Comment on: Early cholestasis in neonatal lupus erythematosus. Ann Saudi Med 2011; 31: 80-2.

To the Editor: I have two comments on the interesting case report by Shahian et al1 on the early cholestasis in neonatal lupus erythematosus (NLE). First, Shahian et al1 has added substantially to the scarcely reported cases of cholestasis in NLE in the first week of life.2 Actually, liver involvement has been noted incidentally in NLE, but it has generally been attributed to the hemodynamic compromise as a result of congenital heart block or systemic toxic reactions.3 Despite the overtly clinical jaundice and biochemically deranged hepatic profile in the studied case report,1 liver biopsy, a critical diagnostic tool, was not contemplated. Various pathologic changes could be revealed by liver biopsy including giant cell transformation, ductal obstruction, and extramedullary hematopoiesis. It is speculated that neonatal hepatitis proceeding to hepatic fibrosis may occur in NLE, analogous to the occurrence of “idiopathic” congenital heart block. The neonatal hepatitis associated with NLE is a form distinguishable from the “idiopathic” group.3

Second, I presume that the main pillar supporting the diagnosis of the NLE in the Shahian et al's case report1 was the serologic tests, namely positive antinuclear antibodies, anti-Ro (SSA), and anti-La (SSB) antibodies. However, anti-ds DNA antibodies, anti-SM antibodies, and anti-U RNP antibodies were not detected. It is noteworthy that NLE could present with negative anti-Ro (SSA), anti-La (SSB) antibodies but with positive anti-RNP antibodies. In such instances, NLE has atypical presentation. Moreover, though these infants are negative for anti-Ro and anti-La antibodies with immunodiffusion and ELISA techniques, these antibodies might be detectable by immunoblotting.45