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Al Atrash E, Azaz A, Said S, Miqdady M. Unique presentation of neonatal liver failure: A case report. World J Clin Pediatr 2024; 13:92263. [PMID: 38947999 PMCID: PMC11212759 DOI: 10.5409/wjcp.v13.i2.92263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/13/2024] [Accepted: 03/14/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Acute fulminant liver failure rarely occurs in the neonatal period. The etiologies include viral infection (15%), metabolic/genetic disease (10%), hematologic disorders (15%), and ischemic injury (5%). Gestational alloimmune liver disease usually manifests as severe neonatal liver failure, with extensive hepatic and extrahepatic iron overload, sparing the reticuloendothelial system. Empty liver failure is a rare cause of liver failure where a patient presents with liver failure in the neonatal period with no hepatocytes in liver biopsy. CASE SUMMARY A 5-week-old male presented with jaundice. Physical examination revealed an alert but deeply icteric infant. Laboratory data demonstrated direct hyperbilirubinemia, a severely deranged coagulation profile, normal transaminase, and normal ammonia. Magnetic resonance imaging of the abdomen was suggestive of perinatal hemochromatosis. Liver biopsy showed histiocytic infiltration with an absence of hepatocytes. No hemosiderin deposition was identified in a buccal mucosa biopsy. CONCLUSION Neonatal liver failure in the absence of hepatocellular regeneration potentially reflects an acquired or inborn defect in the regulation of hepatic regeneration.
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Affiliation(s)
- Eman Al Atrash
- Department of Pediatrics, Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi 971, United Arab Emirates
| | - Amer Azaz
- Department of Pediatrics, Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi 971, United Arab Emirates
| | - Samar Said
- Department of Pathology, Mayo Clinic, Rochester, MN 55905, United States
| | - Mohammad Miqdady
- Department of Pediatrics, Division of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi 971, United Arab Emirates
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2
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Rieneck K, Rasmussen KK, Schoof EM, Clausen FB, Holze H, Bergholt T, Jørgensen MH, Christensen VB, Almaas R, Jordal PL, Locard-Paulet M, Runager K, Nielsen LK, Schlotmann BC, Weischenfeldt JL, Jensen LJ, Dziegiel MH. Hunting for the elusive target antigen in gestational alloimmune liver disease (GALD). PLoS One 2023; 18:e0286432. [PMID: 37862305 PMCID: PMC10588877 DOI: 10.1371/journal.pone.0286432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/16/2023] [Indexed: 10/22/2023] Open
Abstract
The prevailing concept is that gestational alloimmune liver disease (GALD) is caused by maternal antibodies targeting a currently unknown antigen on the liver of the fetus. This leads to deposition of complement on the fetal hepatocytes and death of the fetal hepatocytes and extensive liver injury. In many cases, the newborn dies. In subsequent pregnancies early treatment of the woman with intravenous immunoglobulin can be instituted, and the prognosis for the fetus will be excellent. Without treatment the prognosis can be severe. Crucial improvements of diagnosis require identification of the target antigen. For this identification, this work was based on two hypotheses: 1. The GALD antigen is exclusively expressed in the fetal liver during normal fetal life in all pregnancies; 2. The GALD antigen is an alloantigen expressed in the fetal liver with the woman being homozygous for the minor allele and the father being, most frequently, homozygous for the major allele. We used three different experimental approaches to identify the liver target antigen of maternal antibodies from women who had given birth to a baby with the clinical GALD diagnosis: 1. Immunoprecipitation of antigens from either a human liver cell line or human fetal livers by immunoprecipitation with maternal antibodies followed by mass spectrometry analysis of captured antigens; 2. Construction of a cDNA expression library from human fetal liver mRNA and screening about 1.3 million recombinants in Escherichia coli using antibodies from mothers of babies diagnosed with GALD; 3. Exome/genome sequencing of DNA from 26 presumably unrelated women who had previously given birth to a child with GALD with husband controls and supplementary HLA typing. In conclusion, using the three experimental approaches we did not identify the GALD target antigen and the exome/genome sequencing results did not support the hypothesis that the GALD antigen is an alloantigen, but the results do not yield basis for excluding that the antigen is exclusively expressed during fetal life., which is the hypothesis we favor.
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Affiliation(s)
- Klaus Rieneck
- Laboratory of Blood Genetics, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark
| | - Karen Koefoed Rasmussen
- Laboratory of Blood Genetics, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark
- Department of Technology, Faculty of Health and Technology, University College Copenhagen, Copenhagen, Denmark
| | - Erwin M. Schoof
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Frederik Banch Clausen
- Laboratory of Blood Genetics, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark
| | - Henrietta Holze
- Novo Nordisk Foundation Center for Protein Research, Copenhagen, Denmark
| | - Thomas Bergholt
- Department of Obstetrics and Gynecology, Herlev Hospital, Herlev, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Runar Almaas
- Department of Pediatric Research, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | | | | | - Leif Kofoed Nielsen
- Department of Technology, Faculty of Health and Technology, University College Copenhagen, Copenhagen, Denmark
| | | | | | - Lars Juhl Jensen
- Novo Nordisk Foundation Center for Protein Research, Copenhagen, Denmark
| | - Morten Hanefeld Dziegiel
- Laboratory of Blood Genetics, Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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3
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Mulzer LM, Reutter H, Jüngert J, Knisely AS, Schmid M, Hoerning A, Morhart P. Premature birth associated with a favorable course in gestational alloimmune liver disease (GALD): A case report. Front Pediatr 2023; 11:1104530. [PMID: 37009281 PMCID: PMC10054034 DOI: 10.3389/fped.2023.1104530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/20/2023] [Indexed: 04/04/2023] Open
Abstract
Gestational alloimmune liver disease (GALD) is a rare neonatal disorder with high mortality and morbidity. The patients come to caregivers' attention aged a few hours or days. The disease manifests as acute liver failure with or without siderosis. The differential diagnosis of neonatal acute liver failure (NALF) is broad, including mainly immunologic, infectious, metabolic and toxic disorders. The most common cause, however, is GALD followed by herpes simplex virus (HSV) infection. The best suited pathophysiological paradigm of GALD is that of a maternofetal alloimmune disorder. State of the art treatment combines intravenously administered immunoglobulin (IVIG) with exchange transfusion (ET). We report an infant born at 35 + 2 weeks' gestation in whom GALD had a favorable course, of interest because premature birth in our patient may have exerted protective aspects and lessened morbidity in that intrauterine exposure to maternal complement-fixing antibodies was shortened. The diagnosis of GALD was challenging and difficult. We suggest a modified diagnostic algorithm combining clinical findings with histopathologic findings in liver and lip mucosa and, if available, on abdominal magnetic resonance imaging-study focusing on the liver, spleen, and pancreas. This diagnostic workup must be followed by ET and subsequent administration of IVIG without delay.
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Affiliation(s)
- Linda-Marie Mulzer
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
- Correspondence: Linda-Marie Mulzer
| | - Heiko Reutter
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Jörg Jüngert
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - A. S. Knisely
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Margit Schmid
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - André Hoerning
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), ZSEER, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany
| | - Patrick Morhart
- Department of Pediatrics, University of Erlangen-Nürnberg, Erlangen, Germany
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4
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Demetrian M, Botezatu R, Gică N, Safta V, Grecu G, Dima V, Binișor AD, Panaitescu A. Gestational Alloimune Liver Disease-Case Report. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010066. [PMID: 36670617 PMCID: PMC9857314 DOI: 10.3390/children10010066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 12/29/2022]
Abstract
We describe the case of a newborn with the antenatal onset of hepatic failure, which has been investigated for all etiologies that can cause liver damage: infectious, metabolic, genetic, and immune. The lack of a clear answer regarding the etiology and the response to immunoglobulin therapy led us to the diagnosis of gestational alloimmune liver disease. Gestational alloimunne liver disease is an uncommon and very severe cause of neonatal acute liver failure (NALF). Initially, the therapeutic approach aimed at correcting the effects produced by iron loading, respectively, iron chelators and antioxidants. Since all aspects of this case indicated characteristic features typical for GALD, therapy with intravenous immunoglobulins (IVIG) was introduced. If such therapy alters the prognosis of newborns with GALD, the etiology and pathophysiology remain uncertain. However, in cases regarding severe hepatic failure with the perinatal onset and apparently unknown etiology, immunoglobulin or exchange transfusion therapy should be taken into account even before finalizing all the etiological investigations. The prognosis is uncertain and varies between clinical resolution, chronic hepatitis/cirrhosis, and the need for a hepatic transplant, and overall survival depends on prompt therapeutic intervention.
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Affiliation(s)
| | - Radu Botezatu
- The Obstetrics and Gynecology Department, University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania
| | - Nicolae Gică
- The Obstetrics and Gynecology Department, University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania
| | | | - Georgeta Grecu
- Filantropia Clinical Hospital, 011132 Bucharest, Romania
| | - Vlad Dima
- The Obstetrics and Gynecology Department, University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania
- Correspondence:
| | | | - Anca Panaitescu
- The Obstetrics and Gynecology Department, University of Medicine and Pharmacy Carol Davila, 050474 Bucharest, Romania
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5
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Quelhas P, Jacinto J, Cerski C, Oliveira R, Oliveira J, Carvalho E, dos Santos J. Protocols of Investigation of Neonatal Cholestasis-A Critical Appraisal. Healthcare (Basel) 2022; 10:healthcare10102012. [PMID: 36292464 PMCID: PMC9602084 DOI: 10.3390/healthcare10102012] [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] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/06/2022] [Accepted: 10/08/2022] [Indexed: 11/04/2022] Open
Abstract
Neonatal cholestasis (NC) starts during the first three months of life and comprises extrahepatic and intrahepatic groups of diseases, some of which have high morbimortality rates if not timely identified and treated. Prolonged jaundice, clay-colored or acholic stools, and choluria in an infant indicate the urgent need to investigate the presence of NC, and thenceforth the differential diagnosis of extra- and intrahepatic causes of NC. The differential diagnosis of NC is a laborious process demanding the accurate exclusion of a wide range of diseases, through the skillful use and interpretation of several diagnostic tests. A wise integration of clinical-laboratory, histopathological, molecular, and genetic evaluations is imperative, employing extensive knowledge about each evaluated disease as well as the pitfalls of each diagnostic test. Here, we review the difficulties involved in correctly diagnosing the cause of cholestasis in an affected infant.
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Affiliation(s)
- Patricia Quelhas
- Faculty of Health Sciences, Health Science Investigation Center of University of Beira Interior (CICS-UBI), 6200-506 Covilha, Portugal
| | - Joana Jacinto
- Medicine Department, University of Beira Interior (UBI), Faculty of Health Sciences, 6201-001 Covilha, Portugal
| | - Carlos Cerski
- Pathology Department of Universidade Federal do Rio Grande do Sul (UFRGS), Pathology Service of Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre 90035-903, Brazil
| | - Rui Oliveira
- Centro de Diagnóstico Histopatológico (CEDAP), 3000-377 Coimbra, Portugal
| | - Jorge Oliveira
- Center for Predictive and Preventive Genetics (CGPP), IBMC, UnIGENe, i3S, University of Porto, 4200-135 Porto, Portugal
| | - Elisa Carvalho
- Department of Gastroenterology and Hepatology, Hospital de Base do Distrito Federal, Hospital da Criança de Brasília, Brasília 70330-150, Brazil
| | - Jorge dos Santos
- Faculty of Health Sciences, Health Science Investigation Center of University of Beira Interior (CICS-UBI), 6200-506 Covilha, Portugal
- Correspondence: ; Tel.: +351-911-563
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6
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Ekambaram M, Najar F, Shetty A, Govande V. Newborn with Lethargy, Jaundice, and Coagulopathy. Pediatr Rev 2022; 43:100-103. [PMID: 35102400 DOI: 10.1542/pir.2020-003046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Laboratory results include the following: white blood cell count, 21,600/μL (21.6 × 109/L; reference range, 9,000-30,000/μL [9-30 × 109/L]); hemoglobin, 18.2 g/dL (182 g/L; reference range, 14.0-24.0 g/dL [140-240 g/L]); platelet count, 111 × 103/μL (111 × 109/L; reference range, 150-450 × 103/μL [150-450 × 109/L]); blood type, B+; direct antiglobulin test, negative; and reticulocyte count, 4% (reference range, 3%-7%). Comprehensive metabolic panel is significant for hyponatremia, with a sodium level of 132 mEq/L (132 mmol/L; reference range, 135-145 mEq/L [135-145 mmol/L]). Liver enzyme levels are normal (alanine aminotransferase, 41 U/L [0.68 μkat/L]; aspartate aminotransferase, 86 U/L [1.44 μkat/L]), as are total protein (5.4 g/dL [54 g/L]) and albumin (3.0 g/dL [30 g/L]) levels. Repeated bilirubin level is 12.4 mg/dL (212 µmol/L) at 14 hours after birth, with an elevated direct bilirubin level of 2.9 mg/dL (49.6 µmol/L). Direct or conjugated hyperbilirubinemia is defined as a direct bilirubin level greater than 2 mg/dL (34.2 mmol/L) or more than 20% of total bilirubin. γ-Glutamyl transferase level is normal. Coagulation studies show an elevated prothrombin time of 23.4 seconds (reference range, 11-17 seconds), with an international normalized ratio of 2.1 (reference range, 0.9-1.3); activated partial thromboplastin level is 49.5 seconds (reference range, 30-60 seconds). Fibrinogen level is decreased at 70 mg/dL (0.70 g/L) (reference range, 230-450 mg/dL [230-450 g/L]). Lactate level is 24.3 mg/dL (2.7 mmol/L; reference range, 2.0-26.9 mg/dL [0.22-2.98 mmol/L]). Ammonia level is 96.6 µg/dL (69 μmol/L; reference range, 89.6-149.9 µg/dL [64-107 μmol/L]). Cerebrospinal fluid studies are unremarkable. Magnetic resonance imaging (MRI) of the brain and echocardiography are normal. Ultrasonography of the abdomen shows diffuse hepatic echogenicity. Blood and cerebrospinal fluid cultures are negative. Further testing reveals the diagnosis.
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Affiliation(s)
- Maheswari Ekambaram
- Department of Pediatrics, Baylor Scott & White Medical Center- Round Rock, Round Rock, TX
| | - Fernando Najar
- Division of Neonatology, Department of Pediatrics, Baylor Scott & White Medical Center - Temple, Temple, Texas
| | - Ashith Shetty
- Division of Neonatology, Department of Pediatrics, Baylor Scott & White Medical Center - Temple, Temple, Texas
| | - Vinayak Govande
- Division of Neonatology, Department of Pediatrics, Baylor Scott & White Medical Center - Temple, Temple, Texas
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7
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Chavhan GB, Kamath BM, Siddiqui I, Tomlinson C. Magnetic resonance imaging of neonatal hemochromatosis. Pediatr Radiol 2022; 52:334-339. [PMID: 33710405 DOI: 10.1007/s00247-021-05008-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/15/2020] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
Neonatal hemochromatosis is a rare condition that causes neonatal liver failure, frequently resulting in fetal loss or neonatal death. It is thought that most cases of neonatal hemochromatosis are caused by gestational alloimmune liver disease (GALD), with neonatal hemochromatosis being a phenotype of GALD rather than a disease process. Extrahepatic siderosis in the pancreas, myocardium, thyroid and minor salivary gland is a characteristic feature of neonatal hemochromatosis. There is also sparing of the reticuloendothelial system with no iron deposition in the spleen. Hepatic and extrahepatic siderosis seen in neonatal hemochromatosis is from iron dysregulation secondary to liver damage rather than iron deposition causing the liver damage. The presence of extrahepatic siderosis in the pancreas and thyroid is diagnostic of neonatal hemochromatosis and can be detected noninvasively by multi-echo gradient recalled echo (GRE) T2*-weighted sequence of MRI within hours of birth. This helps to expedite the treatment in the form of intravenous immunoglobulin and exchange transfusion, which improves the survival in these babies. The finding of hepatic siderosis is nonspecific and does not help in the diagnosis of neonatal hemochromatosis because it is seen with other causes of advanced liver disease.
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Affiliation(s)
- Govind B Chavhan
- Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada. .,Medical Imaging Department, University of Toronto, Toronto, ON, Canada.
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Iram Siddiqui
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Christopher Tomlinson
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
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8
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Mugarab-Samedi V, Ryan MD, Awad EHA, Elsharkawy A. The Effect of Prenatal and Postnatal Treatment with Intravenous Immunoglobulin on Severity of Neonatal Hemochromatosis: The Tale of Two Brothers (Case Report). AJP Rep 2021; 11:e102-e104. [PMID: 34221693 PMCID: PMC8245207 DOI: 10.1055/s-0041-1731311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 05/21/2020] [Indexed: 10/30/2022] Open
Abstract
Background Neonatal hemochromatosis (NH) is a rare condition that was the main reason for liver transplantation in infants. With the realization that NH results from the fetal complement-mediated liver injury, intravenous immunoglobulins (IVIG) were successfully introduced for the treatment. Case Presentation We present two cases of NH from the same family to illustrate the role of antenatal treatment with IVIG in alleviation and possible prevention of this serious morbidity. Conclusion A prenatal treatment and early postnatal administration of IVIG are effective ways to manage NH that help to reduce the severity of the symptoms, prevent liver failure, and avoid the need for liver transplantation.
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Affiliation(s)
| | - Michelle D Ryan
- Section of Neonatology, University of Calgary, Calgary, Alberta, Canada
| | | | - Adel Elsharkawy
- Section of Neonatology, University of Calgary, Calgary, Alberta, Canada
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9
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Yeh PJ, Huang SF, Chiang MC, Wang CJ, Lai MW. Efficacy of Intravenous Immunoglobulin/Exchange Transfusion Therapy on Gestational Alloimmune Liver Disease. Front Pediatr 2021; 9:680730. [PMID: 34235125 PMCID: PMC8255369 DOI: 10.3389/fped.2021.680730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Gestational alloimmune liver disease (GALD) is a rare but critical cause of neonatal liver failure. After discovering the maternal-fetal alloimmune mechanism, intravenous immunoglobulin (IVIG) with or without exchange transfusion (ET) has gradually replaced antioxidant cocktails as the first-line therapy. Whether such therapy changes the outcome of neonates with GALD is yet to be defined. Method: We reported a pair of twins with discordant presentations, mild and self-limited in the older, whereas liver failure in the younger, who was successfully rescued by ET and IVIG. To investigate the outcome after therapeutic alteration, 39 cases between 2005 and 2020 from literature research were collected. Results: Half of the collected cases (47.1%) were preterm. Common presentations were ascites, jaundice, respiratory distress, hepatomegaly, and edema. Leading laboratory abnormalities were coagulopathy, hypoalbuminemia, and elevated serum ferritin. Salivary gland biopsy and magnetic resonance imaging detected extrahepatic siderosis in 70% (14/20) and 56% (14/25), respectively. IVIG, ET, and liver transplantation were performed in 19 (48.7%), 15 (38.5%), and 8 (20.5%) patients, respectively. The overall survival (OS) rate and native liver survival (NLS) rate were 64.1% (25/39) and 43.6% (17/39), respectively. Although the compiled results did not support a significant benefit, the OS and NLS were higher in the IVIG with/without ET group compared with those treated with conventional therapy [OS (70 vs. 57.9%) and NLS (55 vs. 31.6%), respectively]. Conclusion: A high index of suspicion for GALD is crucial when facing a neonate with liver failure. Despite no significant influence on the outcome over conventional therapy in such a rare and detrimental disease, IVIG with or without ET can be worth trying before resorting to liver transplantation, which is resource-demanding and technique-challenging in small infants.
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Affiliation(s)
- Pai-Jui Yeh
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shiu-Feng Huang
- Department of Pathology, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan.,Institute of Molecular and Genomic Medicine, National Health Research Institutes, Zhunan, Taiwan
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chao-Jan Wang
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Wei Lai
- Division of Pediatric Gastroenterology, Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Branch and Chang Gung University College of Medicine, Taoyuan, Taiwan.,Liver Research Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
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10
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Abstract
Neonatal acute liver failure (NALF) is a rare disease with a few known primary causes: gestational alloimmune liver disease (GALD), viral infections, metabolic diseases, and ischemic injury. Many cases still do not have a known cause. Laboratory evaluation may suggest a diagnosis. Most of the known causes have disease-specific treatments that improve outcomes. Survival is improving with better knowledge about and treatment options for GALD; however, overall mortality for NALF is still 24%. Liver transplant remains an important option for neonates with an indeterminate cause of NALF and those who do not respond to established treatments.
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Affiliation(s)
- Catherine Larson-Nath
- Pediatric Gastroenterology, Hepatology & Nutrition, University of Minnesota, 2450 Riverside Avenue, Minneapolis, MN 55454, USA
| | - Bernadette E Vitola
- Pediatric Gastroenterology, Hepatology & Nutrition, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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11
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Venkatesh HA, Gupta A. The utility of blood components in the care of sick neonates: An evidence-based review. GLOBAL JOURNAL OF TRANSFUSION MEDICINE 2020. [DOI: 10.4103/gjtm.gjtm_21_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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12
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Tadros HJ, Gupta D, Childress M, Beasley G, Rubrecht AE, Shenoy A, Philip J, Bleiweis MS, Machado DS. Sub-acute neonatal hemochromatosis in an infant with hypoplastic left heart syndrome on ventricular assist device awaiting transplantation. Pediatr Transplant 2019; 23:e13567. [PMID: 31407854 DOI: 10.1111/petr.13567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/10/2019] [Accepted: 07/15/2019] [Indexed: 11/29/2022]
Abstract
Single-ventricle pediatric patients, amongst other children waiting for OHT, are a vulnerable population, especially if candidacy is established before any palliation. NH is a rare disease with poor prognosis in the post-natal period. We present a case of sub-acute NH diagnosed in an infant with HLHS who was listed for OHT while bridged with a pulsatile paracorporeal VAD, with an emphasis on the evolution of the condition throughout the patient's clinical course and the ultimate decision for compassionate deactivation of VAD.
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Affiliation(s)
- Hanna J Tadros
- Congenital Heart Center, Department of Pediatrics, University of Florida, Gainesville, FL, USA.,Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Dipankar Gupta
- Congenital Heart Center, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Megan Childress
- Congenital Heart Center, Department of Pediatrics, University of Florida, Gainesville, FL, USA.,Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Genie Beasley
- Department of Pediatric Gastroenterology, University of Florida, Gainesville, FL, USA
| | - Ashlie E Rubrecht
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, College of Medicine, Gainesville, FL, USA
| | - Archana Shenoy
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, College of Medicine, Gainesville, FL, USA
| | - Joseph Philip
- Congenital Heart Center, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Mark S Bleiweis
- Congenital Heart Center, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Desiree S Machado
- Congenital Heart Center, Department of Pediatrics, University of Florida, Gainesville, FL, USA
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13
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Hemocromatosis neonatal. Diez años en un cambio de paradigma. An Pediatr (Barc) 2019; 91:124-126. [DOI: 10.1016/j.anpedi.2018.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 11/22/2022] Open
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14
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Neonatal haemochromatosis: 10 years into a paradigm shift. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.anpede.2018.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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15
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Abstract
Cholestasis refers to impairment in formation or excretion of bile. This can be due to defects in intrahepatic production of bile, defects in the transmembrane transport of bile, or mechanical obstruction to bile flow. Clinical features of cholestasis reflect the retention of components of bile (bilirubin, bile acids, cholesterol) in the body. In the neonatal period, hyperbilirubinemia can be categorized as either unconjugated (and often benign) hyperbilirubinemia, or conjugated hyperbilirubinemia due to cholestasis. It is for this reason that the first laboratory evaluation in a patient with jaundice, dark urine, and/or acholic stool is a fractionated bilirubin. This article serves as a practical primer for pediatric and neonatology trainees and covers common causes of neonatal cholestasis, as well as the diagnostic work-up and treatment. Causes that are discussed include biliary atresia, idiopathic neonatal hepatitis, gestational alloimmune liver disease, metabolic and genetic diseases, total parenteral nutrition cholestasis, and congenital infection. [Pediatr Ann. 2018;47(11):e433-e439.].
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Chee YY, Wong SCM, Wong MSR. Heterogeneous Presentation of Neonatal Hemochromatosis in Dichorionic Twins. AJP Rep 2018; 8:e332-e334. [PMID: 30464860 PMCID: PMC6246115 DOI: 10.1055/s-0038-1675335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 06/19/2018] [Indexed: 11/30/2022] Open
Abstract
Acute liver failure (ALF) in neonates is rare. Although the incidence is reported to be rare, neonatal hemochromatosis (NH) has to be considered as one of the causes of neonatal ALF. We present a pair of dichorionic twin who had a diverse clinical presentation of NH. One twin passed away despite medical treatment with exchange transfusion and intravenous immunoglobulin (IVIg), whereas the other twin suffered from only mildly deranged liver function, which normalized spontaneously. Early identification of liver failure and clinical awareness of this disease entity are essential to its timely diagnosis and treatment. Antenatal management using IVIg prevents the recurrence of NH in subsequent pregnancies.
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Affiliation(s)
- Yee Yuet Chee
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Siu Chun Mabel Wong
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Ming Sum Rosanna Wong
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong, Hong Kong
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Casas-Alba D, Clotet J, Inarejos EJ, Jou C, Fons C, Molera C. Broadening the spectrum of neonatal hemochromatosis. J Matern Fetal Neonatal Med 2018; 33:1024-1026. [PMID: 30058407 DOI: 10.1080/14767058.2018.1506442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Neonatal hemochromatosis (NH) has been defined as neonatal liver disorder accompanied by extrahepatic siderosis, and gestational alloimmune liver disease (GALD) is the main cause of NH. We report an atypical case of NH that may have gone underdiagnosed. A male infant was born at term after an uneventful antenatal period. At 7 h of life, he was noted to be tachypneic. Chest X-ray was normal and capillary blood gas analysis showed severe lactic acidosis. An extended blood test showed elevated levels of tyrosine and methionine that, after excluding an inborn error of metabolism, led to the diagnosis of acute liver failure. Hyperferritinemia and elevated transferrin saturation were suggestive of NH. Extrahepatic siderosis on MRI confirmed the diagnosis of NH, so even though the infant was in good general condition, a dose of intravenous immunoglobulin was administered and double volume exchange transfusion was performed. Treatment of a suspected case of GALD and prevention in subsequent gestations is imperative.
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Affiliation(s)
- Dídac Casas-Alba
- Pediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Jordi Clotet
- Neonatology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Emilio J Inarejos
- Diagnostic Imaging Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Cristina Jou
- Pathology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Carme Fons
- Pediatric Neurology Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Cristina Molera
- Gastroenterology, Hepatology and Nutrition Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
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Okada N, Sasaki A, Saito J, Mitani Y, Yachie A, Takahashi H, Matsubara S, Tenkumo C, Tanaka H, Hata T, Motomura K, Nagasawa J, Wada Y, Sako M, Yamaguchi K, Matsumoto K, Nakamura H, Sago H, Mizuta K. The Japanese experience and pharmacokinetics of antenatal maternal high-dose immunoglobulin treatment as a prophylaxis for neonatal hemochromatosis in siblings. J Matern Fetal Neonatal Med 2018; 33:142-148. [PMID: 29890876 DOI: 10.1080/14767058.2018.1487940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Background: Neonatal hemochromatosis (NH) is a rare but serious disease causing fulminant hepatic failure. The recurrence rate of NH in a subsequent infant of a mother with an affected infant is 70-90%. Recently, antenatal maternal high-dose intravenous immunoglobulin (IVIG) treatment has been reported to be effective for preventing NH recurrence. However, data on the IgG concentrations during this treatment are limited.Objective: We report a Japanese experience and present a pharmacokinetic simulation model of IgG during IVIG treatment.Methods: Women with histories of pregnancy diagnosed with NH were treated with IVIG weekly from the second trimester until the end of gestation. Serum IgG levels during treatment were collected frequently and pharmacokinetics were simulated by a two-compartment model.Results: Six women were included during eight pregnancies. None experienced severe adverse events. Three out of eight infants showed temporary liver dysfunction, but none required any treatment. A simulation study showed that the estimated trough and peak levels of IgG concentrations during IVIG were 2000-3000 and 4000-5000 mg/dl, respectively.Conclusion: This treatment prevented the recurrence of NH in siblings in Japanese women. We examined the details of serum IgG concentrations and introduced a new pharmacokinetic simulation model of IgG concentrations during IVIG treatment.
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Affiliation(s)
- Noriki Okada
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Aiko Sasaki
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Division of Obstetrics, Tokyo, Japan
| | - Jumpei Saito
- Department of Pharmacy, National Center for Child Health and Development, Tokyo, Japan
| | - Yusuke Mitani
- Perinatal Mother and Infant Care Center, Kanazawa University Hospital, Kanazawa, Japan
| | - Akihiro Yachie
- Department of Pediatrics, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Japan
| | - Shigeki Matsubara
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Japan
| | - Chiaki Tenkumo
- Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Miki, Japan
| | - Hirokazu Tanaka
- Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Miki, Japan
| | - Toshiyuki Hata
- Department of Perinatology and Gynecology, Kagawa University Graduate School of Medicine, Miki, Japan
| | - Kenichiro Motomura
- Department of Allergy and Clinical Immunology, National Center for Child Health and Development, Tokyo, Japan
| | - Junko Nagasawa
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Division of Obstetrics, Tokyo, Japan
| | - Yuka Wada
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Division of Obstetrics, Tokyo, Japan
| | - Mayumi Sako
- Division for Clinical Trials, Department of Clinical Research, Center for Clinical Research and Development, National Center for Child Health and Development, Tokyo, Japan
| | - Koshi Yamaguchi
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Division of Obstetrics, Tokyo, Japan
| | - Kenji Matsumoto
- Department of Allergy and Clinical Immunology, National Center for Child Health and Development, Tokyo, Japan
| | - Hidefumi Nakamura
- Department of Development Strategy, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Division of Obstetrics, Tokyo, Japan
| | - Koichi Mizuta
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
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Taylor SA, Kelly S, Alonso EM, Whitington PF. The Effects of Gestational Alloimmune Liver Disease on Fetal and Infant Morbidity and Mortality. J Pediatr 2018; 196:123-128.e1. [PMID: 29499991 DOI: 10.1016/j.jpeds.2017.12.054] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/14/2017] [Accepted: 12/19/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To evaluate pregnancy outcomes in pedigrees of neonatal hemochromatosis to determine the spectrum of gestational alloimmune liver disease (GALD) in a large cohort. STUDY DESIGN We prospectively collected data from women with a prior offspring with proven neonatal hemochromatosis between 1997 and 2015 and analyzed pregnancy outcomes. RESULTS The pedigrees from 150 women included 350 gestations with outcomes potentially related to GALD. There were 105 live-born infants without liver disease, 157 live-born infants with liver failure, and 88 fetal losses. Fetal loss occurred in 25% of total gestations. Ninety-seven pedigrees contained a single affected offspring, whereas 53 contained multiple affected offspring. Analysis of these 53 pedigrees yielded a per-pregnancy repeat occurrence rate of 95%. Notably, the first poor outcome occurred in the first pregnancy in 60% of pedigrees. Outcomes of the 157 live-born infants with liver failure were poor: 18% survived, 82% died. Of the 134 live-born infants with treatment data, 20 received intravenous immunoglobulin with or without double-volume exchange transfusion of which 9 (45%) survived; 14 infants (10%) received a liver transplant of which 6 (43%) survived. CONCLUSIONS GALD is a significant cause of both fetal loss and neonatal mortality with a high rate of disease recurrence in untreated pregnancies at risk. Poor outcomes related to GALD commonly occur in the first gestation, necessitating a high index of suspicion to diagnose this disorder at first presentation.
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Affiliation(s)
- Sarah A Taylor
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL.
| | - Susan Kelly
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | - Estella M Alonso
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | - Peter F Whitington
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL
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20
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Abstract
BACKGROUND There are limited data on utility of magnetic resonance imaging (MRI) in the assessment of suspected neonatal hemochromatosis (NH). OBJECTIVES The aim of the study was to present our experience with utilization of multi-echo sequence MRI technique in the evaluation of NH and to compare MRI findings in infants with and without NH. METHODS MRI performed for suspected NH were retrospectively reviewed to note the presence and severity of iron deposition (ID) in liver, spleen, pancreas, and kidneys on multi-echo sequences. Findings were compared in infants with and without NH. RESULTS Of 20 infants (9 boys and 11 girls; median age of 12.5 days) included in the study, 7 of 20 had NH and 13 of 20 were assigned to the non-NH group. Higher degree of pancreatic ID was seen in the NH group (P = 0.001) with 4 of 7 evaluable pancreas showing moderate-to-severe degree and 1 of 7 showing mild degree of ID whereas none of the 13 infants in non-NH group showed moderate or severe degree of pancreatic ID. Even though the severity of hepatic ID was higher in NH group (P = 0.033), variable severity of hepatic ID was seen in both groups with most infants in both groups showing moderate-to-severe degree of ID. The severity of splenic ID was not particularly associated with any group (P = 0.774) but there was no moderate or severe degree of ID in NH. Renal ID was seen in two infants in non-NH group. CONCLUSIONS A moderate-to-severe degree of pancreatic ID seen on MRI tends to be associated with NH and should be sought to establish a timely diagnosis of NH. Presence and severity of hepatic ID cannot be used for differentiation of NH from other causes of neonatal liver failure.
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21
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Dubruc E, Nadaud B, Ruchelli E, Heissat S, Baruteau J, Broué P, Debray D, Cordier MP, Miossec P, Russo P, Collardeau-Frachon S. Relevance of C5b9 immunostaining in the diagnosis of neonatal hemochromatosis. Pediatr Res 2017; 81:712-721. [PMID: 28085791 DOI: 10.1038/pr.2017.8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 12/04/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Neonatal hemochromatosis caused by a gestational alloimmune mechanism or gestational alloimmune liver disease (GALD) is a rare perinatal disorder characterized by intra- and extrahepatic iron overload. It is believed to result from complement-mediated liver injury, in which the classical complement pathway is activated by maternal antibody/fetal antigen complexes, leading to hepatocyte lysis by the membrane attack complex C5b9. According to some authors, C5b9 expression in more than 75% of liver parenchyma is specific for GALD. METHODS We conducted a retrospective multicentric immunohistochemical study with anti-C5b9 in GALD cases (n = 25) and non-GALD cases with iron overload (n = 36) and without iron overload (n = 18). RESULTS C5b9 was expressed in 100% of GALD cases but involved more than 75% of the liver parenchyma in only 26% of the cases. C5b9 was detected in 26.75% of the non-GALD cases with more than 75% of positive parenchyma in maternal erythrocytic alloimmunization, herpes and enterovirus hepatitis, bile acid synthetic defect, DGUOK mutation, Gaucher disease, cystic fibrosis, and giant-cell hepatitis with autoimmune hemolytic anemia. CONCLUSION Diagnosis and therapeutic management of GALD cannot only be based on C5b9 expression in liver samples as it is not specific of this disease.
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Affiliation(s)
- Estelle Dubruc
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Béatrice Nadaud
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Eduardo Ruchelli
- Department of pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sophie Heissat
- Department of pediatrics, Hôpital Femme-Mère-Enfant, CHU de Lyon, France
| | - Julien Baruteau
- Pediatric Hepatology and Inborn Metabolic Diseases Unit, University Children's Hospital, Toulouse, France
| | - Pierre Broué
- Pediatric Hepatology and Inborn Metabolic Diseases Unit, University Children's Hospital, Toulouse, France
| | - Dominique Debray
- Department of Pediatric Surgery, Hepatology, and Transplantation, Necker Enfants Malades Hospital, Paris, France
| | | | - Pierre Miossec
- Department of immunology, Hôpital Edouard Herriot, CHU de Lyon, France.,Université Claude Bernard Lyon 1, France
| | - Pierre Russo
- Department of pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sophie Collardeau-Frachon
- Department of pathology, Hôpital Femme-Mère-Enfant, CHU de Lyon, France.,Université Claude Bernard Lyon 1, France.,SOFFOET, Société Française de Foetopathologie, Paris, France
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22
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Ileal atresia and multiple jejunal perforations in a premature neonate with gestational alloimmune liver disease. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2017. [DOI: 10.1016/j.epsc.2017.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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23
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Abstract
OBJECTIVE Acute liver failure (ALF) in early infancy is rare and challenging to recognize and manage. We aim to describe the presentation and outcome of infants with ALF according to their final aetiology to elucidate features to facilitate early recognition leading to prompt diagnosis and management. METHODS All infants presenting within 120 days from birth with liver failure were included in a retrospective review over a 19-year period. The aetiology, clinical features, presenting investigations, and outcome were collected. RESULTS Seventy-eight young infants presented with ALF. The aetiology was established in 94% and included metabolic disease (36%), hypoxic-ischaemic (HI) insult (19%), infection (17%), neonatal haemochromatosis (9%), and infiltrative disease (9%). Infections, infiltrative disease, and acute HI insult usually resulted in higher transaminases and international normalized ratio, whereas neonatal haemochromatosis and tyrosinaemia were characterized by lower or near normal transaminases. Overall jaundice was not visible in 24% of infants at presentation. Forty-five (58%) infants were alive at discharge from hospital. Survival at 1 year was 53% and survival with native liver 50%. Later deaths occurred in infants with mitochondrial disease. Six infants received a liver transplant and 4 subsequently died from their underlying disease. CONCLUSION ALF should be considered in any young infant with a coagulopathy as transaminases and/or bilirubin levels can be near normal at presentation. Better intensive care and the judicious use of liver transplantation may have contributed to the improved outcomes for this group compared with previous decades.
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25
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Shimono A, Imoto Y, Sakamoto H, Chiba Y, Matsumoto K, Kawauchi M, Kusaka T, Tanaka H, Hata T, Kushida Y, Ueno M. An immunohistochemical study of placental syncytiotrophoblasts in neonatal hemochromatosis. Placenta 2016; 48:49-55. [PMID: 27871472 DOI: 10.1016/j.placenta.2016.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 09/27/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Neonatal hemochromatosis (NH) is a rare neonatal disorder that results in liver cirrhosis with hemosiderin deposition in the liver and other organs, similarly to hereditary hemochromatosis. Excess iron is transferred from the mother to fetus through the placenta in NH. We examined the expression of iron metabolism-related substances in placental syncytiotrophoblasts (STB) by immunostaining to clarify how the transfer of iron through STB increases in NH. METHODS Immunostaining was performed using formalin-fixed, paraffin-embedded sections of placentae from three NH cases, four gestational age-matched controls, and, depending on the antibody examined, five to seven full-term controls. The reactivity of immunostaining was assessed by averages of scores assigned by 3 researchers. RESULTS On the microvillar surface of STB, the reactions of the antibodies against transferrin receptor 1 (TFR1), transferrin, ferritin, hepcidin, ferroportin, divalent metal transporter-1 (DMT1), hephaestin, and HFE were stronger in NH than in controls. In the cytoplasm, the reactions of antibodies against TFR1, transferrin, ferritin, hepcidin, DMT1, hephaestin, HFE, and ZIP 14 were stronger in NH than in gestational age-matched controls. Among these reactions, those of anti-TFR1 antibody on the surface of STB in NH was especially marked. DISCUSSION In the placenta of NH, increases in expressions of TFR1, transferrin, and ferritin of which those of TFR1 were especially marked, reflect increased iron influx from the mother to fetus. The hepcidin observed on the surface and in the cytoplasm of STB of NH is suggested to be from the mother, possibly to compensate for the decreased fetal liver-derived hepcidin.
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Affiliation(s)
- Aiko Shimono
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Yuko Imoto
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Haruhiko Sakamoto
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan.
| | - Yoichi Chiba
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Koichi Matsumoto
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Machi Kawauchi
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Hirokazu Tanaka
- Department of Perinatal Medicine, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Toshiyuki Hata
- Department of Perinatal Medicine, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Yoshio Kushida
- Division of Diagnostic Pathology, Kagawa University Hospital, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
| | - Masaki Ueno
- Inflammation Pathology, Department of Pathology and Host Defense, Faculty of Medicine, Kagawa University, 1750-1, Ikenobe, Mikicho, Kitagun, Kagawa Prefecture 761-0793, Japan
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Okada N, Ihara Y, Urahashi T, Sanada Y, Yamada N, Hirata Y, Tashiro M, Katano T, Ushijima K, Otomo S, Takahashi H, Matsubara S, Mizuta K. Antenatal immunoglobulin for prevention of neonatal hemochromatosis. Pediatr Int 2016; 58:1059-1061. [PMID: 27507570 DOI: 10.1111/ped.13028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 04/13/2016] [Accepted: 04/20/2016] [Indexed: 11/27/2022]
Abstract
Neonatal hemochromatosis (NH) is a rare disease with a poor prognosis, particularly prior to 2008. Antenatal maternal high-dose immunoglobulin (Ig) is effective in preventing NH recurrence, but the adverse effects of this treatment have not been documented as yet. Here, we report on a patient who underwent high-dose Ig treatment to prevent NH recurrence. The patient was a 31-year-old pregnant Japanese woman. Her first child died of NH after receiving living donor liver transplantation. The patient received high-dose Ig treatment to prevent recurrence of NH from gestational weeks 16 to 35. During the treatment, platelet count gradually decreased, and cesarean section was required at 35 gestational weeks. The child did not develop liver failure. High-dose Ig prevented the recurrence of NH. Caution should be exercised due to possible adverse effects of this treatment.
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Affiliation(s)
- Noriki Okada
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan.
| | - Yoshiyuki Ihara
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Taizen Urahashi
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Yukihiro Sanada
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Naoya Yamada
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Yuta Hirata
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Masahisa Tashiro
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Takumi Katano
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Kentaro Ushijima
- Department of Pharmacy, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shinya Otomo
- Department of Clinical Pharmacy, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Shigeki Matsubara
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Koichi Mizuta
- Department of Transplant Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
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27
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Choi SJ, Choi JS, Chun P, Yoo JK, Moon JS, Ko JS, Kim WS, Kang GH, Yi NJ. Living Related Liver Transplantation in an Infant with Neonatal Hemochromatosis. Pediatr Gastroenterol Hepatol Nutr 2016; 19:147-51. [PMID: 27437193 PMCID: PMC4942314 DOI: 10.5223/pghn.2016.19.2.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/15/2015] [Accepted: 08/12/2015] [Indexed: 11/18/2022] Open
Abstract
Neonatal hemochromatosis (NH) is a severe neonatal liver injury that is confirmed by extra-hepatic iron accumulation. Although a recent study described treating NH with exchange transfusions and intravenous immunoglobulin, liver transplantation should be considered for patients with severe liver failure that does not respond to other medical treatment. Herein, we report the case of a two-month-old female infant who presented with persistent ascites and hyperbilirubinemia. Her laboratory findings demonstrated severe coagulopathy, high indirect and direct bilirubin levels, and high ferritin levels. Abdominal magnetic resonance imaging presented low signal intensity in the liver on T2-weighted images, suggesting iron deposition. The infant was diagnosed with NH as a result of the clinical findings and after congenital infection and metabolic diseases were excluded. The infant was successfully treated with a living-donor liver transplantation. Living related liver transplantation should be considered as a treatment option for NH in infants.
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Affiliation(s)
- Shin Jie Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jong Sub Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Peter Chun
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jung Kyung Yoo
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jin Soo Moon
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Woo Sun Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Gyeong Hoon Kang
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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28
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Taylor SA, Whitington PF. Neonatal acute liver failure. Liver Transpl 2016; 22:677-85. [PMID: 26946058 DOI: 10.1002/lt.24433] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/16/2016] [Accepted: 02/24/2016] [Indexed: 12/23/2022]
Abstract
Neonatal acute liver failure (NALF) is a rare disease about which there is little published data; however, NALF is an extremely important condition as it is distinct from acute liver failure seen in older children and adults. First, unlike acute liver failure in older patients, NALF can be diagnosed in an infant with cirrhosis. This is due to the fetal-neonatal continuum of liver disease, or the principle that neonatal liver failure may be the result of a liver disease that began in utero. Further differences exist in the mechanism of disease, diagnostic principles, and the common etiologies of NALF when compared with pediatric and adult acute liver failure. This review will address many of the distinguishing features of NALF and focus on the most common etiologies of NALF, including gestational alloimmune liver disease (GALD), the most common cause of NALF. Additionally, this review will provide insight into the pathogenesis, diagnosis, and treatment of this rare condition. Liver Transplantation 22 677-685 2016 AASLD.
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Affiliation(s)
- Sarah A Taylor
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Peter F Whitington
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Clarke NE, Gilby D, Savoia H, Oliver MR, Rogerson S. Fulminant liver failure in a neonate. J Paediatr Child Health 2016; 52:338-341. [PMID: 27124844 DOI: 10.1111/jpc.13090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 09/13/2015] [Accepted: 10/19/2015] [Indexed: 11/27/2022]
Abstract
Neonatal acute liver disease is relatively rare, with multiple different aetiologies including congenital infections, metabolic disorders, gestational alloimmune liver disease, haemophagocytic lymphohistiocytosis, and ischaemic injury. We report a case of neonatal liver failure in a preterm, growth-restricted infant, who underwent extensive investigation and was clinically diagnosed with gestational alloimmune liver disease, which was confirmed on post-mortem examination. We then discuss management of neonatal liver failure and gestational alloimmune liver disease, including maternal management in future pregnancies.
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Affiliation(s)
- Naomi E Clarke
- Department of Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Damien Gilby
- Department of Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Helen Savoia
- Department of Clinical Haematology, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Mark R Oliver
- Department of Gastroenterology, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Women's Research Institute, Melbourne, Victoria, Australia
| | - Sheryle Rogerson
- Department of Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia
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Hemocromatosis neonatal: otra entidad que deja de ser huérfana. Avances en el diagnóstico y manejo de la principal causa de fallo hepático agudo neonatal. An Pediatr (Barc) 2015; 83:218.e1-3. [DOI: 10.1016/j.anpedi.2015.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 02/09/2015] [Indexed: 11/17/2022] Open
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Molera Busoms C, Quintero Bernabeu J, Martín de Carpi J. Neonatal hemochromatosis: Another entity that is no longer orphan. Advances in the diagnosis and management of the main cause of neonatal acute liver failure. An Pediatr (Barc) 2015. [DOI: 10.1016/j.anpede.2015.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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32
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HEPATITIS ALOINMUNE FETAL. REVISTA MÉDICA CLÍNICA LAS CONDES 2015. [DOI: 10.1016/j.rmclc.2015.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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33
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Roumiantsev S, Shah U, Westra SJ, Misdraji J. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 20-2015. A Newborn Girl with Hypotension, Coagulopathy, Anemia, and Hyperbilirubinemia. N Engl J Med 2015; 372:2542-53. [PMID: 26107055 DOI: 10.1056/nejmcpc1404334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Sheflin-Findling S, Annunziato RA, Chu J, Arvelakis A, Mahon D, Arnon R. Liver transplantation for neonatal hemochromatosis: analysis of the UNOS database. Pediatr Transplant 2015; 19:164-9. [PMID: 25557040 DOI: 10.1111/petr.12418] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2014] [Indexed: 11/27/2022]
Abstract
NH is the most common identifiable cause of ALF in the neonate. LT is the definitive treatment for neonates with NH who have failed medical therapy. Our aim was to determine the outcomes of LT in infants with NH. Patients (less than one yr of age) with NH who were listed for LT and patients who underwent LT between 1994 and 2013 were identified from the UNOS database for analysis. Risk factors for death and graft loss were analyzed by multivariate logistic regression. Thirty-eight infants with NH with a total of 43 transplants were identified. One- and five-yr patient and graft survival were 84.2%, 81.6%, 71.1%, and 68.4%, respectively. The outcomes for NH were not significantly different when compared to the same age-matched recipients with other causes of ALF. There were no statistically significant risk factors identified for graft loss or death. Ninety infants with NH were listed for LT. Reasons for removal included transplanted (49%), death (27%), too sick to transplant (7%), and improved status (13%). LT for infants with NH has a high rate of graft loss and death; however, outcomes are comparable to the same age-matched recipients with other causes of ALF.
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Affiliation(s)
- Shari Sheflin-Findling
- Division of Pediatric Hepatology, Mount Sinai Medical Center, New York, NY, USA; Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY, USA
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Heissat S, Collardeau-Frachon S, Baruteau J, Dubruc E, Bouvier R, Fabre M, Cordier MP, Broué P, Guigonis V, Debray D. Neonatal hemochromatosis: diagnostic work-up based on a series of 56 cases of fetal death and neonatal liver failure. J Pediatr 2015; 166:66-73. [PMID: 25444000 DOI: 10.1016/j.jpeds.2014.09.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 08/14/2014] [Accepted: 09/18/2014] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To define an algorithm to improve diagnosis of neonatal hemochromatosis (NH) related to gestational alloimmune liver disease (GALD), which is diagnosed by immunohistochemistry demonstrating activated complement at hepatocytes (IDACH). STUDY DESIGN We assessed 56 instances of fetal death or neonatal liver failure (NLF; 2006-2009), 29 (7 stillborns, 22 NLF) with NH, and 27 (5 stillborns, 22 NLF) without NH (non-NH). Immunohistochemistry was retrospectively performed in 21 cases. Cases were grouped as follows: (1) GALD as demonstrated by IDACH (n = 17); (2) indeterminate for GALD (n = 28); or (3) alternate diagnosis found (n = 11). We compared cases of immunohistochemically proven GALD with those with an alternate diagnosis. RESULTS Of the 12 stillborns, 7 had NH because of GALD (NH-GALD), one was undeterminate, and 4 had alternate diagnoses (GALD excluded). Of the 22 newborns with NH, 6 had NH-GALD, one had mitochondrial respiratory chain disorder (MRCD), and 15 were indeterminate for GALD. Of 22 non-NH newborns, extrahepatic siderosis (EHS) was not assessed in 13 (3 GALD, 1 alternate diagnosis [MRCD] and 9 indeterminate GALD) and excluded in 9 (5 alternate diagnoses and 4 indeterminate GALD). The only clinical features found to be associated with GALD were intrafamilial recurrence, prematurity, and EHS. CONCLUSIONS In unexplained fetal death or NLF, the diagnosis of subsets of NH requires tissue analysis (autopsy) to assess EHS. In patients with NH, if MRCD is ruled out, NH-GALD is likely. The rate of IDACH in the diagnosis of GALD in cases without NH requires further study.
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Affiliation(s)
- Sophie Heissat
- Department of Pediatric Gastroenterology and Hepatology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France.
| | - Sophie Collardeau-Frachon
- Department of Pathology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France
| | - Julien Baruteau
- Department of Pediatric Hepatology and Metabolic Diseases, CHU Toulouse, Toulouse, France
| | - Estelle Dubruc
- Department of Pathology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France
| | - Raymonde Bouvier
- Department of Pathology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon et Université Lyon 1, Lyon, France
| | | | | | - Pierre Broué
- Department of Pediatric Hepatology and Metabolic Diseases, CHU Toulouse, Toulouse, France
| | - Vincent Guigonis
- Department of Pediatrics, Hôpital Mère et Enfant, CHU Limoges, Limoges, France
| | - Dominique Debray
- Medical-Surgical Center, Hepatology, and Transplantation AP-HP, Hôpital Necker Enfants Malades, Paris, France
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Transient neonatal liver disease after maternal antenatal intravenous Ig infusions in gestational alloimmune liver disease associated with neonatal haemochromatosis. J Pediatr Gastroenterol Nutr 2014; 59:629-35. [PMID: 25079484 DOI: 10.1097/mpg.0000000000000514] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Neonatal haemochromatosis is a rare gestational disease that results in severe foetal liver disease with extrahepatic iron overload, sparing the reticuloendothelial system. Recurrence can be prevented with intravenous immunoglobulin (IVIG) infusions during pregnancy, supporting an alloimmune aetiology. The aim of the study was to assess the effect of antenatal treatment with IVIG infusion on the outcome of pregnancies in women with a history of documented neonatal haemochromatosis likely owing to gestational alloimmune disease and to analyse IVIG tolerance. METHODS From 2004 to 2012, 8 pregnant women were treated with IVIG at 1 g/kg body weight weekly from 18 weeks' gestation until birth in a prospective multicentre study. RESULTS All 8 neonates born to the treated women survived. Five developed mild neonatal liver disease with hepatomegaly (n = 1), hyperechogenic liver (n = 2), abnormal liver function tests (n = 1), raised serum ferritin (n = 3) and α-fetoprotein (n = 5) levels, or mild iron overload on liver magnetic resonance imaging (n = 1). Ferritin and α-fetoprotein levels normalised before 14 days and 2 months, respectively. A per-mother-basis analysis comparing outcomes of treated (n = 8) and untreated (n = 9) gestations showed a significant improvement in the survival of neonates with gestational IVIG therapy (survival 8/8 vs 0/9, P < 0.001). Adverse effects of IVIG infusion occurred in 5 mothers leading to discontinuation of treatment in 1 case. Preterm neonates born before 37 weeks' gestation had a decreased risk of neonatal liver disease (P = 0.04). CONCLUSIONS Antenatal treatment with IVIG infusion in women at risk for gestational alloimmune disease recurrence improves the outcome of pregnancies despite mild signs of transient neonatal liver disease.
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Agrawal S, Dhiman RK. Hepatobiliary quiz-9 (2014). J Clin Exp Hepatol 2014; 4:81-4. [PMID: 25755542 PMCID: PMC4188737 DOI: 10.1016/j.jceh.2014.03.054] [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: 12/12/2022] Open
Affiliation(s)
| | - Radha K. Dhiman
- Address for correspondence: Radha K. Dhiman, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Schwaibold EMC, Bartels I, Küster H, Lorenz M, Burfeind P, Adam R, Zoll B. De novo duplication of chromosome 16p in a female infant with signs of neonatal hemochromatosis. Mol Cytogenet 2014; 7:7. [PMID: 24456940 PMCID: PMC3905920 DOI: 10.1186/1755-8166-7-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 01/21/2014] [Indexed: 11/10/2022] Open
Abstract
Reported cases of "pure" duplication of the entire short arm of chromosome 16 (16p) are rare, with only 7 patients described in the literature. We report on a female infant with de novo 16p duplication localized to the short arm of chromosome 6, detected by chromosomal analysis and characterized by array CGH and fluorescence in situ hybridization. This baby girl presented with clinical symptoms characteristic of patients with duplications of the short arm of chromosome 16: psychomotor retardation, constitutional growth delay and specific dysmorphic features, including proximally placed hypoplastic thumbs. In addition, she exhibited evidence of neonatal hemochromatosis as shown by direct hyperbilirubinemia, iron overload and elevated liver enzyme levels. To our knowledge, this is the first report of signs of neonatal hemochromatosis in a patient with 16p duplication.
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Abstract
Neonatal hemochromatosis is a clinical condition in which severe liver disease in the newborn is accompanied by extrahepatic siderosis. Gestational alloimmune liver disease (GALD) has been established as the cause of fetal liver injury resulting in nearly all cases of NH. In GALD, a women is exposed to a fetal antigen that she does not recognize as "self" and subsequently begins to produce IgG antibodies that are directed against fetal hepatocytes. These antibodies bind to fetal liver antigen and activate the terminal complement cascade resulting in hepatocyte injury and death. GALD can cause congenital cirrhosis or acute liver failure with and without iron overload and siderosis. Practitioners should consider GALD in cases of fetal demise, stillbirth, and neonatal acute liver failure. Identification of infants with GALD is important as treatment is available and effective for subsequent pregnancies.
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Affiliation(s)
- Amy G. Feldman
- Address for correspondence. Amy G. Feldman, MD, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 57, Chicago, IL 60611-2605, United States. Tel.: +1 312 227 7600; fax: +1 312 227 9645.
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Lopriore E, Mearin ML, Oepkes D, Devlieger R, Whitington PF. Neonatal hemochromatosis: management, outcome, and prevention. Prenat Diagn 2013; 33:1221-5. [PMID: 24030714 DOI: 10.1002/pd.4232] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 08/30/2013] [Accepted: 08/31/2013] [Indexed: 12/25/2022]
Abstract
Neonatal hemochromatosis (NH) is a rare disorder but the most common cause of acute liver failure in neonates. NH is characterized by severe hepatic injury and iron overload and is associated with high perinatal mortality and morbidity rates. NH is often preceded by oligohydramnios and intrauterine growth restriction, suggesting an important impact of NH during fetal life. Stillbirth and prematurity are not uncommon. During the last decade, major discoveries on the etiology of NH have radically changed the management and outcome of this disease. NH is now regarded as an alloimmune disease and is, as such, often referred to as gestational alloimmune liver disease. Antenatal treatment with intravenous immunoglobulins starting at 14 weeks' gestation has been shown to prevent the development of NH in subsequent pregnancies. Postnatal treatment, previously based on the use of anti-oxidants and chelation therapy, has now successfully been replaced by exchange transfusions and intravenous immunoglobulins substitution. This review summarizes the latest discoveries on the etiology of NH and the new recommendations concerning its management and prevention.
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Affiliation(s)
- Enrico Lopriore
- Division of Neonatology and Gastroenterology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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41
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Hutchings G, Williams O, Sokal E, Wittington PF. Plasmapheresis as an alternative to high-dose intravenous immunoglobulin in the prevention of gestational alloimmune liver disease. Fetal Diagn Ther 2013; 34:180-3. [PMID: 23860191 DOI: 10.1159/000351283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/03/2013] [Indexed: 11/19/2022]
Abstract
Gestational alloimmune liver disease occurs due to trans-placental passage of maternal antibodies to a fetal hepatocyte antigen that produces complement-mediated hepatocyte injury. High-dose intravenous immunoglobulin therapy during gestation is highly effective at decreasing the risk to the neonate but treatment is expensive. This case presents for the first time the use of plasmapheresis as a potential cheaper alternative when treatment with immunoglobulins is unavailable.
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Affiliation(s)
- Graham Hutchings
- Department of Obstetrics, Cliniques Universitaires St Luc, Brussels, Belgium
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42
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Management of acute liver failure in infants and children: Consensus statement of the pediatric gastroenterology chapter, Indian academy of pediatrics. Indian Pediatr 2013; 50:477-82. [DOI: 10.1007/s13312-013-0147-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Babor F, Hadzik B, Stannigel H, Mayatepek E, Hoehn T. Successful management of neonatal hemochromatosis by exchange transfusion and immunoglobulin: a case report. J Perinatol 2013; 33:83-5. [PMID: 23269232 DOI: 10.1038/jp.2012.9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Neonatal hemochromatosis (NH) is a rare and severe liver disease of mainly intra-uterine onset, characterized by neonatal liver failure, hepatic and extrahepatic iron accumulation. This leads to an altered iron metabolism with resulting siderosis. The disease represents the most common cause of liver failure in neonates and is also the most common indication for neonatal liver transplantation. We present a case of a newborn diagnosed with NH and life threatening liver failure. Initial treatment consisted of chelation therapy and antioxidants, but lack of laboratory and clinical improvement led to an exchange transfusion followed by the singular substitution of intravenous immunoglobulin (IVIG). Both, exchange transfusion and IVIG were tolerated well and led to an improvement of the general condition of the patient and recovery of liver synthetic function. The subsequent favorable course of the disease is described in this case report.
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Affiliation(s)
- F Babor
- Department for Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Heinrich Heine-University, Düsseldorf, Germany.
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Collardeau-Frachon S, Heissat S, Bouvier R, Fabre M, Baruteau J, Broue P, Cordier MP, Debray D, Debiec H, Ronco P, Guigonis V. French retrospective multicentric study of neonatal hemochromatosis: importance of autopsy and autoimmune maternal manifestations. Pediatr Dev Pathol 2012; 15:450-70. [PMID: 22901025 DOI: 10.2350/12-02-1155-oa.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Neonatal hemochromatosis is a rare disease that causes fetal loss and neonatal death in the 1st weeks of life and is one of the most common causes of liver failure in the neonate. The diagnosis is mostly made retrospectively, based on histopathologic features of severe liver fibrosis associated with hepatic and extrahepatic siderosis. Several etiologies may underlie this phenotype, including a recently hypothesized gestational alloimmune disease. Fifty-one cases of liver failure with intrahepatic siderosis in fetuses and neonates were analyzed retrospectively. Maternal and infant data were collected from hospitalization and autopsy reports. All available slides were reviewed independently by 3 pathologists. Immunologic studies were performed on maternal sera collected immediately after delivery. The diagnosis of neonatal haemochromatosis was retained in 33 cases, including 1 case with Down syndrome and 1 case with myofibromas. Liver siderosis was inversely proportional to fibrosis progression. In fetuses, iron storage was more frequent in the thyroid than in the pancreas. Perls staining in labial salivary glands was positive in 1 of 5 cases. Abnormal low signal intensity by magnetic resonance imaging was detected in the pancreas in 2 of 7 cases. Renal tubular dysgenesis was observed in 7 of 23 autopsy cases. Chronic villitis was seen in 7 of 15 placentas. Half of the mothers presented with an autoimmune background and/or autoantibodies in their sera. Our work highlights the importance of autopsy in cases of neonatal hemochromatosis and marshals additional data in support of the hypothesis that neonatal hemochromatosis could reflect maternal immune system dysregulation.
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Glomérulopathie extramembraneuse par immunisation immunisationmaterno-fœtale. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2012. [DOI: 10.1016/s0001-4079(19)31687-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Baruteau J, Heissat S, Collardeau-Frachon S, Debray D, Broué P, Guigonis V. Nouveaux concepts dans l’hémochromatose périnatale. Arch Pediatr 2012; 19:755-61. [DOI: 10.1016/j.arcped.2012.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 03/13/2012] [Accepted: 04/11/2012] [Indexed: 11/28/2022]
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48
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Bonilla S, Prozialeck JD, Malladi P, Pan X, Yu S, Melin-Aldana H, Whitington PF. Neonatal iron overload and tissue siderosis due to gestational alloimmune liver disease. J Hepatol 2012; 56:1351-5. [PMID: 22322235 DOI: 10.1016/j.jhep.2012.01.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 01/06/2012] [Accepted: 01/16/2012] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Gestational alloimmune liver disease is the main cause of the neonatal hemochromatosis phenotype, wherein severe neonatal liver disease is associated with iron overload and extrahepatic tissue siderosis. How fetal liver disease produces extrahepatic siderosis is not known. We hypothesized that fetal liver injury causes deficient hepcidin production and poor regulation of placental iron flux. Under the resulting conditions of iron overload, the tissue pattern of extrahepatic siderosis is determined by the normal expression of proteins involved in the import of non-transferrin-bound iron and the export of cellular iron. METHODS Liver and extrahepatic tissues from infants with gestational alloimmune liver disease were examined and compared to normal age-appropriate tissues. RESULTS Serum iron indices indicate iron overload and excess non-transferrin bound iron in gestational alloimmune liver disease. The diseased liver showed significantly reduced hepcidin, hemojuvulin, and transferrin gene expression compared to the normal fetal and neonatal liver. Those extrahepatic tissues that are typically involved in pathological siderosis in neonatal hemochromatosis, whether from normal or diseased newborns, consistently expressed solute carrier family 39 (zinc transporter), member 14 (ZIP14) for non-transferrin-bound iron uptake and expressed little ferroportin for iron export. CONCLUSIONS Excess non-transferrin-bound iron in gestational alloimmune liver disease may result from fetal liver injury that causes reduced synthesis of key iron regulatory and transport proteins. Whereas, the pattern of extrahepatic siderosis appears to be determined by the normal capacity of various tissues to import non-transferrin-bound iron and not export cellular iron.
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Affiliation(s)
- Silvana Bonilla
- Children's Memorial Research Center, The Feinberg School of Medicine of Northwestern University, Chicago, IL 60614, USA
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49
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Tanaka H, Haba R, Itoh S, Sakamoto H, Hata T. Prenatal high-dose immunoglobulin treatment for neonatal hemochromatosis: A case report and review of the literature. J Obstet Gynaecol Res 2011; 37:1891-4. [DOI: 10.1111/j.1447-0756.2011.01680.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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50
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Whitington PF, Pan X, Kelly S, Melin-Aldana H, Malladi P. Gestational alloimmune liver disease in cases of fetal death. J Pediatr 2011; 159:612-6. [PMID: 21592512 DOI: 10.1016/j.jpeds.2011.03.048] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 02/21/2011] [Accepted: 03/22/2011] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To determine whether alloimmune liver disease can be identified as a cause of fetal death. STUDY DESIGN This is a retrospective examination of the autopsy tissue of 6 stillborn fetuses and 2 extreme preterm infants (gestational age, 20 to 34 weeks) drawn from families referred for suspected neonatal hemochromatosis. Thirteen appropriate nondisease controls and 8 cases of neonatal acute liver failure with known etiology were also examined. Liver sections were immunostained using anti-human C5b-9 complex. RESULTS All of the study cases had died with no preceding evidence of fetal distress. Histopathology showed findings of acute liver injury, including global hepatocyte necrosis with minimal reticulum collapse and no fibrosis. Hepatocytes in cases stained strongly positively for C5b-9 complex, suggesting premortem lgG complement-mediated liver injury. Hepatocytes in acute liver failure case controls did not demonstrate a similar mechanism of liver injury. CONCLUSIONS Alloimmune liver disease is sometimes associated with fetal death.
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Affiliation(s)
- Peter F Whitington
- Children's Memorial Research Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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