Upload
others
View
3
Download
0
Embed Size (px)
Citation preview
03/09/2015
1
Neonatal haemochromatosis and
gestational alloimmune liver disease
XXXVII IPPA Course
Fontainebleau France
September 2015
Dr Sophie COLLARDEAU-FRACHON, MD PhD
Department of pathology
Children and Mothers Hospital
CHU de Lyon, France
1
NH: definition
• rare disease
• fetus and neonate
• H Cottier 1957
• hepatic and extrahepatic siderosis sparing the
reticuloendothelial system
• and severe liver disease
S Collardeau-Frachon, IPPA course, September 2015 2
NH is a phenotype : several etiologies2001
2004
Peter Whitington’s group
Chicago’s Northwestern
University
An alloimmune-mediated
mechanism
S Collardeau-Frachon, IPPA course, September 20153
03/09/2015
2
Alloimmune NH
Hypothesis based on:
• recurrence rate > 80%– similar to rhesus incompatibility
– too high for an inheritance explanation
• no mutations in genes of hereditary haemochromatosis
• affects maternal half-siblings but not paternal half-siblings
• intravenous immunoglobulin (IV-Ig) therapy – during pregnancy reduces the severity and the recurrence rate
of the diseaseHigh-dose immunoglobulin during pregnancy for recurrent neonatal haemochromatosis. Whitington PF, Hibbard JU.Lancet 2004;364:1690–98.
– in neonates: improvements in outcomeTreatment of neonatal hemochromatosis with exchange transfusion and intravenous immunoglobulin. Rand EB, Karpen SJ, Kelly S, et al. J Pediatr 2009;155:566–71.
Whitington PF, Malladi P. Neonatal hemochromatosis: is it an
alloimmune disease? J Pediatr Gastroenterol Nutr 2005;40:544–49.
S Collardeau-Frachon, IPPA course, September 2015 4
Alloimmune NH mechanisms
• maternal sensitization
to a fetal hepatocyte
antigen?
• Production of maternal
IgG antibodies directed
against this Ag
• activation of fetal complement via
the classic pathway
• formation of membrane attack
complex on hepatocytes (MAC or
TCC or C5b9)
• Hepatocyte injury and death
transplacental passage of the
IgG antibodies occur in the
subsequent pregnancy
IgG
Hepatocytes
IgG
fetal complement is produced
by the fetus ∼12 WGnature of the fetal hepatocyte
antigen is currently still unknown
S Collardeau-Frachon, IPPA course, September 20155
GALD
• gestational alloimmune liver disease (GALD)-
associated NH (GALD-NH)
• for each case GALD complement-mediated
hepatocyte injury can be demonstrated
• Positive C5b-9 immunostaining on the
hepatocytes
• GALD is considered to be the most common
cause of NH (>95% of cases)
S Collardeau-Frachon, IPPA course, September 2015 6
03/09/2015
3
Cb9 immunostaining on hepatocytes� Pan X, Kelly S, Melin-Aldana H, Malladi P, Whitington PF. Novel mechanism of fetal
hepatocyte injury in congenital alloimmune hepatitis involves the terminal complement cascade. Hepatology 2010;51:2061-68.
� Whitington PF, Pan X, Kelly S, Melin-Aldana H, Malladi P. Gestational alloimmune liver disease in cases of fetal death. J Pediatr. 2011 Oct;159(4):612–6.
Immunohistochemistry for TCC neoantigen in typical cases of NH
with subacute and chronic liver injuryImmunohistochemistry for TCC neoantigen in cases of
NH with acute liver injury
S Collardeau-Frachon, IPPA course,
September 20157
GALD : mechanisms of iron overload
• Complement-mediated liver injury is the primary
event
• It is not a primary iron overload disease
• MAC-mediated cell lysis
• Fetal/neonatal iron overload and siderosis of
extrahepatic tissues result from fetal liver dysfunction
S Collardeau-Frachon, IPPA course, September 2015 8
Proteins involved in iron homeostasis
Iron homeostasis.
Step 1 represents DMT1-mediated iron
absorption into mature enterocytes. Step 2
indicates ferroportin-mediated movement of
iron from enterocytes (and macrophages)
into the circulation. Step 3 illustrates
movement of iron from the circulation into
hepatocytes and duodenal enterocytes
fostered by the complex of Transferrin
receptor 2 and the HFE protein.
Step 4 indicates hepatocyte production and
excretion of hepcidin into the circulation.
Hepcidin downregulates activity of
ferroportin, predominantly in duodenal
enterocytes and macrophages (step 2).
S Collardeau-Frachon, IPPA course, September 2015 9
03/09/2015
4
GALD: mechanisms of iron overload
• Ferroportin is highly expressed in placental
cells
• Hepcidin is produced by the fetal liver and is
the main regulator of iron efflux from the
placenta
• reduced hepatocyte mass in GALD
– ↘ hepcidin production
– impair the feedback control of placental iron flux
S Collardeau-Frachon, IPPA course, September 2015 10
Proposed pathophysiology of neonatal hemochromatosis.
(Left panel) Iron transport across the normal placenta, where maternal transferrin bound iron is taken up through transferrin medicated endocytosis at
the apical (maternal) membrane of the syncytiotrophoblast, which is released at the basolateral membrane by ferroportin and binds to fetal transferrin.
Iron release is controlled by the fetus through fetal hepcidin, which inhibits ferroportin.
(Right panel) Iron transport across the placenta of a fetus with neonatal hemochromatosis. Reduced fetal hepcidin and reduced transferrin concentration
are proposed to result in dysregulated transplacental iron transfer and increased non-transferrin bound iron, which is toxic and primarily stored in tissues
with high expression of the transition metal transport protein ZIP14 and low expression of the iron export protein ferroportin.
S Collardeau-Frachon, IPPA course,
September 201511
GALD : extrahepatic hemosiderosis
determined by the tissue’s capacity for
importing non-transferrin-bound iron (NTBI)
ZIP14 facilitates the uptake of NTBI into various cells
S Collardeau-Frachon, IPPA course,
September 201512
03/09/2015
5
GALD : a spectrum
• fetal acute liver failure and fetal death with or without iron overload
• neonatal liver failure with liver and extrahepatic siderosis
• antenatal cirrhosis and mild neonatal liver disease without hepatic siderosis
• mild neonatal liver disease (anomalies of LFT)
Inter and intrafamilial variability
individual sensitivity to alloimmune injury?
begins in utero in all cases (midgestation) S Collardeau-Frachon, IPPA course, September 2015 13
GALD : clinical presentation
Neonatal Liver Cirrhosis Without Iron Overload Caused by Gestational Alloimmune Liver Disease
Debray FG, de Halleux V, Guidi O, Detrembleur N, Gaillez S, Rausin L, Goyens P, Pan X, Whitington PF.
Pediatrics. 2012 Apr;129(4):e1076-9
2 sets of twins (1 set without pregnancy immunotherapy): 1 infant with liver failure
and the other nearly unaffected (elevated serum AFP and/or ferritin levels)
34.5 weeks of gestation
no liver or extrahepatic siderosis (liver biopsy and MRI)
But antiplatelet antibodies in the mother’s serum→ fetal alloimmune thrombopeniaS Collardeau-Frachon, IPPA course,
September 201514
GALD : clinical presentation• panethnic distribution
• sexe ratio ≈1
• Mother: previous fetal or neonatal loss
• No consanguinity
• Antenatal manifestations: in late second or third trimester
– IUGR, oligohydramnios, hydrops, hepatomegaly, ascites
→ fetal death, stillbirth and prematurity
• Neonatal manifestations:
– Liver failure usually within the first hours of life →
multiorgan failure→ death
• Without treatment: very poor prognosis
S Collardeau-Frachon, IPPA course, September 2015 15
03/09/2015
6
GALD: Laboratory tests
• Liver failure
– severe coagulopathy :↑ INR (normal range in newborns: 0.8–1.5)
– hyperammonemia (>95 umol/L)
– hypoglycemia
– hypoalbuminemia
• Liver function test
– Transaminases and γGT: N or mildly ↑
– ↑ AFP >100 000 ng/mL (normal values in term newborns <80 000 ng/mL)
– ↑direct and indirect bilirubin
• Iron overload
– ↑ ferritin (normal values 40–775 ng/mL)
– hypersaturation (up to 95–100%) of the available transferrin
• Severe thrombocytopenia (platelet count <50 000 μL) +/- anemia
S Collardeau-Frachon, IPPA course, September 2015 16
• nonspecific and may mimic – viral or bacterial infections but negative infectious work-up
– perinatal asphyxia : low Apgar scores +respiratory distress syndrome + premature neonates , tachypnea, pulmonary hypertension, pulmonary hemorrhage
– disseminated intravascular coagulopathy (DIC):consumption of clotting factors and platelets+ schistocytes + severe bleeding
– haemolytic-uraemic syndrome( HUS): acute oligo-anuric renal failure + anemia with fragmented red blood cells (schistocytes )+ thrombocytopenia
– metabolic disorders
– congenital hepatic arteriovenous malformation: patent ductus venosus + DIC
• liver failure and hyperferritinemia are not pathognomonic for NH
present in other causes of fulminant liver
S Collardeau-Frachon, IPPA course, September 2015 17
GALD : clinical & biological
presentation
Doppler ultrasound : patent ductus venosus
• in the setting of portal hypertension
• mistaken for a congenital hepatic arteriovenous shunt
S Collardeau-Frachon, IPPA course, September 2015 18
03/09/2015
7
GALD: pathological findingsacute hepatocyte injury
• fetal acute liver failure and fetal death
• Small proportion of GALD cases
• with or without iron overload: extrahepatic siderosismight not have time to develop
• Liver injury:– Global panlobular hepatocyte necrosis
– no or minimal fibrosis
– no viable hepatocytes
– only ‘‘ghosts’’ remained
– Absent hepatic cords
– # postmortem hepatocyte autolysis in which cords remain
Whitington PF, Pan X, Kelly S, et al. Gestational alloimmune liver
disease in cases of fetal death. J Pediatr 2011;159:612–16
S Collardeau-Frachon, IPPA course, September 2015 19
GALD : pathological findings
acute hepatocyte injury
S Collardeau-Frachon, IPPA course, September 2015 20
Abortion at 33WG
Fetal and placental Hydrops at 27WG
Massive necrosis
no viable hepatocytes
Liver : Perls score 4
Extrahepatic iron: duodenum & stomach
glands only
subacute or chronic liver disease
• in most cases, the process moves more slowly
• starting in midgestation: fetus and neonates
• extrahepatic siderosis present
• Liver injury: – extensive fibrosis with mild inflammation
– loss of hepatocytes
– surviving cells show • giant cell
• or pseudoglandular transformation and varying degrees of cholestasis
• tubular forms devoid of bile, similar to “ductular reaction” neoductules or neocholangioles
– focal nodular regeneration
– most of the iron deposition in the hepatocytes
S Collardeau-Frachon, IPPA course, September 2015 21
GALD: pathological findings
03/09/2015
8
S Collardeau-Frachon, IPPA course, September 2015 22
GALD : pathological findingssubacute/chronic hepatocyte injury
Heterogeneous
Areas with extensive fibrosis and variable nodules
S Collardeau-Frachon, IPPA course, September 2015 23
panlobular fibrosis
loss of hepatocytes
mild inflammation
Pseudoglandular
formations
with bile plug
giant cell
S Collardeau-Frachon, IPPA course, September 201524
neoductules
03/09/2015
9
S Collardeau-Frachon, IPPA course, September 2015 25
Nodular formation: focal nodular regeneration or areas of preserved hepatocytes?
surrounded by fibrosis
Sometimes entirely necrotic
S Collardeau-Frachon, IPPA course, September 2015 26
Liver iron overload
Inside the hepatocytes , giant cells, pseudoacinar formation, neoductules
Some macrophages can be stained
27
1 2
3 4
Liver iron overload: Perls semiquantitative score
< 25%25%–50%,
50%–75% > 75%
S Collardeau-Frachon, IPPA course, September 2015
Perls score is inversely proportional to fibrosis progression
03/09/2015
10
S Collardeau-Frachon, IPPA course, September 2015 28
Birth 33GW, died at 6 days
TOP at 33 WG
S Collardeau-Frachon, IPPA course, September 2015 29
Birth : 30GW
Died at 5 days
Extrahepatic iron overload
• acinar cells of the pancreas
• acinar cells of minor salivary glands
• proximal renal tubules
• thyroid follicles
• adrenal cortex
• myocardium
• parathyroid
• pituitary gland
S Collardeau-Frachon, IPPA course,
September 201530
Extrahepatic iron storage is only seen
after Perls staining
localization varied:
• depending on the age
• within the same sibship
Sometimes:
• only seen in a few organs
• with a mild intensity (high-power
magnification is required)
03/09/2015
11
S Collardeau-Frachon, IPPA course, September 2015 31
In fetuses: more frequent in thyroid than in pancreas
In neonates: more frequent in pancreas than in thyroid
S Collardeau-Frachon, IPPA course,
September 201532
Usually within a few proximal tubules
Extrahepatic iron overload
in GALD and non GALD cases
S Collardeau-Frachon, IPPA course, September 2015 33
Neonatal hemochromatosis phenotype: a multicentric retrospective study
of 72 cases with characterization of hepatic and extrahepatic iron overload.
Béatrice Nadaud, Estelle Dubruc, Sophie Collardeau-Frachon
32 GALD cases
40 non GALD cases
thyroid pancreas kidneys
GALD fetuses: 10 GALD neonates: 22 Non GALD fetuses:13 Non GALD neonates: 27
03/09/2015
12
S Collardeau-Frachon, IPPA course, September 2015 34
myocardium Paratracheal glands
parathyroid Thymus: Hassal corpuscles
GALD: other lesionsHypoperfusion & ischemic lesions
Renal tubular dysgenesis : 30% of our series
– reduced hepatocyte mass
– ↘ hepatic angiotensinogen
– proximal renal tubular development
Other renal ischemic lesions:
• collapse of glomerular tufts with enlargement of the urinary
space often associated with renal tubular dysgenesis
S Collardeau-Frachon, IPPA course,
September 201535
• Bonilla SF, Melin-Aldana H, Whitington PF. Relationship of proximal renal tubular dysgenesis
and fetal liver injury in neonatal hemochromatosis. Pediatr Res 2010;67:188–193.
• Azar D, Bonilla S, Amaro D, Whitington P, Krous H. Reduced angiotensinogen in neonatal
hemochromatosis leads to impaired development of proximal renal tubules and
compensatory glomerular changes. Lab Invest 2011;91:357A.
CD10EMA
Renal tubular dysgenesis : absence or paucity of proximal tubules
S Collardeau-Frachon, IPPA course, September 2015
03/09/2015
13
S Collardeau-Frachon, IPPA course, September 2015 37
Renal tubular dysgenesis and collapse of glomerular tufts
• Significant glyceroluria might be the reflect of
proximal renal tubular dysgenesis?
• 2 siblings
– 1 died of sepsis (E Coli)
– 1 with increased excretion of lactate and pyruvate
• extensive liver siderosis and injury and C5b9+
• siderosis of heart, pancreas, thyroid and renal tubule
• DTR
S Collardeau-Frachon, IPPA course, September 201538
• Hypoperfusion & ischemic lesions
– hypocalvaria
– microcephaly
– with cerebral ischemia
S Collardeau-Frachon, IPPA course, September 2015 39
GALD: other lesions
03/09/2015
14
Chronic fetal distress
thymic hypoplasia
Oligohydramnios sequence
pulmonary hypoplasia
arthrogryposis
facial dysmorphism
Portal hypertension
splenomegaly
patent ductus venosus
Extrahepatic hematopoiesis due to liver failure
S Collardeau-Frachon, IPPA course,
September 201540
GALD: other lesions
Myofibroma: 3 cases reported in the litterature
S Collardeau-Frachon, IPPA course, September 201541
GALD: other lesions
Aksoy F, Go¨ksel S, Ilvan S, Dervis¸og˘lu S, Ramazanog˘lu R. Congenital generalized infantile
myofibromatosis and neonatal hemochromatosis: an autopsy case report. Turk J Pediatr
2000;42:334–337.
Dalhoj J, Kiaer H, Wiggers P, Grady RW, Jones RL, Knisely AS. Iron storage disease in parents and sibs
of infants with neonatal hemochromatosis: 30-year follow-up. Am J Med Genet 1990;37: 342–345.
Collardeau-Frachon S, Heissat S, Bouvier R, Fabre M, et al. French retrospective multicentric study of
neonatal hemochromatosis: importance of autopsy and autoimmune maternal manifestations.
Pediatr Dev Pathol. 2012;15:450-70.
lung heart
S Collardeau-Frachon, IPPA course, September 2015 42
GALD: other lesions: placentaChronic histiocytic intervillositis
CD68
Chronic villitis, some avascular villi, perivillous fibrin deposition
03/09/2015
15
should be suspected :
• in all neonates with antenatal or postnatal
signs of severe liver disease
– growth restricted
– born prematurely
• unexplained fetal demise
– unexpected intrauterine fetal death in the late-
second and third trimester
GALD: diagnosis
S Collardeau-Frachon, IPPA course,
September 201543
Based on :
• demonstration of extrahepatic siderosis
– biopsy of oral mucosal salivary glands: Perls staining
– T2-weighed MRI : low signal intensity in pancreas (heart and adrenal glands) compared to spleen
• Immunohistochemical study with antiC5b9: positive staining on and or hepatocytes >75%
GALD: diagnosis
S Collardeau-Frachon, IPPA course,
September 201544
S Collardeau-Frachon, IPPA course, September 2015 45
MRI-T2: d ecreased T2 signal intensity of the hepatic
parenchyma (long arrows) and pancreas (short arrow)
GALD: diagnosis
iron in oral mucosal salivary glands
Hepatocytes C5b9+
03/09/2015
16
GALD: diagnosis and management
S Collardeau-Frachon, IPPA course, September 2015 46
Comments
1/Extrahepatic iron overload is not specific of GALD
Iron in oral mucosal salivary glands
- is not always present in GALD cases
- can be present in non GALD cases
2/ Be careful with C5b9 immunohistochemistry
-specially on liver biopsy sample
- is not specific of GALD
3/ Always think about other differential diagnoses– importance of autopsy
– importance of liver histological examination
– Intravenous immunoglobulin therapy • is very expensive ( average cost of a treatment course > USD 100,000 / France 65000
euros/ pregnancy)
• and may have side-effects
S Collardeau-Frachon, IPPA course,
September 201547
comments
1/Extrahepatic iron overload is not specific of GALDNH is a phenotype: several diseases can present with hepatic
+/- extrahepatic siderosis
Association
with GALD
S Collardeau-Frachon, IPPA course, September 201548
myofibromatosis
Can be secundary to chronic fetal distress
Infections
• Parvovirus B19: 5*
• CMV:3*
• HSV:3*
• Echovirus
• Adenovirus
• Enterovirus:2*
• Orthomyxovirus A or B
• Respiratory syncytial virus
• Rubella
• Chlamidya psittaci
• Coxiella burnetii
• Mycoplasma pneumoniae
• S aureus
• Toxoplasma gondii:1*
• E Coli:1**Neonatal hemochromatosis phenotype: a multicentric retrospective study
of 72 cases with characterization of hepatic and extrahepatic iron overload.
Béatrice Nadaud, Estelle Dubruc, Sophie Collardeau-Frachon
03/09/2015
17
comments
1/Extrahepatic iron overload is not specific of GALDNH is a phenotype: several diseases can present with hepatic
+/- extrahepatic siderosis
Association
with GALD
• Mitochondrial cytopathies
• DGUOK mutations
• GRACILE syndrome
• Pearson syndrome
• Transaldolase deficiency
• Familial Hemophagocytic
lymphohistiocytosis (FHL)
• Martinez-Frias syndrome
• 16p duplication
• CDG1a (PMM2)
• Mitochondrial cytopathies
• DGUOK mutations
• GRACILE syndrome
• Pearson syndrome
• Transaldolase deficiency
• Familial Hemophagocytic
lymphohistiocytosis (FHL)
• Martinez-Frias syndrome
• 16p duplication
• CDG1a (PMM2)
Personal cases
• Congenital leukemia & chromosomal
breakage syndrome (Bloom syndrome)
• Congenital dyserythropoietic anemia
type I (CDA I)S Collardeau-Frachon, IPPA course, September 2015
49
myofibromatosis
S Collardeau-Frachon, IPPA course, September 2015 50
Mol Genet Metab 2010;101:253-7
GRACILE syndrome
Growth Retardation, Aminoaciduria, Cholestasis, Iron overload, Lactacidosis, Early death
Diseases with NH phenotype13 groups of etiology
Alloimmune diseasesGALD
anti-red cells (Rhesus or private antigens)
anti-platelets
Mitochondrial cytopathies
DGUOK, Gracile, Pearson
Chromosomal anomalies
T21, T18, 16p
Neonatal anemia
Congenital
dyserythropoietic
anemia
Congenital heart disease
Infections
Metabolic disorders
TALDO
Zellweger
Tyrosinemia
CDG1a
Neonatal diabetes
Marinez-Frias
Donohue
Neonatal cholestasis
Delta 4-3 oxo
Congenital proliferation
Leukemia
FHL
Maternal autoimmune disorders
Neonatal lupus
Tricho-hepato-enteric syndrome
Exogeneous
Transfusions
Toxic agentsS Collardeau-Frachon, IPPA course,
September 201551
03/09/2015
18
Maternal autoimmune disorders
and NH
S Collardeau-Frachon, IPPA course, September 201552
dysimmunity manifestations in half of the mothers
5 mothers : personal history of autoimmune disease:
• systemic erythematous lupus (1 case)
• hypothyroidism (2 cases)
• peripheral vascular disease (1 case)
• autoimmune hepatitis (1 case)
9 mothers without clinical autoimmune disorder:
antinuclear autoantibodies at time of delivery
Characterization of the autoantibodies in 4 cases:
• anti-Ro/SSa and anti RLa/SSB in 1 case
• anti-mitochondria and anti-phospholipid in 2
cases
• and anti-cardiolipid in 1 case
Indirect immunofluorescence study :nuclear
staining of hepatocytes and endothelial cells
S Collardeau-Frachon, IPPA course, September 2015 53
2013
Some NH cases could be a possible consequence of autoimmune disorders in the
mothers with transfer of autoantibodies through the placenta
Maternal autoimmune disorders
and NH
Schoenlebe J, Buyon JP, Zitelli BJ, Friedman D, Greco MA, Knisely AS. Neonatal
hemochromatosis associated with maternal autoantibodies against Ro/SS-A and
La/SS-B ribonucleoproteins. Am J Dis Child 1993;147:1072–1075.
1 case
2 / 8 mothers with anti-Ro/SSa and
anti R-La/SSB antibody
AMA in the mother& the child
Diseases with NH phenotype
Alloimmune diseasesGALD
anti-red cells (Rhesus or private antigens)
anti-platelets
Mitochondrial cytopathies
DGUOK, Gracile, Pearson
Chromosomal anomalies
T21, T18, 16p
Neonatal anemia
Congenital
dyserythropoietic
anemia
Congenital heart disease
Infections
Metabolic disorders
TALDO
Zellweger
CDG1a
tyrosinemia
Neonatal diabetes
Martinez-Frias
Donohue
Neonatal cholestasis
Delta 4-3 oxo
Congenital proliferation
Leukemia
FHL
Maternal autoimmune disorders
Tricho-hepato-enteric syndrome
Exogeneous
Transfusions
Toxic agents
Fetus or
at birth
S Collardeau-Frachon, IPPA course,
September 2015
54
03/09/2015
19
Diseases with NH phenotypeExtrahepatic iron overload
Alloimmune diseasesGALD
anti-red cells (Rhesus or private antigens)
anti-platelets
Mitochondrial cytopathies
DGUOK, Gracile, Pearson
Chromosomal anomalies
T21, T18, 16p
Neonatal anemia
Congenital
dyserythropoietic
anemia
Congenital heart disease
Infections
Parvo
CMV
HSV
E.Coli
Metabolic disorders
TALDO
Zellweger
Tyrosinemia
CDG1a
Neonatal diabetes
Martinez-Frias
Donohue
Neonatal cholestasis
Delta 4-3 oxo
Congenital proliferation
Leukemia
FHL
Maternal autoimmune disorders
Tricho-hepato-enteric syndrome
Exogeneous
Transfusions
Toxic agents
Neonatal hemochromatosis phenotype: a multicentric retrospective study
of 72 cases with characterization of hepatic and extrahepatic iron overload.
Béatrice Nadaud, Estelle Dubruc, Sophie Collardeau-Frachon
S Collardeau-Frachon, IPPA course,
September 201555
Diseases with NH phenotypeReticuloendothelial system not spared
Alloimmune diseasesGALD
anti-red cells (Rhesus or private antigens)
anti-platelets
Mitochondrial cytopathies
DGUOK, Gracile, Pearson
Chromosomal anomalies
T21, T18, 16p
Neonatal anemia
Congenital
dyserythropoietic
anemia
Congenital heart disease
Infections
Parvo
CMV
HSV2
E.Coli
Metabolic disorders
TALDO
Zellweger
Tyrosinemia
CDG1A
Neonatal diabetes
Martinez-Frias
Donohue
Neonatal cholestasis
Delta 4-3 oxo
Congenital proliferation
Leukemia
FHL
Maternal autoimmune disorders
Tricho-hepato-enteric syndrome
Exogeneous
Transfusions
Toxic agents
Neonatal hemochromatosis phenotype: a multicentric retrospective study
of 72 cases with characterization of hepatic and extrahepatic iron overload.
Béatrice Nadaud, Estelle Dubruc, Sophie Collardeau-Frachon
S Collardeau-Frachon, IPPA course,
September 201556
Iron in oral mucosal salivary glands
and/or pancreas T2 low signal intensity on MRI
can lack in GALD
S Collardeau-Frachon, IPPA course, September 2015 57
“Siderosis of the buccal glands and other extrahepatic tissues is not seen in neonatal
diseases other than NH/GALD” (Whitington PF. Fetal and infantile hemochromatosis.
Hepatology 2006;43:654–60.): not true
Perls +
- 30% of GALD
- HSV2, T18, enterovirus,CDA1
Pancreas low signal intensity
50% of GALD
Neonatal hemochromatosis phenotype: a multicentric retrospective study
of 72 cases with characterization of hepatic and extrahepatic iron overload.
Béatrice Nadaud, Estelle Dubruc, Sophie Collardeau-FrachonLittérature
• T21
• DGUOK
• Lupus
• 16p
• Delta 4-3 oxo
03/09/2015
20
2/comments
C5b9 immunohistochemistry
Non GALD cases : 37 (31 liver biopsies)– 13 biliary atresia
– 3 PFIC1
– 3 PFIC2
– 3 D4-oxosteroid reductase deficiency
– 3 cases of total parenteral nutrition-associated cholestasis afterbowel resection
– 3 Alagille
– 2 alpha-1-antitrypsin deficiency (PiZZ genotype)
– 2 tyrosinemia type 1
– 1 abetalipoproteinemia
– 1 glycogen storage disease type 1
– 1 inspissated bile syndrome after cardiac surgery
– 1 tricho-hepato-enteric syndrome
– 1 herpes simplex 1
10.8% à 12.5% (range 0%-45%) of hepatocytesexpressed C5b9
2 studies: 41 GALD cases with >75% of hepatic parenchyma stained with anti-C5b9
� Pan X, Kelly S, Melin-Aldana H, Malladi P, Whitington PF. Novel mechanism of fetal hepatocyte injury in
congenital alloimmune hepatitis involves the terminal complement cascade. Hepatology 2010;51:2061-68
9 cases in the upper
quartile of values: 3 PFIC1,
1 D4-3oxo, 1 Alagille, 1
tyrosinemia , 1tricho-
hepato-enteric syndrome,
2 biliary atresia
S Collardeau-Frachon, IPPA course, September 201558
33 GALD cases (27 autopsy and 6 liver explants)
Whitington PF, Pan X, Kelly S, Melin-Aldana H, Malladi P. Gestational alloimmune liver disease in
cases of fetal death. J Pediatr. 2011 Oct;159(4):612–6: 8 cases
1+ = <25%, 2+ = 25%-50%, 3+ = 50%-75%, 4+ = >75% positive hepatocytes
S Collardeau-Frachon, IPPA course, September 201559
2/comments
C5b9 immunohistochemistry
Non GALD cases with NH phenotype: 40 cases
• 2/5 parvo: 5%
• 3 / 4 CMV: <5%
• 1 HSV1: 90%
• 1/2 HSV2: 80%
• 1 /2 Enterovirus:90%
• 1/3 DGUOK: 80%
• 3 /3 Allo-imm anti Red B cells: 80%
• 2/2 T18 < 5%
• 1/3 T21: 90%
• 3/5 heart: 5%
• 1Taldo : 20%
• 1D4-3oxo: 90%
• 2: leukemia <5%
• 1 GRACILE<5%
• 1CDA I
• 1 Martinez-Frias
• 1CDG1a
• 2 FLH
• 1 E coli
32 cases of NH alloimmune type
C5b9 on 20 cases (still available blocks):
anti-C5b9 neoantigen, Quidel, San Diego,CA
dilution: 1/150
expressed in all cases but
>75% in 40%
<75% in 60%
Average: 64%
Non GALD cases without siderosis: 10 cases
• 1 Giant cell hepatitis with autoimmune hemolytic
anemia: 90%
• 1Gaucher : 80%
• 2 BA: 0%
• 2 Alagille: 0%
• 1 A1AT: 0%
• 1PFIC1: 20%
• 1 PFIC2:0%
• 1Tyrosinemia: 0%
Relevance of C5b9 immunostaining in the diagnosis of neonatal
hemochromatosis : a retrospective multicenter study.
Estelle Dubruc, Beatrice Nadaud, Sophie Collardeau-Frachon.S Collardeau-Frachon, IPPA course, September 2015 60
2/comments
C5b9 immunohistochemistry
03/09/2015
21
HES Perls C5b9
Co
ntr
ol c
ase
sa
me
ag
eG
ALD
ca
se
Relevance of C5b9 immunostaining in the diagnosis of neonatal
hemochromatosis : a retrospective multicenter study ;
Estelle Dubruc, Beatrice Nadaud, Sophie Collardeau-Frachon.S Collardeau-Frachon, IPPA course, September 2015
61
HES Perls C5b9
x200
x40
Relevance of C5b9 immunostaining in the diagnosis of neonatal
hemochromatosis : a retrospective multicenter study
Estelle Dubruc, Beatrice Nadaud, Sophie Collardeau-Frachon.
G
A
L
D
C
A
S
E
S
Influence of :
→ fixation : formalin (old cases, different
centers)
→ type of sample: liver biopsy or autopsy
→ Age : neonate (77,5%)/ fetus (62%)
→ Perls : no
→ immune factors ?
S Collardeau-Frachon, IPPA course,
September 2015 62
34GW
died at35days
100%
38GW
died at 45days
100%
32GW
died at 3 days
50%
Born at 32GW died at 5days
40%
F 27 GW
70%
F 29GW
20%
F 32GW
50%
Born at 32GW died at
3 days
50%
F 26 GW
75%
GA
LD ca
ses
03/09/2015
22
S Collardeau-Frachon, IPPA course, September 2015 64
HSV2
Delta4-3 oxoGaucher Giant cell hepatitis Coombs+
DGUOK parvo
No
n G
ALD
case
s
Definitive diagnosis of GALD
• Still remains difficult
– Heterogeneity of liver hemosiderosis & C5b9
expression
• Often a diagnosis of exclusion
• Importance of correlations
– clinical, biological, radiological and pathological
findings
• Easier on autopsy
S Collardeau-Frachon, IPPA course,
September 201565
• 1st pregnancy? Previous cases of child or fetal loss
• Mother auto-immunity?
• Consanguinity?
• Dysmorphism, malformations?
• Onset of symtoms? Immediately after birth or not?
• Karyotype?
• Infections?
• Lactate/pyruvate ratio >20→ mitochondrial respiratorychain disorders
• LFT: low GGT → delta 4-3 oxo
S Collardeau-Frachon, IPPA course,
September 201566
Definitive diagnosis of GALD
Importance of clinical & biological data
03/09/2015
23
• All organs can be examined and sampled
– Look for other macroscopic and microscopic malformations
– Don’t forget to take bone marrow sample
– Placenta : signs of infections or dysimmunity
• Renal tubular dysgenesis: more frequent in GALD cases?
• Allows to do Perls staining on multiple organs
– extrahepatic iron overload is not limited to pancreas and labial salivary
glands
– must be systematic on liver, thyroid, pancreas , kidneys, spleen +/-
lymph nodes and bone marrow
• Allows to take samples for biochemical, genetic, molecular
investigations
– Frozen samples : thymus (lymphocytes), liver, muscle, kidneys, lungs,
placenta
– skin biopsy: fiboblasts cultureS Collardeau-Frachon, IPPA course, September 2015 67
Definitive diagnosis of GALD
autopsy is very hellpful
Acute fetal liver failure:
• parvovirus B19 +++:
– inclusion sometimes difficult to see /macerated
fetus→ immunostaining
• transaldolase deficiency (autosomal recessive) :
– dysmorphism & malformations may lack in fetus
– polyols urinary analysis
– TALDO1 gene
S Collardeau-Frachon, IPPA course,
September 201568
Similar liver lesions than GALD
Subacute/ chronic liver failure:
• DGUOK:
– steatosis might be focal, oncocytic cells not always present
• Congenital dyserythopoietic anemia 1 (autosomal recessive)
– pseudo-tumoral multivisceral hematopoiesis
– Bone marrow: bi-, tri- or tetra-nucleated polychromatic
erythroblasts and internuclear chromatin bridges in some
erythroblasts
– CDAN1 gene
• FHL (autosomal recessive): 5 genes
– carefully look for activated macrophages (sometimes few
in the liver)S Collardeau-Frachon, IPPA course,
September 201569
Similar liver lesions than GALD
03/09/2015
24
Thank you!
S Collardeau-Frachon, IPPA course, September 2015 70