67 Double impact: hypophosphatemic rickets and vitamin D intoxication

Background

Vitamin D prevents deficiency rickets, but its prescription must be weighed carefully!

Objective

We report a rare case of iatrogenic toxic hypervitaminosis D in a child with vitamin D resistant rickets…!

Methods

We admitted a two-year-old girl, presenting signs of rickets resistant to the usual then therapeutic doses of vitamin D3. Vitamin D2 in oral suspension is then ordered in addition, for a few weeks until the onset of hearing loss motivating her hospitalization in pediatrics.

Results

Biological and radiological explorations revealed renal failure with threatening arterial hypertension, as well as diffuse and severe arteriosclerosis on Doppler signal.

Eviction (stopping vitamin D in all its forms), symptomatic and conservative management by (converting-enzyme inhibitors) and hydration allowed a progressive blood pressure normalisation, arteriosclerosis disappearance (undetected by Doppler signal and by angio-scan) along with a gradual normalising of the kidney function; all this over a period of 2 years

The girl actually had hypophosphatemic rickets, and oral phosphorus (syrup) was also prescribed

Conclusion

Vitamin D is potentially toxic with sometimes severe renal risks (lithiasis, nephrocalcinosis), and hypercalcemia might be severe, especially if renal function is impaired.

Blindly treating any rickets with vitamin D can be adventurous and might expose the child to serious morbidity.

74 Hereditary angioedema revealed by compartment syndrome

Background

Hereditary angioedema (HAE) can present with a wide spectrum of clinical symptoms, including articular features like the compartment syndrome.

Objective

We present the peculiar case of a young female patient suffering from this rare complement system disorder and presenting as a « wrist oedema ».

Methods

A 14-year-old girl was admitted in the emergency room during a night shift. She presented with acute compartment (wrist) syndrome due to edematous compression of the median nerve, associated with a typical personal history of HAE. It resolved within 6 h with IV steroids and hyperhydration.

The quantitative and qualitative C1 INH esterase returning negative, the diagnosis of HAE type III was made.

The patient was treated with long-term treatment based on Danazol, (the most frequently prescribed attenuated androgen to treat HAE).

Results

HAE is due to the deficiency or dysfunction of the C1 inhibitor protein (quantitative or qualitative deficiency). A new nomenclature has replaced the initial use of denominations HAE type 1, 2 or 3; to speak rather of HAE with a deficient C1 inhibitor (type 1), with a dysfunctional C1 inhibitor (type 2) or with a normal C1 inhibitor (type 3)

Type 3 HAE is rare and difficult to treat. It may respond to anti-estrogenic drugs such as progestins and especially to androgens; specific (very expensive) molecules do exist and act directly on the bradykinin pathways

Conclusion

A compartment syndrome may reveal extremely rare conditions such as hereditary angioedema.

Early recognition and management are the guarantee of a preserved functional prognosis.

73 Joint pains revealing a dysautonomic syndrome

Background

Primary dysautonomia is a disorder of the autonomic nervous system with nonspecific manifestations, mainly affecting blood pressure and heart rate.

Objective

We report the diagnostic odyssey in an 11-year-old girl starting with arthralgia and leading to the final diagnosis of a rare dysautonomia.

Methods

A 13-year-old girl, with no pathologic history, was admitted to pediatrics for diffuse arthralgia without clinical inflammatory signs.

Biological exploration unmasked a morning proteinuria without hypoalbuminemia and with a normal electrophoretic profile, microcytic anaemia and orthostatic hypotension authenticated during his hospitalization.

Exhaustive explorations were undertaken (including autoimmune panel, ophthalomological examination, full metabolic screen and even renal biopsy), without any conclusive result.

Results

The development—after one year of follow up—of arterial hypertension, associated with orthostatic hypotension and proteinuria, points toward the extremely rare defect in baroreceptors.

The management, in collaboration with the cardiology department, enhanced the patient’s quality of life with a reduction in hypertensive peaks. An appropriate lifestyle also amended the intensity of orthostatic hypotension.

The close multidisciplinary follow-up over >48 months is reassuring.

Conclusion

The peculiar baroreceptor defect in a context of dysautonomia should be kept in mind in the (long) list of differential diagnosis of arthralgias, as joint pain can be triggered by dysautonomia. Management is mainly symptomatic.

Breastfeeding for Primary Prevention of Stroke

A recent review by Zhang et al. published in the "Journal of the National Medical Association" focused on the major and emerging strategies for the prevention of stroke. We would highlight the evolving role of breastfeeding as an efficient intervention in primary prevention of such cardiovascular disease, including in black women.

Abstract OT2-05-03: Does minocycline mitigate chemotherapy induced neuroinflammation? A phase II randomized placebo controlled study

Background: Many breast cancer (BC) patients, particularly those who receive chemotherapy (chemo), experience affective symptoms and cognitive changes that can negatively impact their quality of life. Causal links between inflammatory mediators and the development of depressive-like behavior and cognitive defects, have been established in mouse models, including studies by our group showing increased microglial activation following chemo (A.C DeVries et al). Microglia are resident immune cells of the brain, which release proinflammatory cytokines when activated. Doxorubicin (DOX) induces microglial activation in the brain. Minocycline, a second generation tetracycline, has been shown to suppress inflammation by inhibiting microglial activation in CNS disease models. We hypothesize that (1) chemo activates microglia in the brains of women being treated for BC, which can precipitate or exacerbate depression, anxiety and cognitive deficits and (2) Minocycline administration during neoadjuvant or adjuvant chemo will prevent chemo-induced microglial activation and will reduce affective and cognitive symptom burden. Trial Design: This is a single center, Phase II, double blinded randomized study of minocycline (100 mg twice a day) vs placebo twice a day in women with BC receiving DOX-based or other chemo for BC. Pts will be randomized to either oral minocycline or placebo for up to a 1 week loading period plus chemo treatment period and an optional subsequent 2 week period. Eligibility Criteria: Women diagnosed with BC stages I-III initiating first line adjuvant or neoadjuvant chemo. Aims: (1) to evaluate symptoms related to anxiety and depression and cognitive changes during and after chemo completion (2) to evaluate markers of neuro inflammation as assessed by blood based inflammatory cytokines and central markers of inflammation and microglia activation using 1 F-Fludeoxyglucose and 11C-PK11195 positron emission tomography. Primary endpoints are changes in Center for Epidemiological Studies Depression Scale (CES-D) and State Trait Anxiety Index (STAI) from baseline to end of study after minocycline vs placebo intervention. Secondary endpoints are changes in cognitive function during chemo using validated cognitive testing including N-Back Test, Behavioural Rating Inventory of Executive Function (BRIEF) and the Multifactorial Memory Questionnaire Ability Scale (MMQ). Statistical Methods: Primary analysis for efficacy will be intention-to-treat. The main objective is to preliminarily evaluate the effect of minocycline on chemo-induced depressive symptoms in terms of changes in CES-D and STAI scores. Mixed models will be used to evaluate cognitive function changes. A sample size of 23 per group, will give 80% power to detect an effect size of 0.74 standard deviation (SD) difference between the 2 groups at significance level of 0.10 based on a 2 sided two-sample t-test. From our experience, attrition of less than 20% is expected for studies in this patient population in our center, and to account for this, we plan to recruit up to 60 patients. 16 of 46 evaluable pts have been accrued to date. Accrual started in January 2016. Funded by Pelotonia grant from The OSUCCC. Contact: Study PI: Maryam.lustberg@osumc.edu

Citation Format: Boutrid H, Reinbolt R, Knopp M, Williams N, VanDeusen J, Sardesai S, Noonan A, Flora L, Gleich E, Pan X, Berger M, Vargo C, Wesolowski R, Ramaswamy B, DeVries AC, Lustberg M. Does minocycline mitigate chemotherapy induced neuroinflammation? A phase II randomized placebo controlled study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-05-03.

Lack of effect of SU1498, an inhibitor of vascular endothelial growth factor receptor-2, in a transgenic murine model of retinoblastoma

SU1498, a tyrosine kinase inhibitor of vascular endothelial growth factor receptor 2 (VEGFR-2), has activity against retinal neovascular diseases. To determine if this drug might have clinical utility against retinoblastoma, we evaluated the effects of SU1498, as well as the expression of VEGFR-2, in a transgenic animal model of retinoblastoma. Optical coherence tomography (OCT) was evaluated as a technology to measure retinal tumors in vivo, in response to treatment. Immunofluorescence analysis was performed to evaluate the distribution and expression of VEGFR-2 in enucleated eyes from LHβTag transgenic mice and controls at 4, 8, 12, and 16 weeks of age. VEGFR-2 and phosphorylated (p)VEGFR-2 levels were quantitated by Western blot. OCT was used to pair 10-week-old animals based on tumor volume (n=10), and these animals were treated with 6 periocular injections of SU1498 (50mg/kg, given twice weekly) or vehicle for 3 weeks. Tumor burden was determined by histology and in vivo imaging by OCT. VEGFR-2 and pVEGFR-2 expression levels were upregulated during tumorigenesis. However, SU1498 did not significantly reduce tumor burden compared to vehicle (p=0.29). OCT imaging of one matched pair demonstrated equivalent, linear tumor growth despite treatment with SU1498. Retinal tumors can be followed non-invasively and quantitatively measured with OCT. VEGFR-2 is strongly upregulated during tumorigenesis in transgenic retinoblastoma; however, SU1498 does not decrease tumor volume in transgenic murine RB at the studied dose and route of administration.