The effect of p.Arg25Cys alteration in NKX2-5 on conotruncal heart anomalies: mutation or polymorphism?

Heterozygous mutations in the NKX2-5 gene of patients with various congenital heart defects have been reported. Most of the congenital heart defects associated with the mutations in the NKX2-5 gene are conotruncal heart anomalies, primarily the tetralogy of Fallot. In this study, the authors screened 72 Turkish children with conotruncal heart anomalies and 185 healthy control subjects to find the NKX2-5 alterations. They found one previously documented NKX2-5 missense alteration, heterozygous c.73C>T (p.Arg25Cys), in a 10-year-old boy with tetralogy of Fallot. The same heterozygous alteration was found also in the patient's healthy father and in two unrelated persons in the healthy control group. The current study shows for the first time the presence of p.Arg25Cys in healthy control subjects other than African Americans. These results show that no genetic support exists for the pathogenecity of this alteration, although a previous in vitro study and theoretical predictions suggest a structural/functional difference in the altered protein region.

Bilateral coronary artery dilatation and supravalvular pulmonary stenosis in a child with noonan syndrome

Noonan syndrome is the second most frequent congenital malformation syndrome, after Down syndrome, associated with cardiovascular abnormalities. The most prevalent cardiovascular abnormalities in Noonan syndrome are pulmonary stenosis and hypertrophic cardiomyopathy. We report the case of a 12-year-old girl with Noonan syndrome who had multiple cardiovascular abnormalities, including extensive bilateral coronary artery dilatation, valvular and supravalvular pulmonary stenosis, atrial septal defect, and mitral valve prolapse. Both coronary artery dilatation and supravalvular pulmonary stenosis, although rarely reported, are abnormalities of the cardiovascular system that may occur in Noonan syndrome.

A thoracic complication of ventriculoperitoneal shunt: symptomatic hydrothorax from intrathoracic migration of a ventriculoperitoneal shunt catheter

Thoracic complications of ventriculoperitoneal (VP) shunt are very rare. We report an unusual case of VP shunt intrathoracic migration, associated with symptomatic hydrothorax. The patient was successfully managed with revision. We reviewed the 10 cases reported in the literature and discussed the mechanism of shunt-tip migration.

Primary primitive neuro-ectodermal tumor of cauda equina with intracranial seeding

Primitive neuro-ectodermal tumor (PNET) of the cauda equina is a rare entity. 18 cases have been reported in the literature so far, including 4 cases with intracranial seeding. Moreover parenchymal involvement of brain has never been reported as a form of intracranial seeding from PNET of the cauda equina. A 31 year-old female patient, with PNET of cauda equina showing intracranial seeding 6 months after surgery, is presented in this report. To our knowledge, this is the first adult case of spinal cord PNET with parenchymal involvement of brain. The histopathological, clinical and radiological findings as well as treatment of the patient were evaluated.

Prognostic importance of transferrin receptor expression and correlation with K1-67 labelling indices in intracranial meningiomas

Meningiomas are variously benign, atypical or anaplastic neoplasms and can be treated by surgical removal. However, recurrence can be seen even after complete surgical resection in benign meningiomas and some are histologically aggressive. As predictors of recurrence or malignant proliferation some immunohistochemical markers have been used. In this study, we postoperatively identified TfR (transferrin receptor) staining and Ki-67 proliferative index in patients with intracranial meningiomas and evaluated the correlation between these parameters and the recurrence or malignant proliferation. Immunohistochemical techniques (streptavidin-biotin complex) were used to assess the TfR expression and Ki-67 labelling index in 50 surgically removed intracranial meningiomas. Significantly high TfR expression was observed in all types of meningiomas, eight of which recurred. Four cases died because of primary intracranial pathology and one died from uncontrollable epileptic seizures. Ki-67 levels were high in the cases which showed recurrence and showed atypical features. Based on our observations and the results presented above, meningioma patients with TfR score of 3 or higher and high Ki-67 labelling index must be carefully followed up for recurrence, as well as for malignant transformation. Thus, we suggest that TfR and Ki-67 immunostains should be applied routinely in patients with meningiomas.

Antistreptococcal response is exaggerated in children with familial Mediterranean fever

Familial Mediterranean fever (FMF) is an autosomal recessive disorder. Although the pathogenesis of the disease is not yet completely understood, enhanced acute-phase responsiveness is considered to be one of the most important mechanisms. The presence of high levels of antistreptolysin O (ASO) antibodies and streptococcus-associated diseases, such as acute poststreptococcal glomerulonephritis (AGN) and acute rheumatic fever (ARF), has been reported in patients with FMF. In order to better understand the effect of FMF on antistreptococcal antibody response, we measured ASO and antideoxyribonuclease B (anti-DNAse B) levels in patients with FMF and compared them with those in healthy controls. The study consisted of two parts. In the first step, antistreptococcal antibody levels were analysed in 44 patients with FMF and 165 healthy children who had no history or clinical evidence of upper respiratory tract infection (URTI) for the last 4 months. In the second step, antistreptococcal antibody levels were measured in 15 patients with FMF and 22 healthy controls in response to documented group A beta-haemolytic streptococcal pharyngitis. In the first part of the study, ASO and anti-DNAse B levels in patients with FMF were found to be significantly higher than those in healthy controls (P<0.001). In the second part, ASO and anti-DNAse B titres were found to be significantly higher in patients with FMF than in controls (P<0.001 and <0.05, respectively) 4 weeks after a positive throat culture. We concluded that patients with FMF have an exaggerated response to streptococcal antigens and might be prone to poststreptococcal non-suppurative complications, such as ARF.

DiGeorge syndrome associated with left lung aplasia

We report a patient with clinical and cytogenetic findings consistent with DiGeorge-velocardiofacial syndrome and aplasia of the left lung. To the best of our knowledge, this is the first reported case of DiGeorge-velocardiofacial syndrome associated with unilateral lung aplasia. Gadolinium enhanced three-dimensional magnetic resonance angiography demonstrated associated right-sided aortic arch and left pulmonary artery agenesis.

Conservative management of extradural haematomas: effects of skull fractures on resorption rate

In conservative management of extradural haematomas (EDH), several mechanisms were described to explain the resorption of the haematoma. One of these was the transfer of the clot into the epicranial space through the skull fracture. In this study, the effects of skull fracture and associated intracranial lesions in the conservative management of EDH were investigated. Skull fracture and associated intracranial lesions were found in 71.11% and 51.1% of the patients, respectively. Resorption rate was calculated using an original formula and it was 0.548 +/- 0.227 in patients with skull fracture and 0.507 +/- 0.170 in patients with both skull fractures and additional intracranial lesions. These rates were found to be significantly higher than in the patients without fracture. In conclusion, in the patients with EDH planned to be managed conservatively, skull fracture and additional intracranial lesions must not be thought as risk factors, on the contrary, resorption of the clot might be earlier than in the others.

Conservative management of epidural haematomas. Prospective study of 15 cases

Conservative management of epidural haematoma (EDH) depends on a balance between expansion and resorption rate of the clot. 15 patients with EDH whose CT scans demonstrated a small EDH and were asymptomatic or with minor symptoms or with a delayed diagnosis were treated conservatively. The thickness of haematoma ranged between 4.9-40.8 mm. In two patients, the haematoma extended from the posterior fossa to the supratentorial region. In 7 patients, additional intracranial pathology was detected. None of the patients had neurological deterioration on follow up. The second CT was performed on second day at the earliest, in fourth week at the latest. We conclude that the patients with EDH who are neurologically stable during the first 24 hours after trauma, with small EDH and with minor or no symptoms or signs, might be candidates for conservative management. An absolute precondition for conservative management is close supervision of the patient.