JP. Cardiac fibroblast transcriptome analyses support a role for interferogenic, profibrotic, and inflammatory genes in anti-SSA/Ro-associated congenital heart block. Am J Physiol Heart Circ Physiol 2017. [PMID: 28626076 DOI: 10.1152/ajpheart.00256.2017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The signature lesion of SSA/Ro autoantibody-associated congenital heart block (CHB) is fibrosis and a macrophage infiltrate, supporting an experimental focus on cues influencing the fibroblast component. The transcriptomes of human fetal cardiac fibroblasts were analyzed using two complementary approaches. Cardiac injury conditions were simulated in vitro by incubating human fetal cardiac fibroblasts with supernatants from macrophages transfected with the SSA/Ro-associated noncoding Y ssRNA. The top 10 upregulated transcripts in the stimulated fibroblasts reflected a type I interferon (IFN) response [e.g., IFN-induced protein 44-like (IFI44L), of MX dynamin-like GTPase (MX)1, MX2, and radical S-adenosyl methionine domain containing 2 (Rsad2)]. Within the fibrotic pathway, transcript levels of endothelin-1 (EDN1), phosphodiesterase (PDE)4D, chemokine (C-X-C motif) ligand (CXCL)2, and CXCL3 were upregulated, while others, including adenomedullin, RAP guanine nucleotide exchange factor 3 (RAPGEF3), tissue inhibitor of metalloproteinase (TIMP)1, TIMP3, and dual specificity phosphatase 1, were downregulated. Agnostic Database for Annotation, Visualization and Integrated Discovery analysis revealed a significant increase in inflammatory genes, including complement C3A receptor 1 (C3AR1), F2R-like thrombin/trypsin receptor 3, and neutrophil cytosolic factor 2. In addition, stimulated fibroblasts expressed high levels of phospho-MADS box transcription enhancer factor 2 [a substrate of MAPK5 (ERK5)], which was inhibited by BIX-02189, a specific inhibitor of ERK5. Translation to human disease leveraged an unprecedented opportunity to interrogate the transcriptome of fibroblasts freshly isolated and cell sorted without stimulation from a fetal heart with CHB and a matched healthy heart. Consistent with the in vitro data, five IFN response genes were among the top 10 most highly expressed transcripts in CHB fibroblasts. In addition, the expression of matrix-related genes reflected fibrosis. These data support the novel finding that cardiac injury in CHB may occur secondary to abnormal remodeling due in part to upregulation of type 1 IFN response genes.NEW & NOTEWORTHY Congenital heart block is a rare disease of the fetal heart associated with maternal anti-Ro autoantibodies which can result in death and for survivors, lifelong pacing. This study provides in vivo and in vitro transcriptome-support that injury may be mediated by an effect of Type I Interferon on fetal fibroblasts.
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Affiliation(s)
- Robert M Clancy
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Androo J Markham
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Tanisha Jackson
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Sara E Rasmussen
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Miroslav Blumenberg
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, New York
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9
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Lazzaroni MG, Dall’Ara F, Fredi M, Nalli C, Reggia R, Lojacono A, Ramazzotto F, Zatti S, Andreoli L, Tincani A. A comprehensive review of the clinical approach to pregnancy and systemic lupus erythematosus. J Autoimmun 2016; 74:106-117. [DOI: 10.1016/j.jaut.2016.06.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 01/23/2023]
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10
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Tufan AN, Sag S, Oksuz MF, Ermurat S, Coskun BN, Gullulu M, Budak F, Baran I, Pehlivan Y, Dalkilic E. Prolonged Tpeak-Tend interval in anti-Ro52 antibody-positive connective tissue diseases. Rheumatol Int 2016; 37:67-73. [PMID: 27193468 DOI: 10.1007/s00296-016-3488-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 05/03/2016] [Indexed: 11/25/2022]
Abstract
Patients with connective tissue diseases (CTDs) may have prolonged corrected QT interval which indicates increased risk for ventricular arrhythmias. However, a more sensitive measure of ventricular repolarization, T-peak-to-end (Tpe) interval, has not been studied in CTDs. We aimed to investigate the relationship between ventricular repolarization abnormalities and anti-Ro52-positivity in subjects with connective tissue diseases (CTDs). We enrolled patients with anti-Ro52-positive CTDs, ANA-positive CTDs, and healthy subjects in this cross-sectional study. We excluded conditions potentially affecting the QT interval. We compared the ECG measures between the groups and performed analyses to define factors associated with ventricular repolarization measures. 15 ANA and anti-Ro52-positive, 39 ANA-positive and anti-Ro52-negative, and 22 healthy subjects were enrolled. None of the subjects had rhythm or conduction disturbances. Corrected QT intervals were similar between the groups. Tpe (84, 77.3, and 69.4 msn, respectively) and QT-dispersion (40, 27.2, and 20.1 msn, respectively) were higher in anti-Ro52-positive subjects compared with the ANA-positive and healthy subjects. Anti-Ro52 titers were correlated with Tpe and QT-dispersion (r = 0.52 and p < 0.001 for each). ANA and anti-Ro52-positivity were independently associated with higher Tpe (OR = 7.7, p = 0.001 and OR = 6.9, p = 0.001, respectively), corrected Tpe (OR = 11.3, p = 0.001 and OR = 8.4, p = 0.003, respectively), QT dispersion (OR = 7, p = 0.008 and OR = 13, p < 0.001, respectively), and QTc dispersion (OR = 9.1, p = 0.001 and OR = 14.1, p < 0.001, respectively). This study provides evidence that ANA positivity, especially when concomitant anti-Ro52-positivity is present, significantly deteriorates ventricular repolarization. The aforementioned ventricular repolarization abnormalities may render these subjects susceptible to serious rhythm or conduction disorders in the setting of predisposing conditions.
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Affiliation(s)
- Ayse Nur Tufan
- Department of Rheumatology, Uludag University School of Medicine, Gorukle, Bursa, Turkey.
| | - Saim Sag
- Department of Cardiology, Uludag University School of Medicine, Gorukle, Bursa, Turkey.
| | - Mustafa Ferhat Oksuz
- Department of Rheumatology, Uludag University School of Medicine, Gorukle, Bursa, Turkey
| | - Selime Ermurat
- Department of Rheumatology, Uludag University School of Medicine, Gorukle, Bursa, Turkey
| | - Belkis Nihan Coskun
- Department of Rheumatology, Uludag University School of Medicine, Gorukle, Bursa, Turkey
| | - Mustafa Gullulu
- Department of Nephrology, Uludag University School of Medicine, Gorukle, Bursa, Turkey
| | - Ferah Budak
- Department of Immunology, Uludag University School of Medicine, Gorukle, Bursa, Turkey
| | - Ibrahim Baran
- Department of Cardiology, Uludag University School of Medicine, Gorukle, Bursa, Turkey
| | - Yavuz Pehlivan
- Department of Rheumatology, Uludag University School of Medicine, Gorukle, Bursa, Turkey
| | - Ediz Dalkilic
- Department of Rheumatology, Uludag University School of Medicine, Gorukle, Bursa, Turkey
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11
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Yue Y, Castrichini M, Srivastava U, Fabris F, Shah K, Li Z, Qu Y, El-Sherif N, Zhou Z, January C, Hussain MM, Jiang XC, Sobie EA, Wahren-Herlenius M, Chahine M, Capecchi PL, Laghi-Pasini F, Lazzerini PE, Boutjdir M. Pathogenesis of the Novel Autoimmune-Associated Long-QT Syndrome. Circulation 2015; 132:230-40. [DOI: 10.1161/circulationaha.115.009800] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 05/15/2015] [Indexed: 12/30/2022]
Affiliation(s)
- Yuankun Yue
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Monica Castrichini
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Ujala Srivastava
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Frank Fabris
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Krupa Shah
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Zhiqiang Li
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Yongxia Qu
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Nabil El-Sherif
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Zhengfeng Zhou
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Craig January
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - M. Mahmood Hussain
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Xian-Cheng Jiang
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Eric A. Sobie
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Marie Wahren-Herlenius
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Mohamed Chahine
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Pier-Leopoldo Capecchi
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Franco Laghi-Pasini
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Pietro-Enea Lazzerini
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
| | - Mohamed Boutjdir
- From Cardiovascular Research Program, VA New York Harbor Healthcare System, Brooklyn (Y.Y., U.S., F.F., K.S., Z.L., Y.Q., N.E.-S., M.M.H., X.-C.J., M.B.); Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Italy (M.C., P.-L.C., F.L.-P., P.-E.L.); Departments of Medicine, Cell Biology and Pharmacology, State University of New York Downstate Medical Center, Brooklyn (U.S., F.F., Z.L., Y.Q., M.M.H., X.-C.J., M.B.); Knight Cardiovascular Institute, Oregon Health &
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Ultrasound findings in fetal congenital heart block associated with maternal anti-Ro/SSA and Anti-La/SSB antibodies. Ultrasound Q 2015; 31:34-6. [PMID: 25706362 DOI: 10.1097/ruq.0000000000000112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present the sonographic features of a second-trimester fetus diagnosed with a bradyarrhythmia at 19 weeks' gestation. The mother carried a diagnosis of Sjögren syndrome, including the presence of SSA and SSB antibodies. Ultrasound M-mode and fetal echocardiogram revealed the etiology of the bradycardia to be a complete fetal congenital heart block, likely due to transplacental passage of autoimmune anti-Ro/SSA and anti-La/SSB antibodies. Consequential to the congenital heart block, the fetus developed hydrops fetalis at 21 weeks' gestational age. We discuss the 2 major etiologies of congenital heart block and the implications in subsequent pregnancies.
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Perin F, Rodríguez Vázquez del Rey M, Deiros Bronte L, Ferrer Menduiña Q, Rueda Nuñez F, Zabala Arguelles J, García de la Calzada D, Teodoro Marin S, Centeno Malfaz F, Galindo Izquierdo A. Foetal bradycardia: A retrospective study in 9 Spanish centres. An Pediatr (Barc) 2014. [DOI: 10.1016/j.anpede.2013.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
PURPOSE OF REVIEW Fetal cardiology is a rapidly evolving field. Imaging technology continues to advance as do approaches to in-utero interventions and care of the critically ill neonate, with even greater demand for improvement in prenatal diagnosis of congenital heart disease (CHD) and arrhythmias. RECENT FINDINGS Reviewing the advances in prenatal diagnosis of CHD in such a rapidly developing field is a broad topic. Therefore, we have chosen to focus this review of recent literature on challenges in prenatal detection of CHD, challenges in prenatal counseling, advances in fetal arrhythmia diagnosis, and potential benefits to patients with CHD who are identified prenatally. SUMMARY As methods and tools to diagnose and manage CHD and arrhythmias in utero continue to improve, future generations will hopefully see a reduction in both prenatal and neonatal morbidity and mortality. Prenatal diagnosis can and should be used to optimize location and timing of delivery and postnatal interventions.
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Congenital heart block: current thoughts on management, morphologic spectrum, and role of intervention. Cardiol Young 2014; 24 Suppl 2:41-6. [PMID: 25247254 DOI: 10.1017/s1047951114001358] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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16
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Johnson B. Overview of neonatal lupus. J Pediatr Health Care 2014; 28:331-41. [PMID: 24100008 DOI: 10.1016/j.pedhc.2013.07.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 07/02/2013] [Accepted: 07/17/2013] [Indexed: 11/26/2022]
Abstract
Neonatal lupus (NL) is defined by the presentation of the fetus and the newborn who possess autoantibodies received from the mother. It is the dysfunction of the maternal immune system that leads to the production of autoantibodies to anti-Sjögren syndrome-A, anti-Sjögren syndrome-B, and anti-ribonuclear protein antigens. These antibodies are shared through the placenta and produce bodily changes in the fetal skin and heart, as well as potential changes in other body systems. Congenital complete heart block is the most dangerous manifestation of NL that can occur in utero or after birth. This article will provide an overview the presentation of NL and current therapies. Prenatal steroids have been the mainstay of therapy to try to reverse first- and second-degree congenital heart block and to prevent progression to a more advanced stage. New therapies are combining steroids with intravenous immunoglobulin and plasmapheresis. This article will provide guidelines for practitioners so they can consider NL as a differential diagnosis when presented with cutaneous lesions, congenital heart block, or abnormal findings in the hematologic, hepatobiliary, neurologic, and musculoskeletal systems.
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[Fetal bradycardia: a retrospective study in 9 Spanish centers]. An Pediatr (Barc) 2014; 81:275-82. [PMID: 24548871 DOI: 10.1016/j.anpedi.2013.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/09/2013] [Accepted: 12/26/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study is to review the current management and outcomes of fetal bradycardia in 9 Spanish centers. METHODS Retrospective multicenter study: analysis of all fetuses with bradycardia diagnosed between January 2008 and September 2010. Underlying mechanisms of fetal bradyarrhythmias were studied with echocardiography. RESULTS A total of 37 cases were registered: 3 sinus bradycardia, 15 blocked atrial bigeminy, and 19 high grade atrioventricular blocks. Sinus bradycardia: 3 cases (100%) were associated with serious diseases. Blocked atrial bigeminy had an excellent outcome, except for one case with post-natal tachyarrhythmia. Of the atrioventricular blocks, 16% were related to congenital heart defects with isomerism, 63% related to the presence of maternal SSA/Ro antibodies, and 21% had unclear etiology. Overall mortality was 20% (37%, if terminations of pregnancy are taken into account). Risk factors for mortality were congenital heart disease, hydrops and/or ventricular dysfunction. Management strategies differed among centers. Steroids were administrated in 73% of immune-mediated atrioventricular blocks, including the only immune-mediated IInd grade block. More than half (58%) of atrioventricular blocks had a pacemaker implanted in a follow-up of 18 months. CONCLUSIONS Sustained fetal bradycardia requires a comprehensive study in all cases, including those with sinus bradycardia. Blocked atrial bigeminy has a good prognosis, but tachyarrhythmias may develop. Heart block has significant mortality and morbidity rates, and its management is still highly controversial.
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Sandhya P, Danda D. Role of vacuolar ATPase and Skp1 in Sjögren's syndrome. Med Hypotheses 2014; 82:319-25. [PMID: 24480435 DOI: 10.1016/j.mehy.2013.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 12/23/2013] [Accepted: 12/24/2013] [Indexed: 12/23/2022]
Abstract
Immune mechanisms alone cannot directly account for exocrine gland dysfunction and extraglandular features such as renal tubular acidosis, neuropathy, hearing loss and fatigue in Sjögren's syndrome (SS). Absence of Vacuolar ATPase (V-ATPase) has been reported in SS related renal tubular acidosis (RTA). We hypothesise how defect in V-ATPase could account for decreased neurotransmitter release leading onto exocrine dysfunction, neuroendocrine manifestations and hearing loss which are well described manifestations in SS. S-phase-kinase-associated protein-1 (Skp1) is a constituent of RAVE which is involved in V-ATPase assembly. It is also a component of SCF ligase which is crucial in NFκB signalling. SKP1 also interacts with TRIM 21/Ro 52 which is an autoantigen in SS. By virtue of these interactions, we postulate how a defective skp1 could fit into the existing pathogenesis of SS and also account for increased risk of lymphoma in SS as well as congenital heart block in fetus of mothers with SS.
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Affiliation(s)
- Pulukool Sandhya
- Department of Clinical Immunology and Rheumatology, Christian Medical College and Hospital, Vellore 632004, India.
| | - Debashish Danda
- Department of Clinical Immunology and Rheumatology, Christian Medical College and Hospital, Vellore 632004, India
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Complete congenital foetal heart block: a case report. Facts Views Vis Obgyn 2014; 6:39-42. [PMID: 25009724 PMCID: PMC4086001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Congenital heart block (CHB) is the most severe manifestation of neonatal lupus which can develop into a lethal atrioventricular (AV) block. Complete congenital foetal heart block related to maternal anti-Ro/SSA autoanti-bodies typically develops between 20 and 24 weeks of gestation. CHB with a structurally normal heart is frequently associated with maternal autoantibodies to Ro/SSA and La/SSB. We are presenting a case of foetal complete CHB with high maternal Ro/SSA and La/SSB titre with favourable outcome.
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Di Mauro A, Caroli Casavola V, Favia Guarnieri G, Calderoni G, Cicinelli E, Laforgia N. Antenatal and postnatal combined therapy for autoantibody-related congenital atrioventricular block. BMC Pregnancy Childbirth 2013; 13:220. [PMID: 24286473 PMCID: PMC4219454 DOI: 10.1186/1471-2393-13-220] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 11/23/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Autoantibody-related congenital heart block (CHB) is an autoimmune condition in which trans placental passage of maternal autoantibodies cause damage to the developing heart conduction system of the foetus. CASE PRESENTATION We report a case of an Italian 31-year-old woman, in a good clinical status, referred to our Centre at 26 weeks of her first pregnancy, because of foetal bradycardia, found during routine foetal ultrasonography. Foetal echocardiography revealed a 3rd degree CHB, without any anatomical defects. Despite the mother was asymptomatic for autoimmune disease, anti-Ro/La were searched for, because of the hypothesis of autoantibody-related CHB. High title of maternal anti-Ro/SSA antibodies was found and diagnosis of an autoantibody-related CHB was made. A combination treatment protocol of the mother was started with oral betamethasone, plasmapheresis and IVIG. An emergency C-section was performed at 32 + 3 weeks of gestation because of a non-reassuring cardiotocography pattern. A male newborn (BW 1515 g, NGA, Apgar 8-10) was treated since birth with high-flow O2 for mild RDS. IVIG administration was started at one week, and then every two weeks, until complete disappearance of maternal antibodies from blood. Because of persistent low ventricular rate (<60/min), seven days following birth, pacemaker implantation was performed. The baby is now at 40th week with no signs of cardiac failure and free of any medications. CONCLUSION Up to date, no guidelines have been published for the treatment of "in utero-CHB" and only anecdotal reports are available. It has been stated that a combination therapy protocol is effective in reversing a 2nd degree CHB, but not for 3rd degree CHB. In cases of foetal bradycardia, weekly foetal echocardiographic monitoring needs to be performed and in cases of 2nd degree CHB and 3rd degree CHB maternal therapy could be suggested, as in our case, to avoid foetal heart failure. In cases of 3rd degree CHB often pacemaker implantation is needed.
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Affiliation(s)
- Antonio Di Mauro
- Department of Biomedical Science and Human Oncology, Neonatology and Neonatal Intensive Care Unit, University of Bari, "Aldo Moro", P,zza Giulio Cesare, 11, 70125 Bari, Italy.
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Frodlund M, Dahlström Ö, Kastbom A, Skogh T, Sjöwall C. Associations between antinuclear antibody staining patterns and clinical features of systemic lupus erythematosus: analysis of a regional Swedish register. BMJ Open 2013; 3:e003608. [PMID: 24163206 PMCID: PMC3808756 DOI: 10.1136/bmjopen-2013-003608] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 09/02/2013] [Accepted: 09/24/2013] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Antinuclear antibody (ANA) analysis by immunofluorescence (IF) microscopy remains a diagnostic hallmark of systemic lupus erythematosus (SLE). The clinical relevance of ANA fine-specificities in SLE has been addressed repeatedly, whereas studies on IF-ANA staining patterns in relation to disease manifestations are very scarce. This study was performed to elucidate whether different staining patterns associate with distinct SLE phenotypes. DESIGN Observational cohort study. SETTING One university hospital rheumatology unit in Sweden. PARTICIPANTS The study population consisted of 222 cases (89% women; 93% Caucasians), where of 178 met ≥4/11 of the 1982 American College of Rheumatology (ACR-82) criteria. The remaining 20% had an SLE diagnosis based on positive IF-ANA (HEp-2 cells) and ≥2 typical organ manifestations at the time of diagnosis (Fries' criteria). OUTCOME MEASURES The IF-ANA staining patterns homogenous (H-ANA), speckled (S-ANA), combined homogenous and speckled (HS-ANA), centromeric (C-ANA), nucleolar (N-ANA)±other patterns and other nuclear patterns (oANA) were related to disease manifestations and laboratory measures. Antigen-specificities were also considered regarding double-stranded DNA (Crithidia luciliae) and the following extractable nuclear antigens: Ro/SSA, La/SSB, Smith antigen (Sm), small nuclear RNP (snRNP), Scl-70 and Jo-1 (immunodiffusion and/or line-blot technique). RESULTS 54% of the patients with SLE displayed H-ANA, 22% S-ANA, 11% HS-ANA, 9% N-ANA, 1% C-ANA, 2% oANA and 1% were never IF-ANA positive. Staining patterns among patients meeting Fries' criteria alone did not differ from those fulfilling ACR-82. H-ANA was significantly associated with the 10th criterion according to ACR-82 ('immunological disorder'). S-ANA was inversely associated with arthritis, 'immunological disorder' and signs of organ damage. CONCLUSIONS H-ANA is the dominant IF-ANA pattern among Swedish patients with SLE, and was found to associate with 'immunological disorder' according to ACR-82. The second most common pattern, S-ANA, associated negatively with arthritis and organ damage.
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Affiliation(s)
- Martina Frodlund
- Rheumatology/AIR, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Örjan Dahlström
- Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden
| | - Alf Kastbom
- Rheumatology/AIR, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Thomas Skogh
- Rheumatology/AIR, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Christopher Sjöwall
- Rheumatology/AIR, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Diagnose und Therapie von Herzrhythmusstörungen bei Kindern und Jugendlichen. Monatsschr Kinderheilkd 2013. [DOI: 10.1007/s00112-013-2906-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gleicher N, Elkayam U. Preventing congenital neonatal heart block in offspring of mothers with anti-SSA/Ro and SSB/La antibodies: A review of published literature and registered clinical trials. Autoimmun Rev 2013; 12:1039-45. [DOI: 10.1016/j.autrev.2013.04.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 04/11/2013] [Indexed: 12/14/2022]
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Kurien BT, Dsouza A, Igoe A, Lee YJ, Maier-Moore JS, Gordon T, Jackson M, Scofield RH. Immunization with 60 kD Ro peptide produces different stages of preclinical autoimmunity in a Sjögren's syndrome model among multiple strains of inbred mice. Clin Exp Immunol 2013; 173:67-75. [PMID: 23607771 PMCID: PMC3694536 DOI: 10.1111/cei.12094] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2013] [Indexed: 11/27/2022] Open
Abstract
Sjögren's syndrome is a chronic illness manifested characteristically by immune injury to the salivary and lacrimal glands, resulting in dry mouth/eyes. Anti-Ro [Sjögren's syndrome antigen A (SSA)] and anti-La [Sjögren's syndrome antigen B (SSB)] autoantibodies are found frequently in Sjögren's subjects as well as in individuals who will go on to develop the disease. Immunization of BALB/c mice with Ro60 peptides results in epitope spreading with anti-Ro and anti-La along with lymphocyte infiltration of salivary glands similar to human Sjögren's. In addition, these animals have poor salivary function/low saliva volume. In this study, we examined whether Ro-peptide immunization produces a Sjögren's-like illness in other strains of mice. BALB/c, DBA-2, PL/J, SJL/J and C57BL/6 mice were immunized with Ro60 peptide-274. Sera from these mice were studied by immunoblot and enzyme-linked immunosorbent assay for autoantibodies. Timed salivary flow was determined after pharmacological stimulation, and salivary glands were examined pathologically. We found that SJL/J mice had no immune response to the peptide from Ro60, while C57BL/6 mice produced antibodies that bound the peptide but had no epitope spreading. PL/J mice had epitope spreading to other structures of Ro60 as well as to La, but like C57BL/6 and SJL/J had no salivary gland lymphocytic infiltration and no decrement of salivary function. DBA-2 and BALB/c mice had infiltration but only BALB/c had decreased salivary function. The immunological processes leading to a Sjögren's-like illness after Ro-peptide immunization were interrupted in a stepwise fashion in these differing mice strains. These data suggest that this is a model of preclinical disease with genetic control for epitope spreading, lymphocytic infiltration and glandular dysfunction.
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MESH Headings
- Amino Acid Sequence
- Animals
- Antibodies, Antinuclear/biosynthesis
- Antibodies, Antinuclear/immunology
- Autoantigens/immunology
- Autoimmunity/genetics
- Autoimmunity/immunology
- Carbachol/pharmacology
- Disease Models, Animal
- Epitopes/immunology
- Freund's Adjuvant
- H-2 Antigens/genetics
- H-2 Antigens/immunology
- Haplotypes
- Immunization
- Lymphocyte Subsets/immunology
- Lymphocyte Subsets/pathology
- Male
- Mice
- Mice, Inbred Strains/genetics
- Mice, Inbred Strains/immunology
- Molecular Sequence Data
- Muscle, Smooth/drug effects
- Muscle, Smooth/immunology
- Peptide Fragments/immunology
- Prodromal Symptoms
- RNA, Small Cytoplasmic/immunology
- Receptor, Muscarinic M3/drug effects
- Receptor, Muscarinic M3/immunology
- Ribonucleoproteins/immunology
- Salivary Glands/pathology
- Salivation
- Sjogren's Syndrome/etiology
- Sjogren's Syndrome/immunology
- Specific Pathogen-Free Organisms
- Urinary Bladder
- Xerostomia/etiology
- Xerostomia/immunology
- SS-B Antigen
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Affiliation(s)
- B T Kurien
- Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
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Castro Vilar L, Blanco Pérez S, Vázquez Rodríguez M, Pato Mosquera M, Couso Cambeiro B. Bloqueo aurículo-ventricular congénito completo y anticuerpos maternos anti-Ro positivos. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2013. [DOI: 10.1016/j.gine.2012.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Krishnan A, Pike JI, Donofrio MT. Prenatal evaluation and management of fetuses exposed to Anti-SSA/Ro antibodies. Pediatr Cardiol 2012; 33:1245-52. [PMID: 22614901 DOI: 10.1007/s00246-012-0358-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 04/29/2012] [Indexed: 11/27/2022]
Abstract
Maternal anti-SSA antibodies are common, existing in up to 2 % of the general population. Fetuses exposed to these antibodies are at risk for both cardiac and noncardiac complications. The cardiac complications include arrhythmias, structural disease, and cardiomyopathy. Although rare, the cardiac disease associated with these antibodies is permanent and severe. Current fetal echocardiographic screening tools are nonspecific. The type and frequency of screening needed is controversial. Although promising transplacental treatment strategies exist, prospective randomized studies are lacking. Dexamethasone, the medication used most frequently, imposes significant risks to both mother and fetus. This report presents a discussion of the at-risk population, the spectrum of fetal cardiac disease associated with maternal anti-SSA antibodies, the current fetal echocardiographic screening tools, the therapeutic options, and the management and delivery planning strategies. With appropriate prenatal follow-up, assessment, and delivery planning, even high-risk fetuses can be delivered safely and managed effectively.
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Affiliation(s)
- Anita Krishnan
- Children's National Medical Center, 111 North Michigan Avenue, NW, Washington, DC, 20010, USA.
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Phoon CKL, Kim MY, Buyon JP, Friedman DM. Finding the "PR-fect" solution: what is the best tool to measure fetal cardiac PR intervals for the detection and possible treatment of early conduction disease? CONGENIT HEART DIS 2012; 7:349-60. [PMID: 22494551 DOI: 10.1111/j.1747-0803.2012.00652.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the absence of structural heart disease, the great majority of cases with complete congenital heart block will be associated with the maternal autoantibodies directed to components of the SSA/Ro-SSB/La ribonucleoprotein complex. Usually presenting in fetal life before 26 weeks' gestation, once third-degree (complete) heart block develops, it is irreversible. Therefore, investigators over the past several years have attempted to predict which fetuses will be at risk for advanced conduction abnormalities by identifying a biomarker for less severe or incomplete disease, in this case, PR interval prolongation or first-degree atrioventricular block. In this state-of-the-art review, we critically analyze the various approaches to defining PR interval prolongation in the fetus, and then analyze several clinical trials that have attempted to address the question of whether complete heart block can be predicted and/or prevented. We find that, first and foremost, definitions of first-degree atrioventricular block vary but that the techniques themselves are all similarly valid and reliable. Nevertheless, the task of predicting those fetuses at risk, and who are therefore candidates for treatment, remains challenging. Of concern, despite anecdotal evidence, there is currently no conclusive proof that a prolonged PR interval predicts complete heart block.
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Affiliation(s)
- Colin K L Phoon
- Division of Pediatric Cardiology, Department of Pediatrics, New York University School of Medicine, New York, NY, USA.
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Lindop R, Arentz G, Thurgood LA, Reed JH, Jackson MW, Gordon TP. Pathogenicity and proteomic signatures of autoantibodies to Ro and La. Immunol Cell Biol 2012; 90:304-9. [PMID: 22249199 DOI: 10.1038/icb.2011.108] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Ro/SSA and La/SSB comprise a linked set of autoantigens that are clinically important members of the extractable nuclear antigen family and key translational biomarkers for lupus and primary Sjögren's syndrome. Autoantibodies directed against the Ro60 and La polypeptide components of the Ro/La ribonucleoprotein complex, and the structurally unrelated Ro52 protein, mediate tissue damage in the neonatal lupus syndrome, a model of passively acquired autoimmunity in humans in which the most serious manifestation is congenital heart block (CHB). Recent studies have concentrated on two distinct pathogenic mechanisms by which maternal anti-Ro/La autoantibodies can cause CHB: by forming immune complexes with apoptotic cells in developing fetal heart; and/or by acting as functional autoantibodies that cross-react with and inhibit calcium channels. Although the precise role of the individual autoantibodies is yet to be settled, maternal anti-Ro60 and anti-Ro52 remain the most likely culprits. This article will discuss the molecular pathways that culminate in the development of CHB, including the recent discovery of β2 glycoprotein I as a protective factor, and present a proteomic approach based on direct mass spectrometric sequencing, which may give a more representative snapshot of the idiotype repertoire of these autoantibodies than genomic-based technologies.
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Affiliation(s)
- Rhianna Lindop
- Department of Immunology, Flinders Medical Centre and Flinders University, Bedford Park, South Australia, Australia
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Killen SAS, Buyon JP, Friedman DM. Discordant spectrum of cardiac manifestations of neonatal lupus in twins. Lupus 2011; 21:559-62. [PMID: 22140143 DOI: 10.1177/0961203311430512] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Congenital complete heart block associated with transplacental passage of maternal autoantibodies reactive with SSA/Ro and SSB/La is a rare disease with significant fetal, neonatal, and childhood morbidity and mortality. We present the case of dichorionic, diamniotic twins (female twin A and male twin B) exposed to maternal Ro and La autoantibodies with different disease expression. Twin A (female) had Mobitz type I second degree atrioventricular (AV) block (Wenckebach); twin B (male) had normal sinus rhythm. Both twins had structurally normal hearts but demonstrated echocardiographic evidence of endocardial fibroelastosis (EFE). Following maternal dexamethasone 4 mg once daily, twin A reverted to sinus rhythm in utero; twin B remained in sinus rhythm throughout pregnancy. Echocardiograms after delivery demonstrated resolution of EFE in both fetuses, and EKGs confirmed sinus rhythm. However, at five months of age, Holter monitor demonstrated first degree AV block and intermittent Wenckebach in twin A. Twin B remains in sinus rhythm. This case is one of only three in the literature that describes Mobitz type I second degree atrioventricular block presenting in fetuses exposed to maternal SSA and SSB autoantibodies and is the first case that we have seen reported in twins. Importantly, this case also adds to the growing body of literature describing EFE as a presentation of neonatal lupus with or without conduction system abnormalities, emphasizes the spectrum of cardiac conduction abnormalities in neonatal lupus syndrome, and raises interesting questions about discordant disease expression in twins.
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Affiliation(s)
- S A S Killen
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr Children's Hospital at Vanderbilt, USA.
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Routsias JG, Kyriakidis NC, Friedman DM, Llanos C, Clancy R, Moutsopoulos HM, Buyon J, Tzioufas AG. Association of the idiotype:antiidiotype antibody ratio with the efficacy of intravenous immunoglobulin treatment for the prevention of recurrent autoimmune-associated congenital heart block. ACTA ACUST UNITED AC 2011; 63:2783-9. [PMID: 21618202 DOI: 10.1002/art.30464] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Congenital heart block (CHB), a manifestation of neonatal lupus, is associated with maternal anti-Ro/SSA and anti-La/SSB autoantibodies and recurs in ∼18% of subsequent pregnancies. This study was undertaken to investigate the effect of the idiotype:antiidiotype (Id:anti-Id) antibody ratio in the ability of intravenous immunoglobulin (IVIG) administered during subsequent pregnancies to prevent CHB. METHODS We studied 16 anti-Ro/SSA and anti-La/SSB-positive pregnant women from the Preventive IVIG Therapy for Congenital Heart Block study who had previously given birth to a child with neonatal lupus. In 3 of the mothers, the study pregnancy resulted in the birth of a child with neonatal lupus (2 with CHB and 1 with rash). Sequential serum samples were obtained from all mothers immediately before the administration of IVIG during pregnancy and were evaluated for antibodies against the major B cell epitope 349-364aa of La/SSB (idiotype) and its antiidiotypic antibodies. RESULTS Following IVIG treatment, serum titers of anti-La(349-364) (Id antibodies) decreased in 80% of the mothers, and in 60% an increase in anti-Id antibodies against anti-La(349-364) was observed. The Id:anti-Id ratio was significantly higher in mothers whose offspring developed neonatal lupus compared to mothers who gave birth to a healthy child (P<0.0001). Removal of anti-Id antibodies substantially increased the reactivity against La(349-364) in sera from 5 of 7 mothers tested. All IVIG preparations were examined for Id and anti-Id antibody activity. IVIG from batches administered to mothers who gave birth to a healthy child had an Id:anti-Id activity ratio of <1, in contrast to that given to mothers who gave birth to a child with neonatal lupus. Addition of the IVIG preparations to the maternal sera further enhanced antiidiotypic activity (by up to 4.7-fold) in 11 of 13 patients studied. CONCLUSION This is the first study in humans to demonstrate that IVIG influences the Id-anti-Id network of a specific pathogenic autoantibody. Specifically, we showed that IVIG enhanced the anti-Id antibody response in pregnant women with anti-La/SSB antibodies. A high Id:anti-Id ratio in both the IVIG preparation and the maternal serum may explain the absence of an effect of IVIG in preventing recurrent neonatal lupus in some cases.
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Affiliation(s)
- John G Routsias
- Department of Pathophysiology, Medical School, University of Athens, Athens, Greece
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Clancy RM, Marion MC, Kaufman KM, Ramos PS, Adler A, Harley JB, Langefeld CD, Buyon JP. Identification of candidate loci at 6p21 and 21q22 in a genome-wide association study of cardiac manifestations of neonatal lupus. ACTA ACUST UNITED AC 2010; 62:3415-24. [PMID: 20662065 DOI: 10.1002/art.27658] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Cardiac manifestations of neonatal lupus, comprising atrioventricular conduction defects and cardiomyopathy, occur in fetuses exposed to anti-Ro/SSA antibodies, and carry substantial mortality. There is strong evidence of a genetic contribution to the risk. This study was undertaken to evaluate single-nucleotide polymorphisms (SNPs) for associations with cardiac neonatal lupus. METHODS Children of European ancestry with cardiac neonatal lupus (n = 116) were genotyped using the Illumina 370K SNP platform and merged with 3,351 controls. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for association with cardiac neonatal lupus were determined. RESULTS The 17 most significant associations with cardiac neonatal lupus were found in the HLA region. The region near the MICB gene showed the strongest variant (rs3099844; P(dom) = 4.52 × 10(-10) , OR 3.34 [95% CI 2.29-4.89]), followed by a missense variant within C6orf10 (rs7775397; P(dom) = 1.35 × 10(-9) , OR 3.30), which lies between NOTCH4 and BTNL2, and several SNPs near the tumor necrosis factor α gene, including rs2857595 (P(add) = 1.96 × 10(-9) , OR 2.37), rs2230365 (P(add) = 1.00 × 10(-3) , OR 0.46), and rs3128982 (P(add) = 6.40 × 10(-6) , OR 1.86). Outside the HLA region, an association was detected at 21q22, upstream of the transcription regulator ets-related isoform 1 (rs743446; P = 5.45 × 10(-6) , OR 2.40). HLA notwithstanding, no individual locus previously implicated in autoimmune diseases achieved genome-wide significance. CONCLUSION These results suggest that variation near genes related to inflammatory and apoptotic responses may promote cardiac injury initiated by passively acquired autoantibodies.
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Affiliation(s)
- Robert M Clancy
- New York University Langone School of Medicine, New York, New York 10003, USA.
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David AL, Ataullah I, Yates R, Sullivan I, Charles P, Williams D. Congenital fetal heart block: a potential therapeutic role for intravenous immunoglobulin. Obstet Gynecol 2010; 116 Suppl 2:543-547. [PMID: 20664449 DOI: 10.1097/aog.0b013e3181e75a4a] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Congenital heart block affects 2% of all mothers with anti-Ro/La antibodies, can cause heart failure in utero, and has a 20% mortality rate in the first 3 years of life. Maternal fluorinated steroids to prevent or reverse congenital heart block can cause pregnancy complications. Intravenous immunoglobulin (IVIG) has been given with maternal steroids to prevent the recurrence of congenital heart block, although its efficacy is unproven. CASE We report the use of IVIG to prevent progression of 2:1 congenital heart block with intermittent complete heart block. After two maternal infusions of IVIG (0.4 g/kg) at 31 weeks of gestation, the fetal heart rate reverted to long periods of sinus rhythm, which was sustained until postnatal life. CONCLUSION Our case supports investigating IVIG in the prevention or treatment of this life-threatening condition.
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Affiliation(s)
- Anna L David
- From the Institute for Women's Health, University College London Hospitals; the Cardiac Unit, Great Ormond Street Hospital for Children NHS Trust; and the Division of Immunology, Hammersmith Hospitals NHS Trust, London, United Kingdom
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Abstract
The human fetal heart develops arrhythmias and conduction disturbances in response to ischemia, inflammation, electrolyte disturbances, altered load states, structural defects, inherited genetic conditions, and many other causes. Yet sinus rhythm is present without altered rate or rhythm in some of the most serious electrophysiological diseases, which makes detection of diseases of the fetal conduction system challenging in the absence of magnetocardiographic or electrocardiographic recording techniques. Life-threatening changes in QRS or QT intervals can be completely unrecognized if heart rate is the only feature to be altered. For many fetal arrhythmias, echocardiography alone can assess important clinical parameters for diagnosis. Appropriate treatment of the fetus requires awareness of arrhythmia characteristics, mechanisms, and potential associations. Criteria to define fetal bradycardia specific to gestational age are now available and may allow detection of ion channelopathies, which are associated with fetal and neonatal bradycardia. Ectopic beats, once thought to be entirely benign, are now recognized to have important pathologic associations. Fetal tachyarrhythmias can now be defined precisely for mechanism-specific therapy and for subsequent monitoring of response. This article reviews the current and future diagnostic techniques and pharmacologic treatments for fetal arrhythmia.
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ØStensen M. Intravenous immunoglobulin does not prevent recurrence of congenital heart block in children of SSA/Ro-positive mothers. ACTA ACUST UNITED AC 2010; 62:911-4. [DOI: 10.1002/art.27317] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Batliwalla F, Tracey KJ. Introduction: The first Merinoff Symposium, 'Systemic Lupus: Bringing Science to the Patient'. J Intern Med 2009; 265:622-4. [PMID: 19493055 PMCID: PMC4536564 DOI: 10.1111/j.1365-2796.2009.02097.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- F Batliwalla
- Robert S. Boas Center for Genomics and Human Genetics, Feinstein Institute for Medical Research, Manhasset, NY 11030, USA.
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