First description of the MEGDEHL syndrome in the Tunisian population via whole-exome sequencing: Novel nonsense mutation in SERAC1 gene

INTRODUCTION

MEGDEL syndrome is a rare recessive disorder, with about 100 cases reported worldwide, which is defined by 3-methylglutaconic aciduria (MEG), deafness (D), encephalopathy (E) and Leigh-like syndrome (L). When these manifestations were added to hepatopathy (H), the syndrome was labelled as MEGD(H)EL. Mutations in SERAC1 gene encoding a serine active site containing 1 protein were described in patients affected by this syndrome.

PATIENTS AND METHODS

The present study reports the Whole Exome Sequencing (WES) of the first case of MEGDEHL syndrome in Tunisia in a consanguineous family with three affected children. Bioinformatic analysis was also performed in addition to mtDNA deletion screening and mtDNA copy number quantification in the blood of the indexed case, carried out, respectively by Long-Range PCR and qPCR.

RESULTS

The WES revealed a novel homozygous nonsense mutation (c.1379G > A; p.W460X) in the SERAC1 gene, which was confirmed by Sanger sequencing. This nonsense mutation was present at a homozygous state in the three affected children and was heterozygous in the parents. In silico analysis using various softwares was performed, and the predictive results supported the pathogenic effect of the identified mutation. Further, long-range PCR and qPCR analyses of the patient's blood excluded any mtDNA deletions or depletions.

CONCLUSION

Sequencing results and bioinformatic tools confirmed that the novel mutation (p.W460X) in the SERAC1 gene causes the severe phenotype in the studied family with MEGDEHL syndrome.

Tracheal agenesis clinical presentation in a preterm infant: Prenatal MRI difficulties and autopsy findings

We describe, the clinical presentation of a rare case of Tracheal Agenesis in a preterm infant and we highlight magnetic imaging resonance (MRI) and autopsy findings to better characterize this anomaly. A 30-year-old female presented for acute polyhydramnios at 30 weeks gestation of a male foetus. Prenatal MRI was performed and excluded this diagnosis. After delivery, the neonate presented a respiratory distress. The laryngoscopy control of tube position concluded to an esophageal intubation. A second reading of antenatal MRI was made. An autopsy was performed. The internal examination of the organs revealed broncho-oesophageal fistula. The upper airways were obstructed at the larynx. Fetal MRI should be interpreted with caution when Tracheal Agenesis is highly suspected.

Primary Pulmonary Hypertension Associated with Asymptomatic Methylmalonic Aciduria in a Child

Methylmalonic acidemia or aciduria (MMA) is an inborn error of metabolism that results in the accumulation of methylmalonic acid in blood with an increased excretion in urine. MMA usually presents in early infancy and its effects vary from mild to life-threatening. The clinical symptoms mainly include vomiting, dehydration, hypotonia, developmental delay, and failure to thrive. An association between pulmonary arterial hypertension (PAH) and MMA has been rarely reported. In the present work, the authors report a 16-month boy, who was admitted to the Pediatric Department for cyanosis and fever. He had a family history of primary pulmonary hypertension in a sister. The echocardiography showed a mild pericardial effusion and PAH. The metabolic screening led to the diagnosis of MMA. The condition of the baby worsened rapidly- and he died a few days later. Physicians should be aware about this atypical presentation of the disease, which can be fatal if not diagnosed and managed promptly.

Inborn Errors Of Metabolism In Neonatal Period: A Challenging Management In Tunisia

OBJECTIVE

To assess clinical presentation of inborn errors of metabolism in neonatal period and to identify challenges in their management.

METHODS

This is a retrospective study carried out in the department of Intensive Care and Neonatal Medicine of Monastir in Tunisia from January the 1st 2010 until December the 31st 2017. All hospitalized newborns with life-distress related to confirmed or suspected IEM were included.

RESULTS

We identified thirty-two IEM with an incidence of 1/1630. Sixty five per cent were born to consanguineous parents. Symptoms were already present at birth in 31% of cases and after a symptom-free interval in 69% of cases. The most common presenting manifestations were neurological distress (72%). We confirmed the specific diagnosis for 26 patients, but 6 patients had unidentified IEMs because of difficulties to perform certain analyzes. The diagnosis was confirmed after death in 16% of cases. The most important measures used to manage the intoxication were removal of toxic products and vitamin therapy. The neonatal death rate was 72%.

CONCLUSION

The results illustrate challenges encountered in disease management highlighting the importance of prenatal diagnosis and newborn screening for inherited metabolic disorders, which is not yet available in our country.

Neonatalogist-performed echography in neonatology: a Tunisian experience

INTRODUCTION

Echocardiography is an important tool for diagnosis of cardiac abnormalities that can impact the management and outcome of the sick newborn in the intensive care unit. A preliminary echocardiogram performed by the neonatologist under the supervision of a paediatric cardiologist for interpretation and review is an alternate when there is not a cardiologist on site. The aim of this study was to evaluate frequency of use, neonatal characteristics, and indications of neonatologist-performed echocardiography in a Tertiary Neonatal Care Centre in Tunisia.

METHODS

Prospective observational study in a tertiary Neonatal Intensive Care Unit (NICU) in Monastir (Tunisia) from April 2015 to February 2017.An echocardiography was indicated in these situations: cyanosis, signs of circulatory shock, clinical signs of heart failure, presence of a murmur, arrhythmia, and abnormal pulses in upper and/or lower extremities, suspected persistent pulmonary hypertension in neonates, clinically suspected patent ductus arteriosus, maternal diabetes mellitus and polymalformative syndrome. The findings of echocardiography were confirmed by pediatric cardiologist in case of structural or functional cardiac abnormalities.

RESULTS

675 echocardiography were performed among them 535 were normal and 25 revealed a persistent arterial duct treated with E2 postaglandins (Prostine®) or paracetamol according to a pre-established protocol. 80 Congenital heart diseases were retained, which represented an incidence of 7 ‰ live births. The second time of our work consisted to study the 55 cases of cardiac diseases confirmed after exclusion of atrial communication. The antenatal diagnosis was made in 11% of cases. The main signs indicating the echocardiogram were the heart murmur (22 cases) followed by cyanosis (6 cases). A malformation association and / or a chromosomal aberration have been noted in 36% of cases. For half of the patients, the cardiac ultrasound was performed before the first 24 hours of life. This examination was completed by a thoracic angioscan in 9 patients. 31% of newborns had an infusion of Prostaglandins for an average duration of 11 days [2-60 days]. One-third of newborns (35 cases) required respiratory assistance. A palliative surgery was made in 7 cases and curative one in 4 cases. The average age at the time of the intervention was 20 days. The neonatal mortality rate was 40%.

CONCLUSION

Echocardiography is being utilized progressively on the neonatal unit, and has been indicated to have a high return for both structural and functional cardiac abnormalities. It is important to encourage collaboration with pediatric cardiologists to establish standards for training and to develop guidelines for clinical practice in order to improve neonatal care.

Transported neonates in Tunisia

AIMS

To describe the transport of sick neonates to a tertiary care hospital and evaluate their condition at arrival and outcome.

METHODS

A multicenter, prospective cohort study was performed in 7 NICUs in Tunisia from 1st april to 31 July 2015.Demographic parameters, transport details and clinical features at arrival were recorded. All neonates were followed up till discharge or death.

RESULTS

A total of 239 consecutive neonates were enrolled in the study representing 5.7% of all admitted infants. Maternal risk factors were present in 26% of neonates admitted. Sex-ratio was 1.46. Preterm infants represented 24% of transported babies. Seventeen percent of neonates had severe respiratory distress and 10% had hemodynamic troubles. Referred hospital was not informed in 24% of cases. Regarding the transport mode, 113 newborns (47.5%) were transported in ambulance accompanied by a nurse. Documentation during transfert was present in 14% of cases. Five babies expired on arrival despite resuscitation.  Rate mortality was 8.4%.

CONCLUSION

Transporting neonates in developing countries is a challenge. Organized transport services in Tunisia are not always available. So, in cases of at-risk pregnancy, it is safer to transport the mother prior to delivery than to transfer the sick baby after birth.

Extremely preterm infants in Tunisia: Where are we now?

BACKGROUND

Extremely preterm infants are newborns born before 28 weeks of gestation. Survival of these immature newborns depends on resuscitation and the quality of care during hospitalization.

OBJECTIVE

To determine survival and neurologic outcomes at2 years after extremely preterm birth.

METHODS

It is a retrospective multicentric study in 5 neonatal intensive care units (NICU) in 2012-2013.All live births less than 28 weeks gestation were included.

RESULTS

A total of 109 births were recorded. Prenatal corticosteroids were given in 47% of cases. Mean weight was 989g and mean age was 26 weeks gestation. Ninety percent of patients had respiratory distress syndrome and 67% of them needed respiratory support. Surfactant was given to 29% of newborns. The mortality rate atdischarge was 76%.The first cause of mortality was nosocomial infections. At thecorrected age of 2 years, 27% of survivors had abnormal neurologic outcome.

CONCLUSION

In our study, survival and neurologic outcomes ofextremely preterm infants were poor.In this high-risk population, improving perinatal care remains a challenge to improve long-term outcome in Tunisia.

Duodenal Atresia Associated with Apple Peel Atresia and Situs Inversus Abdominus: A Case Report

Duodenal atresia is rarely associated with situs inversus abdominus. We report a case of duodenal atresia associated with small bowel atresia of apple peel type and situs inversus abdominus.

[Evaluation of the measurement of capillary glucose concentration versus plasma glucose in the newborn]

BACKGROUND

The reliability of blood glucose monitoring in neonatology is not always confirmed. The aim of this study was to evaluate the reliability of blood glucose measurements made with three different devices in newborns.

PATIENTS AND METHODS

The study was prospective, conducted in a medical and neonatal intensive care department over a period of 4 months. Capillary glucose level was measured with three different glucometers and compared with venous glucose level determined using the hexokinase method. An ANOVA and Scheffe test were used for the correlation analysis.

RESULTS

Three hundred and nine infants were included, with a mean age of 55h and a mean term of 39 weeks of gestation. Mean blood glucose in the laboratory was 0.62±0.15g/L, 0.71±0.17g/L for Accu-Chek(®) Active, 0.80±0.17g/L for Accu-Chek(®) Performa, and 0.83±0.12g/L for Bionime. An ANOVA showed statistically significant differences between the measurements made by glucometers compared to the reference blood glucose levels, and the Scheffé method showed that glucometers overestimated the real plasma glucose levels.

CONCLUSION

None of the devices used in this study was satisfactory. However, an estimation of blood glucose taking into consideration this numerical overestimation would allow early detection of hypoglycemia.

[Neonatal hyperthyroidism and maternal Graves disease]

The onset of Graves disease during pregnancy exposes the neonate to the risk of hyperthyroidism. The newborn must be monitored and treatment modalities known to ensure early treatment of the newborn. We report on the case of an infant born at term of a mother with Graves disease discovered during pregnancy. He was asymptomatic during the first days of life, before declaring the disease. Neonatal hyperthyroidism was confirmed by hormonal assays. Hyperthyroidism was treated with antithyroid drugs and propranolol with a satisfactory clinical and biological course. Neonatal hyperthyroidism should be systematically sought in infants born to a mother with Graves disease. The absence of clinical signs during the first days of life does not exclude the diagnosis. The duration of monitoring should be decided according to the results of the first hormonal balance tests.

[Marshall syndrome: Clinical, radiological and genetical features of a Tunisian family]

BACKGROUND

Marshall syndrome is a rare autosomal dominant skeletal dysplasia. It associates a particular facial dysmorphism with midface hypoplasia, ocular abnormalities and sensorineural hearing loss. It is caused by heterozygous mutations in COL11A1 gene coding the 1 chain of collagen XI. Stickler syndrome is the principal differential diagnosis of Marshall syndrome.

AIM

Clinical and radiological study of Marshall syndrome in a Tunisian family with a linkage study of the COL11A1 gene to this disease.

METHODS

We report the clinical and the radiological findings of a Tunisian family including 8 members affected by Marshall syndrome. The linkage of the COL11A1 gene to this disease was tested using the polymorphic microsatellite markers of DNA.

RESULTS

A variability of the clinical expression of Marshall syndrome was reported. Specific Marshall phenotype and an overlapping phenotype between the Marshall and Stickler syndromes were observed among the affected members of this family. The ocular manifestations were also heterogeneous. Marshall syndrome's specific radiological signs were found. The linkage study supports the linkage of the abnormal phenotype to the COL11A1 gene.

CONCLUSION

There is a variability of the clinical expression among the affected members of the study's family. We will continue searching the causative mutation to establish a clear genotype- phenotype correlation.

Laparoscopic treatment of hydatid cyst of the liver in children. A report on 34 cases

PURPOSE

This study evaluated the safety and efficiency of laparoscopically treated liver cysts in children.

METHODS

From September 2001 to July 2004, 34 patients underwent laparoscopic treatment of hydatid cysts of the liver. All patients had chest x-ray, abdominal sonography, and hydatid serology. The different stages of the procedure were the same as in open surgery: puncture, aspiration, injection of scolicidal agent, reaspiration, removal of proligerous membrane, and resection of the dome.

RESULTS

The patients' mean average age was 7 years and 7 months (range, 3-14 years). The number of cysts ranged from 1 to 10 with a diameter of 40 to 150 mm (mean diameter, 65.5 mm). One case had a mesenteric associated hydatid cyst, another splenic hydatid cyst. The average length of hospital stay was 5 days (range, 4-14 days). No per- or postoperative complications were reported. At 12 to 45 months follow-up, no recurrence has been reported.

CONCLUSION

Laparoscopy represents an excellent approach for the treatment of hydatid cyst of the liver in children.

[Pyelogenic cyst in children]

Pyelogenic cyst is an intraparenchymal renal cavity lined by transitional cell epithelium which communicates with a calyx via a neck. It is a rare disease, often discovered incidentally. The diagnosis is based on imaging. Asymptomatic forms require simple surveillance and surgical management is only indicated in forms complicated by urinary tract infections or stones. In the light of a case of pyelogenic cyst revealed by upper urinary tract infection in a 12-year-old girl, the authors recall the clinical, histological and therapeutic features of this rare disease.