Inherited metabolic disorders in Cyprus

Selective screening for inherited metabolic disorders (IMD) began in Cyprus in 1990. Over the last thirty-three years 7388 patients were investigated for IMD and 200 diagnoses were made (diagnostic yield 2.7%). The existence of a single laboratory of Biochemical Genetics for the whole island facilitated the creation of a national registry for IMD. The minimal prevalence of IMD in Cyprus is 53.3 cases per 100,000 live births. The most common group are disorders of amino acid metabolism (41.0%), followed by disorders of carbohydrate metabolism (16.5%), disorders of complex molecule degradation (16.5%), mitochondrial disorders (10.5%) and disorders of vitamin and co-factor metabolism (5.5%). Hyperphenylalaninaemia is the most common IMD (14.0%) followed by galactosaemia (7.0%), glutaric aciduria type I (5.5%) and MSUD (4.0%). Some disorders were found to have a relatively high incidence in specific communities, for example Sandhoff disease among the Cypriot Maronites and GM1 gangliosidosis in one particular area of the island. Other disorders were found to have a relatively higher overall incidence, compared to other Caucasian populations, for example galactosaemia, glutaric aciduria type I and MSUD, while fatty acid oxidation defects, Gaucher disease and classic PKU were found to have a relatively lower incidence. Molecular characterization of selected disorders revealed many novel genetic variants, specific to the Cypriot population.

Molecular analysis of Cypriot patients with Glutaric aciduria type I: identification of two novel mutations

OBJECTIVES

The purpose of this study was to identify the mutations in the glutaryl-CoA dehydrogenase gene (GCDH) in ten Cypriot patients with Glutaric aciduria type I (GAI).

DESIGN AND METHODS

Molecular analysis of the GCDH gene was performed by direct sequencing of the patients' genomic DNA. In silico tools were applied to predict the effect of the novel variants on the structure and function of the protein.

RESULTS

All disease alleles were characterized (mutation detection rate 100%). Five missense mutations were identified: c.192G>T (p.Glu64Asp) and c.803G>T (p.Gly268Val), which are novel, and three previously described mutations, c.1123T>C (p.Cys375Arg), c.1204C>T (p.Arg402Trp) and c.1286C>T (p.Thr429Met).

CONCLUSIONS

Two novel mutations, p.Glu64Asp and p.Gly268Val, account for the majority of disease alleles (76.5%) in Cypriot patients with Glutaric aciduria type I. A founder effect for the p.Glu64Asp and the p.Gly268Val can be suggested based on the place of origin of the carriers of these mutations. Identification of the causative mutations of GAI in Cypriot patients will facilitate carrier detection as well as post- and pre-natal diagnosis.

The diversity of juvenile sarcoidosis symptoms

We report a case of juvenile sarcoidosis, emphasizing the variety of clinical manifestations. The child had uveitis, which is among the most common manifestations of the disease. However, fever of unknown origin, glomerulonephritis and lymphadenopathy were also noticed, underscoring the diversity of the clinical spectrum of the disease.

Breakfast consumption and meal frequency interaction with childhood obesity

OBJECTIVES

Increased meal frequency and daily breakfast consumption have been inversely associated with childhood obesity. The purpose of the study was to examine the possible interaction effect between meal frequency and breakfast consumption on childhood obesity.

METHODS

Seven hundred children (323 boys) aged 10-12 years were enrolled in this cross-sectional study. Several lifestyle, dietary and physical activity characteristics were recorded with food frequency and physical activity questionnaires. Body height and weight were measured and body mass index was calculated in order to classify children as overweight or obese (International Obesity Task Force classification). Multiple logistic regression analysis was used in order to evaluate the interaction between daily breakfast intake and more than three meals per day consumption with overweight or obesity.

RESULTS

Of the children, 27.6% and 9.0% were overweight and obese, respectively. Moreover, 60.2% consumed three or more meals per day and 62.7% consumed breakfast in a regular daily basis. Children who consumed more than three meals per day and also consumed breakfast daily, were two times less likely to be overweight or obese (adjusted odds ratio: 0.49, 95% confidence interval: 0.27-0.88).

CONCLUSION

A combined higher meal frequency and daily breakfast consumption dietary pattern may prevent overweight and obesity in children.

Menetrier's disease associated with Helicobacter pylori: three cases with sonographic findings and a literature review

Menetrier's disease is a rare cause of protein-losing gastropathy characterised by hypertrophy of the gastric folds. Three cases are reported. Helicobacter pylori was detected by culture and CLO test in two cases and on follow-up gastroscopy in the other. The first two patients were given eradication therapy and hypertrophic gastropathy resolved whereas in the third the disease remitted prior to the eradication treatment. Typical sonographic features were thickened gastric wall with preservation of the wall stratification. A review of the literature found eight cases of Menetrier's disease associated with H. pylori in children and these cases are briefly reviewed. H. pylori infection should be considered in all children with Menetrier's disease and, if isolated, eradication treatment should be administered.

Association of extracurricular sports participation with obesity in Greek children

AIM

Childhood obesity has become a modern epidemic with escalating rates. The aim of our study was the assessment of the association between extracurricular sports participation with the obesity status among Greek schoolchildren aged 10-12 years.

METHODS

Seven-hundred children (323 boys) aged 10-12 years were evaluated through a standardized questionnaire. Several lifestyle, dietary and physical activity attributes were recorded. Children according to the median hours of participation in after-school structured physical activity were classified as participating for more or less than 3 hours per week. Body height and mass were measured and body mass index was calculated in order to classify children as overweight or obese according to IOTF classification. Multiple logistic regression analysis was used in order to evaluate the association between the participation of more than 3 hours per week in structured physical activity after school with overweight or obesity.

RESULTS

A total of 48.9% of the boys and 31.8% of the girls were participating for more than 3 hours per week (P<0.001) in extracurricular sport activities. Moreover, 33.9 % of the boys and 22.1 % of the girls were classified as overweight and 9.4% of the boys and 8.6% of the girls as obese (P=0.006). Girls who participated in excess of 3 hours in extracurricular sport activities were 59% less likely to be overweight or obese than their non participating counterparts, adjusted for several confounders (adjusted OR: 0.41, 95% CI: 0.20-0.83).

CONCLUSION

Participation in extracurricular sports activity is inversely related to overweight or obesity in 10-12 years old Greek girls.

Carnitine status and lactate increase in patients with type I juvenile diabetes

AIM

In 32 juvenile patients suffering from insulin dependent diabetes we observed a carnitine imbalance (increase in acylcarnitine and reduction of free carnitine), which was higher in patients with the highest levels of glycosylated hemoglobin. Parallel to that, in patients with the most prominent carnitine imbalance, there was the highest increase in the postprandial lactic acid level and the highest increase in the lactate/pyruvate ratio, without relating to ketosis. In addition, we observed a decrease in free carnitine related to the length of time after appearance of diabetes.

METHODS

This was a prospective study of a cohort of 32 children and young adolescents with insulin dependent diabetes mellitus. All patients were on insulin treatment. Plasma concentrations of total, free and acyl-Carnitine were evaluated in 12 hours fasting blood samples and before the morning administration of insulin. Blood glucose, cholesterol, triglycerides, and lactate, pyruvate, beta-hydroxybutyrate and free fatty acid levels were measured.

RESULTS

The postprandial highest increase of the lactate and lactate/pyruvate ratio observed in patients with the highest degree of carnitine imbalance, namely with poorliest regulated diabetes, raises the question of a coincidental mitochondrial dysfunction. On the ground of our own data, such a claim cannot be substantiated for our patients. In contrast we suggest that the role of other factors like increased gluconeogenesis, degree of ketosis need to be sought.

CONCLUSION

In order to clarify the role of carnitine in the pathophysiology of disease we need also data from other tissues. Carnitine in the peripheral blood reflects only the 1% of the total body carnitine ; furthermore, patients with diabetes exhibit changes in carnitine status not only in the peripheral blood but also in other body tissues, mainly in muscles.

Uveitis: an isolated complication of post-streptococcal syndrome

A child with anterior uveitis as the sole manifestation of group A streptococcal infection is described. There was a history of a 'viral' upper respiratory tract infection 2 weeks before the onset of uveitis. A post-streptococcal phenomenon was diagnosed on the basis of serial ASO titre (ASOT) monitoring. There are few reports of patients with post-streptococcal uveitis. ASOT monitoring should be included in the work-up of uveitis of undetermined aetiology.

Is there an association between wheezing and pneumonia?

OBJECTIVE

The aim of this study was to investigate whether there is a relationship in school aged children between wheezing and pneumonia prior, during, or following the pneumonia episode.

PATIENTS-METHODS

One hundred and three children with community acquired pneumonia who were hospitalised were recruited along with 55 controls.

RESULTS

During hospitalisation wheezing was audible in 11/103 (10.6%) patients with pneumonia and in none of the controls (p=0.009). Wheezing ever or asthma was elicited in 29/103(28%) patients with pneumonia and in 8/55 (14.5%) of the controls and this difference was not significant. Two years after the hospitalisation with pneumonia, wheezing episodes occurred in 12/103 with pneumonia and 1/55 of the controls (p=0.034). Among those who developed asthma following pneumonia 11/12 also had wheezing prior to pneumonia.

CONCLUSION

There is an excess of wheezing prior, during, and after an episode of pneumonia in school aged children and therefore children with pneumonia should be followed up carefully.

Splitting the dose of neonatal BCG vaccination: a naïve practice

Bilateral axillary lymphadenitis complicating BCG vaccination in both arms (0.025 ml) in an immunocompetent 13-month-old boy is described. Prompt administration of isoniazid and erythromycin did not prevent suppuration of the affected lymph nodes. It was managed by bilateral surgical excision of the nodes.

Clinical notations on bacteremic cavitating pneumococcal pneumonia in nonvaccinated immunocompetent children

We describe 10 children who developed lung cavitation during the treatment of bacteremic pneumococcal lobar pneumonia. Chest CT scan showed extensive consolidation with several small lucencies and air-filled cavities. Invasive procedures like aggressive pleural intervention were not needed and the children recovered attaining normal lung function on long-term follow-up.

Secular trend in body height of schoolchildren in Northeast Attica, Greece

AIM

To examine the secular trend for body height in schoolchildren in Northeast Attica, Greece.

METHODS

In 2005 we studied the growth of 4,131 Greek schoolchildren (2,054 boys) aged 5.5-12.6 years. The data were compared with those of a study performed in 1994/95. We also studied the growth of 236 immigrant schoolchildren (95 boys and 141 girls).

RESULTS

For boys in the present study mean height (SD) was 135.6 (11.0) vs 133.8 (10.4) cm in the 1994/95 study, p < 0.001, and for girls of the present study mean height was 135.2 (11.7) vs 133.3 (10.8) cm in 1994/95, p < 0.001. The increase in height was present at almost all ages. There was a significant difference in height between Greek and immigrant boys, 135.6 (11.0) cm and 133.0 (10.2) cm, respectively, p < 0.05. However, there was no significant difference in height between Greek and immigrant girls, 135.2 (11.7) and 133.8 (12.4) cm, respectively.

CONCLUSION

A secular trend in height is still taking place in Greek schoolchildren that is mostly attributed to an increase in height from early life.

Dysregulation of the stress response in asthmatic children

The stress system co-ordinates the adaptive responses of the organism to stressors of any kind. Inappropriate responsiveness may account for increased susceptibility to a variety of disorders, including asthma. Accumulated evidence from animal models suggests that exogenously applied stress enhances airway reactivity and increases allergen-induced airway inflammation. This is in agreement with the clinical observation that stressful life events increase the risk of a new asthma attack. Activation of the hypothalamic-pituitary-adrenal (HPA) axis by specific cytokines increases the release of cortisol, which in turn feeds back and suppresses the immune reaction. Data from animal models suggest that inability to increase glucocorticoid production in response to stress is associated with increased airway inflammation with mechanical dysfunction of the lungs. Recently, a growing body of evidence shows that asthmatic subjects who are not treated with inhaled corticosteroids (ICS) are likely to have an attenuated activity and/or responsiveness of their HPA axis. In line with this concept, most asthmatic children demonstrate improved HPA axis responsiveness on conventional doses of ICS, as their airway inflammation subsides. Few patients may experience further deterioration of adrenal function, a phenomenon which may be genetically determined.

Prevalence of overweight and obesity in young Greek men

We determined the prevalence of overweight and obesity in young Greek men in 2006 and examined variations related to their place of residence and educational level. Body height and weight were measured in 2568 conscripts of the Greek army, aged 19-26 years. The calculated body mass index (BMI, kg m(-2)) was correlated to their socio-demographic characteristics, i.e. level of education and place of residence (urban or rural). Overweight and obesity were defined according to the World Health Organization classification. Mean BMI (standard deviation) of the conscripts was 24.7 (4.2). The prevalence of overweight (30 > BMI > or = 25 kg m(-2)) was 28.5% and correlated positively with a higher educational level, whereas the prevalence of obesity (BMI > or = 30 kg m(-2)) was 10.4% and correlated positively with a lower educational level. Our data were compared with those of similar studies performed in the years 1969: BMI 23.8 (1.4) (P < 0.0001) and 1990: BMI 23.8 (2.9) (P < 0.0001), showing a positive secular trend for BMI in Greek conscripts in the last 16 years. In conclusion, we documented an alarmingly high prevalence of overweight and obesity among young Greek men.

Maturational tempo differences in relation to the timing of the onset of puberty in girls

AIM

To determine maturational tempo differences related to the timing of pubertal onset in girls.

METHODS

We studied longitudinally 307 prepubertal Greek schoolgirls. Age at onset of puberty (B2), peak height velocity (PHV) and age at menarche were recorded. Age at onset of puberty quartiles were determined in order to define girls as early maturers (<9.2 years) and late maturers (>10.6 years). Due to dropout from the study, results for menarche are reported for 182 girls.

RESULTS

Median (1st-3rd quartile) time span from B2 to PHV was longer for early maturers than for average and late maturers, 1.6 (1.0-2.2) years, 1.1 (0.7-1.7) years and 0.9 (0.3-1.1) years, respectively, p < 0.001). There was no significant difference in PHV, in the time interval from PHV to menarche and in adult height (for 75 girls) with respect to whether girls matured early, average or late.

CONCLUSION

A compensatory delay in the maturational tempo in early-maturing girls and a catch-up mechanism in late-maturing girls was shown. The maturational differences manifest as differences in the time span from the onset of puberty to PHV. Early pubertal maturation in girls does not compromise adult height and is not always followed by early menarche.

Cardiac manifestations of inborn errors of metabolism

AIM

The aim of the study was to investigate the frequency and type of cardiac manifestations in a defined group of patients with inborn errors of metabolism. This paper also explores the key role of cardiac manifestations in the diagnosis of inborn errors of metabolism in daily practice.

METHODS

Out of the 287 patients with the potential for inborn errors of metabolism who had been referred to the University Hospital of Heraklion (202 children and adolescents and 85 adults), 41 were found to have a variety of cardiac manifestations, including cardiomyopathy, cardiomegaly, atrioventricular conduction disorders and coronary artery disease.

RESULTS

In 15 out of the 41 patients a diagnosis of inborn errors of metabolism was established, while the total number of patients with inborn errors of metabolism was 60 out of the 287. In 6 out of the 15 patients the major symptoms were from the cardiovascular system and 7 of them were adults with symptoms initiating in childhood.

CONCLUSION

The cardiac findings consist of a neglected area in the diagnosis of the inborn errors of metabolism. Neurologists, pediatricians and internists should cooperate with cardiologists in managing people with unexplained cardiac symptoms and signs and be aware that several inborn errors of metabolism are associated with cardiac abnormalities and mild neurologic findings.

Clinical expression of co-inherited Dubin-Johnson and thalassaemic heterozygous states

Dubin-Johnson syndrome is a worldwide prevalent familial conjugated hyperbilirubinaemia. The identification of multidrug resistance-associated protein 2 provided an understanding of the complex metabolic impairment involved in this syndrome. We report the first family with modified clinical expression of Dubin-Johnson heterozygous state due to genotypic interaction with co-inherited beta and deltabeta thalassaemia, an interaction that has never been described.

Hereditary vitamin D-resistant rickets in Greek children: genotype, phenotype, and long-term response to treatment

We describe four patients (two pairs of children from two unrelated kindreds) from a Greek island, suffering from hereditary vitamin D-resistant rickets (HVDRR) with alopecia. There were two different homozygous mutations in the vitamin D receptor (VDR) gene of the affected members of the two kindreds that resulted in a truncated or missing receptor. The disorder began in early infancy with similar clinical, biochemical and radiological findings in all four patients, namely, alopecia (which provided the initial diagnostic evidence for HVDRR), rachitic deformities, hypocalcemia, hypophosphatemia, secondary hyperparathyroidism, and elevated serum levels of 1,25-dihydroxyvitamin D; however, the patients of kindred B had a more severe clinical expression. Treatment options include oral or intravenous calcium and active vitamin D metabolites. The response varies widely in different cases. Our patients were initially treated with high doses of 1alpha(OH)D3 and oral calcium supplementation. Kindred A patients had a satisfactory response to this regimen, while kindred B patients presented clinical and biochemical improvement when 1alpha(OH)D3 was changed to 1,25(OH)2D3. In the older patients of each kindred, treatment requirements gradually decreased during puberty, and therapy was finally discontinued before adulthood.

Steroid hormones polymorphisms and cholelithiasis in Greek population

BACKGROUND

Genetic variation in genes involved in steroid biosynthesis, metabolism and signal transduction have been suggested to play a role in gallstone disease.

METHODS

To elucidate the possible role of genetic variation in the estrogen receptors alpha and beta (ER-alpha, ER-beta) and androgen receptor (AR) genes in breast cancer risk, the -1174(TA)n, c.1092+3607(CA)(n) and c.172(CAG)n repeat polymorphisms of the three genes were studied. A case-control cohort of 99 patients with cholelithiasis and 179 controls were used.

RESULTS

No significant difference was observed in the frequency distribution of -1174(TA)(0-26) in the ER-alpha gene between patients and controls, while a significant difference was observed in the frequency distribution of repeat polymorphism c.1092+3607(CA)5-27 and c.172(CAG)5-32 in the ER-beta gene and AR gene, respectively (P< or =0.001 and P=0.05, respectively). A significant difference was observed in the repeat genotype distribution (SS, SL, LL) in the (CA)n of the ER-beta gene (P<0.0001) and in the (CAG)n of the AR gene (P< or =0.0001). A significantly decreased odds ratio for cholelithiasis risk was observed in individuals having the SL and LL genotype for ER-beta gene compared with SS genotype (OR=0.212; 95% CI 0.105-0.426; P<0.0001 and OR=0.042; 95% CI 0.018-0.097, respectively) and LL genotype for AR gene (OR=0.622; 95% CI 0.345-1.121; P=0.114 and OR=0.287; 95% CI 0.151-0.543, P<0.0001, respectively). This protective effect of SL and LL genotypes for ER-beta and LL for AR gene remained evident (P<0.0001 for all of them) even after adjustment for various risk factors.

CONCLUSIONS

In conclusion an association for cholelithiasis risk between short alleles for both c.1092+3607(CA)5-27 and c.172(CAG)5-32 repeat polymorphisms of the ER-beta and AR was found in individuals of Greek descent.

Discrepancy between neuroimaging findings and clinical phenotype in Alexander disease

We present a case of infantile-onset Alexander disease (AD) with a novel glial fibrillary acidic protein mutation but without clinical evidence of neurologic deterioration. Brain MRI studies showed typical AD findings and increasing size of frontal cavitations. Serial proton MR spectroscopy demonstrated high levels of myo-inositol and lactic acid and decreasing levels of N-acetylaspartate. The degree of demyelination and the timing of the axonal degeneration may determine phenotypic severity of the disease. Conventional neuroimaging techniques cannot always predict the outcome.

The effect of inhaled budesonide on adrenal and growth suppression in asthmatic children

The present authors evaluated adrenal reserve in asthmatic children on long-term inhaled corticosteroids and whether possible adrenal suppression could be predicted by growth retardation. Low-dose synacthen test (0.5 microg x 1.73 m(-2)) was performed in 72 asthmatic children with a median age of 9.4 (range 4.2-15.7) yrs on long-term treatment (median 18 (range 6-84) months) with low-to-moderate doses (median 363 (range 127-1012) microg x m(-2)) of inhaled budesonide, as well as in 30 controls. Adrenal suppression was considered as a peak serum cortisol <495 nmol x L(-1). The current authors calculated height standard deviation score (HSDS) at the time of testing and height velocity SDS (HVSDS) in the preceding year. Mean HSDS was 0.06+/-1.3 and HVSDS was -0.9+/-2.3. Adrenal suppression was disclosed in 15 asthmatic children (20.8%). There were no differences in HSDS and HVSDS between children with and without adrenal suppression. There was no correlation between peak cortisol response and dose or duration of treatment. However, a positive relationship between HVSDS and duration of treatment was noted. These data suggest that long-term treatment of asthmatic children with low and moderate doses of inhaled budesonide may result in mild adrenal suppression that cannot be predicted by growth deceleration. The negative influence of inhaled corticosteroids on growth becomes less the longer the duration of treatment.

Low vitamin D status in mother-newborn pairs in Greece

Adequate vitamin D status during pregnancy is crucial to assure normal fetal skeletal growth and to provide the vitamin D needed for infants' stores. To determine the actual situation in Greece, we evaluated serum 25-hydroxyvitamin D (25[OH]D), calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), parathyroid hormone (PTH), osteocalcin (OC), and calcitonin (CT) concentrations in 123 healthy mother-newborn pairs recruited from a public hospital of the sunny Athenian region. Blood samples were obtained from pregnant women at term and their neonates (cord blood). The study was conducted between June 2003 and May 2004. None of the mothers has been prescribed vitamin D supplements. Maternal 25(OH)D levels (16.4 [11-21.1] ng/mL) were significantly lower than umbilical venous blood concentrations (20.4 [13.9-30.4] ng/mL) (P < 0.001). A strong correlation was observed between maternal and infant 25(OH)D concentrations (r = 0.626, P < 0.001). Twenty-four (19.5%) mothers and 10 (8.1%) neonates had 25(OH)D <10 ng/mL. Pregnant women who delivered in summer and autumn reported higher levels of 25(OH)D (18.9 [12.9-23.3] ng/mL) than those who delivered in winter and spring (14.6 [10.1-18.5] ng/mL) (P = 0.006). Mothers with a darker phototype had lower levels of serum 25(OH) D than those with a fair phototype (P = 0.023). Umbilical venous blood Ca, P, OC, and CT levels were significantly higher than maternal venous blood levels (P < 0.001). PTH umbilical levels were lower than maternal levels (P < 0.001). Apparently, the abundant sunlight exposure in Athens is not sufficient to prevent hypovitaminosis D. Pregnant women should be prescribed vitamin D supplementations, and the scientific community should consider vitamin D supplementation of foods.

Glucose-6-phosphate dehydrogenase deficiency and Gilbert syndrome: a gene interaction underlies severe jaundice without severe hemolysis

The authors describe the paradoxical clinical phenotype of an undetected severe hemolysis in parallel with the development of severe jaundice in a 13-year-old male suffering from a confirmed interaction of glucose-6-phosphate dehydrogenase deficiency (Mediterranean variant, 563 C/T) and Gilbert syndrome [variant (TA)7/(TA)7]. The child had 2 acute hemolytic episodes at the age of 10 and 13 years following infections of unknown origin. Both episodes were characterized by considerably high bilirubin levels (1st episode: 10.8 mg/dL, 2nd episode: 17.8 mg/dL) associated with unexpectably mild hemolysis indices (1st episode hemoglobin levels, 11.1 g/dL; reticulocyte counts, 2.5%; 2nd episode hemoglobin values, 12.7 g/dL; reticulocyte counts, 2.5%). During the steady-state condition of the child, hemoglobin values were within the normal ranges for his age (14.2 g/dL) and bilirubin levels were slightly elevated (1.70 mg/dL, indirect 1.5 mg/dL). The interaction of the two genetic abnormalities in the causation of this odd clinical phenotype is discussed.

Congenital rickets due to maternal vitamin D deficiency in a sunny island of Greece

A full-term male infant presented with clinical and biochemical findings consistent with the diagnosis of congenital rickets: weak muscle tone, craniotabes, episodes of tremor, hypocalcaemia, elevated serum alkaline phosphatase, secondary hyperparathyroidism, decreased 25-hydroxyvitamin D and normal 1,25-dihydroxyvitamin D serum levels. The mother's history and biochemical findings suggested nutritional vitamin D deficiency. Treatment with calcium and vitamin D resulted in the disappearance of clinical findings of rickets, normalization of the baby's biochemical profile and normal growth. It is surprising that this case occurred in an affluent setting, in the Mediterranean island of Crete, with an abundance of sunlight throughout the year.

CONCLUSION

We report this case in order to emphasize the continuing occurrence of congenital rickets even in populations not considered at risk for hypovitaminosis D. A high index of suspicion is required for prompt diagnosis and treatment, thus preventing complications.

Plasma and urine elastase alpha-1-proteinase inhibitor levels in neonatal urinary tract infection

OBJECTIVE

To examine whether plasma or urine elastase alpha(1)-proteinase inhibitor (E-alpha(1)-PI) levels could be used as a diagnostic marker of urinary tract infection (UTI) in neonates.

SUBJECTS AND METHODS

Plasma and urine E-alpha(1)-PI levels were measured by immunoassay in 23 neonates with UTI at the time of admission and 72 h after the onset of treatment and in 10 'normal' neonates (i.e. with trivial problems). Additionally E-alpha(1)-PI plasma levels were measured in 15 neonates with septicemia.

RESULTS

E-alpha(1)-PI plasma levels did not differ between normal neonates and those with UTI. Urine E-alpha(1)-PI levels were significantly higher in neonates with UTI on admission compared to normal neonates. A significant decrease in urine E-alpha(1)-PI levels was noticed 72 h after the onset of treatment in all but 2 neonates in whom infection persisted. In this study, we have found that the urine E-alpha(1)-PI concentration at a cutoff level of 48 microg/l had a sensitivity of 83%, a specificity of 90%, a positive predictive value of 95% and a negative predictive value of 69% for the diagnosis of neonatal UTI.

CONCLUSION

Elevated levels of E-alpha(1)-PI in urine seem to be a useful tool for the diagnosis of UTI in neonates (even in those that have already been started on antibiotics) and possibly a valuable marker for early recognition of treatment failure.

Hodgkin's disease in a child with sickle cell disease treated with hydroxyurea

Hydroxyurea (HU) is an oral drug that ameliorates the clinical course of sickle cell anemia by increasing the levels of fetal hemoglobin and decreasing the adhesion of red cells to endothelium. Although HU has minimal short-term toxicity, few data are available about the long-term safety and the potential risk for carcinogenesis or leukemogenesis. An 8-year-old child with sickle cell/beta 0-thalassemia who received HU treatment for painful crises is described. Six months after the initiation of the HU treatment he developed Hodgkin's disease, lymphocyte predominance subtype. Chemotherapy induced a complete remission. After discontinuation of chemotherapy the painful crises recurred and bone marrow transplantation was decided at the age of 12 years. Two years after the bone marrow transplantation, the child is in complete remission without painful crises. Although the authors suggest that the development of Hodgkin's disease is a coexisting event, questions arise about the safety of HU treatment in childhood.

Glomerulopathy with mesangial IgM deposits: long-term follow up of 64 children

BACKGROUND

The aim of the present study was to investigate to what extent IgM nephropathy in children with minimal change nephrotic syndrome (MCNS) and diffuse mesangial hypercellularity (DMH) evolves to focal segmental glomerulosclerosis (FSGS).

METHODS

Tissues from renal biopsies were examined by light microscopy (LM), immunofluorescence (IF) and, in four cases, by electron microscopy (EM). From a total of 352 nephrotic children, 121 had renal biopsy results as steroid dependent or resistant. A diagnostic renal biopsy was also performed in 331 children with non-nephrotic proteinuria and/or hematuria. A second renal biopsy was performed in 16 children whose renal function was impaired during the follow up. The clinical course of IgM-positive children was compared with that of IgM-negative children.

RESULTS

Of the 121 nephrotic children with renal biopsy, 85 were MCNS. Twenty were IF positive mainly for IgM, six of whom (30%) presented evolution to FSGS, while of the remaining 65 IF-negative children, only three (4.6%) presented evolution to FSGS. Of the total 331 children with non-nephrotic proteinuria and/or hematuria, 139 were diagnosed as IgA--IgG nephropathy, 44 had positive IF for IgM and 148 were IF negative. Of the 44 children IF positive for IgM, seven (15.9%) presented evolution to FSGS, while none of the 148 IF-negative children presented evolution to FSGS. The follow-up time for all children ranged from 1 to 14 years.

CONCLUSIONS

Of IgM nephropathy patients with MCNS and DMH, a significant percentage develop impaired renal function, due to the evolution of FSGS, as revealed by repeat biopsy during long-term follow up.

Hypercalciuria in children with febrile convulsions

BACKGROUND

The purpose of the present study was to investigate whether idiopathic hypercalciuria may be implicated in the pathogenesis of febrile convulsions.

METHODS

We studied 38 children (22 boys) with febrile convulsions (mean (+/- SD) age 3.25 +/- 1.09 years) and 45 healthy children (28 boys) of similar age who served as controls. Twenty-four hour urine calcium and phosphate, as well as serum calcium, phosphate, alkaline phosphatase and intact parathyroid hormone (PTH) concentrations were determined.

RESULTS

Hypercalciuria (urine Ca >4.0 mg/kg bodyweight per 24 h) was found in nine children with febrile convulsions (23.7%) and in three controls (6.7%). Hypercalciuric children excreted significantly more phosphate in their urine (37.0 +/- 11.6 mg/kg bodyweight per 24 h) than normocalciuric children (18.7 +/- 8.7 mg/kg bodyweight per 24 h) and controls (20.2 +/- 7.6 mg/kg bodyweight per 24 h). They also had higher serum intact PTH concentrations (49.87 +/- 15.36 pg/mL) than normocalciuric (35.39 +/- 15.67 pg/mL) and control children (28.21 +/- 14.00 pg/mL). According to the calcium-loading test, eight of nine children with hypercalciuria had the renal type of the disorder. Furthermore, hypercalciuric children had significantly more convulsive episodes (2.77 +/- 1.98) than normocalciuric children (1.86 +/- 1.24).

CONCLUSIONS

Our results suggest that renal hypercalciuria may be implicated in the pathogenesis of febrile convulsions.

DNA degradation in the kidney of folic acid-treated guinea pigs

Previous investigators agree on the increased DNA synthesis and destruction of tissues caused by folic acid (FA) administered parenterally. This study aims to clarify whether DNA degradation due to the destruction of cells and nuclei precedes DNA synthesis following FA administration. Forty guinea pigs were divided into four groups: group 1, contained 10 controls; in group 2, ten animals received intraperitoneally 300 mg/kg of body wt FA; in group 3, ten animals received FA and 12 h later frusemide intramuscularly in a dose of 7 mg/kg body wt; and finally in group 4, ten animals received frusemide as in group 3. FA produced necrosis of the epithelial cells of the convoluted tubules as the detection of the beta-aminoisobutyric acid end product of DNA and thymine catabolism indicated. Frusemide administered in group 3 had a favourable effect on the acute renal failure induced by FA.

Erythema nodosum in children: a prospective study

BACKGROUND

The studies of series of children with erythema nodosum (EN) are limited and mostly retrospective.

OBJECTIVE

We evaluated the epidemiology, etiology, clinical manifestations, course, and prognosis of EN in children.

METHODS

Thirty-five children with EN (17 boys, 18 girls; mean age, 8.79 years) have been studied. Four excluded children proved, on biopsy, to have leukocytoclastic vasculitis (n = 3) or eosinophilic cellulitis (n = 1).

RESULTS

In 27 of the 35 children (77%), the etiology of EN was established by laboratory investigations. In 25 children the causative factor of EN was an infectious agent (including beta-hemolytic streptococcus [n = 17], and Mycobacterium tuberculosis [n = 2]), whereas in 2 patients, EN was associated with Crohn's disease in one and Hodgkin's disease in the other. In 8 of the 35 children (23%) the etiology of EN remained undetermined. The mean duration of the rash was 11.5 days. Recurrences were noted in only 2 children (1 episode in 1 child and 3 episodes in the other).

CONCLUSION

Currently the most common provoking agent of EN in children in Greece is beta-hemolytic streptococcus. However, Mycobacterium tuberculosis should still be considered as a cause of the disorder. Also, the course of EN is benign and recurrences are exceptional.

Plasma immunoreactive endothelin levels in children with cystic fibrosis

Plasma immunoreactive endothelin levels were determined in 31 children and adolescents with cystic fibrosis and it was examined whether these levels correlated with the severity of the disease. The study comprised 16 cystic fibrosis patients (mean (SD) age 13.0 (4.9) y) with impaired lung function (Group A), 15 cystic fibrosis patients (11.2 (5.5) y) with unimpaired lung function (Group B) and 28 healthy controls (10.6 (4.3) y) (Group C). The selection and classification of patients into groups was based on criteria including the grade of finger-clubbing, the Brasfield chest radiograph score and spirometric and arterial blood gas values. In all subjects, plasma immunoreactive endothelin, atrial natriuretic peptide, renin, serum aldosterone levels and serum and urine electrolytes were measured.

CONCLUSIONS

Plasma endothelin levels were significantly higher in Group A (range 2.5-8.4 pg/ml, median 3.2 pg/ml) than those in Group B (1.3-3.8 pg/ml, median 2.0 pg/ml, p < 0.001) and Group C (1.5-3.5 pg/ml, median 2.5 pg/ml, p < 0.001), whereas they did not differ between groups B and C. They correlated positively with the severity of finger-clubbing, heart rate, arterial blood PCO2, plasma atrial natriuretic peptide levels and serum aldosterone levels and negatively with the arterial blood PO2, forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV1) and the Brasfield chest radiograph score. In multivariate regression analysis PO2 was the only independent factor found to significantly affect plasma endothelin levels. In conclusion, plasma immunoreactive endothelin levels are increased in cystic fibrosis patients with impaired pulmonary function and are related to the severity of the disease.

Atrial natriuretic peptide in children with idiopathic hypercalciuria

We measured plasma atrial natriuretic peptide (ANP) levels in 30 children with idiopathic hypercalciuria (IH) and 19 normal controls (NC). A calcium (Ca) loading test was performed in all patients to determine the type of IH. Subsequently plasma ANP, cAMP and renin activity (PRA), serum total and ionized Ca, intact parathyroid hormone, aldosterone, and 1,25-dihydroxyvitamin D as well as urine Ca, cAMP, and electrolytes were determined in all subjects. The mean (SD) plasma ANP levels were significantly lower in patients with renal hypercalciuria (RH) [21.4 (4.8) pg/ml] than in those with absorptive hypercalciuria (AH) [26.8 (7.6) pg/ml, P<0.05] and NC [27.6 (6.6) pg/ml, P<0.001]. PRA was significantly lower in AH [2.9 (1.3) ng/ml per hour] than in RH patients [7.8 (6.8) ng/ml per hour, P<0.01] and in NC [6.8 (4.6) ng/ml per hour, P<0.005]. Serum aldosterone values were significantly lower in AH [14.5 (11.4) ng/dl] than in RH patients [25.4 (14.1) ng/dl, P<0.05] and in NC [32.6 (20.5), P<0.001]. The lower plasma ANP levels in RH than in AH patients and in NC may be due to Ca depletion. The lower PRA and serum aldosterone levels in AH than in RH patients and in NC may be attributed to Ca excess.

Idiopathic intracranial hypertension in children

We studied prospectively the etiology, clinical presentation, and outcome of idiopathic intracranial hypertension in 36 patients (20 boys and 16 girls) aged 3.5 months to 14 years. The etiology was identified in 28 (77.7%) patients. The most common predisposing factor was middle-ear infection, followed by obesity. Of the 36 cases seen, 26 presented with the classic picture of headaches, papilledema, and elevated cerebrospinal fluid pressure; 8 children had intracranial hypertension in the absence of papilledema and 2 had fundoscopic evidence of papilledema with normal cerebrospinal fluid pressure initially. In four children resolution of intracranial hypertension occurred with removal of the causative agent or appropriate treatment of the underlying condition. In 8 of 17 patients intracranial hypertension resolved with acetazolamide therapy and in 22 of 24 patients it resolved with corticosteroids in combination with acetazolamide. Subnormal visual acuity, narrowing of visual fields, or both were present on the initial examination in 10 patients; 2 of them, who presented with loss of vision, have permanent visual impairment. Four additional patients presented a transient, mild impairment of visual acuity during treatment. Our study confirms the wide clinical spectrum and the difficulties encountered in diagnosis of idiopathic intracranial hypertension. A wide variety of etiologic associations should be investigated to provide definitive therapy. Loss of visual function is the only serious complication.

Insulin dependent diabetes mellitus (IDDM) and autoimmune thyroiditis in a boy with a ring chromosome 18: additional evidence of autoimmunity or IDDM gene(s) on chromosome 18

A 4 year 3 month old boy with insulin dependent diabetes mellitus (IDDM), autoimmune thyroiditis, slight mental retardation, facial dysmorphism, and a de novo ring chromosome 18 (deletion 18q22.3-18qter) is described. This unique association of defects could represent a chance association. Alternatively, the clinical features could be the result of the chromosomal aberration. If so, one could speculate that a gene or genes on chromosome 18 might act as a suppressor or activator of the autoimmune process by itself or in concert with other IDDM loci.

Cat scratch disease in Greece

An indirect fluorescent antibody test for Bartonella henselae, B quintana, and B elizabethae was performed in all 18 children who presented to our paediatric outpatient clinic with cat scratch disease over a six year period. Serum samples were taken on admission, after 15 days, and after six months. Diagnosis was confirmed in 15 patients (83%) and was based on seroconversion or a fourfold change of the antibody titre to B henselae in 12 patients and on a single high titre (> 128) in three patients. Lymphadenopathy was present in all patients, erythema nodosum in one, osteomyelitis in one, hepatitis in one, transverse myelitis in one, and liver or spleen granulomata, or both, in three patients. Cat scratch disease developed in autumn or winter in 12 patients. All had a history of physical contact with a cat. Our study shows that our clinical suspicion was accurate in the diagnosis of cat scratch disease in a high percentage of patients presenting to a hospital and that indirect fluorescent antibody testing for B henselae is a useful diagnostic tool.

Family pattern of idiopathic hypercalciuria and its subtypes

PURPOSE

We determined the mode of inheritance of idiopathic hypercalciuria and its subtypes.

MATERIALS AND METHODS

We evaluated 40 children with symptomatic idiopathic hypercalciuria and 129 of their first-degree relatives (80 parents and 49 siblings). In hypercalciuric individuals in families with at least 2 affected members the type of idiopathic hypercalciuria was determined by the calcium loading test.

RESULTS

Of the 40 affected children 19 (47.5%) had 1 or more affected first-degree relatives (23 of 80 parents and 2 of 49 siblings). In all 44 affected members of the 19 hypercalciuric families (19 index cases, 23 parents and 2 siblings) the type of idiopathic hypercalciuria was determined (absorptive in 38 and renal in 6). Study of the pedigree of the 19 families showed that idiopathic hypercalciuria appears to be transmitted as an autosomal dominant trait. With only 1 exception the subtype of disease was specific for members of the same family.

CONCLUSIONS

Idiopathic hypercalciuria has a familial or sporadic pattern. In the familial pattern an autosomal dominant inheritance is present. The type of the disease is identical in affected members of the same family. The absorptive subtype is more frequent.

Arthritis and vasculitis during the incubation period of varicella

Arthritis and vasculitis are very rare complications of varicella occurring almost exclusively after the eruption of the characteristic rash. We report two children, aged three and seven years, who developed vasculitis and polyarthritis (patient No. 1) and arthritis (patient No. 2) 13 and 9 days, respectively, before the onset of their typical varicella. Arthritis and vasculitis so early in the incubation period of varicella have not been described previously. In all previously reported cases the arthritis occurred after or together with the onset of varicella and only in one instance preceded the exanthem by 2 days. Although this may have been an unfortunate coincidence, an association between varicella zoster virus and these manifestations should be seriously considered. Clinicians confronted with such cases must be cautious and search for varicella infection, especially in times of epidemics.

Relapse of herpes simplex encephalitis after acyclovir therapy

A case of herpes simplex encephalitis in a previously healthy 17-month-old girl relapsing 1 week after completion of a 10-day acyclovir therapy is described. The child responded favourably to a second 10-day course with acyclovir. The time of relapse and the satisfactory response to a second course of acyclovir treatment indicate that the first course of therapy was inadequate for eradication of herpes simplex virus infection.

High mebendazole doses in pulmonary and hepatic hydatid disease

Thirty nine children with 71 hydatid cysts were given mebendazole orally in a dose of 100-200 mg/kg/day for 12 weeks and were followed up for a mean (SD) of 63 (24) months. Twenty children (three of them after a second course) were cured and another two avoided at least one operation. No serious side effects of the drug were observed.

Radiation dose to the bladder wall and the gonads from direct radionuclide cystography in children

A dynamic spherical bladder model, previously developed in our laboratory, was implemented to evaluate the absorbed dose to the bladder wall from 99mTc-pertechnetate and direct radionuclide cystography (DRC). This model takes into account the flow rate of normal saline into the bladder and the bladder volume as a function of the filling time. The DRC examinations of 36 children were analysed and calculations were carried out in order to estimate (a) the absorbed dose to the bladder during and following the DRC examination and (b) the gonadal dose. It is shown that the estimated dose to the bladder wall is much greater than that estimated by static models. It is also shown that the absorbed dose to the bladder due to the activity in the residual urine following the examination is even greater than the dose received during the DRC procedure. Our results indicate that in order to reduce the radiation burden, besides the so far proposed precautions, concerning the shortening of the DRC procedure, the patient should also be well hydrated and encouraged to void frequently after the examination.

Primary nocturnal enuresis in children with vesicoureteric reflux

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RES phagocytosis in children with homozygous beta-thalassemia in relation to blood transfusion

In order to investigate the effect of blood transfusion on the RE cell function in thalassemia major, 14 children with homozygous beta thalassemia were studied prior to and 7 to 10 d following blood transfusion, when, according to previous studies, spleen reaches its minimum size. The denatured human albumin (DHA) low and large dose clearance techniques were used in order to estimate the maximum RES phagocytic capacity. It is shown that, despite the confirmed post-transfusion high hepatosplenic circulation, the RE cell phagocytic capacity is not significantly affected. Furthermore the RES phagocytic capacity of beta-thalassemics is shown to be significantly higher than that of normal controls, and this can probably be attributed to the RES hyperplasia accompanying the disease.

Statistical aspects of hydatid disease in Greek adults

A retrospective study was undertaken to estimate the incidence of hydatidosis among Greeks over 18 years of age. Discharge and operating room records in all community and private hospitals during the period 1 January 1969 to 31 December 1975 were reviewed, and new hydatid patients were registered. Hydatid disease was diagnosed in 4,202 adults. The average annual incidence of all hospital cases was 9.77 per 100,000 population. The diagnosis was confirmed at surgery in 3,397 patients (80.84%). The average annual surgical incidence was 7.89 per 100,000 inhabitants. The incidence of the disease varied among different geographic areas in the country; its percentage was highest in rural areas. In this series, both sexes were equally involved (P greater than 0.1). Solitary organ involvement occurred in 95.88% of cases. Cysts were localized in the liver in 69.64% and in the lungs of 23.43% of the cases with single organ involvement. Liver involvement was more frequent in women, while lung involvement was more frequent in men (P less than 0.001).

Mebendazole in the treatment of hydatid cysts

We report two children with ruptured, multiple hydatid cysts treated with mebendazole. Long term follow up has confirmed the success of this treatment.