Ultraviolet light exposure is not a requirement for the development of cutaneous neonatal lupus

Annular skin lesions in infancy

Annular skin lesions have a unique morphology, and the dramatic appearance of these skin eruptions in infants can cause concern for parents and clinicians. Annular lesions appearing during infancy (defined here as birth to 1 year of age) lend to a broad differential, ranging from benign cutaneous disorders to severe systemic diseases. This review summarizes the pathogenesis, clinical and histopathologic findings, and management options of possible etiologies for annular skin lesions in infants, including annular erythema of infancy, neonatal lupus erythematosus, dermatophyte infections, hemorrhagic edema of infancy, and urticaria multiforme.

Annular skin lesions in infancy

Annular skin lesions have a unique morphology, and the dramatic appearance of these skin eruptions in infants can cause concern for parents and clinicians. Annular lesions appearing during infancy (defined here as birth to 1 year of age) lend to a broad differential, ranging from benign cutaneous disorders to severe systemic diseases. This review summarizes the pathogenesis, clinical and histopathologic findings, and management options of possible etiologies for annular skin lesions in infants, including annular erythema of infancy, neonatal lupus erythematosus, dermatophyte infections, hemorrhagic edema of infancy, and urticaria multiforme.

Macrophage activation syndrome in a newborn: report of a case associated with neonatal lupus erythematosus and a summary of the literature

BACKGROUND

Macrophage activation syndrome (MAS) is a life-threatening hyperinflammatory syndrome and is caused by a severely dysregulated immune response. It has rarely been associated with neonatal lupus.

CASE PRESENTATION

We present a female neonate with MAS born to a mother who had cutaneous lupus erythematosus with circulating anti-nuclear antibodies (ANA), anti-SSA, anti-SSB and anti-extractable nuclear antigen (anti-ENA) antibodies. Because of neonatal lupus (NLE) with a total atrioventricular block, epicardial pacemaker implantation was required on the sixth day of life. Following surgery she developed non-remitting fever and disseminated erythematous skin lesions. A diagnosis of MAS was made based on these symptoms, with hyperferritinemia, elevated transaminases, hypertriglyceridemia, and a skin biopsy that showed hemophagocytosis. Our patient was treated with steroids for 3 months with good effect. No relapse has occurred.

CONCLUSIONS

MAS is a rare complication of neonatal lupus that may be difficult to diagnose, but needs to be treated promptly. In this article, pathogenesis and overlap of MAS and hemophagocytic lymphohistiocytosis (HLH) has been described. Diagnosis of MAS can be difficult. Different diagnostic criteria are used in both diagnosing MAS and HLH. Validated criteria for diagnosis of MAS in other disease than systemic onset JIA have not been validated yet. In NLE, diagnosing MAS is even more difficult, since skin lesions are already common in NLE. We show the potential additional value of skin biopsy in diagnosing MAS.

Pregnancy outcomes in mixed connective tissue disease: a multicentre study

Objectives

In this study we aimed to investigate foetal and maternal pregnancy outcomes from a large multicentre cohort of women diagnosed with MCTD and anti-U1RNP antibodies.

Methods

This multicentre retrospective cohort study describes the outcomes of 203 pregnancies in 94 consecutive women ever pregnant who fulfilled the established criteria for MCTD with confirmed U1RNP positivity.

Results

The foetal outcomes in 203 pregnancies were as follows: 146 (71.9%) live births, 38 (18.7%) miscarriages (first trimester pregnancy loss of <12 weeks gestation), 18 (8.9%) stillbirths (pregnancy loss after 20 weeks gestation) and 11 (5.4%) cases with intrauterine growth restriction. Maternal pregnancy outcomes were as follows: 8 (3.9%) developed pre-eclampsia, 2 (0.9%) developed eclampsia, 31 (15.3%) developed gestational hypertension and 3 (1.5%) developed gestational diabetes. Women with MCTD and aPL and pulmonary or muscular involvement had worse foetal outcomes compared with those without. Moreover, we report a case of complete congenital heart block (0.45%) and a case of cutaneous neonatal lupus, both born to a mother with positive isolated anti-U1RNP and negative anti-Ro/SSA antibodies.

Conclusion

In our multicentre cohort, women with MCTD had a live birth rate of 72%. While the true frequency of heart block associated with anti-U1RNP remains to be determined, this study might raise the consideration of echocardiographic surveillance in this setting. Pregnancy counselling should be considered in women with MCTD.

Mixed connective tissue disease in pregnancy: A case series and systematic literature review

OBJECTIVE

To investigate the impact of medical and obstetric complications associated with mixed connective tissue disease (MCTD) in pregnancy.

METHOD

We analyzed 68 pregnancies from a systematic literature review and 12 pregnancies affected by MCTD at our centre between 1986 and 2015 for medical and obstetric complications.

RESULTS

During pregnancy 37.1% had active MCTD and 26.7% had relapsed. Maternal complications included caesarean section (31.1%, n = 19), preeclampsia (17.6%, n = 13), thromboembolism events, and death (2.5%, n = 2 for each). Fetal complications included prematurity (48.1%, n = 25), intrauterine growth restriction (38.3%, n = 19), and neonatal lupus (28.6%, n = 18, including chondrodysplasia punctata). More than half (n = 10) of the neonatal lupus cases were explained by anti-U1RNP only. The perinatal mortality rate was 17.7% (n = 14). Pregnant women with active disease had higher rates of prematurity (OR = 7.60; 95%CI [1.93; 29.95]) and perinatal death (OR = 16.83; 95%CI [1.90; 147.70]).

CONCLUSION

MCTD in pregnancy puts women at risk of medical and obstetric complications, and disease activity probably increases this risk.

Autoimmune congenital heart block: complex and unusual situations

Autoimmune congenital heart block (ACHB) is an immune-mediated cardiac disease included among the manifestations collectively referred to as neonatal lupus. The placental transference of maternal Ro/La autoantibodies may damage the conduction tissues during fetal development leading to blocking of signal conduction at the atrioventricular (AV) node in an otherwise structurally normal heart. Irreversible complete AV block is the main cardiac manifestation of ACHB, but some babies may develop endocardial fibroelastosis, valvular insufficiency, and/or frank cardiomyopathies with significantly reduced cardiac function requiring transplant. The severity of ACHB is illustrated by a global mortality rate of 20% and pacemaker rates of at least 64%, often within the first year of life. This review analyses the main complex and/or unusual clinical situations associated with ACHB, including unusual maternal immunological profiles, infrequent maternal autoimmune diseases, cardiac damage unrelated to AV block, fetal invasive management, late complications after birth, risk of congenital heart block (CHB) in ovodonation and in vitro fertilization techniques, the role of maternal features other than autoimmunity, the influence of the birth order or the risk of CHB in twins and triplets.

Congenital lupus with multiorgan involvement: a case report and review of literature

Neonatal lupus erythematosus (NLE) is an autoimmune disease caused by transplacental antibodies that can damage fetal tissue and cause various findings. With the exception of congenital heart block, which can be easily recognized at birth because of neonatal cardiac monitoring during the delivery and immediately after birth, most cases of NLE are recognized within days to weeks of life, but fewer than 10 cases with findings present at birth have been reported. We report the case of a newborn with extensive cutaneous eruption at the time of birth and multisystemic involvement, including hematologic, respiratory, hepatic, and neurologic involvement.

Neonatal lupus syndrome associated with ribonucleoprotein antibodies

Neonatal lupus erythematosus (NLE) is a rare acquired autoimmune disease caused by transplacental transfer of maternal immunoglobulin G antibodies to the fetus. NLE has well-recognized cutaneous features and may also manifest in other organs. The majority of cases are associated with Ro/SSA and La/SSB antibodies. Neonatal lupus due to antiribonucleoprotein (RNP) antibodies has rarely been reported. On rare occasions RNP has been found in association with other antibodies. We report a case of NLE occurring solely due to RNP antibodies presenting as varicelliform lesions at birth. We recorded the features in our case and 14 additional cases identified in the literature. It is important to recognize that maternal transfer of RNP antibodies may produce the classic cutaneous features of neonatal lupus. The limited case reports of this condition suggest that manifestations are limited to the skin; specifically, there are no reports of cardiac involvement. The long-term outcome remains unknown. RNP-positive, Ro/La-negative NLE seems to represent a different clinical subset of NLE. The recognition of RNP antibody NLE as a benign condition limited to the skin is helpful in planning antenatal care for subsequent pregnancies.

Neonatal lupus erythematosus

Neonatal lupus erythematosus (NLE) refers to a clinical spectrum of cutaneous, cardiac, and systemic abnormalities observed in newborn infants whose mothers have autoantibodies against Ro/SSA and La/SSB. The condition is rare and usually benign and self-limited but sometimes may be associated with serious sequelae. We review the pathophysiology, clinical features, and management of infants with this condition. Neonates with NLE should be managed at a tertiary care center. Multidisciplinary team involvement may also be indicated. In mothers with anti-Ro/SSA and/or anti-La/SSB antibodies and infants with congenital heart block, the risk of recurrence in subsequent offspring is 17–25%. Therefore, careful monitoring of subsequent pregnancies with serial ultrasonography and echocardiography is essential.

Congenital lupus erythematosus

Neonatal lupus erythematosus (NLE) is an autoimmune disease affecting the fetus as a result of transplacental transfer of anti-Ro autoantibodies. Typically, it presents in the first few months of life with an annular form of subacute cutaneous lupus erythematosus. We report an unusual case of NLE presenting at birth with scaly erythematous telangiectatic patches and macules with skin atrophy involving the face, head, and upper trunk. Thrombocytopenia was discovered on laboratory investigations. Histopathology of skin biopsy was consistent with subacute cutaneous lupus. The mother was clinically free of disease and had no family history of autoimmune disease. Serology (extra-nuclear antigens) was positive in both the baby and the mother. This is a rare presentation of a rare disease.

Congenital lupus erythematosus presenting at birth with widespread erosions, pancytopenia, and subsequent hepatobiliary disease

Neonatal lupus erythematosus is an uncommon disease caused by transplacental passage of maternal anti-Ro (SS-A), anti-LA (SS-B), or anti-U1RNP antibodies. Cutaneous findings of neonatal lupus are variable, but annular, erythematous plaques occurring within a few weeks of birth are most typical. Cutaneous lesions of congenital onset lupus erythematosus can differ from that of neonatal lupus erythematosus, presenting with atrophy or scarring, and less commonly, erosions. We report an unusual case of congenital lupus erythematosus presenting at birth with widespread erosions, pancytopenia, and subsequent hepatobiliary disease.

Peripartum bilateral uterine rupture in a patient with mixed connective tissue disease with favorable outcome for the severely asphyctic newborn after hypothermia

PURPOSE

Information about fetal and maternal outcome in pregnant women with mixed connective tissue disease (MCTD) is rare and in part contradictory. The purpose of this study is to review published literature about MCTD in pregnancy in the context of a rare case of peripartum bilateral uterine rupture in a patient with MCTD with favorable outcome for the severely asphyctic newborn after hypothermia.

METHOD

The study included a selective literature review based on a PubMed search using the search terms MCTD, Sharp syndrome, uterine rupture and hypothermia, and a detailed report of our case with regard to the MCTD of the patient.

RESULTS

Rupture to the backside of the uterus during delivery, independent of prior cesarean section, was unpredictable and its cause remains unclear. The clinical outcome of the newborn was surprisingly favorable and there were no signs of neurodevelopmental sequelae in spite of the fact that the newborn was asphyctic and had a large excess of acids in the umbilical cord blood gas analysis. The favorable outcome is due to treatment with whole body hypothermia.

CONCLUSIONS

Any type of prior surgery of the uterus puts the patient at risk during delivery. MCTD might be a risk factor during birth. These patients should be followed closely during pregnancy and should deliver at a center, which provides all options for immediate surgical and neonatological intervention.

Pregnancy in Mixed Connective Tissue Disease

This article discusses fetal and maternal morbidity in women who have mixed connective tissue disease.

Congenital lupus erythematosus: case report and review of the literature

Congenital presentation of neonatal lupus erythematous is very rare. We describe an infant who had congenital neonatal lupus erythematosus with atrophic lesions on the face and scarring lesions on the trunk. All radiologic, virologic, and hematologic assays were normal. Skin biopsy specimen and immunofluorescence findings led us to suspect neonatal lupus, a diagnosis confirmed by positivity for anti-Sjörgen syndrome and antinuclear antibodies both in the child and her mother. In this infant, skin manifestations represented the stable and irreversible outcome of an inflammatory stage that occurred during pregnancy.

[Neonatal lupus syndrome]

Neonatal lupus syndrome is a passively acquired autoimmune syndrome in which pathogenic autoantibodies (anti-SSA/Ro, anti-SSB/La, and both, or rarely anti-U(1)RNP antibodies) are transmitted from a mother to her fetus through the placenta. The major clinical manifestations in the infants are cardiac (congenital heart block), dermatologic (skin lesion), hepatic (elevated hepatic enzymes), and hematologic (cytopenia). Congenital complete heart block (CCHB) is irreversible, while noncardiac manifestations are transient, resolving by one-year-old of age without specific treatments. Two prospective studies show that the prevalence of CCHB in children from a woman previously known to have anti-SSA/Ro antibodies is approximately 2%. However, when the previous pregnancy is complicated by CCHB and skin lesion, the recurrence rates of these symptoms go much higher to 10.5% and 26%, respectively, in the subsequent pregnancy.

Hypersensitivity reactions in neonates and infants

Although rare, several hypersensitivity reactions can occur in the infant population. Several types of hypersensitivity reactions are discussed, including urticaria, drug eruptions, erythema multiforme, allergic contact dermatitis, and vasculitis (acute hemorrhagic edema of infancy); neonatal lupus also is discussed. Although most of these conditions are benign, their presentations can be dramatic and a cause of concern for both parents and physicians. Important considerations and differences in the diagnosis and management of these conditions in children under the age of 6 months are discussed.