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Sheng X, Song X, Xiong Y, Ren T, Chang X, Wu J, Cao J, Cheng T, Wang M. Maternal and infant outcomes of pregnancy associated with anti-SSA/RO antibodies: a systematic review and meta-analysis. Pediatr Rheumatol Online J 2023; 21:22. [PMID: 36870970 PMCID: PMC9985242 DOI: 10.1186/s12969-023-00803-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/26/2023] [Indexed: 03/06/2023] Open
Abstract
OBJECTIVE The relationship between anti-SSA/RO antibodies and pregnancy has been reported previously, and we aim to visualize the rates of maternal and infant outcomes with anti-SSA/RO. METHODS We systematically searched records from Pubmed, Cochrane, Embase, and Web of Science databases, pooled incidence rates of adverse outcomes of pregnancy, and 95% confidence intervals (CIs) were performed with RStudio. RESULTS A total of 890 records comprising 1675 patients and 1920 pregnancies were searched from the electronic databases. For maternal outcomes, the pooled estimate rates were 4% for termination of pregnancy, 5% for spontaneous abortion, 26% for preterm labor, and 50% for cesarean operation. While for fetal outcomes, the pooled estimate rates were 4% for perinatal death, 3% for intrauterine growth retardation, 6% for endocardial fibroelastosis, 6% for dilated cardiomyopathy, 7% for congenital heart block, 12% for congenital heart block recurrence, 19% for cutaneous neonatal lupus erythematosus, 12% for hepatobiliary disease and 16% for hematological manifestations. A subgroup analysis of congenital heart block prevalence was performed, diagnostic method and study region were found to affect heterogeneity to some extent. CONCLUSION Cumulative analysis of data from real-world studies confirmed adverse pregnancy outcomes of women with anti-SSA/RO, serves as a reference and a guide for the diagnosis and subsequent treatment of these women, thereby enhancing maternal and infant health. Additional studies with real-world cohorts are required to validate these results.
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Affiliation(s)
- Xiangrui Sheng
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Xiaohui Song
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Yue Xiong
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Tian Ren
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Xin Chang
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Jian Wu
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China
| | - Jing Cao
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China.
| | - Tao Cheng
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China.
| | - Mingjun Wang
- Department of Rheumatology, The First Affiliated Hospital of Soochow University, No.188 Shizi St, Suzhou, 215006, Jiangsu, China.
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Wang X, Liu XW, Han L, Li MT, Zhao JL, Sun L, Han JC, Zeng XF, Tian XP, Zhao Y, He YH. Cardiac manifestations in a Chinese cohort of fetuses from mothers with anti-Ro and anti-La antibodies. Front Pediatr 2022; 10:904138. [PMID: 35967560 PMCID: PMC9371606 DOI: 10.3389/fped.2022.904138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/11/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To analyze the clinical characteristics, echocardiographic features, and prognosis of fetuses based on three groups of cardiac manifestations associated with maternal anti-Ro and anti-La antibodies in China. This study included three groups: the isolated-arrhythmia, isolated-endocardial fibroelastosis (EFE), and mixed groups. METHODS We prospectively evaluated 36 fetuses with cardiac manifestations due to maternal anti-Ro and anti-La antibodies from our center between 2016 and 2020 in China. Clinical and echocardiographic data were collected. RESULTS There were 13 patients (36%) in the isolated-arrhythmia group, eight (22%) in the isolated-EFE group, and 15 (42%) in the mixed group. All patients in the isolated-EFE group presented with mild EFE. Severe EFE was identified in four patients (27%) in the mixed group. Atrioventricular block (AVB) was more common in the isolated-arrhythmia group (13, 100%) than in the mixed group (6, 40%; p = 0.001). Moderate-severe mitral regurgitation (p = 0.006), dilated cardiomyopathy (DCM, p = 0.017), and low cardiovascular profile scores (p = 0.013) were more common in the mixed group than in the other two groups. Twenty-one mothers decided to terminate the pregnancy and 15 fetuses were born with regular perinatal treatment. They all survived at 1 year of age. One patient in the isolated-arrhythmia group and two in the mixed group required a pacemaker due to third-degree AVB or atrioventricular junctional rhythm. Five patients in the isolated-EFE group and five in the mixed group had no DCM or heart failure and the location of mild EFE was significantly reduced. CONCLUSION Fetal cardiac manifestations due to maternal anti-Ro and anti-La antibodies can be divided into three groups, i.e., the isolated-arrhythmia, isolated-EFE, and mixed groups. AVB usually occurs in the isolated-arrhythmia group. Severe EFE, moderate-severe mitral regurgitation, and DCM mainly appear in the mixed group. Location of mild EFE significantly reduces after birth and the outcome of fetuses with mild EFE depends on the presence of arrhythmia and its subtypes.
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Affiliation(s)
- Xin Wang
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao-Wei Liu
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ling Han
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Meng-Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiu-Liang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Lin Sun
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jian-Cheng Han
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao-Feng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xin-Ping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Ying Zhao
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi-Hua He
- Echocardiography Medical Center, Maternal-Fetal Medicine Center in Fetal Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Gryka-Marton M, Szukiewicz D, Teliga-Czajkowska J, Olesinska M. An Overview of Neonatal Lupus with Anti-Ro Characteristics. Int J Mol Sci 2021; 22:9281. [PMID: 34502221 PMCID: PMC8431034 DOI: 10.3390/ijms22179281] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 01/23/2023] Open
Abstract
Neonatal lupus erythematosus (NLE) is a syndrome of clinical symptoms observed in neonates born to mothers with antibodies to soluble antigens of the cell nucleus. The main factors contributing to the pathogenesis of this disease are anti-Sjögren Syndrome A (anti-SS-A) antibodies, known as anti-Ro, and anti-Sjögren Syndrome B (anti-SS-B) antibodies, known as anti-La. Recent publications have also shown the significant role of anti-ribonucleoprotein antibodies (anti-RNP). Seropositive mothers may have a diagnosed rheumatic disease or they can be asymptomatic without diagnosis at the time of childbirth. These antibodies, after crossing the placenta, may trigger a cascade of inflammatory reactions. The symptoms of NLE can be divided into reversible symptoms, which concern skin, hematological, and hepatological changes, but 2% of children develop irreversible symptoms, which include disturbances of the cardiac stimulatory and conduction system. Preconceptive care and pharmacological prophylaxis of NLE in the case of mothers from the risk group are important, as well as the monitoring of the clinical condition of the mother and fetus throughout pregnancy and the neonatal period. The aim of this manuscript is to summarize the previous literature and current state of knowledge about neonatal lupus and to discuss the role of anti-Ro in the inflammatory process.
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Affiliation(s)
- Malgorzata Gryka-Marton
- Department of Biophysics, Physiology and Pathophysiology, Faculty of Health Sciences, Medical University of Warsaw, 02-004 Warsaw, Poland;
- Department of Systemic Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
| | - Dariusz Szukiewicz
- Department of Biophysics, Physiology and Pathophysiology, Faculty of Health Sciences, Medical University of Warsaw, 02-004 Warsaw, Poland;
| | - Justyna Teliga-Czajkowska
- Department of Obstetrics and Gynecology Didactics, Faculty of Health Sciences, Medical University of Warsaw, 00-315 Warsaw, Poland;
| | - Marzena Olesinska
- Department of Systemic Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, 02-637 Warsaw, Poland;
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Abstract
BACKGROUND Neonatal lupus erythematosus (NLE) results from cross-placental transfer of maternal autoantibodies. Neonates can present with cardiac, cutaneous, hepatobiliary, hematologic, and neurologic complications from antibody-mediated organ toxicity. Scant evidence exists on long-term clinical characteristics and outcomes of patients with neonatal lupus. OBJECTIVES To characterize the autoantibody profile, laboratory, and clinical features of patients with NLE. MATERIALS/METHODS This was a single-site retrospective cohort study of patients at the Children's Hospital of Philadelphia with NLE. Data were collected on clinical, laboratory, and autoantibody profile at time of presentation, as well as long-term complications. RESULTS Thirteen patients were included. Congenital cardiac findings were reported in 3 patients, with 1 having persistent cardiac sequelae. Cardiac manifestations were correlated with anti-Ro/SSA positivity in our cohort. Two patients had neurologic findings, with good long-term outcomes. Cutaneous findings were present in all patients, and many resolved without topical steroid treatment. Hematologic and hepatobiliary findings were common, but uncomplicated, with complete resolution by 6 months after initial presentation in all. Maternal rheumatologic disease, treatment, and race were not associated with systemic manifestations. CONCLUSIONS Patients born to mothers with positive anti-Ro/SSA titers may benefit from routine cardiac monitoring in utero and at birth. Routine EEG or head ultrasound monitoring in patients who are autoantibody positive for NLE may be unnecessary. Information regarding long-term outcomes in NLE can be used to guide familial counseling and the use of serial laboratory testing.
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Affiliation(s)
- Yixin Ally Wang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cathryn Sibbald
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amanda T Moon
- Section of Dermatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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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: 15] [Impact Index Per Article: 3.8] [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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Neonatal lupus: Follow-up in infants with anti -SSA/Ro antibodies and review of the literature. Autoimmun Rev 2017; 16:427-432. [DOI: 10.1016/j.autrev.2017.02.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 02/12/2017] [Indexed: 11/20/2022]
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Savino F, Viola S, Tarasco V, Locatelli E, Ricagni A, Coppo P. Neonatal lupus erythematosus: a cutaneous cases based update. Ital J Pediatr 2016; 42:1. [PMID: 26743447 PMCID: PMC4705598 DOI: 10.1186/s13052-015-0208-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/24/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Neonatal Lupus Erythematosus (NLE) is an uncommon autoimmune disease characterized by cutaneous, hepatic, hematological, neurological and cardiac involvement. CASE PRESENTATION Here we report four cases of cutaneous NLE which were referred to our department in the last 10 years and update literature. The newborns presented with different skin, clinical and laboratory features. This underlines the phenotypic variability of NLE. We investigated the passage of maternal antinuclear antibodies (ANA) and extractable nuclear antigen antibodies (ENA) - particularly anti-Ro/SSA, anti-La/SSB and anti-U1 ribonucleoprotein RNP - through the placenta. Despite the positive family background, cutaneous NLE and serological data improved in infants within 4 months without treatment. CONCLUSION The evolution of cutaneous NLE may be the spontaneous regression of lesions within six months without progression to Systemic Lupus Erytehmatosus.
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Affiliation(s)
- Francesco Savino
- Department of Pediatrics and Adolescence - Regina Margherita Children's Hospital, Azienda Ospedaliera Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia, 94, Torino, 10126, Italy.
| | - Serena Viola
- Department of Pediatrics and Adolescence - Regina Margherita Children's Hospital, Azienda Ospedaliera Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia, 94, Torino, 10126, Italy.
| | - Valentina Tarasco
- Department of Pediatrics and Adolescence - Regina Margherita Children's Hospital, Azienda Ospedaliera Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia, 94, Torino, 10126, Italy.
| | - Emanuela Locatelli
- Department of Pediatrics and Adolescence - Regina Margherita Children's Hospital, Azienda Ospedaliera Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia, 94, Torino, 10126, Italy.
| | - Alberto Ricagni
- Department of Pediatrics and Adolescence - Regina Margherita Children's Hospital, Azienda Ospedaliera Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia, 94, Torino, 10126, Italy.
| | - Paola Coppo
- Department of Surgery, Dermatology Unit, Regina Margherita Children's Hospital, University of Turin, Turin, Italy.
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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: 14] [Impact Index Per Article: 1.4] [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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Beretta S, Fabiano V, Zuccotti GV. Neonatal Lupus or Not? An Intriguing Immunological Dilemma. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2014; 27:99-102. [PMID: 35923013 DOI: 10.1089/ped.2014.0361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Anti-Ro antibodies appear to represent a direct pathogenic factor in neonatal lupus (NL) neutropenia. Resolution of NL neutropenia is expected when anti-Ro antibodies are cleared. In this report, we describe a case of persistent neutropenia in a baby born to an anti-Ro-positive mother. The initial diagnosis of NL neutropenia was later called into question due to the identification of positive anti-neutrophil antibodies and transient hypogammaglobulinemia of infancy. The patient seemed to have had overlapping causes of her hematologic manifestations. To our knowledge, no other similar cases have been previously reported in the literature. Newborns are not routinely tested for white blood cell count, and several neutropenia cases remain undetected.
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Affiliation(s)
- Silvia Beretta
- Department of Pediatrics, Luigi Sacco Hospital, Università degli Studi di Milano, Milan, Itali
| | - Valentina Fabiano
- Department of Pediatrics, Luigi Sacco Hospital, Università degli Studi di Milano, Milan, Itali
| | - Gian Vincenzo Zuccotti
- Department of Pediatrics, Luigi Sacco Hospital, Università degli Studi di Milano, Milan, Itali
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Abstract
Neonatal lupus erythematosus is an immune-mediated disease caused by transplacental passage of maternal autoantibodies, primarily anti-Ro (SSA) and anti-La (SSB). The major clinical manifestations are congenital heart block, cutaneous lupus lesions, and hematologic problems. Hepatic, pulmonary, and neurological involvements are rare. We report a 5-day-old male neonate, born to a clinically asymptomatic mother, presenting with conjugated hyperbilirubinemia, cutaneous lupus lesions, congenital heart block, and thrombocytopenia. Both the neonate and his mother had high titers of antinuclear antibodies (1:640), anti-Ro (SSA), and anti-La (SSB) antibodies. The thrombocytopenia improved with prednisolone (2 mg/kg/day) for 14 days. The skin lupus rashes and bilirubin resolved 2 months later, and liver enzymes were completely normal by 6 months.
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Affiliation(s)
- Mozhgan Shahian
- Division of Neonatology, Department of Pediatrics, Shiraz University of Medical Sciences, Shiraz, Iran
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