The clinical spectrum of anti-Ro-positive cutaneous neonatal lupus erythematosus

Diffusive mediator feedbacks control the health-to-disease transition of skin inflammation

The spatiotemporal dynamics of inflammation provide vital insights into the understanding of skin inflammation. Skin inflammation primarily depends on the regulatory feedback between pro- and anti-inflammatory mediators. Healthy skin exhibits fading erythema. In contrast, diseased skin exhibits expanding erythema with diverse patterns, which are clinically classified into five types: circular, annular, arcuate, gyrate, and polycyclic. Inflammatory diseases with expanding erythema are speculated to result from the overproduction of pro-inflammatory mediators. However, the mechanism by which feedback selectively drives the transition from a healthy fading erythema to each of the five types of diseased expanding erythema remains unclear. This study theoretically elucidates the imbalanced production between pro- and anti-inflammatory mediators and prospective treatment strategies for each expanding pattern. Our literature survey showed that eleven diseases exhibit some of the five expanding erythema, thereby suggesting a common spatiotemporal regulation underlying different patterns and diseases. Accordingly, a reaction-diffusion model incorporating mediator feedback reproduced the five observed types of diseased expanding and healthy fading patterns. Importantly, the fading pattern transitioned to the arcuate, gyrate, and polycyclic patterns when the productions of anti-inflammatory and pro-inflammatory mediators were lower and higher, respectively than in the healthy condition. Further depletion of anti-inflammatory mediators caused a circular pattern, whereas further overproduction of pro-inflammatory mediators caused an annular pattern. Mechanistically, the bistability due to stabilization of the diseased state exhibits circular and annular patterns, whereas the excitability exhibits the gyrate, polycyclic, arcuate, and fading patterns as the threshold of pro-inflammatory mediator concentration relative to the healthy state increases. These dynamic regulations of diffusive mediator feedback provide effective treatment strategies for mediator production wherein skins recover from each expanding pattern toward a fading pattern. Thus, these strategies can estimate disease severity and risk based on erythema patterns, paving the way for developing noninvasive and personalized treatments for inflammatory skin diseases.

An Uncommon Presentation of Neonatal Lupus Erythematosus: A Case Report

Neonatal lupus erythematosus (NLE) is a rare autoimmune disorder of newborns and infants, born to usually asymptomatic mothers with lupus erythematosus. Clinical manifestations include variable cutaneous findings, with possible cardiac or hepatic involvement. We present a case of a 3-month-old baby girl with NLE, born to an asymptomatic mother. Her atypical clinical presentation included hypopigmented atrophic scars on the temples. She improved with topical pimecrolimus cream, with almost complete resolution of the facial lesions and improvement in atrophy noted at the 4-month follow-up visit. Cutaneous findings of hypopigmentation and atrophic scarring are less commonly reported. To our knowledge, no similar cases have been published in the Middle East. We aim to share this interesting case, highlight the different clinical presentations of NLE and raise awareness among physicians about this variable phenotype of NLE for timely diagnosis of this uncommon entity.

Cutaneous manifestations of lupus erythematosus: A practical clinicopathologic review for pathologists

Accurate diagnosis of connective tissue diseases is often challenging and relies on careful correlation between clinical and histopathologic features, direct immunofluorescence studies, and laboratory workup. Lupus erythematosus (LE) is a prototype of connective tissue disease with a variety of cutaneous and systemic manifestations. Microscopically, cutaneous LE is classically characterized by an interface dermatitis, although other histopathologic patterns also exist depending on the clinical presentation, location, and chronicity of the skin lesions. In this article, we review the clinical, serologic, histopathologic, and direct immunofluorescence findings in LE-specific and LE-nonspecific skin lesions, with an emphasis on lesser known variants, newly described features, and helpful ancillary studies. This review will guide general pathologists and dermatopathologists in accurately diagnosing and subclassifying cutaneous LE.

Neonatal lupus presenting as a non-specific rash in primary care

Neonatal lupus erythematosus is a rare autoimmune disease caused by passive transplacental acquisition of maternal autoantibodies manifesting in cutaneous, cardiac, haematological and hepatobiliary abnormalities. The hallmark dermatological finding is erythematous annular lesions with a predilection for photo-exposed areas of the skin. We present a case of a female infant born to a mother with Sjogren's syndrome, who initially presented to an ambulatory care setting with non-specific erythematous papules involving the face and scalp. Within 6 days the rash changed in appearance, consisting of widespread erythematous annular and polycyclic lesions with central violaceous clearing and atrophy. Serological tests revealed asymptomatic anemia and leukopenia, elevated liver enzymes, and positive antinuclear antibodies (ANA) and anti-SSb/La antibodies. Further cardiac evaluation was normal. She was managed conservatively in the outpatient setting with topical steroids, avoidance of sunlight and fluorescent light exposure, and primary care, rheumatological and dermatological follow-up.

Retrospective, single-center case series of neonatal lupus

BACKGROUND

Neonatal lupus erythematosus (NLE) results from cross-placental transfer of maternal autoantibodies. Neonates can present with cardiac, cutaneous, hepatobiliary, hematologic, and neurologic complications from antibody-mediated organ toxicity. Scant evidence exists on long-term clinical characteristics and outcomes of patients with neonatal lupus.

OBJECTIVES

To characterize the autoantibody profile, laboratory, and clinical features of patients with NLE.

MATERIALS/METHODS

This was a single-site retrospective cohort study of patients at the Children's Hospital of Philadelphia with NLE. Data were collected on clinical, laboratory, and autoantibody profile at time of presentation, as well as long-term complications.

RESULTS

Thirteen patients were included. Congenital cardiac findings were reported in 3 patients, with 1 having persistent cardiac sequelae. Cardiac manifestations were correlated with anti-Ro/SSA positivity in our cohort. Two patients had neurologic findings, with good long-term outcomes. Cutaneous findings were present in all patients, and many resolved without topical steroid treatment. Hematologic and hepatobiliary findings were common, but uncomplicated, with complete resolution by 6 months after initial presentation in all. Maternal rheumatologic disease, treatment, and race were not associated with systemic manifestations.

CONCLUSIONS

Patients born to mothers with positive anti-Ro/SSA titers may benefit from routine cardiac monitoring in utero and at birth. Routine EEG or head ultrasound monitoring in patients who are autoantibody positive for NLE may be unnecessary. Information regarding long-term outcomes in NLE can be used to guide familial counseling and the use of serial laboratory testing.

[Polymorphism and differential diagnosis of neonatal lupus erythematosus]

INTRODUCTION

Neonatal lupus erythematosus (NEL) is a rare condition secondary to transplacental transfer of maternal anti-nuclear antibodies, generally anti-Ro/SSA. The most common signs are dermatological and cardiac. The most frequently reported clinical association is periorbital erythema, known as "owl eye", and bipolar erythematous maculopapular plaques with fine scales. However, many semiological variants can result in diagnostic errors or delays.

PATIENTS AND METHODS

This was a single-centre retrospective observational study collating all cases of NEL seen at paediatric dermatology consultations between 2010 and 2018. The diagnosis of NEL was confirmed by the presence of specific antinuclear antibodies (ANA) in the mother. The aim was to describe the different clinical forms of NEL and to discuss differential diagnosis.

RESULTS AND DISCUSSION

We identified ten cases of NEL, all addressed without diagnosis or with misdiagnosis. They were divided into 3 groups based on the semiology of skin lesions: 5 presented inflammatory macular papules on the cephalic extremity and head; 3 presented acquired periorbital depigmentation; 2 presented atrophic and diffuse livedoid lesions. None had heart disease and associated haematological and hepatic damage was mild. Spontaneous remission was seen in all cases before the age of 6 months. The mothers, who were generally symptom-free or paucisymptomatic, presented anti-Ro/SSA NAAs.

CONCLUSION

Recognition of the different clinical forms of NEL enables early institution of suitable therapy and monitoring of subsequent pregnancies.

Effect of in utero hydroxychloroquine exposure on the development of cutaneous neonatal lupus erythematosus

OBJECTIVE

Cutaneous neonatal lupus (cNL) occurs in possibly 5%-16% of anti-Ro±anti-La antibody-exposed infants. Data suggest in utero exposure to hydroxychloroquine (HCQ) may prevent cardiac NL. The aim was to assess whether in utero exposure to HCQ decreases the risk of cNL and/or delays onset.

METHODS

A multicentre case-control study was performed with 122 cNL cases and 434 controls born to women with a rheumatological disease who had documentation of maternal anti-Ro±anti-La antibodies at pregnancy and confirmation of medication use and the child's outcome. A secondary analysis was performed on 262 cNL cases, irrespective of maternal diagnosis, to determine if HCQ delayed time to cNL onset.

RESULTS

Twenty (16%) cNL cases were exposed to HCQ compared with 146 (34%) controls (OR 0.4 (95% CI 0.2 to 0.6); p<0.01). Exposure to HCQ was associated with a reduced risk of cNL; exposure to anti-La antibody and female gender were associated with an increased risk of cNL. Exposure to HCQ remained significantly associated with a reduced cNL risk in the analyses limited to mothers with systemic lupus erythematosus and those who developed rash ≤1 month. When analysing all 262 cNL cases, HCQ-exposed infants were older (6.0 (95% CI 5.7 to 6.3) weeks) at cNL onset versus HCQ-non-exposed infants (4.4 (95% CI 3.9 to 5.0) weeks), but the difference was not statistically significant (p=0.21).

CONCLUSION

Exposure to HCQ was associated with a reduced risk of cNL. Among cNL cases, those exposed to HCQ tend to have later onset of rash. Both findings suggest a protective effect of HCQ on cNL.

Neonatal lupus erythematosus complicated by mucocutaneous and visceral hemangiomas

Neonatal lupus erythematosus (NLE) is a passively acquired autoimmune syndrome resulting from transplacental passage of maternal anti-Ro/SSA and/or anti-La/SSB antibodies to the fetus. Characteristic manifestations of NLE include transient dermatitis, hepatic and hematologic abnormalities and congenital heart block. Skin lesions in NLE resemble subacute cutaneous lupus erythematosus and typically consist of annular, erythematous, scaly plaques. Telangiectasias, vascular abnormalities resulting from dilation of superficial dermal vessels, may also affect the skin in a minority of patients. The etiology of telangiectasias in NLE is unknown, but disordered angiogenesis likely plays a role. Hemangiomas are a common disorder of angiogenesis frequently encountered in infancy. There have been no reported cases of neonatal lupus associated with the development of hemangiomas. We present a case of an infant diagnosed with NLE after manifesting classic dermatitis, hepatic and hematologic abnormalities who later developed mucocutaneous and visceral hemangiomas. We further postulate that disordered angiogenesis, possibly dysregulated production of vascular endothelial growth factor, may play a primary role in the development of these cutaneous vascular lesions in NLE. Lupus (2007) 16, 904—907.

Neonatal lupus erythematosus: a review of 123 cases in China

AIM

To analyze the clinical features, outcomes and prognosis of neonatal lupus erythematosus (NLE) in China.

METHOD

We reviewed 12 NLE cases at the Peking Union Medical College Hospital and compared the data with 111 cases reported in China between 1990 and 2014. The Chinese medical journal search engines used in this study were Wanfang.data and Science China.

RESULTS

No gender dominance in NLE incidence was found. Cutaneous lesions were present in more than 96% of patients, while cardiac, hematological and hepatobiliary manifestations were seen in 12.61%, 45.53% and 17.89% of cases, respectively. Congenital heart block (CHB) tended to be more persistent, with two cases showing CHB for 1 year and three cases persisting for 7-10 years. In this study more than 90% of mothers were anti-Sjögren's syndrome A positive, and 65.04% were asymptomatic prior to the pregnancy.

CONCLUSION

These results indicate that clinicians, especially dermatologists, in China should improve their recognition of this disease to avoid misdiagnosis, and more attention should be paid to the follow-up of NLE patients and their asymptomatic mothers.

Review of the cutaneous manifestations of autoimmune connective tissue diseases in pediatric patients

Autoimmune connective tissue diseases are chronic inflammatory disorders associated with complex genetic and environmental interplay resulting in a variety of cutaneous and systemic manifestations. Pediatric onset of these disorders carries a unique diagnostic pressure for the clinician due to the potential years of disease burden and complications. Mortality and morbidity from these disorders has fallen dramatically over the past fifty years due to increasing awareness of these disease sequelae and utilization of systemic treatment modalities when necessary. This review highlights the clinical features that are unique to pediatric presentations of lupus erythematosus, juvenile idiopathic arthritis, juvenile dermatomyositis, juvenile onset systemic sclerosis and morphea. Each of these disorders has a distinct appearance corresponding to a particular cutaneous and systemic clinical course and prognosis. Awareness of the associated potential systemic complications can also alert the clinician to make astute management decisions when confronted with a probable rheumatologic case. Cutaneous symptoms may predate onset of systemic symptoms and by keeping the rheumatologic differential diagnoses in mind, the dermatologist can play a key role in potentially offsetting autoimmune disease burden in children.

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

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

Seeing double: annular diaper rash in twins

We report a case of dichorionic, diamniotic twins who developed similar erythematous, annular, erosive plaques in the inguinal folds in the first few weeks of life that were refractory to topical antifungals and oral antibiotics. The twins were found to have high transaminase levels, antinuclear antibody positivity, and anti-SSS/Ro) and anti-SSB/La autoantibodies. The rash resolved without scarring by 7 months of age with the use of low-potency topical corticosteroids. We suggest that physicians consider neonatal lupus erythematosus in neonates with atypical eruptions occurring in sun-protected skin.

Cutaneous neonatal lupus with cutis marmorata telangiectatica congenita-like lesions

Neonatal lupus is a rare disease caused by the transplacental transfer of maternal autoantibodies to the foetus, characterized by transient clinical manifestations such as cutaneous, haematological, and hepatobiliary events or permanent such as congenital heart block. The typical cutaneous manifestations include erythematous, scaly, annular or arched lesions on the face, with slight central atrophy and photosensitivy, clinically and histologically similar to subacute cutaneous lupus. However, in some cases, the lesions may resemble those in cutis marmorata telangiectatica congenita, although this phenomenon is rare and only eight such cases have been reported to date. We report a case of cutaneous neonatal lupus with atypical lesions on the limbs, which had a reddish-purple marbled appearance, resembling the lesions in cutis marmorata telangiectatica congenita.

Neonatal lupus syndrome associated with ribonucleoprotein antibodies

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

Neonatal lupus erythematosus and its clinical variability

Neonatal lupus erythematosus (NLE) is a rare disease affecting newborns that is caused by maternal autoantibodies transmitted across the placenta. The disease may affect the skin, the heart, and rarely the hepatobiliary or hematological systems. A serious complication affecting some patients with NLE is atrioventricular heart block (AV block). The clinical picture of cutaneous NLE varies considerably. NLE presents with confluent, scaly, periorbital erythema, or erythematous infiltrated plaques with central vesicles and lesions resembling seborrheic eczema or fungal infection. In any newborn with such skin lesions, NLE should be included in the differential diagnosis. Dermatologists play an important role in the diagnosis. We review different skin lesions occurring in neonatal lupus erythematosus based on five patients from our own clinic.

Congenital and neonatal lupus erythematosus: two case reports

Neonatal lupus erythematosus is an autoimmune disease produced by the passage of maternal antinuclear antibodies and extractable nuclear antigen antibodies through the placenta. At the moment of the diagnosis, the mothers are asymptomatic in 40 to 60% of cases. The most common manifestations are cutaneous lesions and congenital heart block. The cutaneous findings are variable and usually begin within the first weeks or months of life. Congenital lupus erythematosus is a congenital variant of neonatal lupus erythematosus. We present one case of congenital lupus erythematosus and one case of neonatal lupus erythematous, showing the variability of this disease.

Neonatal lupus syndrome in a Nigerian child

Neonatal lupus is a rare syndrome resulting from passively transferred maternal autoantibodies during pregnancy. A male infant was delivered at term to a 29-year-old primiparous woman who was diagnosed of systemic lupus erythematosus 2 years earlier and had detectable levels of autoantibodies (antinuclear antibody (ANA), anti-dsDNA, anti-Ro and anti-La/SSB) in second trimester. However, the pregnancy was otherwise uneventful. He presented at the age of 8 week with a widespread hypopigmented macular rash on the trunk and patchy alopecia involving the hair line and the occipito-parietal regions of 3 weeks duration, anaemia and symptomatic thrombocytopaenia. Serologic test for autoantibodies was positive for ANA and anti-La/SSB. Further evaluation was normal. He was managed conservatively with blood products and topical corticosteroids. Mother was also advised to avoid direct exposure to sunlight and fluorescent light. Haematological parameters gradually normalised over 2 months and the skin lesions resolved completely by the age of 6 months.

Cardiac manifestations of neonatal lupus: a review of autoantibody-associated congenital heart block and its impact in an adult population

Within the last decade the prevalence of adult patients living with congenital heart disease equals that seen in children. This expanding population poses a challenge to clinical cardiologists who will be caring for patients with the clinical manifestations of this condition. Neonatal lupus is a model of passively acquired autoimmunity and is responsible for the majority of clinical cases of congenital heart block (CHB). This review will focus on the presentation, pathophysiology, and the long-term follow-up of CHB associated with neonatal lupus, and discuss important diagnostic tests, familial implications, and pacemaker issues associated with the care of an adult with CHB.

Emerging roles for the Ro 60-kDa autoantigen in noncoding RNA metabolism

All cells contain an enormous variety of ribonucleoprotein (RNP) complexes that function in diverse processes. Although the mechanisms by which many of these RNPs contribute to cell metabolism are well understood, the roles of others are only now beginning to be revealed. A member of this latter category, the Ro 60-kDa protein and its associated noncoding Y RNAs, was discovered because the protein component is a frequent target of the autoimmune response in patients with the rheumatic diseases systemic lupus erythematosus and Sjögren's syndrome. Recent studies have shown that Ro is ring shaped, binds the single-stranded ends of misfolded noncoding RNAs in its central cavity, and may function in noncoding RNA quality control. Although Ro is not present in yeast, many bacterial genomes contain potential Ro orthologs. In the radiation-resistant eubacterium Deinococcus radiodurans, the Ro ortholog functions with exoribonucleases during stress-induced changes in RNA metabolism. Moreover, in both D. radiodurans and animal cells, Ro is involved in the response to multiple types of environmental stress. Finally, Y RNAs can influence the subcellular location of Ro, inhibit access of the central cavity to other RNAs, and may also act as binding sites for proteins that influence Ro function. WIREs RNA 2011 2 686-699 DOI: 10.1002/wrna.85 For further resources related to this article, please visit the WIREs website.

Neonatal lupus erythematosus in identical twins, showing transient bullous lesions

One of identical twin girls was born with ulcers on her leg, and shortly after birth developed a flaccid blister on the leg. Subepidermal blister with vacuolar degeneration of basal cell layer and the heavy infiltration of mononuclear cells in the upper dermis were observed in the blister lesion. She also had generalized livedo. Her identical twin sister did not exhibit ulcers or blisters, but was born with milia on her limbs. Their mother was found to have lupus erythematosus with positive anti-Ro/SSA antibodies and developed Sjögren syndrome. We emphasize neonatal blistering and congenital milia unique manifestations of neonatal lupus erythematosus.

Neonatal lupus erythematosus: clinical character, investigation, and outcome

Neonatal lupus erythematosus is an uncommon maternal auto-antibody-associated disease characterized by cutaneous, cardiac, hepatic, hematological, neurological, and pulmonary involvement. A retrospective study was performed to review clinical manifestations, investigation results, outcomes of neonatal lupus erythematosus patients and their mothers at the Department of Pediatrics, Siriraj Hospital during 1993 to 2008. Seventeen neonatal lupus erythematosus patients (10 girls and seven boys) were identified. Cutaneous, cardiac, hepatobiliary, and hematological involvement was found in 70.6%, 64.7%, 52.9%, and 35.3% of infants, respectively. Skin lesions were erythematous patches (91.7%), subacute cutaneous lupus erythematosus (50%), petechiae (41.7%), persistent cutis marmorata (16.7%), and discoid lesions (8.3%). Congenital heart block was found in nine cases, and structural abnormalities were found in nine cases. All sera of patients were positive for antinuclear antibodies. Patients (87.5%) showed positive antiRo/SSA, and 50% had positive antiLa/SSB antibodies. Most neonatal lupus erythematosus mothers (64.7%) were asymptomatic. Five mothers were diagnosed with systemic lupus erythematosus, and one mother was diagnosed with mixed connective tissue disease. All maternal sera was positive for antinuclear antibodies and antiRo/SSA antibody. Seven patients required pacemaker implantation. The mortality rate was 11.8%, caused by congestive heart failure and pneumonia. Antinuclear antibody tests should be used as one of the screening tests in mothers or patients suspected of having neonatal lupus erythematosus.

Cutaneous lupus in infancy and childhood

Cutaneous lupus may occur in infancy as transient lesions associated with and probably caused by maternal autoantibodies, or later in childhood, associated with the endogenous development of autoimmunity. In this review, clinical findings, diagnosis, management, and pathogenesis of neonatal lupus are discussed, and the management of cutaneous lupus in children is detailed.

Non-cardiac manifestations of neonatal lupus erythematosus

Neonatal lupus erythematosus (NLE) is characterized by the transplacental passage of maternal anti-Ro and/or anti-La antibodies and characteristic illnesses in the foetus/neonate. Most attention has focused on the most serious complication- cardiac involvement. This article will focus on non-cardiac involvement. Skin involvement (cutaneous NLE) is present in 15-25% of children with NLE. The rash of NLE tends to be photosensitive but may be present at birth or in non-sun exposed areas. It is most frequently seen around the eyes, not in the malar area, but also occurs in other parts of the body. The pathology resembles the rash of subacute cutaneous lupus erythematosus. Anti-Ro antibodies are present in >95% with the remaining mothers having anti-U1RNP antibodies only. Asymptomatic elevation of liver function tests, which may be associated with evidence of cholestasis, is seen in 10-25% of cases of NLE. Mild hepatomegaly and less commonly splenomegaly may be present. Liver involvement seen in isolation or associated with other features. The pathology resembles idiopathic neonatal giant cell hepatitis. Any haematological lineage, neutropenia and thrombocytopenia most commonly, may be affected by NLE. Haematological involvement is almost always asymptomatic. There are protean manifestations of neurologic involvement in NLE: hydrocephalus, non-specific white matter changes, calcification of the basal ganglia and a 'vasculopathy'. The most unusual feature of NLE is the radiographic finding of stippling of the epiphyses (chondrodysplasia punctata). Overall, non-cardiac involvement of NLE is more common than cardiac. The study of these manifestations may lead to new insight into how autoantibodies lead to disease.

Neonatal lupus erythematosus: three case reports and review of the Chinese literature

To recognize the clinical characteristics and outcomes of neonatal lupus erythematosus (NLE), the authors retrospectively review 3 NLE babies in their department and compared their data with 51 NLE cases reported in the available Chinese literature between January 1991 and December 2008. Most of the cases were located near the eastern coast of China, and clinical manifestation of 72.22% of the cases occurred in 2-week-old babies. Skin findings occurred in 94.44% of the patients, 12.96% with complete heart block (CHB), 22.22% with thrombocytopenia, and 14.81% with transient elevated transaminase levels. Cutaneous lesions, thrombocytopenia, and transaminase level showed improvement; 3 CHB cases had persisted after 7 to 10 years follow-up, and 1 case died in 5 months. Twenty-four (44.44%) pregnant woman with anti-Ro/SSA and/or anti-La/SSB antibodies are asymptomatic, and antibody status is first indicated when their child shows symptoms of NLE. Thus, all pregnant women should be screened for anti-Ro/ SSA and anti-La/SSB antibodies.

Cutaneous lupus erythematosus: issues in diagnosis and treatment

Cutaneous lupus erythematosus (LE) may present in a variety of clinical forms. Three recognized subtypes of cutaneous LE are acute cutaneous LE (ACLE), subacute cutaneous LE (SCLE), and chronic cutaneous LE (CCLE). ACLE may be localized (most often as a malar or 'butterfly' rash) or generalized. Multisystem involvement as a component of systemic LE (SLE) is common, with prominent musculoskeletal symptoms. SCLE is highly photosensitive, with predominant distribution on the upper back, shoulders, neck, and anterior chest. SCLE is frequently associated with positive anti-Ro antibodies and may be induced by a variety of medications. Classic discoid LE is the most common form of CCLE, with indurated scaly plaques on the scalp, face, and ears, with characteristic scarring and pigmentary change. Less common forms of CCLE include hyperkeratotic LE, lupus tumidus, lupus profundus, and chilblain lupus. Common cutaneous disease associated with, but not specific for, LE includes vasculitis, livedo reticularis, alopecia, digital manifestations such as periungual telangiectasia and Raynaud phenomenon, photosensitivity, and bullous lesions. The clinical presentation of each of these forms, their diagnosis, and the inter-relationships between cutaneous LE and SLE are discussed. Common systemic findings in SLE are reviewed, as are diagnostic strategies, including histopathology, immunopathology, serology, and other laboratory findings. Treatments for cutaneous LE initially include preventive (e.g. photoprotective) strategies and topical therapies (corticosteroids and topical calcineurin inhibitors). For skin disease not controlled with these interventions, oral antimalarial agents (most commonly hydroxychloroquine) are often beneficial. Additional systemic therapies may be subdivided into conventional treatments (including corticosteroids, methotrexate, thalidomide, retinoids, dapsone, and azathioprine) and newer immunomodulatory therapies (including efalizumab, anti-tumor necrosis factor agents, intravenous immunoglobulin, and rituximab). We review evidence for the use of these medications in the treatment of cutaneous LE.

Anti-RNP neonatal lupus in a female newborn

We describe a case of neonatal lupus erythematosus in a term female infant who presented at birth with mild, scattered facial erythema and ice-pick lesions at lateral and superior borders of her face. These lesions then progressed to an erythematous raccoon-like mask following exposure to the sun. Initial blood work performed at four-months-old showed speckled anti-nuclear antibody titers of 1:320, with negative anti-Ro/SSA and La/SSB negative and a positive anti-RNP. The infant had no evidence of cardiac, haematological or hepatobilary involvement initially or throughout her course of evaluation. The patient’s mother was asymptomatic throughout the investigation of the infant but through blood work and evolvement of symptoms, she was diagnosed with mixed connective tissue disease.

[Cutis marmorata telangiectatica congenita. Review of 33 cases]

INTRODUCTION

Cutis marmorata telangiectatica congenita (CMTC) is an uncommon congenital vascular malformation characterized by the presence of a localized or generalized pattern, frequently asymmetrical, with reticulated, erythematous or violaceous macules, present at birth or shortly thereafter.

PATIENTS AND METHOD

Retrospective study of 33 cases of CMTC diagnosed between 1994 and 2007 in our hospital. Clinical and follow-up data were recorded in all cases. In some patients additional tests were performed.

RESULTS

Most of the patients (51.5%) were female. In 87.9% of the cases lesions were observed at birth. All the cases were sporadic. CMTC was localized in 72.7% of the patients, being distributed mainly over the lower limbs. Associated anomalies were noted in 60.6%, with predominance of skin alterations (14 cases). Extracutaneous anomalies were present in 11 patients, most commonly atrophy and hypertrophy in the involved limbs. In none of the cases were there ocular or neurological manifestations. The average follow-up time was 14 months. Improvement of the lesions was observed in 45%, and in one case there was complete resolution.

CONCLUSIONS

CMTC is a malformative disease which is frequently associated with other abnormalities. An appropriate assessment and follow-up of these patients is advisable. Performing a thorough medical history, including full physical examination is necessary. If the head is affected, ocular and neurological examination should be performed. The prognosis is generally good, with a tendency to improvement or disappearance in most cases.

Periorbital cutaneous neonatal lupus

The authors report 3 infant girls with a similar periorbital eruption. A 5-month-old infant girl presented with a 3-month history of a photosensitive facial eruption that had failed to respond to topical 1% hydrocortisone cream. The otherwise healthy infant was the product of a term pregnancy. The 25-year-old mother was in good health except for occasional arthralgias. She had 2 other healthy children. Physical examination revealed a well-developed, well-nourished infant with annular, polycyclic, erythematous scaly plaques involving the cheeks and periorbital region (Figure 1). Potassium hydroxide scraping from the face was negative for dermatophyte and yeast. Laboratory studies revealed normal complete blood cell count, normal liver function tests, strongly positive anti-SSA antibody at 118 units (>80 units, strongly positive), and a negative anti-SSB antibody. Cardiac examination and electrocardiogram (ECG) were also normal. Laboratory evaluation of the mother revealed a positive anti-SSA at 158 units and mild anemia, but anti-SSB, anti-Smith, U1RNP, and anti-Scl-70 antibodies were all negative. Within 4 months the facial eruption cleared completely with the use of desonide cream 0.05% applied twice a day and sun protection. A 6-month-old girl was referred for dermatitis that began on the trunk and face at about 2 months of age. Although the truncal component resolved after 2 months, the facial dermatitis persisted. The infant was in good health and was the first-born child. The mother was known to have Sjögren syndrome. Physical examination revealed the characteristic erythematous, annular, scaling, polycyclic plaques along the forehead, periorbital cheeks, and eyelids (Figure 2). Laboratory evaluation of the infant revealed normal complete blood cell count, liver function tests, and chemistry profile. Anti-SSA antibody was positive at >6 units (reference, <1 unit) and anti-SSB antibody was positive at 2.84 units (reference, <1 unit). U1RNP antibody was negative. Cardiac examination and ECG were normal. The skin abnormalities cleared completely in 6 weeks with the topical application of tacrolimus 0.03% ointment and sun protection. A 5-month-old girl presented with a 2-month history of a persistent facial dermatitis. The infant was in good health and was the product of a healthy first pregnancy and delivery. The mother was in good health. Physical examination of the infant revealed erythematous, annular, polycyclic periorbital patches (Figure 3). Laboratory evaluation revealed positive SSA and SSB antibodies (units unavailable) and normal complete blood cell count, liver function tests, and chemistry profile. Cardiac examination and ECG were normal. The mother's laboratory results were also positive for anti-SSA and anti-SSB antibodies (units unavailable). The infant's facial eruption resolved without specific treatment.

Cutis marmorata telangiectatica congenita and neonatal lupus

Cutis marmorata telangiectatica congenita is an uncommon congenital vascular anomaly that is characterized by persistent, reticulated, violaceous pigmentation. We describe a female infant with vascular lesions consistent with this entity who was born to a mother with previously diagnosed systemic lupus erythematosus. Antinuclear antibodies and anti-Ro/SSA antibodies were detected in both mother and infant, supporting a diagnosis of neonatal lupus. This presentation is consistent with the rarely reported association between neonatal lupus and cutis marmorata telangiectatica congenita that suggests the latter is part of the cutaneous spectrum of the former. A thorough maternal history and laboratory investigations should be considered for infants with cutis marmorata telangiectatica congenita and their mothers in order to rule out the presence of an underlying autoimmune disease.

[Neonatal lupus erythematosus: 4 cases and clinical review]

Neonatal lupus erythematosus (NLE) is an infrequent disease in newborns caused by the transplacental passage of maternal Anti-Ro/SSA, Anti-La/SSB and/or Anti-U1 RNP antibodies. The most common manifestations are cutaneous and cardiac. We carried out a retrospective study of cases of NLE diagnosed in the last 10 years at the Hospital Universitario Insular in Gran Canaria. Complete data was obtained for 4 patients. Three cases had circulating Anti-Ro antibodies in the mother and in the newborns, while in the fourth case they were Anti-RNP. Two mothers were diagnosed with systemic lupus, one with mixed connective tissue disease and the other with leucocytoclastic vasculitis. The skin lesions consisted of urticaria-like and desquamative lesions. One patient presented with ulceration. The histological study of the urticaria-like lesions showed a non-specific perivascular infiltrate; the desquamative lesions were consistent with subacute lupus erythematosus.

Le lupus néonatal

Children born from mothers positive for autoantibodies against SSA/Ro and/or anti-SSB/La ribonucleoproteins may develop heart conduction tissue damage resulting in atrioventricular block and/or transient skin rash, liver enzyme abnormalities and anaemia/thrombocytopenia. Additional transient electrocardiographic abnormalities (sinus bradycardia, QT interval prolongation) have been reported. Such clinical and laboratory manifestations are included in the so-called neonatal lupus syndromes, independently whether the mother is suffering from a systemic autoimmune disease or is totally asymptomatic. The prevalence of the congenital heart block is around 2%, of neonatal rash around 20%, while laboratory abnormalities in asymptomatic babies can be detected in up to 40% of cases. The risk of recurrence of complete heart block is almost 10 times higher in the following pregnancies. Most of the mothers are asymptomatic at delivery and are identified only by the birth of an affected child. Their long-term outcome is generally more reassuring than previously assumed. Serial echocardiograms and obstetric sonograms, performed at least every 2 weeks, starting from 16 weeks gestation, are recommended in anti-Ro/SSA positive pregnant women: the goal is to detect early fetal abnormalities, that might precede complete atrioventricular block and that might be a target for preventive therapy. Transplacental passage of maternal anti-SSA/Ro -SSB/La IgG is thought to be pivotal in inducing tissue damage. However, the discordant appearance of the syndrome in twins does suggest a role also for fetal or environmental factors.

Neonatal lupus erythematosus: a review of the racial differences and similarities in clinical, serological and immunogenetic features of Japanese versus Caucasian patients

There has been tremendous interest in neonatal lupus erythematosus (NLE) since the reports of anti-Ro/SSA antibodies as a diagnostic marker. Recent studies, including ours, have revealed racial differences as well as similarities in the clinical features and immunogenetic backgrounds of Japanese and Caucasian patients with NLE. The frequency of photosensitivity and subacute cutaneous LE lesions is not high in Japanese infants with NLE, which is in sharp contrast to their Caucasian American counterparts. The majority of Japanese infants with NLE develop annular, erythematous or edematous lesions which have also been reported in association with Sjögren's syndrome. The frequency of isolated congenital heart block (CHB) is about 50% in Japanese anti-Ro/SSA positive neonatal lupus infants; this is similar to the frequency among Caucasians. The HLA-DR3 phenotype, which is found in the great majority of Caucasian mothers of NLE infants, is absent in Japanese mothers. Finally, both Japanese and Caucasian children with CHB are often identical to their mothers in their alleles of HLA-DRB1, DQA1 and DQB1 loci.

Clinical and prognostic value of autoantibodies in puerto Ricans with systemic lupus erythematosus

The aim of this study was to determine the association between lupus autoantibodies and the clinical manifestations and outcome in a cohort of Puerto Ricans patients with systemic lupus erythematosus (SLE). All patients fulfilled the American College of Rheumatology classification criteria for SLE. Demographic parameters, clinical manifestations over time and damage accrual were obtained at the last study visit. Disease damage was assessed with the Systemic Lupus International Collaborating Clinics Damage Index (SDI). ANA, ANA pattern, and anti-dsDNA, anti-Smith, anti-Ro (SSA), anti-La (SSB) and anti-snRNP antibodies were measured at the time of SLE diagnosis. Chi-square test, Fisher exact test, ANOVA, logistic regression and general lineal model analyses were used to evaluate these associations. Ninety-six percent of patients were females. The cohort had a mean age of 40.2 +/- 12.0 years and mean disease duration of 9.6 +/- 7.0 years. Patients with elevated anti-dsDNA antibodies were more likely to have vasculitis, pericardial effusion, renal involvement, anaemia, leukopenia, lymphopenia and thrombocytopenia. Anti-Smith antibodies were positively associated with skin ulcerations, elevated liver enzymes, renal involvement and thrombocytopenia. Anti-Ro antibodies were related with the presence of discoid lupus, serositis, pneumonitis, elevated liver enzymes, hemolytic anaemia, leukopenia and lymphopenia. No positive associations were found for anti-snRNP or anti-La antibodies. The presence of anti-dsDNA, anti-Smith and anti-Ro antibodies was associated with higher SDI scores. In conclusion, anti-dsDNA, anti-Smith and anti-Ro antibodies are associated with several clinical manifestations and more damage accrual in Puerto Ricans with SLE. These findings provide valuable clinical and prognostic information for this ethnic population.

Congenital lupus erythematosus: case report and review of the literature

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

Transient autoimmunity related to maternal autoantibodies: neonatal lupus

Neonatal lupus (NLE) is an autoimmune disease associated with maternal antibodies to Ro/La and characterized by cutaneous lesions, heart block, cardiomyopathy, hepatobiliary disease, and hematologic cytopenias. In most cases, only one organ is affected, although multiple organ involvement is not unusual. Since NLE is presumably caused by maternal autoantibodies, the disease process is transient. However, cardiac NLE, in particular, may be fatal or persistently disabling. Optimal therapy has not yet been determined. Mothers of babies with NLE are often initially asymptomatic, but eventually most develop symptoms of autoimmune disease, particularly diseases associated with anti-Ro/La autoantibodies, such as Sjogren's syndrome and systemic lupus erythematosus. Children who have had NLE are probably at increased risk for autoimmunity later in life, sometimes as early as pre-adolescence, but the magnitude of the risk for the children is not known. Only a small percentage of babies exposed to maternal autoantibodies to Ro and/or La develop NLE. The factors governing which babies develop disease and, if disease develops, which organs will be affected have yet to be fully elucidated. In this review the clinical features, diagnosis, therapy, and prognosis of NLE are discussed, and a summary of experimental data relating to pathogenesis is presented.

Life-threatening cutaneous conditions in neonates

One of the major medical concerns in neonates is their vulnerability to life-threatening complications. Early diagnosis of potentially serious medical conditions is essential in prevention of such complication by prompt administration of appropriate treatments. Recognition of cutaneous manifestations of potentially fatal diseases may assist a clinician in management of newborns. To overview the full spectrum of this category of conditions, Medline search was performed for cases of cutaneous manifestations associated with mortality during the first month of live that were published in the English language literature since 1977. This is a concise review of the clinical aspects of most of the potentially life-threatening disorders in neonates divided by basic morphology of their cutaneous manifestations.