A Korean male with Kleefstra syndrome presented with micropenis

Kleefstra syndrome is caused by chromosome 9q34.3 deletion or heterozygous mutations in the euchromatin histone methyl transferase 1 (EHMT1) gene. It can be accompanied by intellectual disability, distinctive facial features, microcephaly, psychiatric disorders, hypotonia in childhood, hearing loss, heart defects, renal defects, epilepsy, speech anomalies, and obesity. Furthermore, genital anomalies are present in 30%-40% of male patients with Kleefstra syndrome, but their mechanisms have not been elucidated. Herein, we report a patient with Kleefstra syndrome presenting with micropenis. The patient was transferred to Kyungpook National University Children's Hospital for management of imperforate anus on the day of birth. Physical examination revealed micropenis with stretched penile length of 0.9 cm and facial dysmorphisms, including hypertelorism and anteverted nares. Chromosomal microarray revealed 424-kb heterozygous deletion at chromosome 9q34.3 (arr[hg19] 9q34.3 (140,234,315-140,659,055)x1). Among the involved main OMIM genes, phenotypically relevant genes were EHMT1 and NSMF. Endocrinological investigation showed low basal gonadotropin and testosterone levels. Anterior pituitary hormones and steroid hormone levels were in the normal range. Testicular function was normal based on human chorionic gonadotropin stimulation test. The patient experienced improvement in penile length growth with intramuscular testosterone enanthate injection initiated at 4 months of age. The purpose of this study is to describe the etiology, endocrine laboratory tests, and treatment of micropenis in Kleefstra syndrome.

Metabolic Impacts of Discontinuation and Resumption of Recombinant Human Growth Hormone Treatment during the Transition Period in Patients with Childhood-Onset Growth Hormone Deficiency

BACKGROUND

Discontinuing growth hormone (GH) treatment during the transition to adulthood has been associated with adverse health outcomes in patients with childhood-onset growth hormone deficiency (CO-GHD). This study investigated the metabolic changes associated with interrupting GH treatment in adolescents with CO-GHD during the transition period.

METHODS

This study included 187 patients with CO-GHD who were confirmed to have adult GHD and were treated at six academic centers in Korea. Data on clinical parameters, including anthropometric measurements, metabolic profiles, and bone mineral density (BMD) at the end of childhood GH treatment, were collected at the time of re-evaluation for GHD and 1 year after treatment resumption.

RESULTS

Most patients (n=182, 97.3%) had organic GHD. The median age at treatment discontinuation and re-evaluation was 15.6 and 18.7 years, respectively. The median duration of treatment interruption was 2.8 years. During treatment discontinuation, body mass index Z-scores and total cholesterol, low-density lipoprotein, and non-high-density lipoprotein (HDL) cholesterol levels increased, whereas fasting glucose levels decreased. One year after GH treatment resumption, fasting glucose levels, HDL cholesterol levels, and femoral neck BMD increased significantly. Longer GH interruption (>2 years, 60.4%) resulted in worse lipid profiles at re-evaluation. The duration of interruption was positively correlated with fasting glucose and non-HDL cholesterol levels after adjusting for covariates.

CONCLUSION

GH treatment interruption during the transition period resulted in worse metabolic parameters, and a longer interruption period was correlated with poorer outcomes. GH treatment should be resumed early in patients with CO-GHD during the transition period.

Case report of compound CFTR variants in Korean siblings with cystic fibrosis: importance of differentiating cystic fibrosis from inflammatory bowel disease

The prevalence of cystic fibrosis (CF) is considerably lower in Asian populations compared with that of Caucasians. Cases of CF are typically due to mutations in the CF transmembrane conductance regulator gene with autosomal recessive inheritance. Here, we report two cases of newly diagnosed CF in Korea-a 13-year-old boy and his 5-year-old brother. The older brother was admitted to our hospital for evaluation and treatment of recurrent abdominal pain, frequent diarrhea, and failure to thrive. Fecal calprotectin (FC) was elevated, and when combining this with his clinical presentation, inflammatory bowel disease (IBD) or eosinophilic gastroenteritis (EoGE) was the first impression of his disease. Several ulcerative lesions were observed on ileocolonoscopy. However, incidental findings of suspicious bronchiectatic lesions were observed on plain radiography, which were confirmed by chest computed tomography. Moreover, diffuse bowel wall thickening with pancreatic atrophy was also incidentally detected by computed tomography of the abdomen. Comprehensively, these findings were highly suggestive of CF. Therefore, diagnostic exome sequencing was conducted, which revealed compound heterozygous variants of c.263T>G (p.Leu88*) and c.2977G>T (p.Asp993Tyr) in the CF transmembrane conductance regulator gene. Although symptoms in the younger brother were not as prominent as the older brother, genetic test was also conducted, which revealed the same mutation. We report the identification of a novel variant, p.Asp993Tyr, in siblings with Korean heritage. Although CF is rare in Koreans, it should be included in the differential diagnosis of IBD.

Precocious puberty in Korean girls with and without exposure to endocrine-disrupting chemicals in toy slime: a comparative analysis

BACKGROUND

Toy slime is popular in Korea, and in parallel, pre-pubertal girls visit hospitals for early pubertal signs. Thus far, numerous studies have investigated the association of endocrine-disrupting chemicals (EDCs) with precocious puberty (PP). However, there is a lack of studies on the clinical manifestations and sex hormones. We aimed to investigate early pubertal development in Korean girls with or without a history of toy slime exposure and determine changes in bone age, Tanner stage, and sex hormones.

METHODS

In this study, 140 girls underwent stimulation tests at Kyungpook National University Children's Hospital Endocrinology Department, during January 2018 and December 2020. Patients were divided into two groups for gonadotropin-releasing hormone (GnRH) stimulation test and frequency of exposure to toy slime (EDCs). GnRH stimulation test was conducted after an intravenous injection of 100 µg of luteinizing hormone-releasing hormone. Slime exposure was defined as Slime ≥ 3 times/week for ≥ 3 months.

RESULTS

History of slime exposure was found in 14 of 58 and 65 of 82 patients in the central PP (CPP) and non-CPP groups, respectively. Slime-exposed patients had advanced bone age, although their Tanner stage was low. Patients with a history of toy slime exposure were 5.5 times more likely to be diagnosed with non-CPP than patients without slime exposure (p < 0.05).

CONCLUSIONS

Exposure to toy slime in prepubertal girls may be associated with rapid clinical advancement of pubertal development and bone age, and the patients appear more likely to be diagnosed with non-CPP.

Increase in blood glucose level and incidence of diabetic ketoacidosis in children with type 1 diabetes mellitus in the Daegu-Gyeongbuk area during the coronavirus disease 2019 (COVID-19) pandemic

Background

The coronavirus disease 2019 (COVID-19) outbreak in the Daegu-Gyeongbuk area in 2020 has caused difficulties in the daily life and hospital care of children with type 1 diabetes mellitus (T1DM). We detected an increase in blood sugar levels in these children and the number of patients hospitalized with more severe diabetic ketoacidosis (DKA) compared to those before COVID-19.

Methods

This single-center study was conducted at Kyungpook National University Children’s Hospital. The following patient groups were included; 45 returning patients diagnosed with T1DM and undergoing insulin treatment for more than 2 years and 20 patients newly diagnosed with T1DM before and after COVID-19 were selected by age matching. Returning patients before and after the outbreak were selected, and changes in hemoglobin A1c (HbA1c) levels were retrospectively reviewed. The HbA1c levels and severity of symptoms in newly diagnosed patients during hospitalization were examined.

Results

HbA1c levels in returning patients with T1DM were significantly increased after COVID-19 (before, 7.70%±1.38% vs. after, 8.30%±2.05%; p=0.012). There were 10 and 10 newly diagnosed patients before and after COVID-19, respectively. The proportion of patients with drowsiness and dyspnea at the time of admission was higher after COVID-19 than before (before, 2 of 10 vs. after, 4 of 10). The HbA1c levels were higher in newly diagnosed patients hospitalized after COVID-19 than before (before, 11.15% vs. after, 13.60%; p=0.036).

Conclusion

Due to COVID-19 in the Daegu-Gyeongbuk area, there was an increase in blood glucose levels in children with T1DM and in the incidence of severe DKA in newly diagnosed diabetes mellitus patients.

A cell function study on calcium regulation of a novel calcium-sensing receptor mutation (p.Tyr825Phe)

PURPOSE

Autosomal dominant hypocalcemia with hypercalciuria is a genetic disease characterized by hypoparathyroidism with hypercalciuria. We discovered a novel variant (p.Tyr825Phe[Y825F]) of the CASR gene in a neonate with congenital hypoparathyroidism and hypercalciuria and conducted a cell function study to determine whether the CASR-Y825F variant was pathogenic.

METHODS

To perform a functional study on CaSR-Y825F, we constructed expression vectors expressing wild-type (WT) CASR and CASR-Y825F. After transfection of each expression vector into HEK293 cells, we examined alterations in intracellular signaling. Mitogen-activated protein kinase (MAPK) signaling activity of HEK293 cells expressing CASR-WT or CASR-Y825F was determined. Changes in intracellular calcium ions ([Ca2+]i) by extracellular calcium ion ([Ca2+]e) stimulation were quantitatively compared and analyzed.

RESULTS

Cells expressing CASR-Y825F showed elevated of MAPK signaling (phospho-ERK [pERK], phospho-JNK [pJNK], phospho-p38 [pp38]) and increased [Ca2+]i levels at low [Ca2+]e stimulation compared with cells expressing CASR-WT. Additionally, [Ca2+]i levels in HEK293 cells expression CASR-WT and CASR-Y825F were determined at 340 nm/380 nm wavelength ratios using Fura-2 AM. At [Ca2+]e concentrations of 2.5 mM and 3 mM, the ratios of CASR-Y825F cells were higher (2.6 and 3.5, respectively) than those of CASR-WT cells (1.04 and 1.40, respectively).

CONCLUSION

This cell function study proved that the CASR-Y825F expressed in HEK293 cells elevated MAPK signaling (pERK, pJNK, pp38) and increased [Ca2+]i to induce hypocalcemia.

Clinical, endocrinological, and molecular features of four Korean cases of cytochrome P450 oxidoreductase deficiency

PURPOSE

Cytochrome P450 oxidoreductase (POR) deficiency is a rare autosomal recessive disorder caused by mutations in the POR gene encoding an electron donor for all microsomal P450 enzymes. It is characterized by adrenal insufficiency, ambiguous genitalia, maternal virilization during pregnancy, and skeletal dysplasia. In this study, we investigated the clinical, hormonal, and molecular characteristics of patients with POR deficiency in Korea.

METHODS

This study included four patients with POR deficiency confirmed by biochemical and molecular analysis of POR. Clinical and biochemical findings were reviewed retrospectively. Mutation analysis of POR was performed by Sanger sequencing after polymerase chain reaction amplification of all coding exons and the exon-intron boundaries.

RESULTS

All patients presented with adrenal insufficiency and ambiguous genitalia regardless of their genetic sex. Two patients harbored homozygous p.R457H mutations in POR and presented with adrenal insufficiency and genital ambiguity without skeletal phenotypes. The other two patients with compound heterozygous mutations of c.[1329_1330insC];[1370G&gt;A] (p.[I444Hfs*6];[R457H]) manifested skeletal abnormalities, such as craniosynostosis and radiohumeral synostosis, suggesting Antley-Bixler syndrome. They also had multiple congenital anomalies involving heart, kidney, and hearing ability. All patients were treated with physiologic doses of oral hydrocortisone.

CONCLUSION

We report the cases of 4 patients with POR deficiency identified by mutation analysis of POR. Although the study involved a small number of patients, the POR p.R457H mutation was the most common, suggesting founder effect in Korea. POR deficiency is rare and can be misdiagnosed as 21-hydroxylase or 17α-hydroxylase/17,20-lyase deficiency. Therefore, molecular analysis is critical for confirmatory diagnosis.

Severe recurrent nocturnal hypoglycemia during chemotherapy with 6-mercaptopurine in a child with acute lymphoblastic leukemia

Various endocrine dysfunctions occur during chemotherapy, including hypoglycemia. However, reports of hypoglycemia associated with 6-mercaptopurine (6-MP) are rare. Herein, we report an 8-year-old boy with severe symptomatic hypoglycemia likely due to 6-MP during chemotherapy. He had been diagnosed with acute lymphoblastic leukemia 3 years previously and was in the maintenance chemotherapy period. Treatment included oral dexamethasone, methotrexate, and 6-MP, of which only 6-MP was administered daily. Hypoglycemic symptoms appeared mainly at dawn, and his serum glucose dropped to a minimum of 37 mg/dL. Laboratory findings showed nothing specific other than increased serum cortisol, free fatty acids, ketone, alanine aminotransferase, and aspartate aminotransferase. Under the hypothesis of hypoglycemia due to chemotherapy drugs, we changed the time of 6-MP from evening to morning and recommended him to ingest carbohydrate-rich foods before bedtime. Hypoglycemia improved dramatically, and there was no further episode during the remaining maintenance chemotherapy period. To the best of our knowledge, this is the first report of this type of hypoglycemia occurring in an Asian child including Korean.

Abstract 4306: Combined effects of chemotherapy to reduce metastasis caused by insufficient hyperthermia

Hyperthermia therapy is one of the most widely studied non-surgical methods for breast tumors, which eliminates tumor by inducing acute stress on tumor cells. However, it has been extensively known that the viability of the tumor cells is highly influenced by the applied temperature. Insufficient thermal stress during hyperthermia treatments may alter tumor microenvironment by promoting epithelial to mesenchymal-like transition (EMT) and as a result, enhancing the outgrowth of residual tumor cells. Therefore, cells that have survived from sublethal thermal stress and experienced EMT may cause substantial clinical problems. In this case, hyperthermia requires additional therapy in order to promote cell death of more invasive tumor cells that have resisted to the thermal stimulus. In this study, we confirmed that the co-treatment of chemotherapy with hyperthermia may overcome the phenotypical transition caused by insufficient heat treatment. After exposing breast cancer cells (MCF-7) into two different temperature conditions (42°C and 47°C) for an hour, we have verified that 10.51 ± 1.71% and 18.27 ± 10.66% of cells experienced apoptosis or necrosis when the cells were exposed to 42°C and 47°C, respectively. At the same time, cancer cells showed higher invasiveness, spear-like morphology, and enhanced migratory behaviors as the exposed temperature increases, which is mainly shown among the cells that have experienced EMT. Further western blot assay and quantitative real-time polymerase chain reaction (qRT-PCR) using mesenchymal marker (vimentin) and epithelial marker (E-cadherin) also support that the mesenchymal-like phenotype has been highly increased on the cells that have resisted to the thermal stress. However, when chemotherapy was conducted after the heat treatment, cell viability was highly reduced. Paclitaxel (11.7 nM), cisplatin (3.3 μM), and combination of two anticancer drugs were treated for 24 hours on the cells that have been exposed to different temperatures, respectively. As a result, death rate of tumor cells has increased from 11.31 to 66.69%. Especially, when paclitaxel and cisplatin were co-treated, the death rate was up to 73.75 ± 4.37% after cells were exposed to 47°C. In conclusion, cancer cells that have survived from insufficient hyperthermia showed high potential to promote metastasis or recurrence but additional chemotherapy can successfully reduce the side effects induced by insufficient hyperthermia treatment.

Citation Format: Tae Hee Lee, Jiyoon Bu, Byoung Hyuck Kim, Young Jun Kim, Yoon-Tae Kang, Jung Eun Moon, Young-Ho Cho. Combined effects of chemotherapy to reduce metastasis caused by insufficient hyperthermia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4306. doi:10.1158/1538-7445.AM2017-4306

Merits and potential downsides of the 2013 ACC/AHA cholesterol management guidelines

New guidelines from the American College of Cardiology and the American Heart Association on cholesterol management introduced substantial changes from the previous Adult Treatment Panel III guidelines and generated an immediate storm of controversy upon their release in November 2013. Four categories of individuals that can benefit from statin therapy, including three high-risk groups, have been identified. The fourth category of primary prevention has proven to be the most contentious, with criticism centering on the algorithm used to estimate ten-year risk for atherosclerotic cardiovascular disease and the optimal threshold for statin therapy. Although the risk assessment algorithm can be further refined, it represents an improvement from the previous calculator since it better captures risk in women and African Americans. However, the elimination of lipid targets in the new guidelines discounts a wealth of clinical trial and epidemiological evidence indicating that, with regards to low-density lipoprotein cholesterol, "lower is better." Recommendations regarding the use of nonstatin drugs, while appropriate, could potentially be revised in the future. In general, the new guidelines stress the necessity of addressing the multiple factors that contribute to cardiovascular risk, and they provide a valuable opportunity for physicians to address the importance of lifestyle modifications to lower a patient's overall risk.

Interference of hepatitis C virus replication in cell culture by antisense peptide nucleic acids targeting the X-RNA

The RNA-dependent RNA polymerase (RdRp) of hepatitis C virus (HCV) is the essential catalytic enzyme for viral genome replication. It initiates minus-strand RNA synthesis from a highly conserved 98-nt sequence, called the X-RNA, at the 3'-end of the plus-strand viral genome. In this study, we evaluated the antiviral effects of peptide nucleic acids (PNAs) targeting the X-RNA. Our in vitro RdRp assay results showed that PNAs targeting the three major stem-loop (SL) domains of X-RNA can inhibit RNA synthesis initiation. Delivery of X-RNA-targeted PNAs by fusing the PNAs to cell-penetrating peptides (CPPs) into HCV-replicating cells effectively suppressed HCV replication. Electrophoretic mobility shift assays revealed that the PNA targeting the SL3 region at the 5'-end of X-RNA dissociated the viral RdRp from the X-RNA. Furthermore, delivery of the SL3-targeted PNA into HCV-infected cells resulted in the suppression of HCV RNA replication without activation of interferon β expression. Collectively, our results indicate that the HCV X-RNA can be effectively targeted by CPP-fused PNAs to block RNA-protein and/or RNA-RNA interactions essential for viral RNA replication and identify X-RNA SL3 as an RdRp binding site crucial for HCV replication. In addition, the ability to inhibit RNA synthesis initiation by targeting HCV X-RNA using antisense PNAs suggests their promising therapeutic potential against HCV infection.

A phase 1 study of a meningococcal native outer membrane vesicle vaccine made from a group B strain with deleted lpxL1 and synX, over-expressed factor H binding protein, two PorAs and stabilized OpcA expression

This phase I clinical trial assessed the safety and immunogenicity of a native outer membrane vesicle (NOMV) vaccine prepared from an lpxL1(-) synX(-) mutant of strain 8570(B:4:P1.19,15:L8-5) of Neisseria meningitidis. Additional mutations enhance the expression of factor H binding protein variant 1 (fHbp v.1), stabilize expression of OpcA and introduce a second PorA (P1.22,14). Thirty-six volunteers were assigned to one of four dose groups (10, 25, 50 and 75 mcg, based on protein content) to receive three intramuscular injections at six week intervals with aluminum hydroxide adjuvant. Specific local and systemic adverse events were solicited by diary and at visits on days 2, 7, and 14 after each vaccination. Blood chemistries, complete blood count, and coagulation studies were measured on each vaccination day and again 2 and 14 days later. Blood for ELISA and serum bactericidal assays was drawn two and six weeks after each vaccination. The proportion of volunteers who developed a fourfold or greater increase in bactericidal activity to the wild type parent of the vaccine strain at two weeks after the third dose was 27 out of 34 (0.79, 95% C.I. 0.65-0.93). Against four other group B strains the response rate ranged from 41% to 82% indicating a good cross reactive antibody response. Depletion assays show contributions to bactericidal activity from antibodies to lipooligosaccharide (LOS), fHbp v.1 and OpcA.

Sero-epidemiology of hepatitis A virus infection among healthcare workers in Korean hospitals

Hepatitis A virus (HAV) has been increasingly reported in Korea as has an outbreak in Korean healthcare workers (HCWs). This 2008 study evaluated the sero-epidemiology of HAV infections among 3696 HCWs in four Korean hospitals. HCWs were tested for immunoglobulin G anti-HAV antibodies using commercially available kits. Data including demographic characteristics, occupation, workplace and serological status for other hepatitis viruses were collected. Statistical analyses were conducted to identify variables related to HAV seropositivity. Among the 3696 participants, 2742 (74%) were women and the majority (96%) were aged 20-39 years (median: 28; range: 19-68). Eighteen percent were physicians, 46% nurses, 10% nurses' aides, 11% paramedical technicians and 15% administrative staff. Seropositivity for HAV significantly increased with age (P<0.001): 1.8% for < or =24 years, 14.7% for 25-29 years, 41.8% for 30-34 years, 75.5% for 35-39 years, and 93.7% for > or =40 years. Among those aged 20-39 years, age-specific HAV seroprevalence was significantly lower in physicians than in the other occupational groups (P<0.001). In Korea, mass vaccination to HCWs aged < or =29 years or screening for seropositivity and vaccinating non-immune subjects aged 30-39 years should be considered, especially in physicians.