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Ro antibodies and review of the literature
Neonatal Lupus: Follow-up in infants with anti-SSA/Ro antibodies and review of the literature Antonio Alberto Zuppa, Riccardo Riccardi, Simonetta Frezza, Francesca Gallini, Rita Maria Paola Luciano, Giovanni Alighieri, Costantino Romagnoli, Sara De Carolis PII: DOI: Reference:
S1568-9972(17)30050-2 doi:10.1016/j.autrev.2017.02.010 AUTREV 1976
To appear in:
Autoimmunity Reviews
Received date: Accepted date:
8 January 2017 12 February 2017
Please cite this article as: Zuppa Antonio Alberto, Riccardi Riccardo, Frezza Simonetta, Gallini Francesca, Luciano Rita Maria Paola, Alighieri Giovanni, Romagnoli Costantino, De Carolis Sara, Neonatal Lupus: Follow-up in infants with anti-SSA/Ro antibodies and review of the literature, Autoimmunity Reviews (2017), doi:10.1016/j.autrev.2017.02.010
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ACCEPTED MANUSCRIPT Neonatal Lupus: follow-up in infants with anti-SSA/Ro antibodies and review of the literature
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Zuppa Antonio Albertoa, Riccardi Riccardoa, Frezza Simonettaa, Gallini Francescaa, Luciano Rita Maria Paolaa, Alighieri Giovannib, Romagnoli Costantinoa, De Carolis Sarac a
Department of Pediatrics, Division of Neonatology, Catholic University of Sacred Heart, Rome, Italy Department of Pediatrics, "Card. G. Panico" Hospital, Tricase, Italy c Department of Obstetrics and Gynaecology, Catholic University of Sacred Heart, Rome, Italy
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Zuppa AA and Frezza S are Co-Authors
Corresponding Author:
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Riccardo Riccardi
Departments of Pediatrics Division of Neonatology
Catholic University of Sacred Heart Largo Agostino Gemelli, 1 00168 Rome, Italy E-Mail: [email protected] Tel: 0630154726
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Abstract
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Neonatal Lupus Syndrome (NLS) is a distinct clinical entity caused by transplacental passage of maternal anti-SSA/Ro antibodies (Ab). Mothers may have systemic lupus erythematosus, Sjögren syndrome, or other connective tissue disease, or may be completely healthy at the time of giving birth. NLS includes several clinical manifestations: complete congenital heart block (CCHB) and cutaneous lupus are the most common, while hepatobiliary disease, hematological manifestations and central nervous system involvement may occur.
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Data from literature on the incidence of the different clinical manifestations of NLS are difficult to compare because they come mostly from retrospective studies or prospective studies, but up to date no systematic follow-up was carried out. We performed a large prospective single-center study with a systematic clinical and instrumental follow-up until 9 months of life, in order to evaluate the incidence and the clinical impact of NLS features. From 2004 to 2014 all infants born in our center to mothers with anti-SSA/Ro Ab were enrolled in a specific diagnostic and follow-up (FU) program.
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At birth, 50 infants born to mothers with anti-SSA/Ro Ab were found positive for anti-SSA/Ro Ab. Infants were tested for anti SSA/Ro Ab at 3 months of life, if positive they were re-tested at 6 and 9 months. At 9 months anti-SSA/Ro Ab were positive in 10% of children. In two cases (4%) a CCHB was identified during pregnancy and required pacemaker implantation at birth. In 10% of cases a transient ECG alterations was found during follow-up. Hematological NLS features (anemia, neutropenia, thrombocytopenia) were found at birth and during FU in several patients, in all cases without clinical manifestations and in most cases with complete normalization at 9 months. Mild and transient elevation of aminotransferases between 3 and 6 months of life were found in 56% and 40% of patient, respectively; non-specific ultrasound cerebral anomalies in absence of clinical neurological signs were found at birth in 9 patients (18%), subsequently normalized. Prenatal maternal screening is of primary importance in order to early detect CCHB, which requires maternal treatment and pacemaker implantation at birth. Infants born to mothers with anti-SSA/Ro Ab should be monitored for all NLS features at birth. However, during the first months of life, these infants seem to develop only mild, transient and self-limited clinical manifestations, which in most cases are completely solved at 9 months of life. This consideration, together with the evidence that only 10% of infants had anti-SSA/Ro Ab persistent in blood at 9 months, suggests that follow-up of these children can be performed until 6-9 months of life with good clinical safety. Moreover, a clinical and laboratory monitoring at 3 months of life, when the highest incidence of hematological features and liver tests alterations are observed, is strongly recommended. In the future, it would be clarified if a follow-up until adulthood would be indicated in cases with persistent anti SSA/Ro or in all infants born to mother with anti SSA/Ro.
Keywords: Neonatal Lupus, Congenital heart block, Anti SSA/Ro
ACCEPTED MANUSCRIPT Take-home message During the first months of life infants with anti-SSA/Ro Ab develop only mild and self-limited clinical manifestations, which in most cases are completely solved at 9 months of life. The highest incidence of hematological features and liver tests alterations is observed at 3 months of life.
Follow-up of these children can be performed until 6-9 months of life with good clinical safety, but persistent presence of anti-SSA/Ro Ab are observed at 9 months of life in 10% of infants.
Future studies could clarify if follow-up until adulthood is required in all cases or has to be restricted to the persistent positive anti-SSA/Ro Ab ones.
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ACCEPTED MANUSCRIPT 1. Introduction Neonatal Lupus Syndrome (NLS) is an acquired autoimmune disease caused by transplacental passage of maternal anti-SSA/Ro and/or anti-SSB/La autoantibodies [1–5].
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Mothers may have systemic lupus erythematosus (SLE), Sjögren syndrome (SS), other connective tissue disease, or may be completely healthy at the time of giving birth. The laboratory hallmark of the disease is the presence of anti-SSA/Ro antibodies [6].
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NLS includes several clinical manifestations: congenital heart block (CHB) and cutaneous lupus are the most common, while hepatobiliary disease, hematological manifestations and central nervous system (CNS) involvement may occur [7]. Rectal bleeding and plantar atrophy are also reported [8]. The non-cardiac manifestations of NLS are most transient and resolve as maternal antibodies are cleared from the neonatal circulation, while a complete atrio-ventricular block in a structurally normal heart is considered permanent [9].
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The skin rash is highly characteristic and it may be rarely present at birth, but it appears more frequently in the second and the third month of life [10]. This rash is most common on the head and neck, which are most exposed to ultraviolet rays [11]. Hepatobiliary involvement is described between 10% and 25% of NLS cases and it may cause congenital liver failure, cholestasis or a late and transient increase of transaminases [12–14]. Hematological manifestations of NLS may be anemia, neutropenia, thrombocytopenia [15,16]. CNS involvement in newborns is possible but uncommon. Few reports are available and frequency and different patterns of CNS findings are not exactly known [17–19].
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Data from literature on the incidence of the different clinical manifestations of NLS are difficult to compare, because they come mostly from retrospective studies or prospective studies, but in which no systematic follow-up was carried out [20]. Few data are also available for the follow-up of children with NLS [21].
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We performed a large prospective single-center study with a systematic clinical and instrumental follow-up until 9 months of life, in order to evaluate the incidence and the clinical impact of NLS features and their correlation with anti-SSA/Ro Antibodies (Ab). 2. Materials and methods Since 2004 to 2014 all infants born to mothers with anti-SSA/Ro antibodies (Ab) in our center were enrolled in a specific diagnostic and follow-up program. Follow-up evaluation was performed at 3, 6 and 9 months of life in infants with persistent anti-SSA/Ro Ab and/or important clinical manifestations. For each infants, data on the mother diagnosis and therapy before and during pregnancy, and data on the pregnancy outcome with particular interest for the laboratory and instrumental tests (level of antiextractable nuclear antigens [ENA] Ab, ultrasound evaluation of fetal growth, fetal echocardiography, Doppler velocimetry of maternal and fetal vessels, non-stress test and hemochromocytometric and blood clotting tests) were collected. At birth and during follow-up, clinical and anthropometric data were recorded, and the following tests were performed: Anti ENA Ab detected by ELISA [22]: o Anti-SSA/Ro, anti-SSB/La (normal values < 25 U/ml) o Anti-RNP (normal values <9 U/ml)
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o Anti Sm (normal values <25 U/ml) CBC with differential white cell count SGOT, SGPT, γGT Cerebral ultrasonography Electrocardiography (ECG) and echocardiography.
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Heart manifestations o Atrioventricular block of any degree o Late conduction o Dilatative cardiomyopathy Hepatobiliary manifestations o Liver failure (with clinical signs of liver damage due to hemochromatosis) o Jaundice (with high conjugated bilirubin) o Increased serum level of liver enzymes SGOT (normal values < 45 U/l), SGPT (normal values <45 U/l), γGT (normal values <90 U/l), alkaline phosphatase (normal values <110 U/l) Haematologic manifestations o Anemia (hematocrit < 30%) o Thrombocytopenia (platelets < 100000/μl) o Neutropenia (neutrophil < 1000/μl) Skin manifestations o Rash in the shape of large annular spots of squamous erythema, hypopigmeted areas, mainly located on the face, in the periorbital area, and on the scalp Echoencephalographic abnormalities o Lenticulostriate vasculopathy o Pseudocystis of the choroid plexus.
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According to the descriptions reported in the literature, the following clinical and laboratory signs have been considered typical of the NLS:
3. Results Fifty infants born to mothers with anti-SSA/Ro Ab were found positive for anti-SSA/Ro Ab in the first day of life. The prevalence of infants born to mothers with anti-SSA/Ro Ab observed at our hospital was 0.25% of the maternal-newborn population. General features of the infants are shown in Tab 1. Seventeen infants were positive for anti SSA/Ro Ab, 21 for anti SSA/Ro and anti SSB/La Ab, in the other cases infants were positive for anti-SSA/Ro with other anti-ENA Ab combined differently: the neonatal antibody pattern resulted consistent with the maternal pattern because of the transplacental passage of Ab (Tab 2).
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Table 1 General features of infants in this series Sex
27 female/23 male
Birth weight (g ± SD)
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36 ± 4 2745 ± 1115
Birth weight percentile (mean ± SD)
23 EU/ 2 VE/ 25 CS
Length of stay (days ± SD)
6±2
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N° 17 21 2 2 2 3 3
% 34 42 4 4 4 6 6
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Anti SSA-Ro Anti SSA-Ro, Anti SS-B/LA Anti SSA-Ro, Anti SS-B/LA, Anti Sm Anti SSA-Ro, Anti SS-B/LA, anti RNP Anti SSA-Ro, Anti Sm Anti SSA-Ro, Anti RNP Anti SSA-Ro, Anti Sm, Anti RNP
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Table 2 Neonatal anti-ENA antibodies patterns at birth
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EU= eutocic delivery; VE= vacuum extraction; CS= Caesarean section
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Mode of delivery
40 ± 25
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Gestational age (weeks ± SD)
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Infants were tested for anti SSA/Ro Ab at 3 months of life, only infants who were found positive at the previous control were re-tested at 6 and 9 months. The rate of positivity and anti SSA/Ro Ab mean value are showed in Tab 3. In Figure 1 the progressive reduction of anti SSA/Ro titer in the positive population is shown. Two infants with complete congenital heart block (CCHB) at birth were lost at follow-up, because they were referred to another Pediatric Hospital of Rome for pace-maker implantation in the first day of life. Table 3 Infants positive for anti SS-A/Ro Ab during Follow-up Mean Value Age N° % (UI/ml) Birth 50 100 186.9
125.5
3 months
37
74
162.5
96.1
6 months
17
34
84.6
69.3
9 months
5
10
41.4
10.3
SD
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Figure 1 Mean value of Anti SSA\Ro antibodies titer during follow-up in our series
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The most frequent maternal autoimmune disease was SLE (25/50); 15 mothers had primary SS, 5 had SLE combined with SS and 2 were diagnosed with mixed connective tissue disease; 3 were asymptomatic.
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3.1. Skin involvement
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Most of the women (43) underwent corticosteroid therapy during pregnancy. In 4 cases corticosteroid therapy was combined with hydroxychloroquine and in 1 case with azathioprine. In 5 cases women did not receive steroid therapy: 3 received hydroxychloroquine alone, 1 received tacrolimus alone and 1 received a combination of hydroxychloroquine and azathioprine. Only 2 women didn’t receive any therapy during pregnancy.
None of the babies presented the typical skin rash or other skin lesions at birth and during the follow up 3.2 Heart involvement
In 2 cases (4%) a CCHB was identified during pregnancy (Tab 4). In the first case a third degree intrauterine AV block was identified at 24 gestational weeks and treatment with high-dose betamethasone was started. A preterm delivery (31th gestational week) was needed because of fetal distress, with a live female infant weighting 1210 g. The neonate required a pace-maker implantation within the first 12h of life; at 5 years follow up, she is in good health. In the second case, the CCHB was diagnosed at 22 gestational week; then, high-dose betamethasone was administered. This pregnancy ended with a delivery at the 32 nd gestational week of a live female infant weighting 1500 g, who died in the first day of life, despite the pacemaker implantation. At birth 1 newborn (2%) showed a first-degree atrioventricular block, that remained at 3, 6 and 9 months of life with a good clinical course. One case of right bundle brunch block (RBBB) persisted during the followup, but had a good clinical course. Four cases (8%) of transient alterations in ventricular repolarization resulted at the ECG which disappeared at 3 months, were also observed.
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Ab patterns
Clinical course
CCHB
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4%
Anti-SSA/Ro + AntiSSB/LA
Pace-maker implantation in the first day of life
First degree AV block
1
2%
Anti-SSA/Ro + AntiSSB/LA
Persisting until 13 months of life
Right bundle brunch block (RBBB)
1
2%
Anti-SSA/Ro + AntiSSB/LA
Persisting until 13 months of life
Altered cardiac repolarization
4
8%
Anti-SSA/Ro + AntiSSB/LA
Normalized at 3 months of life
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3.3 Haematological involvement
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At birth 1 infant with a slight and transient thrombocytopenia was found, 2 infants had neutropenia and 1 infants had anemia (Tab 5). At 3 months 12 children had neutropenia, 12 anemia and no cases of thrombocytopenia. At 6 months we observed: 6 children with anemia, 2 children with neutropenia, 2 children with associated neutropenia and anemia, no cases of thrombocytopenia. At 9 months 1 child presented persistent neutropenia. In all cases children had a good clinical course without clinical manifestations related to laboratory findings and no medical intervention was needed.
Table 5 Hematological involvement in this series
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Anemia Thrombocytopenia Neutropenia Total
Birth (%) 1 (2) 1 (2) 2 (4) 4 (8)
3 months (%) 12 (24) 0 12 (24) 24 (48)
6 months (%) 6 (12) 0 4 (8) 10 (20)
9 months (%) 0 0 1 (2) 1 (2)
3.4. Hepatobiliary involvement At birth 1 child had a mild elevation of liver test according to age-related normal values (Tab 6). At 3 months follow-up a mild elevation of aminotransferases, alkaline phosphatase and gammaGT, without clinical manifestations were encountered in 28 babies (56%). At 6 months this condition was persistent in 20 babies (40%) and at 9 months in 3 babies (6%).
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Table 6 Hepatobiliary involvement in this series Birth (%)
3 months (%)
6 months (%)
9 months (%)
0
6 (12)
3 (6)
0
0
16 (32)
12 (24)
0
1 (2) 0 0
2 (4) 2 (4) 2 (4)
2 (18) 1 (2) 2 (12)
1 (2) 0 2 (4)
Total
1 (2)
28 (56)
20 (40)
3 (6)
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↑SGOT/SGPT, ↑γGT ↑SGOT/SGPT, ↑γGT ↑ alkaline phosphatase ↑SGOT/SGPT ↑γGT ↑ alkaline phosphatase
3.5. Neurological involvement
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At birth and during follow-up neurological clinical examination was normal without any clinical neurological signs in all cases.
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At birth 9 infants (18%) had echo-encephalographic abnormalities at the cerebral ultrasonography: Mild cerebral ventricular dilatation and subependymal pseudocysts (n=1)
Echogenic lenticulostriate vessels (n=1)
Subependymal hemorrhage (n=1)
Intraventricular hemorrhage (n=1)
Subependymal pseudocysts in two cases (n=2)
Moderate cerebral ventricular dilatation, large cable septum pellucidum periventricular white matter echogenicity (n=1)
Intraventricular hemorrhage and peripheral cerebral areas dilatation (n=1)
Subependymal pseudocysts and lenticulostriate vasculopathy (n=1)
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and increased
At 3 months persistent ultrasonography alterations were found in 2 cases. At 6 and 9 months no alteration was detected. 4. Discussion NLS is a model of passively acquired autoimmune disease in which pathogenic autoantibodies are transplacentally acquired by the fetus. Mothers may have systemic lupus erythematosus, Sjogren Syndrome, or other connective tissue diseases, or may be completely healthy at the time of delivery [23]. The laboratory hallmark of the disease is the presence of the Anti-SSA/Ro autoantibodies [6]. Anti-SSA/Ro autoantibodies are IgG, specific towards intracellular RNPs. From the 12th week, they cross the placenta and damage the developing fetal tissue, producing transient manifestation in the neonate. Apart from maternal IgG, environmental factors and fetal genetic components may contribute to the
ACCEPTED MANUSCRIPT pathogenesis of NLS or amplify the effects of the antibodies, which may be necessary but insufficient in causing the tissue injury [24].
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The identification of infants born to mothers who are positive for the anti-SSA/Ro antibodies is possible when maternal clinical history suggests the presence of anti-ENA antibodies. In this study the maternal population includes also symptomless mothers who took an anti-ENA antibody test without showing clear signs of an autoimmune disease, as reported in the literature [14]. We could confirm that the presence of anti-SSA/Ro antibodies, with or without anti-La, rather than the type of maternal autoimmune disease, is the risk factor for the development of NLS. This observation underlines the importance of this antibodies screening during pregnancy, to identify cases at risk in patients affected by autoimmune disease.
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Nowadays, in cases of women with anti-ENA positivity, steroid treatment is generally used to improve the pregnancy outcome, but its efficacy has been debated [25]. Recently, some authors suggest that a triple therapy combining plasmapheresis, IVIG and glucocorticoids may stop the natural evolution of the fetal cardiac affectation in positive anti-SSA/Ro antibody patients [26, 27]. In our population no link was found among maternal diagnosis, maternal therapy and maternal antibody blood levels with neonatal outcomes.
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The most important manifestation of NLS is CCHB. CCHB mostly develops between the 18th and the 24th gestational week and presents with a low ventricular rate, usually ranging from 40 to 60 bpm. CCHB is a potentially lethal condition and morbidity in surviving fetuses is substantial, with more than 2/3 of affected children requiring permanent pacemaker implantation [28–30]. A recent study on 214 cases of high-grade CHB has shown an overall mortality rate of 22.9% and the need of pacemaker implantation in 79.1% of cases [25]. According to our findings, all grades of CHB are possible, although the CCHB occurs more frequently. First or second degree CHB can progress in the years up to a CCHB [31]. These findings seem to suggest that the CCHB is the final stage of a gradually developing damage of the cardiac conduction tissue, starting in utero [32]. Our findings of other conduction abnormalities in addiction to CHB support the hypothesis that all parts of the fetal heart are susceptible to the injury by maternal autoantibodies.
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In all newborns of this study no skin rash was seen, maybe because they were not exposed to ultraviolet rays. According to literature data, UV exposure may accelerate apoptosis in keratinocytes, with the presentation of intracellular SSA/Ro or RNP antigens. These antigens binding to specific antibodies may cause the rash [11]. The hematological manifestations include thrombocytopenia, anemia and neutropenia, they are more often observed at 1 to 2 months of age [33]. In our experience hematological abnormalities were more frequent at 3 months, children were completely asymptomatic and laboratory alterations mostly resolved during follow-up. The lower incidence of hematological abnormalities at birth suggests that these findings detected after the neonatal period are probably not strictly related to the anti-SSA/Ro Ab, and could be linked to other mechanisms [32]. The etiopathogenetic role of anti-SSA/Ro antibodies in hematological manifestations of NLS should be further clarified. A likely pathogenetic mechanism for neutropenia seems to be the cross-reactivity of a membrane protein, similar to the antigen Ro 60kDa, the reaction between this membrane protein and the anti SSA/Ro antibodies may activate the complement system and cause neutrophils’ apoptosis [34–36]. Hepatobiliary disease is less commonly described than other NLS features, but it is a well established manifestation. In a retrospective analysis of the US Research Registry for Neonatal Lupus, about 10% of patients with NLS also had probable or possible hepatobiliary disease [37]. Three clinical variants of hepatobiliary disease were observed: a severe liver failure presenting during gestation or the neonatal
ACCEPTED MANUSCRIPT period; a conjugated hyperbilirubinemia with mild or no elevations of aminotransferases, occurring in the first week of life; and a mild elevation of aminotransferases occurring at approximately 2-3 months of life. In our series we found only the third clinical variant described, observing an high incidence of transient, mild to moderate, transaminases elevation.
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Furthermore, 9 newborns of this study had non-specific CNS anomalies on cerebral US in absence of any clinical neurological signs. Although CNS involvement is a not well-recognized manifestation of NLS, to our knowledge, other studies reported non-specific brain involvement [17,18,38]. Neuroimaging findings are characterized by non-specific lesions that could be considered with a favorable outcome, although longterm sequelae cannot be excluded. Few data are also available about the long-term neurological development, but high incidence of neuropsychiatric abnormalities is reported by Askanase et al [39].
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In our population, an association between anti-SSA/Ro Ab positivity during follow-up and presence of clinical manifestations was observed. This finding is consistent with data reported in the literature, according to which an etiopathogenetic role is played by this Autoantibody [1,4,5,14]. We do not find any correlation between the antibodies titer and the severity of clinical manifestations. The presence of more serious clinical manifestations in case of a combined positivity for both the anti-SSA/Ro Ab and the antiSSB/La Ab has been reported in the literature[40]. Our data confirm this previous observation, in fact 2 children with CCHB and 6 children with other cardiac manifestations were positive for anti SSA/Ro and anti SSB/La Ab at the time of diagnosis.
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In particular, our study allow to observe how the gradual decrease of anti-SSA/Ro Ab titer correlates with the gradual disappearance of related clinical manifestations, which are clinically benign and transient, except for CCHB. However, 10% of infants showed persistent anti-SSA/Ro levels at 9 months of life.
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Data of the literature on the incidence of the different features of NLS are difficult to compare, because they come mostly from case reports or retrospective studies, with different inclusion criteria [32,33,41–45]. Few data are available from prospective studies in which newborns of mothers with anti-SSA/Ro Ab were enrolled and are shown in Tab 8 [32,33,44].
Table 8 Prevalence of NLS features: Review of the literature
Authors
Study design
Patients n°
NLS features Follow up CCHB %
Other Cardiac %
Skin %
Hematological %
Hepatobiliary %
CNS %
Cimaz R et al. (2003) [33]
Prospective
128
6-9 months
1.6
41
16
27
26
NR
Motta M et al. (2007) [32]
Prospective
51
Not performed
2
15.7
3.9
3.9
0
NR
Boros C et al. (2007) [44]
Prospective
47
12 months
40
36
36
8
Present study (2016)
Prospective
50
9 months
0
24
56
18
25.5 4
12
Definitions: NR: not reported; CCHB: complete congenital heart block; “Other Cardiac” complains: I or II degree AV block, prolonged QT interval; CNS: central nervous system
ACCEPTED MANUSCRIPT Our results show an incidence of CCHB slightly higher than other prospective studies, this can be explained by the fact that our hospital is a reference center for autoimmune diseases during pregnancy. Boros et al reported the incidence of cardiac NLS features (CCHB, I or II degree AV block, prolonged QT interval) in their population without specifying the incidence of CCHB.
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The incidence of skin rash is very variable in the different studies, this finding is difficult to explain, but the different UV exposure of the newborns at birth could be an important factor, as already mentioned.
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The incidence of hematological and hepatobiliary NLS features in our study results comparable with other prospective studies in which follow-up was performed. Motta et al checked CBC and hepatic function tests only at birth, therefore they found a lower incidence. Our study confirms that the highest incidence of hematological and hepatobiliary NLS features is observed at 3 months of life, as observed in other studies.
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Boros et al suggest that hydrocephalus and macrocephaly are manifestations of NLS, because they find a significantly higher prevalence in newborns with NLS than that shown in the general population. In our series we do not find any child with these conditions, we observed only non-specific CNS anomalies on cerebral US. These anomalies resolved during follow-up and did not present any clinical correlate. It would be emphasized that our study is the only one in which a cerebral US evaluation was performed at birth to all infants with anti-SSA/Ro Ab.
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5. Conclusion
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The type, frequency and severity of the clinical manifestations of NLS are often incomplete or even insufficiently investigated. Prenatal maternal screening is of primary importance in order to early detect CCHB, which can require maternal treatment and pacemaker implantation at birth. Infants born to mothers with anti-SSA/Ro Ab should be monitored for all NLS features at birth.
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Moreover, during the first months of life, infants with anti-SSA/Ro Ab seem to develop only mild, transient and self-limited clinical manifestations, which in most cases are completely solved at 9 months of life. This consideration together with the evidence that only 10% of infants had anti-SSA/Ro persistent in blood at 9 months suggests that follow-up of these children could be performed until 6-9 months of life with good clinical safety. However, we recommended clinical and laboratory monitoring at 3 months of life, when the highest incidence of hematological and hepatobiliary NLS features is observed. Furthermore, as late-onset of autoimmune disease in NLS babies is described [21], its identification would require clinical follow-up until adulthood. Future studies could clarify if the follow-up is needed in all cases or restricted to the persistent positive Ab ones.
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Buyon JP, Hiebert R, Copel J, Craft J, Friedman D, Katholi M, et al. Autoimmune-associated congenital heart block: demographics, mortality, morbidity and recurrence rates obtained from a national neonatal lupus registry. J Am Coll Cardiol 1998;31:1658–66. Waltuck J, Buyon JP. Autoantibody-associated congenital heart block: outcome in mothers and children. Ann Intern Med 1994;120:544–51. Eronen M, Sirèn MK, Ekblad H, Tikanoja T, Julkunen H, Paavilainen T. Short- and long-term outcome of children with congenital complete heart block diagnosed in utero or as a newborn. Pediatrics 2000;106:86–91. Z ppa Delog B De Rosa G De ca D Visin ni Cota et al. Neonatal l p s: di erent clinical neonatal e pression in siblings . rch diatrie Organe O a oci te r diatrie 2004;11:936–9. doi:10.1016/j.arcped.2004.05.009. Motta M, Rodriguez-Perez C, Tincani A, Lojacono A, Chirico G. Outcome of infants from mothers with anti-SSA/Ro antibodies. J Perinatol 2007;27:278–83. doi:10.1038/sj.jp.7211688. Cimaz R, Spence DL, Hornberger L, Silverman ED. Incidence and spectrum of neonatal lupus erythematosus: a prospective study of infants born to mothers with anti-Ro autoantibodies. J Pediatr 2003;142:678–83. doi:10.1067/mpd.2003.233. Zuppa AA, De Luca D, De Turris P, Cota F, Tortorolo G. Usefulness of rh-G-CSF in early-onset severe neutropenia in neonatal lupus syndrome. J Pediatr Hematol Oncol 2004;26:609–11. Kanagasegar S, Cimaz R, Kurien BT, Brucato A, Scofield RH. Neonatal lupus manifests as isolated neutropenia and mildly abnormal liver functions. J Rheumatol 2002;29:187–91. Kurien BT, Newland J, Paczkowski C, Moore KL, Scofield RH. Association of neutropenia in systemic lupus erythematosus (SLE) with anti-Ro and binding of an immunologically cross-reactive neutrophil membrane antigen. Clin Exp Immunol 2000;120:209–17. Lee LA, Sokol RJ, Buyon JP. Hepatobiliary disease in neonatal lupus: prevalence and clinical characteristics in cases enrolled in a national registry. Pediatrics 2002;109:E11. Cabañas F, Pellicer A, Valverde E, Morales C, Quero J. Central nervous system vasculopathy in neonatal lupus erythematosus. Pediatr Neurol 1996;15:124–6. Askanase AD, Izmirly PM, Katholi M, Mumtaz J, Buyon JP. Frequency of neuro-psychiatric dysfunction in anti-SSA/SSB exposed children with and without neonatal lupus. Lupus 2010;19:300– 6. doi:10.1177/0961203309354542. Gordon P, Khamashta MA, Rosenthal E, Simpson JM, Sharland G, Brucato A, et al. Anti-52 kDa Ro, anti-60 kDa Ro, and anti-La antibody profiles in neonatal lupus. J Rheumatol 2004;31:2480–7. Wisuthsarewong W, Soongswang J, Chantorn R. Neonatal lupus erythematosus: clinical character, investigation, and outcome. Pediatr Dermatol n.d.;28:115–21. doi:10.1111/j.15251470.2011.01300.x. Li Y-Q, Wang Q, Luo Y, Zhao Y. Neonatal lupus erythematosus: a review of 123 cases in China. Int J Rheum Dis 2015;18:761–7. doi:10.1111/1756-185X.12652. Kobayashi R, Mii S, Nakano T, Harada H, Eto H. Neonatal lupus erythematosus in Japan: a review of the literature. Autoimmun Rev 2009;8:462–6. doi:10.1016/j.autrev.2008.12.013. Boros CA, Spence D, Blaser S, Silverman ED. Hydrocephalus and macrocephaly: new manifestations of neonatal lupus erythematosus. Arthritis Rheum 2007;57:261–6. doi:10.1002/art.22543. De Carolis S, Salvi S, Botta A, Santucci S, Martino C, Garofalo S, Ferrazzani S. Which Intrauterine Treatment for Autoimmune Congenital Heart Block? The Open Autoimmunity Journal, 2010, 2, 1-10.
S1568-9972(17)30050-2 doi:10.1016/j.autrev.2017.02.010 AUTREV 1976
To appear in:
Autoimmunity Reviews
Received date: Accepted date:
8 January 2017 12 February 2017
Please cite this article as: Zuppa Antonio Alberto, Riccardi Riccardo, Frezza Simonetta, Gallini Francesca, Luciano Rita Maria Paola, Alighieri Giovanni, Romagnoli Costantino, De Carolis Sara, Neonatal Lupus: Follow-up in infants with anti-SSA/Ro antibodies and review of the literature, Autoimmunity Reviews (2017), doi:10.1016/j.autrev.2017.02.010
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ACCEPTED MANUSCRIPT Neonatal Lupus: follow-up in infants with anti-SSA/Ro antibodies and review of the literature
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Zuppa Antonio Albertoa, Riccardi Riccardoa, Frezza Simonettaa, Gallini Francescaa, Luciano Rita Maria Paolaa, Alighieri Giovannib, Romagnoli Costantinoa, De Carolis Sarac a
Department of Pediatrics, Division of Neonatology, Catholic University of Sacred Heart, Rome, Italy Department of Pediatrics, "Card. G. Panico" Hospital, Tricase, Italy c Department of Obstetrics and Gynaecology, Catholic University of Sacred Heart, Rome, Italy
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Zuppa AA and Frezza S are Co-Authors
Corresponding Author:
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Riccardo Riccardi
Departments of Pediatrics Division of Neonatology
Catholic University of Sacred Heart Largo Agostino Gemelli, 1 00168 Rome, Italy E-Mail: [email protected] Tel: 0630154726
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Abstract
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Neonatal Lupus Syndrome (NLS) is a distinct clinical entity caused by transplacental passage of maternal anti-SSA/Ro antibodies (Ab). Mothers may have systemic lupus erythematosus, Sjögren syndrome, or other connective tissue disease, or may be completely healthy at the time of giving birth. NLS includes several clinical manifestations: complete congenital heart block (CCHB) and cutaneous lupus are the most common, while hepatobiliary disease, hematological manifestations and central nervous system involvement may occur.
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Data from literature on the incidence of the different clinical manifestations of NLS are difficult to compare because they come mostly from retrospective studies or prospective studies, but up to date no systematic follow-up was carried out. We performed a large prospective single-center study with a systematic clinical and instrumental follow-up until 9 months of life, in order to evaluate the incidence and the clinical impact of NLS features. From 2004 to 2014 all infants born in our center to mothers with anti-SSA/Ro Ab were enrolled in a specific diagnostic and follow-up (FU) program.
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At birth, 50 infants born to mothers with anti-SSA/Ro Ab were found positive for anti-SSA/Ro Ab. Infants were tested for anti SSA/Ro Ab at 3 months of life, if positive they were re-tested at 6 and 9 months. At 9 months anti-SSA/Ro Ab were positive in 10% of children. In two cases (4%) a CCHB was identified during pregnancy and required pacemaker implantation at birth. In 10% of cases a transient ECG alterations was found during follow-up. Hematological NLS features (anemia, neutropenia, thrombocytopenia) were found at birth and during FU in several patients, in all cases without clinical manifestations and in most cases with complete normalization at 9 months. Mild and transient elevation of aminotransferases between 3 and 6 months of life were found in 56% and 40% of patient, respectively; non-specific ultrasound cerebral anomalies in absence of clinical neurological signs were found at birth in 9 patients (18%), subsequently normalized. Prenatal maternal screening is of primary importance in order to early detect CCHB, which requires maternal treatment and pacemaker implantation at birth. Infants born to mothers with anti-SSA/Ro Ab should be monitored for all NLS features at birth. However, during the first months of life, these infants seem to develop only mild, transient and self-limited clinical manifestations, which in most cases are completely solved at 9 months of life. This consideration, together with the evidence that only 10% of infants had anti-SSA/Ro Ab persistent in blood at 9 months, suggests that follow-up of these children can be performed until 6-9 months of life with good clinical safety. Moreover, a clinical and laboratory monitoring at 3 months of life, when the highest incidence of hematological features and liver tests alterations are observed, is strongly recommended. In the future, it would be clarified if a follow-up until adulthood would be indicated in cases with persistent anti SSA/Ro or in all infants born to mother with anti SSA/Ro.
Keywords: Neonatal Lupus, Congenital heart block, Anti SSA/Ro
ACCEPTED MANUSCRIPT Take-home message During the first months of life infants with anti-SSA/Ro Ab develop only mild and self-limited clinical manifestations, which in most cases are completely solved at 9 months of life. The highest incidence of hematological features and liver tests alterations is observed at 3 months of life.
Follow-up of these children can be performed until 6-9 months of life with good clinical safety, but persistent presence of anti-SSA/Ro Ab are observed at 9 months of life in 10% of infants.
Future studies could clarify if follow-up until adulthood is required in all cases or has to be restricted to the persistent positive anti-SSA/Ro Ab ones.
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ACCEPTED MANUSCRIPT 1. Introduction Neonatal Lupus Syndrome (NLS) is an acquired autoimmune disease caused by transplacental passage of maternal anti-SSA/Ro and/or anti-SSB/La autoantibodies [1–5].
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Mothers may have systemic lupus erythematosus (SLE), Sjögren syndrome (SS), other connective tissue disease, or may be completely healthy at the time of giving birth. The laboratory hallmark of the disease is the presence of anti-SSA/Ro antibodies [6].
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NLS includes several clinical manifestations: congenital heart block (CHB) and cutaneous lupus are the most common, while hepatobiliary disease, hematological manifestations and central nervous system (CNS) involvement may occur [7]. Rectal bleeding and plantar atrophy are also reported [8]. The non-cardiac manifestations of NLS are most transient and resolve as maternal antibodies are cleared from the neonatal circulation, while a complete atrio-ventricular block in a structurally normal heart is considered permanent [9].
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The skin rash is highly characteristic and it may be rarely present at birth, but it appears more frequently in the second and the third month of life [10]. This rash is most common on the head and neck, which are most exposed to ultraviolet rays [11]. Hepatobiliary involvement is described between 10% and 25% of NLS cases and it may cause congenital liver failure, cholestasis or a late and transient increase of transaminases [12–14]. Hematological manifestations of NLS may be anemia, neutropenia, thrombocytopenia [15,16]. CNS involvement in newborns is possible but uncommon. Few reports are available and frequency and different patterns of CNS findings are not exactly known [17–19].
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Data from literature on the incidence of the different clinical manifestations of NLS are difficult to compare, because they come mostly from retrospective studies or prospective studies, but in which no systematic follow-up was carried out [20]. Few data are also available for the follow-up of children with NLS [21].
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We performed a large prospective single-center study with a systematic clinical and instrumental follow-up until 9 months of life, in order to evaluate the incidence and the clinical impact of NLS features and their correlation with anti-SSA/Ro Antibodies (Ab). 2. Materials and methods Since 2004 to 2014 all infants born to mothers with anti-SSA/Ro antibodies (Ab) in our center were enrolled in a specific diagnostic and follow-up program. Follow-up evaluation was performed at 3, 6 and 9 months of life in infants with persistent anti-SSA/Ro Ab and/or important clinical manifestations. For each infants, data on the mother diagnosis and therapy before and during pregnancy, and data on the pregnancy outcome with particular interest for the laboratory and instrumental tests (level of antiextractable nuclear antigens [ENA] Ab, ultrasound evaluation of fetal growth, fetal echocardiography, Doppler velocimetry of maternal and fetal vessels, non-stress test and hemochromocytometric and blood clotting tests) were collected. At birth and during follow-up, clinical and anthropometric data were recorded, and the following tests were performed: Anti ENA Ab detected by ELISA [22]: o Anti-SSA/Ro, anti-SSB/La (normal values < 25 U/ml) o Anti-RNP (normal values <9 U/ml)
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o Anti Sm (normal values <25 U/ml) CBC with differential white cell count SGOT, SGPT, γGT Cerebral ultrasonography Electrocardiography (ECG) and echocardiography.
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Heart manifestations o Atrioventricular block of any degree o Late conduction o Dilatative cardiomyopathy Hepatobiliary manifestations o Liver failure (with clinical signs of liver damage due to hemochromatosis) o Jaundice (with high conjugated bilirubin) o Increased serum level of liver enzymes SGOT (normal values < 45 U/l), SGPT (normal values <45 U/l), γGT (normal values <90 U/l), alkaline phosphatase (normal values <110 U/l) Haematologic manifestations o Anemia (hematocrit < 30%) o Thrombocytopenia (platelets < 100000/μl) o Neutropenia (neutrophil < 1000/μl) Skin manifestations o Rash in the shape of large annular spots of squamous erythema, hypopigmeted areas, mainly located on the face, in the periorbital area, and on the scalp Echoencephalographic abnormalities o Lenticulostriate vasculopathy o Pseudocystis of the choroid plexus.
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According to the descriptions reported in the literature, the following clinical and laboratory signs have been considered typical of the NLS:
3. Results Fifty infants born to mothers with anti-SSA/Ro Ab were found positive for anti-SSA/Ro Ab in the first day of life. The prevalence of infants born to mothers with anti-SSA/Ro Ab observed at our hospital was 0.25% of the maternal-newborn population. General features of the infants are shown in Tab 1. Seventeen infants were positive for anti SSA/Ro Ab, 21 for anti SSA/Ro and anti SSB/La Ab, in the other cases infants were positive for anti-SSA/Ro with other anti-ENA Ab combined differently: the neonatal antibody pattern resulted consistent with the maternal pattern because of the transplacental passage of Ab (Tab 2).
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Table 1 General features of infants in this series Sex
27 female/23 male
Birth weight (g ± SD)
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36 ± 4 2745 ± 1115
Birth weight percentile (mean ± SD)
23 EU/ 2 VE/ 25 CS
Length of stay (days ± SD)
6±2
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N° 17 21 2 2 2 3 3
% 34 42 4 4 4 6 6
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Anti SSA-Ro Anti SSA-Ro, Anti SS-B/LA Anti SSA-Ro, Anti SS-B/LA, Anti Sm Anti SSA-Ro, Anti SS-B/LA, anti RNP Anti SSA-Ro, Anti Sm Anti SSA-Ro, Anti RNP Anti SSA-Ro, Anti Sm, Anti RNP
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Table 2 Neonatal anti-ENA antibodies patterns at birth
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EU= eutocic delivery; VE= vacuum extraction; CS= Caesarean section
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Mode of delivery
40 ± 25
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Gestational age (weeks ± SD)
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Infants were tested for anti SSA/Ro Ab at 3 months of life, only infants who were found positive at the previous control were re-tested at 6 and 9 months. The rate of positivity and anti SSA/Ro Ab mean value are showed in Tab 3. In Figure 1 the progressive reduction of anti SSA/Ro titer in the positive population is shown. Two infants with complete congenital heart block (CCHB) at birth were lost at follow-up, because they were referred to another Pediatric Hospital of Rome for pace-maker implantation in the first day of life. Table 3 Infants positive for anti SS-A/Ro Ab during Follow-up Mean Value Age N° % (UI/ml) Birth 50 100 186.9
125.5
3 months
37
74
162.5
96.1
6 months
17
34
84.6
69.3
9 months
5
10
41.4
10.3
SD
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Figure 1 Mean value of Anti SSA\Ro antibodies titer during follow-up in our series
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The most frequent maternal autoimmune disease was SLE (25/50); 15 mothers had primary SS, 5 had SLE combined with SS and 2 were diagnosed with mixed connective tissue disease; 3 were asymptomatic.
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3.1. Skin involvement
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Most of the women (43) underwent corticosteroid therapy during pregnancy. In 4 cases corticosteroid therapy was combined with hydroxychloroquine and in 1 case with azathioprine. In 5 cases women did not receive steroid therapy: 3 received hydroxychloroquine alone, 1 received tacrolimus alone and 1 received a combination of hydroxychloroquine and azathioprine. Only 2 women didn’t receive any therapy during pregnancy.
None of the babies presented the typical skin rash or other skin lesions at birth and during the follow up 3.2 Heart involvement
In 2 cases (4%) a CCHB was identified during pregnancy (Tab 4). In the first case a third degree intrauterine AV block was identified at 24 gestational weeks and treatment with high-dose betamethasone was started. A preterm delivery (31th gestational week) was needed because of fetal distress, with a live female infant weighting 1210 g. The neonate required a pace-maker implantation within the first 12h of life; at 5 years follow up, she is in good health. In the second case, the CCHB was diagnosed at 22 gestational week; then, high-dose betamethasone was administered. This pregnancy ended with a delivery at the 32 nd gestational week of a live female infant weighting 1500 g, who died in the first day of life, despite the pacemaker implantation. At birth 1 newborn (2%) showed a first-degree atrioventricular block, that remained at 3, 6 and 9 months of life with a good clinical course. One case of right bundle brunch block (RBBB) persisted during the followup, but had a good clinical course. Four cases (8%) of transient alterations in ventricular repolarization resulted at the ECG which disappeared at 3 months, were also observed.
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Ab patterns
Clinical course
CCHB
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4%
Anti-SSA/Ro + AntiSSB/LA
Pace-maker implantation in the first day of life
First degree AV block
1
2%
Anti-SSA/Ro + AntiSSB/LA
Persisting until 13 months of life
Right bundle brunch block (RBBB)
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2%
Anti-SSA/Ro + AntiSSB/LA
Persisting until 13 months of life
Altered cardiac repolarization
4
8%
Anti-SSA/Ro + AntiSSB/LA
Normalized at 3 months of life
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3.3 Haematological involvement
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At birth 1 infant with a slight and transient thrombocytopenia was found, 2 infants had neutropenia and 1 infants had anemia (Tab 5). At 3 months 12 children had neutropenia, 12 anemia and no cases of thrombocytopenia. At 6 months we observed: 6 children with anemia, 2 children with neutropenia, 2 children with associated neutropenia and anemia, no cases of thrombocytopenia. At 9 months 1 child presented persistent neutropenia. In all cases children had a good clinical course without clinical manifestations related to laboratory findings and no medical intervention was needed.
Table 5 Hematological involvement in this series
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Anemia Thrombocytopenia Neutropenia Total
Birth (%) 1 (2) 1 (2) 2 (4) 4 (8)
3 months (%) 12 (24) 0 12 (24) 24 (48)
6 months (%) 6 (12) 0 4 (8) 10 (20)
9 months (%) 0 0 1 (2) 1 (2)
3.4. Hepatobiliary involvement At birth 1 child had a mild elevation of liver test according to age-related normal values (Tab 6). At 3 months follow-up a mild elevation of aminotransferases, alkaline phosphatase and gammaGT, without clinical manifestations were encountered in 28 babies (56%). At 6 months this condition was persistent in 20 babies (40%) and at 9 months in 3 babies (6%).
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Table 6 Hepatobiliary involvement in this series Birth (%)
3 months (%)
6 months (%)
9 months (%)
0
6 (12)
3 (6)
0
0
16 (32)
12 (24)
0
1 (2) 0 0
2 (4) 2 (4) 2 (4)
2 (18) 1 (2) 2 (12)
1 (2) 0 2 (4)
Total
1 (2)
28 (56)
20 (40)
3 (6)
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↑SGOT/SGPT, ↑γGT ↑SGOT/SGPT, ↑γGT ↑ alkaline phosphatase ↑SGOT/SGPT ↑γGT ↑ alkaline phosphatase
3.5. Neurological involvement
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At birth and during follow-up neurological clinical examination was normal without any clinical neurological signs in all cases.
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At birth 9 infants (18%) had echo-encephalographic abnormalities at the cerebral ultrasonography: Mild cerebral ventricular dilatation and subependymal pseudocysts (n=1)
Echogenic lenticulostriate vessels (n=1)
Subependymal hemorrhage (n=1)
Intraventricular hemorrhage (n=1)
Subependymal pseudocysts in two cases (n=2)
Moderate cerebral ventricular dilatation, large cable septum pellucidum periventricular white matter echogenicity (n=1)
Intraventricular hemorrhage and peripheral cerebral areas dilatation (n=1)
Subependymal pseudocysts and lenticulostriate vasculopathy (n=1)
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and increased
At 3 months persistent ultrasonography alterations were found in 2 cases. At 6 and 9 months no alteration was detected. 4. Discussion NLS is a model of passively acquired autoimmune disease in which pathogenic autoantibodies are transplacentally acquired by the fetus. Mothers may have systemic lupus erythematosus, Sjogren Syndrome, or other connective tissue diseases, or may be completely healthy at the time of delivery [23]. The laboratory hallmark of the disease is the presence of the Anti-SSA/Ro autoantibodies [6]. Anti-SSA/Ro autoantibodies are IgG, specific towards intracellular RNPs. From the 12th week, they cross the placenta and damage the developing fetal tissue, producing transient manifestation in the neonate. Apart from maternal IgG, environmental factors and fetal genetic components may contribute to the
ACCEPTED MANUSCRIPT pathogenesis of NLS or amplify the effects of the antibodies, which may be necessary but insufficient in causing the tissue injury [24].
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The identification of infants born to mothers who are positive for the anti-SSA/Ro antibodies is possible when maternal clinical history suggests the presence of anti-ENA antibodies. In this study the maternal population includes also symptomless mothers who took an anti-ENA antibody test without showing clear signs of an autoimmune disease, as reported in the literature [14]. We could confirm that the presence of anti-SSA/Ro antibodies, with or without anti-La, rather than the type of maternal autoimmune disease, is the risk factor for the development of NLS. This observation underlines the importance of this antibodies screening during pregnancy, to identify cases at risk in patients affected by autoimmune disease.
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Nowadays, in cases of women with anti-ENA positivity, steroid treatment is generally used to improve the pregnancy outcome, but its efficacy has been debated [25]. Recently, some authors suggest that a triple therapy combining plasmapheresis, IVIG and glucocorticoids may stop the natural evolution of the fetal cardiac affectation in positive anti-SSA/Ro antibody patients [26, 27]. In our population no link was found among maternal diagnosis, maternal therapy and maternal antibody blood levels with neonatal outcomes.
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The most important manifestation of NLS is CCHB. CCHB mostly develops between the 18th and the 24th gestational week and presents with a low ventricular rate, usually ranging from 40 to 60 bpm. CCHB is a potentially lethal condition and morbidity in surviving fetuses is substantial, with more than 2/3 of affected children requiring permanent pacemaker implantation [28–30]. A recent study on 214 cases of high-grade CHB has shown an overall mortality rate of 22.9% and the need of pacemaker implantation in 79.1% of cases [25]. According to our findings, all grades of CHB are possible, although the CCHB occurs more frequently. First or second degree CHB can progress in the years up to a CCHB [31]. These findings seem to suggest that the CCHB is the final stage of a gradually developing damage of the cardiac conduction tissue, starting in utero [32]. Our findings of other conduction abnormalities in addiction to CHB support the hypothesis that all parts of the fetal heart are susceptible to the injury by maternal autoantibodies.
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In all newborns of this study no skin rash was seen, maybe because they were not exposed to ultraviolet rays. According to literature data, UV exposure may accelerate apoptosis in keratinocytes, with the presentation of intracellular SSA/Ro or RNP antigens. These antigens binding to specific antibodies may cause the rash [11]. The hematological manifestations include thrombocytopenia, anemia and neutropenia, they are more often observed at 1 to 2 months of age [33]. In our experience hematological abnormalities were more frequent at 3 months, children were completely asymptomatic and laboratory alterations mostly resolved during follow-up. The lower incidence of hematological abnormalities at birth suggests that these findings detected after the neonatal period are probably not strictly related to the anti-SSA/Ro Ab, and could be linked to other mechanisms [32]. The etiopathogenetic role of anti-SSA/Ro antibodies in hematological manifestations of NLS should be further clarified. A likely pathogenetic mechanism for neutropenia seems to be the cross-reactivity of a membrane protein, similar to the antigen Ro 60kDa, the reaction between this membrane protein and the anti SSA/Ro antibodies may activate the complement system and cause neutrophils’ apoptosis [34–36]. Hepatobiliary disease is less commonly described than other NLS features, but it is a well established manifestation. In a retrospective analysis of the US Research Registry for Neonatal Lupus, about 10% of patients with NLS also had probable or possible hepatobiliary disease [37]. Three clinical variants of hepatobiliary disease were observed: a severe liver failure presenting during gestation or the neonatal
ACCEPTED MANUSCRIPT period; a conjugated hyperbilirubinemia with mild or no elevations of aminotransferases, occurring in the first week of life; and a mild elevation of aminotransferases occurring at approximately 2-3 months of life. In our series we found only the third clinical variant described, observing an high incidence of transient, mild to moderate, transaminases elevation.
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Furthermore, 9 newborns of this study had non-specific CNS anomalies on cerebral US in absence of any clinical neurological signs. Although CNS involvement is a not well-recognized manifestation of NLS, to our knowledge, other studies reported non-specific brain involvement [17,18,38]. Neuroimaging findings are characterized by non-specific lesions that could be considered with a favorable outcome, although longterm sequelae cannot be excluded. Few data are also available about the long-term neurological development, but high incidence of neuropsychiatric abnormalities is reported by Askanase et al [39].
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In our population, an association between anti-SSA/Ro Ab positivity during follow-up and presence of clinical manifestations was observed. This finding is consistent with data reported in the literature, according to which an etiopathogenetic role is played by this Autoantibody [1,4,5,14]. We do not find any correlation between the antibodies titer and the severity of clinical manifestations. The presence of more serious clinical manifestations in case of a combined positivity for both the anti-SSA/Ro Ab and the antiSSB/La Ab has been reported in the literature[40]. Our data confirm this previous observation, in fact 2 children with CCHB and 6 children with other cardiac manifestations were positive for anti SSA/Ro and anti SSB/La Ab at the time of diagnosis.
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In particular, our study allow to observe how the gradual decrease of anti-SSA/Ro Ab titer correlates with the gradual disappearance of related clinical manifestations, which are clinically benign and transient, except for CCHB. However, 10% of infants showed persistent anti-SSA/Ro levels at 9 months of life.
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Data of the literature on the incidence of the different features of NLS are difficult to compare, because they come mostly from case reports or retrospective studies, with different inclusion criteria [32,33,41–45]. Few data are available from prospective studies in which newborns of mothers with anti-SSA/Ro Ab were enrolled and are shown in Tab 8 [32,33,44].
Table 8 Prevalence of NLS features: Review of the literature
Authors
Study design
Patients n°
NLS features Follow up CCHB %
Other Cardiac %
Skin %
Hematological %
Hepatobiliary %
CNS %
Cimaz R et al. (2003) [33]
Prospective
128
6-9 months
1.6
41
16
27
26
NR
Motta M et al. (2007) [32]
Prospective
51
Not performed
2
15.7
3.9
3.9
0
NR
Boros C et al. (2007) [44]
Prospective
47
12 months
40
36
36
8
Present study (2016)
Prospective
50
9 months
0
24
56
18
25.5 4
12
Definitions: NR: not reported; CCHB: complete congenital heart block; “Other Cardiac” complains: I or II degree AV block, prolonged QT interval; CNS: central nervous system
ACCEPTED MANUSCRIPT Our results show an incidence of CCHB slightly higher than other prospective studies, this can be explained by the fact that our hospital is a reference center for autoimmune diseases during pregnancy. Boros et al reported the incidence of cardiac NLS features (CCHB, I or II degree AV block, prolonged QT interval) in their population without specifying the incidence of CCHB.
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The incidence of skin rash is very variable in the different studies, this finding is difficult to explain, but the different UV exposure of the newborns at birth could be an important factor, as already mentioned.
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The incidence of hematological and hepatobiliary NLS features in our study results comparable with other prospective studies in which follow-up was performed. Motta et al checked CBC and hepatic function tests only at birth, therefore they found a lower incidence. Our study confirms that the highest incidence of hematological and hepatobiliary NLS features is observed at 3 months of life, as observed in other studies.
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Boros et al suggest that hydrocephalus and macrocephaly are manifestations of NLS, because they find a significantly higher prevalence in newborns with NLS than that shown in the general population. In our series we do not find any child with these conditions, we observed only non-specific CNS anomalies on cerebral US. These anomalies resolved during follow-up and did not present any clinical correlate. It would be emphasized that our study is the only one in which a cerebral US evaluation was performed at birth to all infants with anti-SSA/Ro Ab.
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The type, frequency and severity of the clinical manifestations of NLS are often incomplete or even insufficiently investigated. Prenatal maternal screening is of primary importance in order to early detect CCHB, which can require maternal treatment and pacemaker implantation at birth. Infants born to mothers with anti-SSA/Ro Ab should be monitored for all NLS features at birth.
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Moreover, during the first months of life, infants with anti-SSA/Ro Ab seem to develop only mild, transient and self-limited clinical manifestations, which in most cases are completely solved at 9 months of life. This consideration together with the evidence that only 10% of infants had anti-SSA/Ro persistent in blood at 9 months suggests that follow-up of these children could be performed until 6-9 months of life with good clinical safety. However, we recommended clinical and laboratory monitoring at 3 months of life, when the highest incidence of hematological and hepatobiliary NLS features is observed. Furthermore, as late-onset of autoimmune disease in NLS babies is described [21], its identification would require clinical follow-up until adulthood. Future studies could clarify if the follow-up is needed in all cases or restricted to the persistent positive Ab ones.
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