What is the origin of pathogenic IgA in neonatal linear IgA bullous dermatosis (LABD)?
This case study of a newborn with neonatal LABD and a healthy asymptomatic mother used split-skin indirect immunofluorescence testing to find that maternal breast milk contained immunoglobulin A (IgA) autoantibodies, which bound to the dermal side of the basement membrane zone. In addition, immunohistochemical staining demonstrated the deposition of secretory IgA in the neonatal skin by highlighting the presence of J chain—not seen in other cases of LABD—indicating that the autoantibodies producing blisters were derived from the maternal breast milk.
In neonatal LABD cases, maternal breast milk should be examined for IgA autoantibodies, and if they are present, breast milk feeding should be discontinued.
Neonatal linear immunoglobulin A (IgA) bullous dermatosis (LABD) is a rare disease that can be fatal when associated with respiratory failure. All previously reported cases of neonatal LABD have been in newborns with healthy asymptomatic mothers, and the pathogenic IgA was of unknown origin.
To clarify the origin of IgA associated with LABD in neonates born of healthy asymptomatic mothers.
Design, Setting, and Participants
This case study analyzed the laboratory findings of a single breast-fed newborn male with neonatal LABD admitted to the Keio University Hospital in Tokyo and his healthy asymptomatic mother. The healthy newborn developed life-threatening blisters and erosions of the skin and mucous membranes on day 4 after birth. Blood serum, skin, and maternal breast milk were examined for IgA autoantibodies.
Main Outcomes and Measures
Histopathologic and immunofluorescence analyses of specimens (serum, skin, and breast milk) from the patient and his mother.
Histopathologic evaluation of the newborn’s skin revealed subepidermal blisters with neutrophil infiltrates, and immunofluorescence testing showed linear IgA deposition along the basement membrane zone (BMZ), which lead to the diagnosis of neonatal LABD. Indirect immunofluorescence using normal human skin after treatment with 1-mol/L sodium chloride showed the patient to have circulating IgA binding to the dermal side of BMZ. Immunohistochemical staining proved the deposition of secretory IgA in the neonatal skin by demonstrating the presence of J chain—not been seen in other LABD cases—indicating that the autoantibodies producing the blisters were derived from the maternal breast milk. Although no circulating IgA against the skin was detected in mother's sera, the breast milk contained IgA that reacted with the dermal side of the BMZ. No new blister formation was observed after cessation of breastfeeding.
Conclusions and Relevance
The results of this case study suggest a passive transfer of pathogenic IgA to a newborn from an asymptomatic mother via breast milk. In prior reports, no serum from asymptomatic mothers of newborns with LABD had IgA autoantibodies binding to skin components; however, in this case, we found that the maternal breast milk contained IgA autoantibodies associated with neonatal LABD. In neonatal LABD, maternal breast milk should be examined for IgA autoantibodies and breast milk feeding should be discontinued as soon as neonatal LABD is suspected.
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Egami S, Suzuki C, Kurihara Y, et al. Neonatal Linear IgA Bullous Dermatosis Mediated by Breast Milk–Borne Maternal IgA. JAMA Dermatol. Published online July 14, 2021. doi:10.1001/jamadermatol.2021.2392
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