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Washington J, Ritch R, Liu Y. Homocysteine and Glaucoma. Int J Mol Sci 2023; 24:10790. [PMID: 37445966 DOI: 10.3390/ijms241310790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 06/10/2023] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
Elevated levels of homocysteine (Hcy), a non-proteinogenic amino acid, may lead to a host of manifestations across the biological systems, particularly the nervous system. Defects in Hcy metabolism have been associated with many neurodegenerative diseases including glaucoma, i.e., the leading cause of blindness. However, the pathophysiology of elevated Hcy and its eligibility as a risk factor for glaucoma remain unclear. We aimed to provide a comprehensive review of the relationship between elevated Hcy levels and glaucoma. Through a systemic search of the PubMed and Google Scholar databases, we found that elevated Hcy might play an important role in the pathogenesis of glaucoma. Further research will be necessary to help clarify the specific contribution of elevated Hcy in the pathogenesis of glaucoma. A discovery and conceptual understanding of Hcy-associated glaucoma could be the keys to providing better therapeutic treatment, if not prophylactic treatment, for this disease.
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Affiliation(s)
- Joshua Washington
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Robert Ritch
- New York Eye & Ear Infirmary, New York, NY 10003, USA
| | - Yutao Liu
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
- James & Jean Culver Vision Discovery Institute, 4 Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
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Candela E, Zagariello M, Di Natale V, Ortolano R, Righetti F, Assirelli V, Biasucci G, Cassio A, Pession A, Baronio F. Cystathionine Beta-Synthase Deficiency: Three Consecutive Cases Detected in 40 Days by Newborn Screening in Emilia Romagna (Italy) and a Comprehensive Review of the Literature. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020396. [PMID: 36832525 PMCID: PMC9955056 DOI: 10.3390/children10020396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023]
Abstract
Cysthiatonine beta-synthase (CBS) deficiency (CBSD) is an autosomal recessive rare disorder caused by variations on CBS that leads to impaired conversion of homocysteine (Hcy) to cystathionine. Marked hyperhomocysteinemia is the hallmark of the disease. The administration of pyridoxine, the natural cofactor of CBS, may reduce total plasma Hcy. Patient phenotype is classified on pyridoxine responsivity in two groups: pyridoxine-responsive and non-responsive patients. Ectopia lentis, bone deformities, developmental delay, and thromboembolism are the classic signs and symptoms of the disease. Early diagnosis and treatment impact patients' natural history. Therapy aims to lower promptly and maintain Hcy concentrations below 100 μmol/L. Depending on the patient's phenotype, the treatment goals could be obtained by the administration of pyridoxine and/or betaine associated with a methionine-restricted diet. CBSD could be diagnosed in the early days of life by expanded newborn screening (ENS), however, the risk of false negative results is not negligible. In Emilia-Romagna (Italy), during the first 10 years of screening experience, only three cases of CBSD identified have been diagnosed, all in the last two years (incidence 1:118,000 live births). We present the cases and a comprehensive review of the literature to emphasize the role of ENS for early diagnosis of CBSD and its potential pitfalls, reiterating the need for a more effective method to screen for CBSD.
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Affiliation(s)
- Egidio Candela
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Michele Zagariello
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Valeria Di Natale
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Rita Ortolano
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence: ; Tel.: +39-051-214-3168
| | - Francesca Righetti
- Centro Laboratoristico Regionale di Riferimento Screening Neonatale e Malattie Endocrino-Metaboliche, UO Pediatria IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Valentina Assirelli
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giacomo Biasucci
- The Pediatric Unit, Maternal and Child Department, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Alessandra Cassio
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Andrea Pession
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Federico Baronio
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Rahman M, Sharma M, Aggarwal P, Singla S, Jain N. Homocystinuria and ocular complications - A review. Indian J Ophthalmol 2022; 70:2272-2278. [PMID: 35791106 PMCID: PMC9426183 DOI: 10.4103/ijo.ijo_309_22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Homocystinuria is a rare metabolic inborn disorder caused due to dysfunctional cystathionine β-synthase (CBS) enzyme activity, thus resulting in elevated levels of methionine and homocysteine in the blood and urine. The timely recognition of this rare metabolic disorder and prompt methionine-restricted diet are crucial in lessening the systemic consequences. The recalcitrant cases have a higher risk for cardiovascular diseases, neurodegenerative diseases, neural tube defects, and other severe clinical complications. This review aims to present the ophthalmic spectrum of homocystinuria and its molecular basis, the disease management, as well as the current and potential treatment approaches with a greater emphasis on preventive strategies.
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Affiliation(s)
- Mehzabeen Rahman
- Department of Ophthalmology, Tirupati Eye Center, Noida, Uttar Pradesh, India
| | - Mohita Sharma
- Department of Ophthalmology, Tirupati Eye Center, Noida, Uttar Pradesh, India
| | - Pragati Aggarwal
- Department of Ophthalmology, Tirupati Eye Center, Noida, Uttar Pradesh, India
| | - Silkee Singla
- Department of Ophthalmology, Tirupati Eye Center, Noida, Uttar Pradesh, India
| | - Neha Jain
- Department of Ophthalmology, Tirupati Eye Center, Noida, Uttar Pradesh, India
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Garanto A, Ferreira CR, Boon CJF, van Karnebeek CDM, Blau N. Clinical and biochemical footprints of inherited metabolic disorders. VII. Ocular phenotypes. Mol Genet Metab 2022; 135:311-319. [PMID: 35227579 PMCID: PMC10518078 DOI: 10.1016/j.ymgme.2022.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 01/19/2022] [Accepted: 02/11/2022] [Indexed: 12/11/2022]
Abstract
Ocular manifestations are observed in approximately one third of all inherited metabolic disorders (IMDs). Although ocular involvement is not life-threatening, it can result in severe vision loss, thereby leading to an additional burden for the patient. Retinal degeneration with or without optic atrophy is the most frequent phenotype, followed by oculomotor problems, involvement of the cornea and lens, and refractive errors. These phenotypes can provide valuable clues that contribute to its diagnosis. In this issue we found 577 relevant IMDs leading to ophthalmologic manifestations. This article is the seventh of a series attempting to create and maintain a comprehensive list of clinical and metabolic differential diagnoses according to system involvement.
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Affiliation(s)
- Alejandro Garanto
- Department of Pediatrics, Amalia Children's Hospital Radboud Center for Mitochondrial and Metabolic Diseases, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Human Genetics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Camiel J F Boon
- Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands and Amsterdam University Medical Centers, Academic Medical Center, Department of Ophthalmology, University of Amsterdam, Amsterdam, the Netherlands.
| | - Clara D M van Karnebeek
- Department of Pediatrics, Amalia Children's Hospital Radboud Center for Mitochondrial and Metabolic Diseases, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Departments of Pediatrics and Human Genetics, Emma Children's Hospital, Amsterdam Reproduction and Development, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Nenad Blau
- Division of Metabolism, University Children's Hospital, Zürich, Switzerland.
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Hua N, Ning Y, Zheng H, Zhao L, Qian X, Wormington C, Wang J. Recurrent dislocation of binocular crystal lenses in a patient with cystathionine beta-synthase deficiency. BMC Ophthalmol 2021; 21:212. [PMID: 33985475 PMCID: PMC8120774 DOI: 10.1186/s12886-021-01974-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 05/05/2021] [Indexed: 12/03/2022] Open
Abstract
Background Ectopia lentis is the common ocular manifestation of homocystinuria resulting from cystathionine beta-synthase (CBS) deficiency which has a high risk of thromboembolic complications. Case presentation The present study reports the case of a teenager with recurrent lens dislocation and glaucoma. He was diagnosed with CBS deficiency according to a high level of serum homocysteine and compound heterozygous mutations at two different positions on the CBS gene. Antiglaucoma eyedrops and a mydriatic successfully controlled the intraocular pressure, while oral pyridoxine and betaine uptake lowered the serum homocysteine level effectively. Conclusions Children with CBS deficiency may suffer from ectopia lentis, glaucoma and/or amblyopia. We firstly discovered a new mutation of CBS c. 697 T > G which had not been reported before. The patient was pyridoxine responsive and well controlled by medicine.
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Affiliation(s)
- Ning Hua
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, No. 251 Fukang Road, Nankai District, Tianjin, China.
| | - Yuxian Ning
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, No. 251 Fukang Road, Nankai District, Tianjin, China
| | - Hui Zheng
- Tianjin Eye Hospital, Tianjin, China
| | - Ledong Zhao
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, No. 251 Fukang Road, Nankai District, Tianjin, China
| | - Xuehan Qian
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, No. 251 Fukang Road, Nankai District, Tianjin, China
| | - Charles Wormington
- Salus Univerisity Pennsylvania College of Optometry, Elkins Park, PA, USA
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Ramakrishnan E, Muthu S, Balasubramaniam P, Chellamuthu G, Priyadharshini K. Holistic Approach in the Management of Skeletal Deformity in a Case of Homocystinuria. J Orthop Case Rep 2021; 11:1-5. [PMID: 34327154 PMCID: PMC8310640 DOI: 10.13107/jocr.2021.v11.i04.2126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Homocystinuria has a wide range of clinical presentations ranging from near normal intelligence and appearance with just lens dislocation and minimal skeletal deformities to severe mental retardation with gross skeletal deformities. In this background, we describe one such case with skeletal deformity managed comprehensively. CASE REPORT A 17-year-old boy presented with complaints of deformity of the left lower limb since childhood more evident for the past 5 years along with a history of blurring of vision. On examination the pubis-heal length > crown-pubis length along with genu valgum of left lower-limb with 16 cm intermalleolar distance. He also had a superolateral subluxation of the lens in both eyes. Valgus angle was 16° on the left leg compared to 6° on the right. The diagnosis of homocystinuria was confirmed by biochemical investigations. The left side genu valgum was addressed with medial closing wedge osteotomy and fixed with distal femur locking compression plating. Lens subluxation was treated with posterior chamber intra-ocular lens surgery. He was also given medical treatment and on regular monitoring of his homocysteine levels. The patient had good functional outcome at 2-year follow-up. CONCLUSION Homocystinuria is a rare disease that needs early identification and effective management to avoid complications. Skeletal complications are common and include genu valgum, pes cavus, chest wall deformities, and skeletal deformities such as kyphosis and scoliosis. Skeletal deformities can be avoided when identified early and associated osteoporosis which is managed effectively. A holistic approach is needed in the management of such patients with inter-departmental coordination to bring quality to the life of patients with homocystinuria.
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Affiliation(s)
- Eswar Ramakrishnan
- Department of Orthopaedics and Traumatology, Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | - Sathish Muthu
- Orthopaedic Research Group, Coimbatore, Tamil Nadu, India
- Address of Correspondence: Dr. Sathish Muthu, Orthopaedic Research Group, Coimbatore, Tamil Nadu, India. E-mail:
| | - Pasupathy Balasubramaniam
- Department of Orthopaedics and Traumatology, Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
| | | | - Kavya Priyadharshini
- Orthopaedic Research Group, Coimbatore, Tamil Nadu, India
- Government Hospital, Musiri, Trichy, Tamil Nadu, India
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Morrison T, Bösch F, Landolt MA, Kožich V, Huemer M, Morris AAM. Homocystinuria patient and caregiver survey: experiences of diagnosis and patient satisfaction. Orphanet J Rare Dis 2021; 16:124. [PMID: 33691747 PMCID: PMC7945666 DOI: 10.1186/s13023-021-01764-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/25/2021] [Indexed: 12/03/2022] Open
Abstract
Background The main genetic causes of homocystinuria are cystathionine beta-synthase (CBS) deficiency and the remethylation defects. Many patients present in childhood but milder forms may present later in life. Some countries have newborn screening programs for the homocystinurias but these do not detect all patients.
Results HCU Network Australia is one of the very few support groups for patients with homocystinurias. Here we report the results of its survey of 143 patients and caregivers from 22 countries, evaluating current diagnostic pathways and management for the homocystinurias. Most (110) of the responses related to patients with CBS deficiency. The diagnosis was made by newborn screening in 20% of patients and in 50% of the others within 1 year of the initial symptom but in 12.5% it took over 15 years. The delay was attributed mainly to ignorance of the disease. Physicians need to learn to measure homocysteine concentrations in children with neurodevelopmental problems, and in patients with heterogeneous symptoms such as thromboembolism, dislocation of the optic lens, haemolytic uraemic syndrome, and psychiatric disease. Even when the diagnosis is made, the way it is communicated is sometimes poor. Early-onset CBS deficiency usually requires a low-protein diet with amino acid supplements. More than a third of the participants reported problems with the availability or cost of treatment. Only half of the patients always took their amino acid mixture. In contrast, good adherence to the protein restriction was reported in 98% but 80% said it was hard, time-consuming and caused unhappiness. Conclusions There is often a long delay in diagnosing the homocystinurias unless this is achieved by newborn screening; this survey also highlights problems with the availability and cost of treatment and the palatability of protein substitutes.
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Affiliation(s)
- T Morrison
- HCU Network Australia, Baulkham Hills, Australia
| | - F Bösch
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland
| | - M A Landolt
- Division of Child and Adolescent Health Psychology, Department of Psychology, University of Zurich, Zurich, Switzerland.,Department of Psychosomatics and Psychiatry and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - V Kožich
- Department of Pediatrics and Inherited Metabolic Disorders, Charles University-First Faculty of Medicine, General University Hospital, Prague, Czech Republic
| | - M Huemer
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland. .,Department of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria.
| | - A A M Morris
- Division of Evolution and Genomic Sciences, Institute of Human Development, University of Manchester, Manchester, UK.,Willink Metabolic Unit, Manchester Centre for Genomic Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Gus PI, Donis KC, Marinho D, Martins TF, de Souza CFM, Carloto RB, Leivas G, Schwartz IVD. Ocular manifestations in classic homocystinuria. Ophthalmic Genet 2020; 42:71-74. [PMID: 32940091 DOI: 10.1080/13816810.2020.1821384] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Classic homocystinuria (HCU), or cystathionine beta-synthase (CBS) deficiency, is a rare inborn error of methionine metabolism. Main clinical features may include skeletal and vascular manifestations, developmental delay, intellectual disability and eye disorders. MATERIAL AND METHODS This is an observational and retrospective study aiming at describing eye abnormalities presented by a cohort of late-diagnosed HCU patients. Data regarding ophthalmological evaluation included visual acuity, refraction, biomicroscopy, Perkins tonometry, fundus examination, retinography, biometry, ocular ultrasound, optical coherence tomography, anterior segment photography and topography. RESULTS Ten patients with HCU (20 eyes) were included. The most frequent findings were ectopia lentis(n = 20) and myopia (n = 9). Biometry, ultrasound, OCT and topography findings were available for four patients. One patient had keratoconus; one had abnormal retinal pigmentation; and two had lens surgery scars with irregular astigmatism. CONCLUSIONS Eye abnormalities are very frequent in late-diagnosed HCU patients. The presence of ectopia lentis should always raise the diagnostic hypothesis of HCU.
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Affiliation(s)
- Patrícia Ioschpe Gus
- Ophthalmology Division, Hospital de Clínicas de Porto Alegre (HCPA) , Porto Alegre, Brazil
| | - Karina Carvalho Donis
- Medical Genetics Division, Hospital de Clínicas de Porto Alegre (HCPA) , Porto Alegre, Brazil
| | - Diane Marinho
- Ophthalmology Division, Hospital de Clínicas de Porto Alegre (HCPA) , Porto Alegre, Brazil
| | | | | | - Rafael Barboza Carloto
- Medical Student, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS) , Porto Alegre, Brazil
| | - Gabriel Leivas
- Medical Student, Universidade Federal do Rio Grande do Sul (UFRGS) , Porto Alegre, Brazil
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Tang SZ, Liu YN, Hu SH, Chen H, Zhao H, Feng XM, Pan XJ, Chen P. Mutation analysis of FBN1 gene in two Chinese families with congenital ectopia lentis in northern China. Int J Ophthalmol 2019; 12:1674-1679. [PMID: 31741853 DOI: 10.18240/ijo.2019.11.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 06/12/2019] [Indexed: 01/27/2023] Open
Abstract
AIM To summarize the phenotypes and identify the underlying genetic cause of the fibrillin-1 (FBN1) gene responsible for congenital ectopia lentis (EL) in two Chinese families in northern China. METHODS A detailed family history and clinical data from all participants were collected by clinical examination. The candidate genes were captured and sequenced by targeted next-generation sequencing, and the results were confirmed by Sanger sequencing. Haplotyping was used to confirm the mutation sequence. Real-time PCR was used to determine the FBN1 messenger ribonucleic acid (mRNA) levels in patients with EL and in unaffected family members. RESULTS The probands and other patients in the two families were affected with congenital isolated EL. A heterozygous FBN1 mutation in exon 21 (c.2420_IVS20-8 delTCTGAAACAinsCGAAAG) was identified in FAMILY-1. A heterozygous FBN1 mutation in exon 14 (c.1633C>T, p.R545C) was identified in FAMILY-2. Each mutation co-segregated with the affected individuals in the family and did not exist in unaffected family members and 200 unrelated normal controls. CONCLUSION The insertion-deletion mutation (c.2420 IVS20-8delTCTGAAACA insCGAAAG) in the FBN1 gene is first identified in isolated EL. The mutation (c.1633C>T) in the FBN1 gene was a known mutation in EL patient. The variable phenotypes among the patients expand the phenotypic spectrum of EL in a different ethnic background.
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Affiliation(s)
- Su-Zhen Tang
- Department of Human Anatomy, Histology and Embryology, School of Basic Medicine, Qingdao University, Qingdao 266071, Shandong Province, China
| | - Ya-Ning Liu
- Department of Human Anatomy, Histology and Embryology, School of Basic Medicine, Qingdao University, Qingdao 266071, Shandong Province, China
| | - Shao-Hua Hu
- Department of Human Anatomy, Histology and Embryology, School of Basic Medicine, Qingdao University, Qingdao 266071, Shandong Province, China
| | - Hao Chen
- Department of Human Anatomy, Histology and Embryology, School of Basic Medicine, Qingdao University, Qingdao 266071, Shandong Province, China
| | - Hui Zhao
- The 971 Hospital of the Chinese People's Liberation Army Navy, Qingdao 266071, Shandong Province, China
| | - Xue-Mei Feng
- Department of Human Anatomy, Histology and Embryology, School of Basic Medicine, Qingdao University, Qingdao 266071, Shandong Province, China
| | - Xiao-Jing Pan
- Qingdao Eye Hospital, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao 266071, Shandong Province, China
| | - Peng Chen
- Department of Human Anatomy, Histology and Embryology, School of Basic Medicine, Qingdao University, Qingdao 266071, Shandong Province, China
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Abstract
Homocystinuria is the second most common treatable aminoacidopathy. Clinically, affected patients present with eye, skeleton, central nervous system, and most importantly, vascular system abnormalities. This autosomal recessive disorder leads to accumulation of homocysteine and its metabolites in the blood and urine. In this report, we present a case with clinical and biochemical findings of homocystinuria with stroke and a positive familial history of the disease in her brother. A 4-year-old girl was admitted to pediatric emergency ward because of acute onset of right hemiparesis and subsequent generalized tonic–clonic seizures. Cranial magnetic resonance imaging revealed acute infarct areas in the left cerebral hemisphere. Metabolic screening revealed elevated concentrations of serum homocysteine and methionine and a normal serum concentration of vitamin B12. These findings, along with a positive familial history led to the diagnosis of homocystinuria. In any child who presents with stroke, some rare condition such as homocystinuria should be considered in diagnosis.
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Affiliation(s)
- Ali Mazaheri
- Fellow of Pediatric Endocrinology, Child growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Neda Mostofizadeh
- Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahin Hashemipour
- Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Overwater E, Floor K, van Beek D, de Boer K, van Dijk T, Hilhorst-Hofstee Y, Hoogeboom AJM, van Kaam KJ, van de Kamp JM, Kempers M, Krapels IPC, Kroes HY, Loeys B, Salemink S, Stumpel CTRM, Verhoeven VJM, Wijnands-van den Berg E, Cobben JM, van Tintelen JP, Weiss MM, Houweling AC, Maugeri A. NGS panel analysis in 24 ectopia lentis patients; a clinically relevant test with a high diagnostic yield. Eur J Med Genet 2017. [PMID: 28642162 DOI: 10.1016/j.ejmg.2017.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Several genetic causes of ectopia lentis (EL), with or without systemic features, are known. The differentiation between syndromic and isolated EL is crucial for further treatment, surveillance and counseling of patients and their relatives. Next generation sequencing (NGS) is a powerful tool enabling the simultaneous, highly-sensitive analysis of multiple target genes. OBJECTIVE The aim of this study was to evaluate the diagnostic yield of our NGS panel in EL patients. Furthermore, we provide an overview of currently described mutations in ADAMTSL4, the main gene involved in isolated EL. METHODS A NGS gene panel was analysed in 24 patients with EL. RESULTS A genetic diagnosis was confirmed in 16 patients (67%). Of these, four (25%) had a heterozygous FBN1 mutation, 12 (75%) were homozygous or compound heterozygous for ADAMTSL4 mutations. The known European ADAMTSL4 founder mutation c.767_786del was most frequently detected. CONCLUSION The diagnostic yield of our NGS panel was high. Causative mutations were exclusively identified in ADAMTSL4 and FBN1. With this approach the risk of misdiagnosis or delayed diagnosis can be reduced. The value and clinical implications of establishing a genetic diagnosis in patients with EL is corroborated by the description of two patients with an unexpected underlying genetic condition.
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Affiliation(s)
- E Overwater
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands; Department of Clinical Genetics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - K Floor
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - D van Beek
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - K de Boer
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - T van Dijk
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - Y Hilhorst-Hofstee
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - A J M Hoogeboom
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - K J van Kaam
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - J M van de Kamp
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - M Kempers
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - I P C Krapels
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - H Y Kroes
- Department of Clinical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - B Loeys
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - S Salemink
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C T R M Stumpel
- Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Clinical Genetics and School for Oncology & Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, The Netherlands
| | - V J M Verhoeven
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Ophthalmology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - J M Cobben
- Department of Medical Genetics, St George's University Hospital London, London, United Kingdom; Department of Pediatrics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - J P van Tintelen
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands; Department of Clinical Genetics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M M Weiss
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - A C Houweling
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
| | - A Maugeri
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands
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12
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Morris AAM, Kožich V, Santra S, Andria G, Ben-Omran TIM, Chakrapani AB, Crushell E, Henderson MJ, Hochuli M, Huemer M, Janssen MCH, Maillot F, Mayne PD, McNulty J, Morrison TM, Ogier H, O'Sullivan S, Pavlíková M, de Almeida IT, Terry A, Yap S, Blom HJ, Chapman KA. Guidelines for the diagnosis and management of cystathionine beta-synthase deficiency. J Inherit Metab Dis 2017; 40:49-74. [PMID: 27778219 PMCID: PMC5203861 DOI: 10.1007/s10545-016-9979-0] [Citation(s) in RCA: 184] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 08/11/2016] [Accepted: 09/12/2016] [Indexed: 12/17/2022]
Abstract
Cystathionine beta-synthase (CBS) deficiency is a rare inherited disorder in the methionine catabolic pathway, in which the impaired synthesis of cystathionine leads to accumulation of homocysteine. Patients can present to many different specialists and diagnosis is often delayed. Severely affected patients usually present in childhood with ectopia lentis, learning difficulties and skeletal abnormalities. These patients generally require treatment with a low-methionine diet and/or betaine. In contrast, mildly affected patients are likely to present as adults with thromboembolism and to respond to treatment with pyridoxine. In this article, we present recommendations for the diagnosis and management of CBS deficiency, based on a systematic review of the literature. Unfortunately, the quality of the evidence is poor, as it often is for rare diseases. We strongly recommend measuring the plasma total homocysteine concentrations in any patient whose clinical features suggest the diagnosis. Our recommendations may help to standardise testing for pyridoxine responsiveness. Current evidence suggests that patients are unlikely to develop complications if the plasma total homocysteine concentration is maintained below 120 μmol/L. Nevertheless, we recommend keeping the concentration below 100 μmol/L because levels fluctuate and the complications associated with high levels are so serious.
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Affiliation(s)
- Andrew A M Morris
- Institute of Human Development, University of Manchester, Manchester, UK.
- Willink Unit, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals, St Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK.
| | - Viktor Kožich
- Institute of Inherited Metabolic Disorders, Charles University in Prague-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Saikat Santra
- Clinical IMD, Birmingham Children's Hospital, Birmingham, UK
| | - Generoso Andria
- Department of translational medicine, Federico II University, Naples, Italy
| | | | | | - Ellen Crushell
- National Centre for Inherited Metabolic Disorders, Temple Street Children's University Hospital, Dublin, Ireland
| | - Mick J Henderson
- Willink Unit, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals, St Mary's Hospital, Oxford Road, Manchester, M13 9WL, UK
- Biochemical Genetics, St James' University Hospital, Leeds, UK
| | - Michel Hochuli
- Division of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zürich, Zurich, Switzerland
| | - Martina Huemer
- Division of Metabolism and Children's Research Center, University Children's Hospital Zürich, Zurich, Switzerland
- Rare Disease Initiative Zürich, University of Zürich, Zurich, Switzerland
- Dept. of Paediatrics, Landeskrankenhaus Bregenz, Bregenz, Austria
| | - Miriam C H Janssen
- Department of Internal medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Philip D Mayne
- Newborn Bloodspot Screening Laboratory, Temple Street Children's University Hospital, Dublin, Ireland
| | - Jenny McNulty
- National Centre for Inherited Metabolic Disorders, Temple Street Children's University Hospital, Dublin, Ireland
| | | | - Helene Ogier
- Service de Neurologie Pédiatrique et des Maladies Métaboliques, Hôpital Robert Debré, Paris, France
| | | | - Markéta Pavlíková
- Institute of Inherited Metabolic Disorders, Charles University in Prague-First Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | | | - Allyson Terry
- Institute of Human Development, University of Manchester, Manchester, UK
- Dietetic Department, Alder Hey Hospital, Liverpool, UK
| | - Sufin Yap
- Dept of Inherited Metabolic Diseases, Sheffield Children's Hospital, Sheffield, UK
| | - Henk J Blom
- Laboratory of Clinical Biochemistry and Metabolism, Department of General Pediatrics, Adolescent Medicine and Neonatology, University Medical Centre Freiburg, Freiburg im Breisgau, Germany
| | - Kimberly A Chapman
- Division of Genetic and Metabolism, Children's National Health System, Washington, DC, USA
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Mahale RR, Mehta A, Rau T, Acharya P, Srinivasa R. Arterial Stroke as an Isolated Manifestation of Homocystinuria in an Infant. J Pediatr Neurosci 2017; 12:206-207. [PMID: 28904589 PMCID: PMC5588656 DOI: 10.4103/jpn.jpn_4_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rohan R Mahale
- Department of Neurology, MS Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India
| | - Anish Mehta
- Department of Neurology, MS Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India
| | - T Rau
- Department of Paediatrics, MS Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India
| | - Purushottam Acharya
- Department of Neurology, MS Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India
| | - Rangasetty Srinivasa
- Department of Neurology, MS Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India
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Mundada V, Krishnakumar D, Chitre M, Das T. Answers to Epilogue questions. Arch Dis Child Educ Pract Ed 2016; 101:165. [PMID: 27194774 DOI: 10.1136/archdischild-2014-306744a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 05/10/2015] [Indexed: 11/03/2022]
Affiliation(s)
- Vivek Mundada
- Department of Paediatric Neurology, Addenbrooke's Hospital, Cambridge, UK
| | - Deepa Krishnakumar
- Department of Paediatric Neurology, Addenbrooke's Hospital, Cambridge, UK
| | - Manali Chitre
- Department of Paediatric Neurology, Addenbrooke's Hospital, Cambridge, UK
| | - Tilak Das
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
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15
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Visual outcome and incidence of glaucoma in patients with microspherophakia. Eye (Lond) 2014; 29:350-5. [PMID: 25397784 DOI: 10.1038/eye.2014.250] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 09/15/2014] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION A number of ocular complications have been reported in microspherophakia. The literature however is limited to small case reports and the incidence of these complications is largely unknown. Our study describes a series of patients who presented to our hospital from 1998 to 2008. MATERIAL AND METHODS Data on the clinical and surgical findings of patients presented to us from 1998 to 2008 with microspherophakia were retrieved from the medical records and the results analyzed. RESULTS Thirty-six eyes of 18 patients were reviewed. The mean age at presentation was 16±10 years. All patients had varying degrees of lenticular myopia with a mean of -11.07±5.03 D. Glaucoma developed in 16 eyes (44.4%). Half of them had high IOP at presentation. Despite medical and surgical management IOP remained high in five eyes at the last follow-up. Sixteen eyes (44.4%) required lensectomy for dislocated crystalline lens. Lensectomy did not have any impact on the intraocular pressures. Homocysteinuria was the most common systemic association noted. CONCLUSION Microspherophakia is associated with a high incidence of lenticular myopia, subluxation of the crystalline lens and glaucoma. Management of glaucoma is difficult with the IOP remaining high in spite of combined medical and surgical management.
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Abstract
Homocystinuria due to cystathionine β-synthase deficiency is an inborn error of metabolism first described almost 50 years ago, which involves the accumulation of plasma homocysteine and other metabolites. Without early detection and appropriate treatment, common and sometimes lethal consequences include ocular abnormalities, osteoporosis, developmental delays, marfanoid phenotype, vascular disease, and mental retardation. Almost 50% of subjects develop a psychiatric disorder during their life, but only 2.8% present a psychiatric symptom as the initial manifestation. Among this group, psychotic disorders are infrequent. We describe the case of a 17-year-old boy presenting with a first episode psychosis and an unknown homocystinuria due to cystathionine β-synthase deficiency, which led to a lethal outcome.
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Adam S, Almeida MF, Carbasius Weber E, Champion H, Chan H, Daly A, Dixon M, Dokoupil K, Egli D, Evans S, Eyskens F, Faria A, Ferguson C, Hallam P, Heddrich-Ellerbrok M, Jacobs J, Jankowski C, Lachmann R, Lilje R, Link R, Lowry S, Luyten K, MacDonald A, Maritz C, Martins E, Meyer U, Müller E, Murphy E, Robertson LV, Rocha JC, Saruggia I, Schick P, Stafford J, Stoelen L, Terry A, Thom R, van den Hurk T, van Rijn M, van Teefelen-Heithoff A, Webster D, White FJ, Wildgoose J, Zweers H. Dietary practices in pyridoxine non-responsive homocystinuria: a European survey. Mol Genet Metab 2013; 110:454-9. [PMID: 24206934 DOI: 10.1016/j.ymgme.2013.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 10/05/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Within Europe, the management of pyridoxine (B6) non-responsive homocystinuria (HCU) may vary but there is limited knowledge about treatment practice. AIM A comparison of dietetic management practices of patients with B6 non-responsive HCU in European centres. METHODS A cross-sectional audit by questionnaire was completed by 29 inherited metabolic disorder (IMD) centres: (14 UK, 5 Germany, 3 Netherlands, 2 Switzerland, 2 Portugal, 1 France, 1 Norway, 1 Belgium). RESULTS 181 patients (73% >16 years of age) with HCU were identified. The majority (66%; n=119) were on dietary treatment (1-10 years, 90%; 11-16 years, 82%; and >16 years, 58%) with or without betaine and 34% (n=62) were on betaine alone. The median natural protein intake (g/day) on diet only was, by age: 1-10 years, 12 g; 11-16 years, 11 g; and >16 years, 45 g. With diet and betaine, median natural protein intake (g/day) by age was: 1-10 years, 13 g; 11-16 years, 20 g; and >16 years, 38 g. Fifty-two percent (n=15) of centres allocated natural protein by calculating methionine rather than a protein exchange system. A methionine-free l-amino acid supplement was prescribed for 86% of diet treated patients. Fifty-two percent of centres recommended cystine supplements for low plasma concentrations. Target treatment concentrations for homocystine/homocysteine (free/total) and frequency of biochemical monitoring varied. CONCLUSION In B6 non-responsive HCU the prescription of dietary restriction by IMD centres declined with age, potentially associated with poor adherence in older patients. Inconsistencies in biochemical monitoring and treatment indicate the need for international consensus guidelines.
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Affiliation(s)
- S Adam
- Glasgow Royal Infirmary, Royal Hospital for Sick Children, UK
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Martínez-Gutiérrez JD, Mencía-Gutiérrez E, Gracia-García-Miguel T, Gutiérrez-Díaz E, López-Tizón E. Classical familial homocystinuria in an adult presenting as an isolated lens subluxation. Int Ophthalmol 2011; 31:227-32. [PMID: 21626167 DOI: 10.1007/s10792-011-9444-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 05/11/2011] [Indexed: 11/30/2022]
Abstract
To report a case of late diagnosis of a classical familial homocystinuria based on an ophthalmologic examination. A 35-year-old male with Marfan-like phenotype complained of a progressive increase of myopia during the previous 2 years. Ophthalmologic exploration showed a bilateral subluxation of the lens with inferior and nasal displacement. Biochemical study detected a profile of increased amino acid levels (homocysteinemia) consistent with suspected homocystinuria. Vascular and skeletal studies ruled out Marfan syndrome. Response to treatment demonstrated B(6)-non-responsive homocystinuria. Molecular study showed compound heterozygous T353 N and D444 N mutations of the cystathionine beta-synthase (CBS) gene, and also a C667T homozygous mutation of the methylenetetrahydrofolate-reductase (MTHFR) gene. Family study showed classical homocystinuria in his father and sister, although they did not present any systemic or ocular features of the disease. Homocystinuria is a metabolic disease usually presenting at an early age as vascular, skeletal and neuropsychiatric abnormalities, as well as ectopia lentis. Our case is atypical because of the absence of thromboembolism and the mild phenotype, in spite of being B(6)-non-responsive, and the association of a rare compound heterozygous mutation of the CBS gene and also an homozygous mutation of the MTHFR gene. It is necessary to rule out homocystinuria in patients with ectopia lentis, even in the absence of systemic symptoms.
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Alehan F, Saygi S, Gedik S, Kayahan Ulu EM. Stroke in early childhood due to homocystinuria. Pediatr Neurol 2010; 43:294-6. [PMID: 20837312 DOI: 10.1016/j.pediatrneurol.2010.05.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 03/24/2010] [Accepted: 05/11/2010] [Indexed: 11/25/2022]
Abstract
A previously healthy girl, age 3 years 9 months, presented with right-sided hemiparesis and seizures. Ischemic infarction was confirmed through magnetic resonance imaging and magnetic resonance angiography. Extensive evaluation to discover the underlying etiologies and risk factors predisposing this patient to stroke included coagulation defects, cardiac anomalies, congenital inborn metabolism deficiency, and infections and trauma. Based on the clinical and laboratory results, a diagnosis of homocystinuria was made. Homocystinuria is an inherited disorder that affects the metabolism of the amino acid methionine. Although homocystinuria is usually associated with ischemic strokes, the sudden onset of stroke as the initial clinical presentation of homocystinuria is very rare in early childhood. Based on this case, however, metabolic screening for hyperhomocystinemia is recommended in any child presenting with a stroke.
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Affiliation(s)
- Füsun Alehan
- Division of Child Neurology, Baskent University Faculty of Medicine, Ankara, Turkey
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20
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Aguirre Errasti C, Egurbide Arberas MV, Martínez Berriotxoa A. Homocisteína en la clínica humana. Med Clin (Barc) 2009; 133:472-8. [DOI: 10.1016/j.medcli.2008.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 11/17/2008] [Indexed: 11/16/2022]
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21
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Abstract
The association of genetic factors and cerebral infarction (CI) has long been established. A positive family history alone is a recognized risk factor for CI and vascular events in general. However, there are certain inherited conditions that further increase the risk of stroke. These conditions are generally metabolic and mitochondrial genetic defects that have variable modes of inheritance. This article reviews major inherited metabolic disorders that predispose an individual to CI. Ten main conditions will be discussed: Fabry's disease, cerebrotendinous xanthomatosis, tangier disease, familial hypercholesterolemia, homocystinuria, methylmalonic acidemia, glutaric aciduria type I, propionic acidemia, ornithine transcarbamylase deficiency and mitochondrial encephalopathy, lactic acidosis and stroke-like phenomenon.
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Affiliation(s)
- Kavita Kalidas
- Department of Neurology, University of South Florida College of Medicine, Tampa, FL 33606, USA.
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22
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Abstract
Bone tissue quality is determined not only by multiple architectural variables, but also by the mechanical properties of collagen type 1. Homocysteinuria is a genetic disease whose manifestations include severe hyperhomocysteinemia and decreased bone strength. The effects of smaller homocysteine elevations on bone tissue are difficult to demonstrate in clinical studies. Studies in animals and in humans suggest that homocysteine may weaken collagen crosslinks and, if present in large amounts, interfere with bone remodeling. Whether routine homocysteine assays should be performed to detect bone frailty remains unclear. In clinical practice, the focus should be on identifying patients with potential causes of homocysteine elevation (e.g., medications), who should then be given vitamin D and folic acid supplementation if needed. This approach may improve not only bone health, but also vascular and general health.
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Affiliation(s)
- Régis Levasseur
- Service de Rhumatologie et Pôle ostéo-articulaire, CHU d'Angers, Inserm U922, Faculté de Médecine d'Angers, 49933 Angers Cedex, France.
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Vascular and connective tissue features in 5 Italian patients with homocystinuria. Int J Cardiol 2008; 134:251-4. [PMID: 18280597 DOI: 10.1016/j.ijcard.2007.12.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Accepted: 12/11/2007] [Indexed: 11/20/2022]
Abstract
Homocystinuria is a metabolic disorder associated with defects in genes encoding for methionine metabolism enzymes. Vascular and connective tissue manifestations such as deep venous thrombosis, ectopia lentis and skeletal alterations are the major clinical features. We investigated the clinical manifestations of 5 Italian homocystinuric patients, performed mutation screening analysis on cystationine beta-synthase (CBS) gene and searched for genotype/phenotype correlations. We detected mild cardiovascular and skin connective tissue stigmas in these patients, never reported in homocystinuric patients before. We found 1 novel and 7 known mutations. Our patients carried no other mutation associated with venous thrombosis. Our data stress the importance of extending the clinical investigation for connective tissue manifestations in homocystinuric patients to all the organs/systems involved in Marfan syndrome, also suggesting long term follow-ups for cardiovascular manifestations.
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Persa C, Osmotherly K, Chao-Wei Chen K, Moon S, Lou MF. The distribution of cystathionine beta-synthase (CBS) in the eye: implication of the presence of a trans-sulfuration pathway for oxidative stress defense. Exp Eye Res 2006; 83:817-23. [PMID: 16769053 DOI: 10.1016/j.exer.2006.04.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2006] [Revised: 02/23/2006] [Accepted: 04/07/2006] [Indexed: 11/16/2022]
Abstract
Clinical abnormalities in cystathionine-beta-synthase (CBS) deficiency, a key enzyme in the trans-sulfuration pathway, associate with many eye disorders. However, little is known about this enzyme in the eye. The goal of this study is to examine the distribution of CBS in the various regions of the eye, including conjunctiva, cornea, iris, lens, vitreous, retina and optic nerve using fresh eyes from both pigs (6 months) and humans (4-82 years). We have found that pig eye showed the highest CBS protein presence in cornea, conjunctiva and iris, followed by retina and optic nerve. The whole lens had a relatively lower amount and vitreous body had none. CBS protein distribution in the human eyes showed a similar pattern, with high level in the anterior segments but much lower amount in retina and optic nerve. CBS in anterior segments remained high throughout the lifespan, but retinal CBS showed a trend of age-dependent increase. The presence of CBS in human and pig eye tissues was further confirmed by RT-PCR, CBS activity assay, both showed similar distribution profiles as the Western blot analysis. This is the first evidence of the presence of CBS enzyme in the eye outside of the lens, which indicates that a functional trans-sulfuration pathway may be present in various eye tissues.
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Affiliation(s)
- Cristina Persa
- Department of Veterinary and Biomedical Sciences, University of Nebraska-Lincoln, 134 VBS, 68583-0905, USA
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26
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Abstract
BACKGROUND Inborn errors of metabolism are a significant cause of morbidity and death among children. Inconsistencies in how individual states arrive at screening strategies, however, lead to marked variations in testing between states. OBJECTIVE To determine the cost-effectiveness of each component test of a multitest newborn screening program, including screening for phenylketonuria, congenital adrenal hyperplasia, congenital hypothyroidism, biotinidase deficiency, maple syrup urine disease, galactosemia, homocystinuria, and medium-chain acyl-CoA dehydrogenase deficiency. METHODS A decision model was used, with cohort studies, government reports, secondary analyses, and other sources. Discounted costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios were measured. RESULTS All except 2 screening tests dominated the "no-test" strategy. The 2 exceptions were screening for congenital adrenal hyperplasia, which cost slightly more than $20,000 per QALY gained, and screening for galactosemia, which cost $94,000 per QALY gained. The screening test with the lowest expected cost was tandem mass spectrometry. The results found in our base-case analysis were stable across variations in nearly all variables. In instances in which changes in risks, sequelae, costs, or utilities did affect our results, the variation from base-case estimates was quite large. CONCLUSIONS Newborn screening seems to be one of the rare health care interventions that is beneficial to patients and, in many cases, cost saving. Over the long term, funding comprehensive newborn screening programs is likely to save money for society.
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Affiliation(s)
- Aaron E Carroll
- Children's Health Services Research, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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27
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Reply to Late spontaneous anterior dislocation of an intraocular lens (IOL) with the capsular bag. Eye (Lond) 2006. [DOI: 10.1038/sj.eye.6701927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Kobayasi T. Dermal elastic fibres in the inherited hypermobile disorders. J Dermatol Sci 2006; 41:175-85. [PMID: 16326076 DOI: 10.1016/j.jdermsci.2005.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Revised: 09/30/2005] [Accepted: 10/04/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Elastic fibres in the inherited hypermobile disorders are probably abnormal on the inherited grounds. The abnormality may contribute for diagnosis and investigation of connective tissue biology. OBJECTIVE The abnormality will be specific for every disorders and disclosed in the age-dependent change when exposure-dependent change was excluded. MATERIALS AND METHODS Skin specimens from Ehlers-Danlos syndrome and hypermobile syndrome, Marfan syndrome, Osteogenesis imperfecta type I, homocysteinuria and normal controls are studied by routine electron microscopy. Age-dependent ultrastructural change of broad elastic fibres was evaluated in reticular dermis. RESULTS Age-dependent change was categorized in infantile, adolescent, adult and senile pattern. Infantile pattern showed normal ultrastructure. Degeneration was first found in adolescent pattern by disarrayed microfibrils and degenerate matrix. Degeneration proceeded in adult pattern and ended in senile pattern. Typical abnormality developed in adult pattern. Ehlers-Danlos syndrome and hypermobile syndrome showed no specific abnormality but the degeneration began earlier and was severer than the control. Marfan syndrome showed defects of microfibrils and matrix surface. Moth-eaten figure was characteristic. Osteogenesis imperfecta showed abnormal matrix and revealed homogenous bulges of matrix. Homocysteinuria was specified by numerous microfibrils on the matrix surface in infantile pattern. CONCLUSION Abnormality of elastic fibre was recognized in the reticular dermis of elbow. Ehlers-Danlos syndrome and hypermobile syndrome showed no specific abnormality but the degeneration was more intensive than the control. Abnormality of Marfan syndrome was degeneration of elastic microfibrils and matrix surface, Osteogenesis imperfecta was characterized by excess amount of matrix. Homocysteinuria revealed numerous microfibrils. Ultrastructural abnormality provided grounds for studies on histopathology and biology of elastic fibre.
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Affiliation(s)
- Takasi Kobayasi
- Department of Dermatology, University of Copenhagen, Bispebjerg Hospital, D-92, Bispebjerg Bakke 23, Copenhagen NV DK-2400, Denmark.
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Palomino JC, Lobato RD, Campollo J, Fernández-Alen J, Lagares A. Unruptured dural arteriovenous malformation of the transverse-sigmoid sinus presenting with focal symptoms and coma. Neurocirugia (Astur) 2005; 15:458-67. [PMID: 15558203 DOI: 10.1016/s1130-1473(04)70458-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We are presenting the case of a 63 year-old man with a dural arteriovenous malformation of the transverse sigmoid sinus who developed focal deficits followed by less localized symptoms such a disorientation, lethargy and eventually comatose status. Initial cerebral angiography showed retrograde filling of the cortical and deep cerebral venous system with marked delay in venous empting. Following embolization clinical symptoms completely cleared at the time that control angiography showed retrograde venous flow turning anterograde. Patient's symptoms recurred four months later when there was a relapse of retrograde cerebral venous drainage at the time he developed thrombosis of the superior longitudinal and right transverse sinuses. Sinus thrombosis and thrombosis of the central retinal artery were coincidental with hypercoagulability related to hyperhomocysteinemia. Since control angiography still showed persistence of the AV shunting radical excision of the involved dural sinuses was performed. The final outcome was excellent. The physiopathological mechanism responsible for neurological deficits in our patient most likely was ischemia of venous origin secondary to venous hypertension resulting from retrograde cerebral venous drainage. The clinical and angiographic presentation in few similar cases reported in the literature is reviewed.
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Affiliation(s)
- J C Palomino
- Service of Neurosurgery and Section of Neuroradiology, Hospital Doce de Octubre, Faculty of Medicine, University Complutense, Madrid, Spain
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Mulvihill A, O'Keeffe M, Yap S, Naughten E, Howard P, Lanigan B. Ocular axial length in homocystinuria patients with and without ocular changes: effects of early treatment and biochemical control. J AAPOS 2004; 8:254-8. [PMID: 15226727 DOI: 10.1016/j.jaapos.2004.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To establish whether myopia in homocystinuria could be due to increased ocular axial length. METHODS Measurement of ocular axial length by A-scan ultrasound in eyes of homocystinuria patients. RESULTS Patients were divided into three groups. Group I, with no ocular pathology (28 eyes), had mean refractive error of -0.25 D (spherical equivalent) and mean axial length of 23.4 mm +/- 0.9 (+/-1 standard deviation) mm. Group II, with phacodonesis or lens subluxation (12 eyes), had mean refractive error of -10.7 D and mean axial length of 23.8 mm +/-1.9 mm. Patients with phacodonesis had simple myopia whereas those with lens subluxation had marked myopic astigmatism. Group III included patients with complete lens dislocation in at least one eye (12 eyes) and were optically aphakic with a mean refractive error of +12.9 D and mean axial length of 24.9 mm +/- 0.9 mm. All Group I patients had good long-term metabolic control while those in Groups II and III did not. Group III eyes had significantly longer mean axial length than Group I (P =.0018) or normal eyes (P =.0163). There was no statistical difference in mean axial length between Group I and normal eyes. CONCLUSIONS Ocular axial length is significantly increased in individuals with homocystinuria and lens dislocation. Increased axial length is a complication that has not been previously described in homocystinuria and may be preventable with early treatment and good biochemical control.
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Logan NS, Gilmartin B, Marr JE, Stevenson MR, Ainsworth JR. Community-based study of the association of high myopia in children with ocular and systemic disease. Optom Vis Sci 2004; 81:11-3. [PMID: 14747755 DOI: 10.1097/00006324-200401000-00004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE High myopia in childhood is associated with important ocular and systemic conditions. However in the UK, high myopia in early childhood is not specifically identified in current ophthalmology, optometry, or orthoptic protocols for screening, referral, or investigation. An ongoing study in the West Midlands, UK, is investigating high myopia presenting to community health care clinics with the aim of compiling guidelines for assessment and subsequent referral. METHODS Children with high myopia were identified from community optometric and orthoptic sources and invited for an ophthalmology and optometry examination to ascertain possible ocular or systemic disease. RESULTS High myopia with no associated ocular or systemic condition was present in 15 (56%) of the children. In seven children (25%), associated ocular problems were found including unrecognized retinal dystrophies and amblyopia. Systemic disorders associated with high myopia were found in five children (19%) and included Sticklers syndrome, Weill-Marchesani syndrome, and homocystinuria. In one child, the diagnosis made before this study was found to be incorrect, and in another child, the results were inconclusive. In two cases, the diagnosis of a systemic condition in the child led to the identification of the disease in at least one relative. CONCLUSIONS There is a high prevalence of ocular and systemic abnormality in young children seen in the community. Optometric and ophthalmologic assessment of children less than 10 years with myopia > or =5 D is likely to identify significant ocular or systemic disease, a proportion of which will respond to medical intervention. Detection and prompt referral of these cases by community health care services may be expected to prolong vision and possibly life expectancy.
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Affiliation(s)
- N S Logan
- Human Myopia Research Centre, School of Life and Health Sciences, Aston University, Birmingham, United Kingdom.
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Gaustadnes M, Wilcken B, Oliveriusova J, McGill J, Fletcher J, Kraus JP, Wilcken DE. The molecular basis of cystathionine beta-synthase deficiency in Australian patients: genotype-phenotype correlations and response to treatment. Hum Mutat 2002; 20:117-26. [PMID: 12124992 DOI: 10.1002/humu.10104] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cystathionine beta-synthase (CBS) deficiency is the most common cause of homocystinuria. It is inherited as an autosomal recessive trait and common clinical features are: dislocation of the optic lens, osteoporosis, mental retardation, and thromboembolism. We determined the molecular basis of CBS deficiency in 36 Australian patients from 28 unrelated families, using direct sequencing of the entire coding region of the CBS gene. The G307S and I278T mutations were the most common mutations. They were present in 19% and 18% of independent alleles, respectively. In total, seven novel and 20 known mutations were detected. Of those, the two novel missense mutations (C109R and G347S), as well as two known missense mutations (L101P and N228K), were expressed in E. Coli. All mutant proteins completely lacked catalytic activity. Furthermore, we studied the correlation between genotype and the biochemical response to pyridoxine treatment in the patients of whom 13 were pyridoxine responsive, 21 were non-responsive, and two were partially responsive. The G307S mutation always resulted in a severe non-responsive phenotype, whereas I278T resulted in a milder B6 responsive phenotype. From our results, we were also able to establish three other mild mutations: P49L, R369C, and V371M.
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Affiliation(s)
- Mette Gaustadnes
- Cardiovascular Genetics Laboratory, Prince of Wales Hospital, Randwick, New South Wales, Australia
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Abstract
Screening of newborn infants for genetic disease began over 35 years ago as a public health measure to prevent mental retardation in phenylketonuria (PKU). It was so successful that tests for several other genetic disorders were added. We review the current status of this screening, including discussions of the genetic disorders often covered and the results of newborn screening for them. We emphasize recent advances. These include expansion of coverage for genetic disorders with the new methodology of tandem mass spectrometry (MS-MS) and the introduction of molecular (DNA) testing to increase the specificity of testing for several disorders, thereby reducing false-positive rates. These and other advances have also produced issues of criteria for screening, missed cases, and appropriate use of stored newborn specimens.
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Affiliation(s)
- H L Levy
- Genetic Service, Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Yap S, Boers GH, Wilcken B, Wilcken DE, Brenton DP, Lee PJ, Walter JH, Howard PM, Naughten ER. Vascular outcome in patients with homocystinuria due to cystathionine beta-synthase deficiency treated chronically: a multicenter observational study. Arterioscler Thromb Vasc Biol 2001; 21:2080-5. [PMID: 11742888 DOI: 10.1161/hq1201.100225] [Citation(s) in RCA: 159] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An inborn error of metabolism, homocystinuria due to cystathionine beta-synthase deficiency, results in markedly elevated levels of circulating homocysteine. Premature vascular events are the main life-threatening complication. Half of all untreated patients have a vascular event by 30 years of age. We performed a multicenter observational study to assess the effectiveness of long-term homocysteine-lowering treatment in reducing vascular risk in 158 patients. Vascular outcomes were analyzed and effectiveness of treatment in reducing vascular risk was evaluated by comparison of actual to predicted number of vascular events, with the use of historical controls from a landmark study of 629 untreated patients with cystathionine beta-synthase deficiency. The 158 patients had a mean (range) age of 29.4 (4.5 to 70) years; 57 (36%) were more than 30 years old, and 10 (6%) were older than 50 years. There were 2822 patient-years of treatment, with an average of 17.9 years per patient. Plasma homocysteine levels were markedly reduced from pretreatment levels but usually remained moderately elevated. There were 17 vascular events in 12 patients at a mean (range) age of 42.5 (18 to 67) years: pulmonary embolism (n=3), myocardial infarction (n=2), deep venous thrombosis (n=5), cerebrovascular accident (n=3), transient ischemic attack (n=1), sagittal sinus thrombosis (n=1), and abdominal aortic aneurysm (n=2). Without treatment, 112 vascular events would have been expected, for a relative risk of 0.09 (95% CI 0.036 to 0.228; P<0.0001). Treatment regimens designed to lower plasma homocysteine significantly reduce cardiovascular risk in cystathionine beta-synthase deficiency despite imperfect biochemical control. These findings may be relevant to the significance of mild hyperhomocysteinemia that is commonly found in patients with vascular disease.
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Affiliation(s)
- S Yap
- National Center for Inherited Metabolic Disorders, The Children's Hospital, Dublin, Ireland
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Mulvihill A, Yap S, O'Keefe M, Howard PM, Naughten ER. Ocular findings among patients with late-diagnosed or poorly controlled homocystinuria compared with a screened, well-controlled population. J AAPOS 2001; 5:311-5. [PMID: 11641642 DOI: 10.1067/mpa.2001.118219] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Untreated homocystinuria (HCU) leads to systemic and ocular complications preventable by early treatment. METHODS This study describes the ocular features in HCU patients who had late diagnosis or were noncompliant with treatment compared with a control group of early-diagnosed and well-controlled subjects. RESULTS Fourteen late-diagnosed HCU patients with a median age at diagnosis of 4 years (range, 1.25-28 years) were studied. Five patients were born outside of Ireland or before screening began. All 14 patients had lens subluxation or dislocation at diagnosis. Only 28.6% of eyes had 20/40 vision or better. Three patients were tested for HCU following the diagnosis in a sibling. Four patients attended ophthalmology departments for a median of 12.8 years (range, 4-23 years) prior to diagnosis of HCU; all had steadily progressive myopic astigmatism and lens subluxation. Six patients who became poorly controlled in their teens or early twenties showed significant progression of their myopia, and 3 had phacodonesis or lens subluxation develop. All eyes in this group had 20/40 vision or better. Fifteen patients who were detected in the newborn period and remained well controlled had no evidence of lens subluxation. All of the control group patients had 20/20 vision bilaterally. The difference in visual acuity between late-diagnosed patients and the control group was highly significant (P =.0002). The differences in refractive errors between the groups were also highly significant (P =.0001). CONCLUSIONS Lens subluxation is a principal feature of untreated HCU, yet we found a median lag period of 5.5 years in 4 cases before diagnosis. Young persons with marked and progressive myopia or idiopathic lens subluxation should be screened for HCU.
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Affiliation(s)
- A Mulvihill
- Department of Paediatric Ophthalmology, The Children's Hospital, Dublin, Ireland
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Marr JE, Halliwell-Ewen J, Fisher B, Soler L, Ainsworth JR. Associations of high myopia in childhood. Eye (Lond) 2001; 15:70-4. [PMID: 11318301 DOI: 10.1038/eye.2001.17] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE High myopia in early childhood is a recognised association of ocular and systemic disease. The aim of this study was to describe the types, pattern and frequency of these associations. METHODS All children presenting to two ophthalmology units over 3 years who were found to have high myopia were recruited. High myopia was defined as one or both eyes demonstrating 6 dioptres spherical equivalent or more of myopic refractive error on retinoscopy. We limited the age to less than 10 years old. A retrospective case review was undertaken of the 112 consecutive children who fulfilled the criteria above. The demographic data, source and indication for referral were recorded along with the ocular and systemic findings and diagnosis. RESULTS Only 9 (8%) of the children had 'simple high myopia' with no associated ocular or systemic associations. In 54% there was an underlying systemic association with or without further ocular problems (e.g. developmental delay, prematurity, Marfan, Stickler, Noonan, Down syndrome) and in the remaining 38% there were further ocular problems associated with the high myopia (e.g. lens subluxation, coloboma, retinal dystrophy, anisometropic amblyopia). A family history of high myopia did not preclude associated abnormality: in 4 cases the diagnosis of a systemic condition in the child led to the identification of the disease in at least one myopic relative. Asian (p < 0.001) and male (p < 0.05) patients were overrepresented in the series. CONCLUSION High myopia is strongly associated with systemic and ocular problems; it may be the reason for the child's initial medical referral and an important clue to an underlying systemic or ocular condition. Referrals infrequently originated from community optometrists despite prior attendance. We suggest that all children under 10 years of age with high myopia are referred to a paediatric ophthalmology clinic for review and we propose a structured clinical evaluation in the hospital eye clinic.
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Affiliation(s)
- J E Marr
- Birmingham Children's Hospital, UK
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Gray RG, Preece MA, Green SH, Whitehouse W, Winer J, Green A. Inborn errors of metabolism as a cause of neurological disease in adults: an approach to investigation. J Neurol Neurosurg Psychiatry 2000; 69:5-12. [PMID: 10864596 PMCID: PMC1737019 DOI: 10.1136/jnnp.69.1.5] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- R G Gray
- West Midlands Regional Metabolic Disease Service, Birmingham Children's Hospital NHS Trust, UK.
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Green A, Pollitt RJ. Population newborn screening for inherited metabolic disease: current UK perspectives. J Inherit Metab Dis 1999; 22:572-9. [PMID: 10407789 DOI: 10.1023/a:1005572710844] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Some of the generally accepted criteria for screening programmes are inappropriate for newborn metabolic screening as they ignore the family dimension and the importance of timely genetic information. Uncritical application of such criteria creates special difficulties for screening by tandem mass spectrometry, which can detect a range diseases with widely different natural histories and responsiveness to treatment. Further difficulties arise from increasing demands for direct proof of the effects of screening on long-term morbidity and mortality. The randomized controlled trial is held to be the gold standard, but for ethical and practical reasons it will be impossible to achieve for such relatively rare diseases. This approach also oversimplifies the complex matrix of costs and benefits of newborn metabolic screening. A more workable approach could involve Bayesian synthesis, combining quantitative performance data from carefully designed prospective pilot studies of screening with existing experience of the natural history, diagnosis, and management of the individual disorders concerned.
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Affiliation(s)
- A Green
- Clinical Chemistry Department, Birmingham Children's Hospital, UK
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