Neonatal lupus erythematosus: an acquired autoimmune disease to be taken seriously

AIM

This review aims to summarize the epidemiology, pathogenesis, clinical features, management, prognosis and regression of Neonatal lupus erythematosus (NLE) with a view to providing directions for standardized diagnosis, treatment and further research.

METHODS

We conducted a comprehensive literature review of NLE. NLE-related peer-reviewed papers were searched through PubMed/Medline were searched up to November 2024.

RESULTS

NLE is a rare acquired autoimmune disease (AD) linked to organ damage from maternal autoantibodies crossing the placenta to the foetus. However, not all mothers have ADs or associated antibodies. The disease involves autoantibody-induced inflammation, apoptosis, fibrosis, calcium channel dysregulation in cardiomyocytes, and increased interferon expression. NLE incidence shows no sex difference, but there is a differential distribution of clinical features across ethnic groups. The frequency of organ involvement in NLE patients is more common in the cutaneous and cardiac. NLE also affects the haematological and hepatobiliary systems, and some patients may experience neurological and endocrinological involvement. Steroids and immunoglobulins can aid in the recovery of some patients. Proper use of antimalarials during prenatal and gestational periods may prevent or improve the prognosis of patients with congenital heart block (CHB). Implantation of a pacemaker is effective in maintaining cardiac function in children with complete atrioventricular block. Symptoms associated with NLE may improve with antibody depletion, but some patients may experience sequelae such as irreversible CHB, neuropsychiatric disorders and developmental delays. Universal screening for autoantibodies to Sjögren syndrome A or B autoantigens should be offered to women of childbearing age experiencing desiccation syndrome. Antibody-positive individuals require appropriate reproductive counselling and advice, along with close foetal monitoring starting at 16 weeks of gestation and postnatal prognostic follow-up.

CONCLUSION

Epidemiologic investigations and clinical studies on NLE are currently inadequate, and large-scale epidemiologic investigations, prospective clinical studies, and basic research are needed in the future to improve the understanding of the disease and the standardization of its clinical management.

Clinical characteristics of neonatal lupus erythematosus complicated by congenital heart block: a multi-center retrospective study in East China

Congenital heart block (CHB) is the most high-risk and prognosis-poor phenotype of neonatal lupus erythematosus (NLE). This study aimed to investigate the clinical characteristics of NLE patients complicated by CHB. This was a multi-center retrospective study. Data were retrospectively collected from NLE patients diagnosed between January 1, 2011, and December 31, 2023, at the Affiliated Children's Hospital of Soochow University, the Affiliated Suzhou Hospital of Nanjing Medical University, Yangzhou Maternity and Child Health Care Hospital, and Huai'an Maternity and Child Health Care Hospital. The patients were divided into CHB and non-CHB groups based on the presence or absence of CHB. Clinical data were compared between the two groups, and logistic regression analysis was performed to identify risk factors associated with CHB. The outcomes of patients in the CHB group were determined through follow-ups. Ninety-one NLE patients were included, with 15 cases complicated by CHB. Among the CHB patients, five had third-degree CHB (5.49%), four had second-degree CHB (4.40%), and six had first-degree CHB (6.59%). The CHB group had significantly higher levels of maternal allergic diseases and double-positive anti-SSA and anti-SSB antibodies compared with the non-CHB group, as well as higher serum levels of creatine kinase (CK), lactate dehydrogenase, and hydroxybutyrate dehydrogenase. Multivariate logistic regression analysis indicated that high serum CK levels predicted CHB in NLE patients. The most common organ involvement in the CHB group was hematologic, followed by the skin, structural heart abnormalities, digestive, and central nervous systems. However, no significant differences were observed between the two groups. In the CHB group, other symptoms resolved spontaneously within the first 2 years of life, and pacemaker implantation was performed in four patients with third-degree CHB at around 1 year of age. Elevated serum CK levels may indicate CHB in NLE patients. Hematologic involvement was most common in NLE patients with CHB. Pacemaker implantation was shown to effectively treat patients with third-degree CHB.

Neonatal lupus erythematosus presenting with congenital heart block: clinical characteristics and follow-up

OBJECTIVE

Congenital heart block (CHB) in patients with neonatal lupus erythematosus (NLE) is usually irreversible. Our study aimed to investigate the clinical characteristics and prognostic follow-up results of patients with NLE presenting with CHB and to provide a reference for the clinical treatment and management of such patients.

METHODS

Six patients with NLE and CHB at the Children's Hospital of Soochow University between January 1, 2011, and December 31, 2023, were retrospectively analyzed. Prenatal maternal data, clinical characteristics, laboratory investigations, treatments, and follow-ups were analyzed using descriptive statistics.

RESULTS

Six patients with NLE and CHB-four females, two males, and five preterm infants-were included. Three patients had degree III CHB, one had degree II CHB, and two had degree I CHB. The diagnostic gestational age for CHB was 23.6 ± 2.7 weeks. Four patients experienced varying degrees of bradycardia during the fetal period. Of the six pregnant mothers, three had systemic lupus erythematosus, one had Sjogren's syndrome, and one was positive for the anti-SSA/Ro autoantibody after the postpartum patient was seropositive. All pregnant mothers with autoimmune diseases were in remission and stable before delivery. One case of mildly active lupus in early pregnancy resolved after low-dose oral steroid hormone administration. All six patients with NLE-related manifestations, except CHB, showed improvement in systemic symptoms within 6 months. One patient was implanted with a pacemaker for exercise intolerance and complete atrioventricular block (CAVB) at the age of 1 year and 5 months and is now tolerating activity well without abnormal cardiac rhythms. One of the six patients had a global developmental delay, and two had a motor developmental delay.

CONCLUSIONS

Fetal echocardiography should be performed in high-risk pregnancies between 16 weeks of gestation and 1 month after birth. Patients with NLE and CHB are prone to varying degrees of growth retardation. Pacemaker implantation is an effective treatment for children with CAVB. Key Points • CHB in patients with NLE is usually irreversible. • Patients with NLE and CHB are prone to varying degrees of growth retardation. • Implantation of a pacemaker is an effective treatment for children with CAVB.

Congenital Complete Heart Block-To Stimulate (When?) or Not to Stimulate?

This article presents the case of a 27-year-old female patient with idiopathic congenital complete heart block who does not consent to the implantation of a cardiac pacemaker but was referred by her primary care physician for cardiological evaluation. The conduction disturbance was recognized at the age of 6 and was asymptomatic. The professional disqualification from pacemaker implantation included a detailed history of a patient's symptoms, an echocardiographic assessment of the heart, exercise testing and ECG Holter monitoring. The aid of salbutamol administered orally was also useful.

Molecular Mechanisms of Fetal and Neonatal Lupus: A Narrative Review of an Autoimmune Disease Transferal across the Placenta

This study, conducted by searching keywords such as "maternal lupus", "neonatal lupus", and "congenital heart block" in databases including PubMed and Scopus, provides a detailed narrative review on fetal and neonatal lupus. Autoantibodies like anti-Ro/SSA and anti-La/SSB may cross the placenta and cause complications in neonates, such as congenital heart block (CHB). Management options involve hydroxychloroquine, which is able to counteract some of the adverse events, although the drug needs to be used carefully because of its impact on the QTc interval. Advanced pacing strategies for neonates with CHB, especially in severe forms like hydrops, are also assessed. This review emphasizes the need for interdisciplinary care by rheumatologists, obstetricians, and pediatricians in order to achieve the best maternal and neonatal health in lupus pregnancies. This multidisciplinary approach seeks to improve the outcomes and management of the disease, decreasing the burden on mothers and their infants.

Newborns with congenital complete heart block: Advice for perinatal care providers

Congenital complete heart block (CCHB) is a rare, but a potentially life-threatening manifestation of autoimmune diseases in neonates. Bradycardia in CCHB can be misdiagnosed as foetal distress in utero and thus precipitating a Caesarean section. We report a case series of three neonates with bradycardia without any electrolyte abnormalities and structurally normal hearts with favourable outcomes.

[Research progress on the manifestations and prognosis of neonatal lupus erythematosus in various systems]

Neonatal lupus erythematosus (NLE) is caused by the transmission of maternal anti-Ro/SSA antibodies, anti-La/SSB antibodies, and other autoantibodies to the fetus through the placenta. Usually, with the disappearance of autoantibodies in the children's body, abnormal changes in the mucocutaneous, blood system, and digestive system can spontaneously subside, but the damage to various systems caused by autoantibodies may persist for a long time. This article provides a comprehensive review of the manifestations and prognosis of NLE in various systems, including mucocutaneous, blood system, circulatory system, nervous system, digestive system, respiratory system, aiming to provide reference for clinical work.

Long term clinical outcomes in patients requiring cardiac pacing due to congenital complete heart block

Background

Isolated congenital complete heart block (CCHB) is rare cardiac condition associated with maternal Anti-Rho antibodies. It is managed with permanent pacemaker insertion. We sought to determine the long-term outcomes of individuals with CCHB who had undergone pacemaker insertion.

Methods

A database search was performed at a UK tertiary cardiac referral centre. The online medical records of patients with CCHB were analysed for pacing requirements and complications, echocardiographic data, and clinical status.

Results

A total of 72 patients (female n = 46) were identified, 20% of whom were autoantibody positive. Mean age of initial implantation was 15.5 years (SD 12.7) with mean follow up of 21 years (SD 8.3). 88% of patients were NYHA class I at censure of data. Major adverse cardiac events (MACE) were observed in 2 patients with 0% mortality throughout the follow up period. 16 patients (22.2%) developed cardiomyopathy, of which 15 had CRT devices inserted.Five patients had device related infections and 7 required system extractions. Mean left ventricular ejection fraction on most recent echocardiogram was 53.7% (SD 8.40) with no significant change compared with their historic scan. Mild tricuspid regurgitation was the most frequently observed valvular pathology, identified in 28% of patients. Only 2 patients (2.7%) had severe valve incompetence but neither required surgical intervention.

Conclusion

Long-term outcomes for patients with congenital complete heart block who undergo pacemaker insertion are highly favourable. Despite high pacing requirements over an extended period, the incidence of MACE and pacing related complications is low. Cardiac function and valvular competence are largely preserved but dilated cardiomyopathy remains a late concern in a minority; ongoing clinical surveillance is paramount in this population.

Transient Congenital Complete Heart Block: A Case Report

Congenital complete heart block is defined as a complete atrioventricular block occurring prenatally, at birth, or within the first month of life. Congenital complete heart block has a high mortality rate, and in infants with normal heart morphology, it is often associated with maternal connective tissue disease. In these latter cases, neonatal congenital complete heart block is usually irreversible. We present a rare case of a female neonate who had bradycardia noted at a gestational age of 37 weeks. Her mother had no autoimmune disease history. She had no structural heart disease, and the serology surveys for autoantibodies including SSA/Ro and SSB/La were all negative. Without intervention or medication, her congenital complete heart block completely recovered to a normal sinus rhythm within 5 days. The cause of the transient congenital complete heart block was unknown in this case.

Long-term outcome of children born from mothers with autoimmune diseases

Autoimmune diseases often affect young women and this may represent a problem in family planning. Pregnancies in these patients may carry several complications but nowadays the continued amelioration in treatment and management has greatly improved the pregnancy outcome. The main concern of these women obviously is the short- and long-term outcome of their children. A child born from a woman with autoimmune disease is potentially exposed in utero to maternal autoantibodies, cytokines, and drugs, and each item could impair his or her development. In addition, the maternal genetic heritage can favor autoimmunity. All these items could have a role, for example, in the development of autoimmune diseases (the same as the mother or different ones) or neurological disorders. Data in literature are controversial. This review will gather the available data possibly providing a useful tool for counseling future mothers.

Chronic performance of subxiphoid minimally invasive pericardial Model 20066 pacemaker lead insertion in an infant animal model

PURPOSE

To describe chronic performance of subxiphoid minimally invasive pacemaker lead insertion in a piglet model.

METHODS

Minimally invasive pacemaker lead implantation was performed through a 10-mm incision under direct visualization using the PeriPath port. Epicardial access was obtained and the commercially available Medtronic Model 20066 pacemaker lead was inserted into the pericardial space and epicardial fixation was performed using the side-action helix. The lead was connected to a pacemaker generator in a para-rectus pocket. Animals underwent a 12-14-week observation period and lead impedances, R-wave amplitudes, and ventricular capture thresholds were tested biweekly. After the survival period, animals were euthanized and gross and histopathology were performed.

RESULTS

Subxiphoid minimally invasive pacemaker lead placement was performed in 8 animals (median 4.9 kg) with 100% acute success. Median procedure time was 65 min (IQR 60.5-77). At implant, median lead impedance was 650 Ω (IQR 244-984), R-wave amplitude 11.1 mV (IQR 8-12.3), and ventricular capture threshold 1.5 V @ 0.4 ms (IQR 1-2.6). Over a median survival period of 13 weeks, there was a median lead impedance change of + 262 Ω (IQR 5.3-618.3), R-wave change of - 4.5 mV (IQR - 7.1-- 2.7) and capture threshold change (1.0 ms) of + 1.5 V (IQR 0-3.3). At autopsy, epicardial fixation sites showed fibrovascular proliferation and minimal chronic inflammation.

CONCLUSIONS

Subxiphoid pericardial pacemaker placement is safe and effective in a piglet model. Further study and development of leads designed for pericardial placement are warranted.

Congenital heart block: Pace earlier (Childhood) than later (Adulthood)

Congenital complete heart block (CCHB) occurs in 2-5% of pregnancies with positive anti-Ro/SSA and/or anti-La/SSB antibodies, and has a recurrence rate of 12-25% in a subsequent pregnancy. After trans-placental passage, these autoantibodies attack and destroy the atrioventricular (AV) node in susceptible fetuses with the highest-risk period observed between 16 and 28 weeks' gestational age. Many mothers are asymptomatic carriers, while <1/3 have a preexisting diagnosis of a rheumatic disease. The mortality of CCHB is predominant in utero and in the first months of life, reaching 15-30%. The diagnosis of CCHB can be confirmed by fetal echocardiography before birth and by electrocardiography after birth. Whether early in-utero detection and treatment might prevent or reverse this condition remains controversial. In addition to autoantibody-associated CCHB, there is also an isolated (absent structural heart disease) nonimmune early- or late-onset heart block detected later in childhood that may be associated with specific genetic markers or other pathogenic mechanisms. In isolated immune or non-immune CCHB, cardiac pacemakers are implanted in symptomatic patients, however, data on the natural history of CCHB in the adult life indicate that all patients, even if asymptomatic, should receive a pacemaker when first diagnosed. However, important issues have emerged in these patients wherein life-long conventional right ventricular apical pacing may produce left ventricular dysfunction (pacing-induced cardiomyopathy) necessitating a priori alternate site pacing or subsequent upgrading to biventricular pacing. All these issues are herein reviewed and two algorithms are proposed for diagnosis and management of CCHB in the fetus and in the older individual.