Spondyloenchondrodysplasia Due to Mutations in ACP5: A Comprehensive Survey

Purpose

Spondyloenchondrodysplasia is a rare immuno-osseous dysplasia caused by biallelic mutations in ACP5. We aimed to provide a survey of the skeletal, neurological and immune manifestations of this disease in a cohort of molecularly confirmed cases.

Methods

We compiled clinical, genetic and serological data from a total of 26 patients from 18 pedigrees, all with biallelic ACP5 mutations.

Results

We observed a variability in skeletal, neurological and immune phenotypes, which was sometimes marked even between affected siblings. In total, 22 of 26 patients manifested autoimmune disease, most frequently autoimmune thrombocytopenia and systemic lupus erythematosus. Four patients were considered to demonstrate no clinical autoimmune disease, although two were positive for autoantibodies. In the majority of patients tested we detected upregulated expression of interferon-stimulated genes (ISGs), in keeping with the autoimmune phenotype and the likely immune-regulatory function of the deficient protein tartrate resistant acid phosphatase (TRAP). Two mutation positive patients did not demonstrate an upregulation of ISGs, including one patient with significant autoimmune disease controlled by immunosuppressive therapy.

Conclusions

Our data expand the known phenotype of SPENCD. We propose that the OMIM differentiation between spondyloenchondrodysplasia and spondyloenchondrodysplasia with immune dysregulation is no longer appropriate, since the molecular evidence that we provide suggests that these phenotypes represent a continuum of the same disorder. In addition, the absence of an interferon signature following immunomodulatory treatments in a patient with significant autoimmune disease may indicate a therapeutic response important for the immune manifestations of spondyloenchondrodysplasia.

Molecular basis of β-thalassemia in Karnataka, India

In β-thalassemia, point mutations in the β-globin gene are largely responsible for either decreased or no β-globin synthesis. The β-globin gene has three exons and two introns. The molecular characterization of β-thalassemia is absolutely necessary for carrier screening, for genetic counseling, and to offer prenatal diagnosis. The objective of the present study was to identify the rare mutations in β-globin gene of β-thalassemia patients. We have sequenced the entire β-globin gene in 36 clinically identified thalassemia patients from the Karnataka region using polymerase chain reaction and sequencing. Our analysis revealed 11 β-thalassemia variants. The most common being IVSII-16 G>C, IVSI-5G>C, IVSII-74 T>G, codon 3 (T>C), and Poly A site (T>C). In addition, we have also documented a novel deletion at codon 6 (-CT) (HBB:c.16delCT). These data are useful in future molecular screening of the population for implementing a thalassemia prevention and control program. Further it is found that family studies and comprehensive hematological analyses would provide useful insights for accurate molecular diagnosis of thalassemia phenotype and offers an interesting subject for further investigations in the Indian populations.

Tartrate-resistant acid phosphatase deficiency causes a bone dysplasia with autoimmunity and a type I interferon expression signature

We studied ten individuals from eight families showing features consistent with the immuno-osseus dysplasia spondyloenchondrodysplasia (SPENCD). Of particular note was the diverse spectrum of autoimmune phenotypes observed in these patients, including systemic lupus erythematosus (SLE), Sjögren's syndrome, haemolytic anemia, thrombocytopenia, hypothyroidism, inflammatory myositis, Raynaud's disease, and vitiligo. Haplotype data indicated the disease gene to be on chromosome 19p13 and linkage analysis yielded a combined multipoint lod score of 3.6. Sequencing of the ACP5 gene, encoding tartrate resistant acid phosphatase (TRAP), identified biallelic mutations in each of the patients studied, and in vivo testing confirmed a loss of expressed protein. All eight patients assayed demonstrated elevated serum interferon alpha activity, and gene expression profiling in whole blood defined a type I interferon signature. Our findings reveal a previously unrecognised link between TRAP activity and interferon metabolism, and highlight the importance of type I interferon in the genesis of autoimmunity.

'Thinfat' phenotype in newborns

OBJECTIVE

The objectives of the study was to know whether the 'thinfat' phenotype exists in newborns, in Central Karnataka and to correlate various factors that contribute to this peculiar phenotype, with emphasis on genetic and maternal environmental factors.

METHODS

For 1000 consecutive singleton term newborns, weight, length, head, mid arm, abdominal circumferences, biceps and subscapular skinfolds were measured at birth and compared with measurements of white Caucasian babies born in Southampton UK and Mysore babies at birth.

RESULTS

The Davangere babies were significantly smaller in all measurements at birth (p < 0.001) compared to Southampton babies. The deficit varied according to the measurements; It was greatest for birth weight (-1.6 SD, CI -3.0, -0.2), mid arm circumference (-2.0 SD, CI -3.3, -0.8), head circumference (-1.8 SD, CI -3.1, -0.5) and least for length (-0.4 SD, CI -1.9, 1.1) and subscapular skin fold (-0.3 SD, CI -0.25, -0.12). Predictors of skinfold thickness were maternal body mass index (p < 0.05), maternal mid arm circumference (p < 0.001) and consanguinity (p < 0.05).

CONCLUSION

Despite being small, truncal adiposity was present in Davangere neonates confirming the 'thinfat' phenotype. The role of consanguinity in other words, the role of genes, is important in determining this 'thinfat' phenotype in newborns.

Kallmann's syndrome

Kallmann's syndrome is a rare genetic disorder due to abnormal migration of olfactory axons and gonadotropin releasing hormone producing neurons, characterized by hypogonadism and anosmia. The prevalence of Kallmann's syndrome is 1:10,000 to 1:60,000 with a male to female ratio of 5:1. The inheritance of Kallmann's syndrome may be X-linked, autosomal recessive or autosomal dominant with variable penetrance, mutation involving KAL-1 and KAL-2 gene respectively. We report a case of Kallmann's syndrome in a 19-year-old boy with characteristic clinical, biochemical and MRI findings.

Baseline Widal titres in healthy children

OBJECTIVE

To determine the baseline Widal titres in apparently healthy children in Davangere.

METHODS

Cross-sectional study was done on 250 children. Widal titers were found using tube agglutination test.

RESULTS

Out of 250,64.2% had a titre of less than 1:20,22.4% had a titre equal to 1:20,9.6% had a titre of 1:40 and 3.6% had a titre of 1:80 to 'O' antigen and 67.2% had a titre of less than 1:20, 21.2% had a titre equal to 1:20, 8% had a titre of 1:40 and 3.6% had a titre of 1:80 to 'H' antigen of S. enterica subsp. enterica ser. Typhi. No children in age group 6 months-2 years had a titre of 1:80 to either antigen. All children in this age group had a titre of less than 1:20 to AH antigen and older children had a titre upto 1:40 dilution.

CONCLUSION

Baseline titres for either S. enterica subsp. enterica ser. Typhi antigen in 6 month-2 year was 1:40 and older children was 1:80. Baseline titres for H antigen of S. enterica subsp. enterica ser. Paratyphi A in 6 month-2 year was less than 1:20 and for older children was 1:40 dilution.

Absence of Wharton's jelly around the umbilical arteries

Wharton's jelly is a specialized tissue which acts as supportive and protective structure substituting for the adventitia of the umbilical vessels. Absence of Wharton's jelly around the umbilical arteries is very rare and an unusual cause of perinatal mortality. We report a case of absent Wharton's jelly around the umbilical arteries with patent vitellointestinal duct--a rare association.

Osteopetrosis with Arnold Chiari malformation type I and brain stem compression

Osteopetrosis is a collective term for a range of sclerosing bone diseases resulting from an absence or defective function of osteoclasts. The clinical expression is variable and includes skeletal, hematological and neurological manifestations. The common neurological manifestation includes cranial neuropathies involving optic, cochlear, facial and trigeminal nerves. Spastic quadriplegia occurring as a result of brain stem compression in osteopetrosis is uncommon. The association of Type 1 Arnold Chiari malformation with osteopetrosis resulting in brain stem compression syndrome is an extremely rare entity.

A syndrome of immunodeficiency, autoimmunity, and spondylometaphyseal dysplasia

We treated a 5-year-old boy, in our hospital in south India, who had a history of recurrent respiratory infections, tuberculosis, and severe varicella infection. He was short in build and a radiological examination revealed evidence of spondylometaphyseal dysplasia. Investigation of the immune system was suggestive of compromised cellular immunity. Immunofluorescence and immunoblot assay for antibodies detected underlying multiple disorders such as systemic lupus erythematosus (SLE), autoimmune thrombocytopenia, and juvenile rheumatoid arthritis (JRA). Roifman et al. described a similar syndrome in 2000 and 2003, which was characterized by spondylometaphyseal dyplasia, combined immunodeficiency, and autoimmunity and called it Roifman-Costa syndrome (OMIM 607944). Hence a diagnosis of Roifman-Costa syndrome was made. Ours shall be the first report of such a condition from the Indian subcontinent and hence the communication.

Eventration of the diaphragm and associations

Eventration of the diaphragm, most often an isolated entity and detected incidentally, has been known to be associated with several genetic syndromes. Authors report their experience of seeing diaphragmatic eventration in association with Poland syndrome and wandering spleen syndrome and briefly discuss the literature.

Hyperekplexia in two siblings

Hyperekplexia is a rare, hereditary, non-epileptic disorder characterized by an exaggerated startle reaction to unexpected auditory, somatosensory and visual stimuli. The authors describe a one-day-old term neonate, who presented with jitteriness and episodic tonic spasms, and his elder sister with hyperekplexia. Hyperekplexia though is a rare disorder is one of the differential diagnoses for refractory tonic spasms in infancy. The prognosis is generally good in hereditary hyperekplexia. Recent molecular studies have revealed many associated mutations in the glycine receptor alpha and beta subunit genes.

Fetal valproate syndrome

Fetal Valproate Syndrome results from prenatal exposure to valproic acid. It is characterized by distinctive facial appearance, a cluster of minor and major anomalies and central nervous system dysfunction. Here we report a 4-year-old boy with typical facial features of Fetal Valproate Syndrome.

Yunis Varon syndrome

In this communication is reported a neonate with Yunis Varon syndrome, a rare autosomal recessive disorder, born to a consanguineously married couple who had microcephaly, wide cranial sutures, prominent eyes, hypertelorism, dysplastic ears, sparse hairs, cupid bow like upper lip with median pseudocleft and labio-gingival retraction. Bilateral hypoplasia of thumbs, absent great toes, short phalanges were other features. Additional features in this case included median pseudocleft unreported earlier and C.T. findings of underdeveloped gyri, ischemic changes in temperoparietal region and bilateral lacunar infarcts in middle cerebral artery territory.

Jarcho-Levin syndrome

Jarcho-Levin syndrome is an eponym that represents a spectrum of short trunk skeletal dysplasias with variable involvement of the vertebrae and ribs. Initially considered to be lethal, it is now accepted as compatible with life in its milder presentations. Here are reported two neonates with the lethal variety of this syndrome. One neonate had associated anomalies like hydrocephalus, hydroureteronephrosis and meningomyelocoele while the other had no additional anomalies. Also is reviewed the literature regarding this less understood disorder focusing on the applied clinical aspects that have stemmed out from the recent molecular research.

Larsen syndrome--lethal variety

Larsen syndrome is a condition characterized by generalized defect in collagen formation. Autosomal dominant, autosomal recessive and even sporadic fresh mutations have been reported. Very few cases of lethal variety of Larsen syndrome have been reported in the world. The authors emphasize the importance of recognition of this condition which is often misdiagnosed.

Branchio-oculo-facial syndrome

Branchio-oculo-facial syndrome (BOFS) is a very rare autosomal dominant disorder with incomplete penetrance and variable expression; with phenotypic variation ranging from mild to severe forms, involving eye, ear, oral and craniofacial structure. We report three members of one family, showing great variability in its phenotypic expression and review the recent literature.

Fibrochondrogenesis

Fibrochondrogenesis is a rare lethal short-limb skeletal dysplasia. Till now only fifteen cases have been reported since Lazzaroni-Fossati first described it in 1978. Hence reported a case of fibrochondrogenesis in a child born to a consanguineously married couple with characteristic physical and radiological features and discuss the incidence, inheritence, ultrasonographic, clinical, radiological and pathological characteristics of this disorder.

Fibrochondrogenesis

Fibrochondrogenesis is a rare lethal short-limb skeletal dysplasia. Till now only fifteen cases have been reported since Lazzaroni-Fossati first described it in 1978. Hence reported a case of fibrochondrogenesis in a child born to a consanguineously married couple with characteristic physical and radiological features and discuss the incidence, inheritance, ultrasonographic, clinical, radiological and pathological characteristics of this disorder.

Langer-giedion syndrome with renal cyst

Here it is reported a 4-year-old boy with Langer-Giedion syndrome (Trichorhino phalangeal syndrome-II), who had characteristic features of TRP II, associated with multiple renal cysts hitherto unreported. This could be a new association in this syndrome that may serve to support the concept of contiguous gene syndrome in patients with TRP II.

Jatropha curcas - poisoning

Jatropha curcas is common plant found all over India more commonly in the southern parts. Though it is a common cause of accidental poisoning among children in these parts, standard texts rarely cover it. Gastrointestinal manifestations are predominant feature of poisoning with the seeds of Jatropha curcas. Mortality is rare.

Johanson--blizzard syndrome

Johanson-Blizzard syndrome is an extremely rare ectodermal dysplastic disorder characterized by aplasia or hypoplasia of alae nasi, midline scalp defects, growth retardation, varying degrees of mental retardation, hypothyroidism, exocrine pancreatic insufficiency and congenital deafness. This condition is supposed to be an autosomal recessive disorder. We are reporting a female neonate with the characteristic features and an uncommon less emphasized feature viz. cafe-au-lait spots.

Cerebro-oculo-facio-skeletal (COFS) syndrome in siblings

The authors report two sibs with COFS syndrome and review the relevant literature in brief. They emphasize the importance of prenatal diagnosis in this syndrome that has many mimics.

Kabuki make-up syndrome

Kabuki make-up syndrome is a rare disorder characterized by mental retardation, postnatal dwarfism and peculiar facies. This condition is believed to be common in Japan, but has been reported from other parts of the world. The authors report a case of this syndrome in an eight-year-old girl, with the characteristic findings from India.

Juvenile idiopathic osteoporosis

Juvenile idiopathic osteoporosis (JIO) is a very rare condition of primary bone demineralisation that presents in childhood. Most pediatricians are unfamiliar with this condition owing to the difficulty in recognition and a long list of differential diagnosis. We report an 8-year-old girl who presented with generalized severe osteoporosis. Diagnosis of JIO was made by excluding other common causes of osteoporosis in this age.

Sirenomelia with radial dysplasia

Sirenomelia is a rare anomaly usually associated with other multiple malformations. In this communication the authors report a case of sirenomelia associated with multiple malformations, which include radial hypoplasia also. Though several theories have been proposed regarding the etiology of multiple malformation syndromes in the past, the recent theory of primary developmental defect during blastogenesis holds good in this case.

Neonatal mechanical ventilation

OBJECTIVE

This study was undertaken to analyze indications, complications, outcome and the factors influencing neonatal mechanical ventilation.

METHODS

Prospective observational study conducted on 102 consecutive newborns, who required mechanical ventilation in a medical college tertiary neonatal care setting.

RESULTS

The commonest indication was birth asphyxia (37.3%), followed by hyaline membrane disease (HMD) (31.4%), meconium aspiration syndrome (MAS) (21.2%), septicemia (14.7%) and apnea of prematurity (5.9%). The overall survival rate in our study was 51%. Babies weighing less than 1.5 kg and less than 32 weeks of gestation had survival rates of 30% and 25% respectively. The best outcome among various indications was observed in babies with MAS (63.6%) followed by pneumonia (62.5%) and HMD (53.1%). Babies with birth asphyxia and septicemia had a low survival rate of only 42% and 40% respectively. The overall complication rate in the study was 58.8%. Common complications encountered were septicemia (42%), tube block (36%) and air leak (15%).

CONCLUSION

About half (51%) of newborns requiring mechanical ventilations for various indications survived and more than half (58.8%) developed complications. The study also reconfirms that survival rate increases with birth weight and gestational age irrespective of indication.

Rickets in osteopetrosis--a paradoxical association

Osteopetrosis is a hereditary bone disease with intense positive balance of body calcium. Infantile variety is often associated with rickets--a paradoxical association. Two siblings with osteopetro rickets are reported in the article. The pathophysiologic mechanism of the paradoxical association has been explained and various management options have been discussed. Both cases were treated with high dose calcitriol and calcium supplements.

Normal variants of skin in neonates

2221 consecutive live births taking place between March 1994 and February 1995 were evaluated for a minimum period of 5 days to note for the occurrence of various normal anatomical variants specially those of skin. Birth weight, gestational age, maternal age, socio-economic status and consanguinity were carefully recorded in all the cases. Mongolian spots (72%), Epstein pearls (43.8%), Milia (26.2%) and Erythema toxicum (25.2%), were the common dermatological variants noted. Maturity of the babies and possibly genetic factors (consanguinity) are important factors in their causation as ordered in our study.

Sydenham's chorea

OBJECTIVE

To study the clinical profile in patients with Sydenham's chorea.

DESIGN

Prospective.

SETTING

Medical college and hospital.

SUBJECTS

Sixty cases with Sydenham's chorea, between 1988 and 1994, were studied. Of these 36 were girls; the mean age at presentation was 11.1 yr (range 7-16 yr).

RESULTS

Female predominance was apparent only after 9 years of age. There was a high familial incidence for both chorea and rheumatic fever. Generalized chorea was seen in 40 and hemichorea in 20 patients. The chorea lasted from 5 to 40 days; 13 patients had recurrent episodes. Gait disturbances, dysarthria and weakness were common. Six patients had co-existing heart disease, 4 had arthritis and one had subcutaneous nodules. A raised ESR and positive ASO titer were seen in 37 and 20 patients respectively.

CONCLUSIONS

There was an increased incidence of Sydenham's chorea after 9 years of age in girls possibly suggesting the influence of female sex hormones. A high incidence of neurologic manifestations were noted. Acute phase reactants were raised in almost half the patients. Sodium valproate, whenever used, was effective in controlling the chorea.