The autosomal dominant polycystic kidney disease gene in a Jewish family from Uzbekistan is PKD1

A large Jewish family from Tashkent (Uzbekistan) was studied for linkage of autosomal dominant polycystic kidney disease (ADPKD) to molecular markers on the short arm of chromosome 16. A restriction fragment length polymorphism (RFLP) analysis was performed on 28 family members, including 9 ADPKD diagnosed patients in 3 consecutive generations. A specific haplotype was found to segregate with the disease in eight of the nine affected individuals. The peak lod scores for linkage between the disease phenotype and the five informative flanking markers were: 3'HVR 1.70 at theta = 0.08; GGG1 1.18 at theta = 0.001; CMM65 1.50 at theta = 0.001; 26-6 0.86 at theta = 0.001 and 218EP6 1.39 at theta = 0.001. A particular haplotype of these markers segregated with the disease phenotype. The peak lod score of this haplotype was 3.046. Homogeneity test, comparing this family to 40 PKD European families, showed that the conditional probability that it belongs to the same group is 1.000. Taken together, these findings show that the defective gene in this Jewish family from Uzbekistan is PKD1. To our knowledge, this is the first ADPKD family in Israel in whom linkage studies were performed and one of the few originating from populations outside the Western world.

Reason for referrals among military primary care physicians

In order to assess the reasons for high referral rates to secondary medical care services in the Israel Defence Force-Medical Corps, we conducted a study in which 28 physicians in five primary care clinics took part. Seven hundred thirty-seven patients were referred to specialists. The referral reasons were learned from questionnaires filled in for each of these patients. The study shows that factors related to the physicians are important in determining when referral is made: Israeli medical graduates showed less confidence than their peer graduates outside of Israel. A possible explanation is that the Israeli graduates are better prepared for working in a scientific, sophisticated medical environment rather than the ambulatory primary care environment.

Hereditary ovarian cancer: a dilemma in prognosis

Five women in three generations developed ovarian cancer. We closely monitored 36 descendent women in this family who were at high risk for developing this disease. Prophylactic oophorectomy is considered the optimal way to prevent the development of ovarian cancer. In the light of the young age of the women at risk and their strong objection to oophorectomy, we closely monitored the examinees for early signs of cancer for more than 5 years. None of them developed cancer. The dilemma in treatment of women at risk is discussed.

Hypodipsic hypernatremia and hypertriglyceridemia associated with cleft lip and cleft palate: a new hypothalamic dysfunction syndrome?

We report on a 4-month-old girl with congenital hypodipsic hypernatremia resulting from decreased sensitivity of the hypothalamic osmoreceptors with increased tonicity in association with hyperlipemia and cleft lip and cleft palate. We postulate that the link among these various derangements is hypothalamic dysfunction.

Transport into brain of buthionine sulfoximine, an inhibitor of glutathione synthesis, is facilitated by esterification and administration of dimethylsulfoxide

Buthionine sulfoximine (BSO), an inhibitor of glutathione synthesis, is poorly transported into the brain of adult mice, and only a slight decrease (approximately 10%) in the level of brain glutathione is found 30-60 min after intraperitoneal administration of BSO. When BSO is given as the ethyl ester, the brain level of BSO increases substantially after 5-15 min, and the glutathione level decreases by about 25% after 30-60 min. When BSO or its ester is given in 15% dimethylsulfoxide solution the brain levels of BSO are increased significantly and the brain glutathione levels are decreased by 20-35%. These observations suggest procedures that may be useful in decreasing the glutathione levels of the brains of adult animals. The finding that administration of BSO ethyl ester led to about a 25% decrease in the brain level of glutathione within 15 min suggests that a fraction of brain glutathione turns over very rapidly and may therefore be of special physiological significance.

Doxycycline prophylaxis for shigellosis

The efficacy of oral doxycycline, 100 mg/d for 14 days, in reducing the incidence of shigellosis in newcomers to an area hyperendemic for the disease was examined in a double-blind, placebo-controlled trial. Of 107 entrants, 100 completed the study; 50 received the drug and 50 received a placebo. Diarrheal disease and associated symptoms were monitored for 8 weeks. Starting on the 3rd day of the trial, an outbreak was observed, and Shigella flexneri type 2a was isolated from 6 subjects. Eight of the subjects in the treatment group had diarrhea (16%) compared with 37 in the placebo group (74%), providing a 79% protection rate. There was no significant difference in the occurrence of accompanying symptoms between the subjects suffering from diarrhea in both groups, but the duration of disease was shorter in the treatment group. Serologic study of the outbreak showed no significant difference in antibody response to S flexneri between the treatment (14 of 43) and placebo (18 of 39) groups. Doxycycline prophylaxis apparently is effective and probably does not prevent subclinical infection.

Glutathione ester prevents buthionine sulfoximine-induced cataracts and lens epithelial cell damage

Treatment of newborn rats and mice with buthionine sulfoximine, an inhibitor of glutathione synthesis, leads to development of cataracts, which are not prevented by treatment with glutathione, but they are prevented by treatment with glutathione monoester. Cataracts are associated with glutathione deficiency in the lens epithelium, which undergoes severe degeneration. The findings indicate that glutathione normally functions in the protection of the lens and lens epithelium against oxidative injury, suggesting that procedures that increase lens glutathione levels might be useful for prevention of other types of cataracts. Relatively low doses of buthionine sulfoximine produce cataracts in newborn animals, and treatment of pregnant mice with buthionine sulfoximine during the last part of gestation leads to cataract formation in the offspring. The high sensitivity of the developing lens to the effects of glutathione deficiency suggests that this tissue may be a useful model for studies on glutathione function.

Ultrastructural abnormalities in endoscopically and histologically normal and involved colon in ulcerative colitis

Twenty colonoscopies (eight complete or almost complete; 12 short) were carried out on 15 patients with ulcerative colitis with the aim of comparing the endoscopic aspects with the light and electron microscopic features in biopsies taken from multiple sites. Patients with severe attacks were examined without prior preparation (two examinations). When the attack was mild to moderate (11 examinations), or the patient was in remission (seven examinations), two saline enemas were given up to 1 h before examination. There was a favorable correlation between the endoscopic and light microscopic features in 94.7% of the biopsies (total number of biopsies, 76). The electron microscope findings greatly exceeded those observed by light microscope and indicated that the major abnormality resides within the colonic epithelial cells. Distinctive ultrastructural changes were present both in apparently uninvolved (endoscopically and histologically) parts of colon and in inactive stages of ulcerative colitis. These findings suggest that colonic mucosal involvement may be universal, persist during clinical remission, and precede the light microscopic findings. They also support the importance of maintenance therapy.

Failure of etretinate therapy in twins with severe congenital lamellar ichthyosis

We cared for twin females with severe lamellar exfoliation of the newborn (collodion babies) and a family history of death of two brothers at age 3 months. The twins were given a controlled trial of etretinate (Ro 10-9359, Tigason) after not responding to other therapeutic modalities. One of the infants received 1 mg/kg body weight of the drug for 24 hours, while her identical twin sister did not have the medication. Monthly skin biopsies taken from both patients during nine months of therapy did not demonstrate any histologic difference under light microscopy. The clinical course in both infants was basically the same. Etretinate plasma level measurements proved that the drug was absorbed from the gastrointestinal tract. We conclude that in the very severe forms of congenital lamellar ichthyosis, oral retinoids may fail to produce any beneficial effects.

Gastrointestinal abnormalities in the syndrome of mosaic trisomy 9

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Hydrocortisone resolves persistent neonatal jaundice in multiple hormone deficiencies

Association of prolonged neonatal cholestasis with hypoglycemia, small penis and congenital hypothalamo-hypopituitary derangement is presented. The infant's jaundice was unresponsive to thyroxine replacement therapy but resolved rapidly with hydrocortisone therapy. The time relationships between persistent jaundice and thyroxine and cortisol deficiencies are discussed.

Hyperkalemia as a late side effect of prolonged adrenocorticotropic hormone therapy for infantile spasms

Two infants developed hyperkalemia shortly after cessation of prolonged ACTH therapy for infantile spasms. We wish to call for cautious approach at time of cessation of prolonged ACTH therapy because of possible unexpected and only partially understood hazardous side effects such as hyperkalemia.

Noonan's syndrome and neurofibromatosis

A child with Noonan syndrome and multiple cafe au lait spots, compatible in size and number with von Recklinghausen's neurofibromatosis, is presented. These features may represent a distinct genetic entity rather than the coincidence of two diseases.

Adenovirus type 3 infection with systemic manifestation in apparently normal children

Between July 1983 and February 1984, eight children with adenovirus Type 3 infection, proven by virus isolation from sputum, stool or nasopharyngeal swabs and a fourfold increase in complement fixation antibody titers against the virus, were treated in our department. All eight patients had fever lasting at least 7 days, hepatomegaly, diffuse pulmonary infiltrates and abnormal liver function tests. Seven of the patients exhibited dyspnea and pulmonary wheezing. Six of the patients developed changes in state of consciousness, and three had repeated convulsions. EEG patterns in three of the patients were compatible with encephalopathy. Other clinical manifestations included: follicular tonsillitis in two patients, diarrhea in two, pneumothorax in one, and shock with disseminated intravascular coagulation in one. The spectrum of adenovirus Type 3 infection reported here has been described previously only in the viral hemorrhagic fevers. This adenovirus Type 3 infection shares the potential for disseminated disease that has been described previously for Type 7, simulating Reye's syndrome.

Acute dystonic reaction to bethanechol--a direct acetylcholine receptor agonist

Bethanechol is a direct agonist of the acetylcholine receptor that was recently introduced in the therapy of gastro-oesophageal reflux. Acute dystonic reactions to bethanechol were observed in a 10-month-old infant who also demonstrated similar dystonic reactions to dopamine receptor blocking agents of two different classes. This first report of acute dystonic reaction to cholinergic agonists in human is in accord with the current theories of the rôle of acetylcholine and dopamine in the pathogenesis of acute dystonic reactions.

Interstitial 7q deletion [46,XY,del (7) (pter----cen::q112----qter)] in a retarded quadriplegic boy with normal beta glucuronidase

A 14-year-old severely retarded male with deletion of chromosomal band 7 cen----q112 is described. Clinical features include short stature, microcephaly, unusual facies with narrow forehead, short nose, malar hypoplasia, protruding alveolar ridges and incisors, receding chin, relatively long philtrum, and large ears. In addition, he had bilateral inguinal herniae cryptorchidism with hypogonadism, pulmonic stenosis, and spastic quadriplegia. Normal activity of beta-glucuronidase was found in the patient's leukocytes. This finding suggests that the gene is not in the deleted region, narrowing the smallest region of overlap to 7q112----q22.

Possible Waardenburg syndrome with gastrointestinal anomalies

We describe a patient with possible Waardenburg syndrome associated with anal atresia and oesophageal atresia with tracheooesophageal fistula. Three other published cases with atretic gastrointestinal anomalies associated with the Waardenburg syndrome are reviewed. We conclude that the association between atretic lesions of the gastrointestinal tract and the Waardenburg syndrome may be a significant one.

Elevated serum calcitriol concentrations do not fall in response to hyperphosphatemia in familial tumoral calcinosis

Five affected members in two branches of a Druze Arab kindred presented with calcified deposits in or about the hips and knees, indicating the diagnosis of tumoral calcinosis. Serum vitamin D metabolite concentrations, immunoreactive parathyroid hormone, and the tubular reabsorption of phosphate were measured in three affected siblings, as well as in their parents and an unaffected sibling. Normocalcemia and hyperphosphatemia with an elevated tubular maximum for phosphate per glomerular filtration rate were found in the affected patients. Levels of serum immunoreactive parathyroid hormone were normal, and the calcitriol value (1,25-dihydroxyvitamin D) was normal or elevated in the three affected patients. A trial of a low-phosphorus diet and oral aluminum hydroxide gel did not lower serum phosphate levels or improve the calcified deposits. These findings suggest that serum calcitriol values do not decline in response to hyperphosphatemia in tumoral calcinosis and that hyperphosphatemia with elevated tubular reabsorption of phosphate is a constant feature of this disorder because the kidney fails to excrete the increased filtered load of phosphate.

Cross resistance to esters of methotrexate in a doxorubicin-resistant subline of P388 murine leukemia

Resistance to methotrexate was developed by continuous exposure of P388 murine leukemia cells in vitro to increasing concentrations of methotrexate up to 1 X 10(-7) M. Once established, the resistance to methotrexate was stable. This was also found in methotrexate-resistant cells that were maintained in methotrexate-free medium for more than 4 months. The sensitivity of the methotrexate-resistant P388 cells to doxorubicin was comparable to the sensitivity measured in the parental cell line. Another methotrexate-resistant cell line was developed, in a similar way, from doxorubicin-resistant P388 cells. This methotrexate-resistant cell line maintained its original resistance to doxorubicin. In methotrexate-sensitive cells, the dimethyl and dibutyl esters of methotrexate were 18.3- and 2.7-fold less active, respectively, than the free methotrexate in inhibiting cell growth. In methotrexate-resistant cells, the inhibitory effect of the methotrexate dimethyl ester was similar to its effect on the methotrexate-sensitive cell line. The activity of the methotrexate dibutyl ester was 3.3-fold lower than its activity in the parental cell line. However, both esters of methotrexate were much more active than free methotrexate in the methotrexate-resistant cell line. In the doxorubicin-resistant cell line, the activity of free methotrexate was comparable to its activity in the doxorubicin-sensitive parent cell line. However, this cell line was remarkably resistant to the ester analogs of methotrexate. The clinical implications of these findings are discussed.

A comparison of insulin receptors in the developing fetal lung in normal and in streptozotocin-induced diabetic pregnancies

Insulin receptors from fetal rat lungs of normal and streptozotocin-induced diabetic pregnancies were examined for their binding capacities and association constants. Sprague-Dawley rats, given a single dose of streptozotocin at 7 days' gestation, became hypoinsulinemic and hyperglycemic within 48 hours, although they remained healthy enough to carry fetuses to term. The fetuses of the streptozotocin-treated pregnancies had hyperglycemia (3,750 +/- 400 micrograms glucose/ml vs 390 +/- glucose/ml for control subjects), but were not hyperinsulinemic. Insulin receptor binding capacities of fetal lungs from control pregnancies increased as a function of gestational age from 16 to 21 days. Receptor binding capacities of lungs from streptozotocin-treated pregnancies also increased with gestational age until 21 days, when they dropped to 50% of control values. It was demonstrated in organ culture that fetal lung receptors from normal pregnancies of 20 days' gestation could be down-regulated in the presence of insulin and that this down-regulation is coupled to a biologic effect of insulin, hexose transport. It was concluded that fetal lung insulin receptors can be regulated by insulin concentrations in vitro and by experimental diabetic pregnancies in vivo.

X-linked lymphoproliferative syndrome. A new kindred with variable phenotypic expression

A kindred with five affected maternally related male members showed variable phenotypic expression of the X-linked lymphoproliferative syndrome. In one of the children, agammaglobulinemia developed following infectious mononucleosis. His brother had aplastic anemia in infancy and 21/2 years later died of overwhelming pneumonia resulting from ornithosis. A third brother died of reticulum cell sarcoma. Two maternally related male cousins died of reticulum cell sarcoma of the neck.

Cystine accumulation and clearance in normal and cystinotic fibroblasts exposed to cystine dimethyl ester

Exposure of cultured skin fibroblasts of normals and cystinotic patients to 0.5 mmol/l[35S]cystine dimethyl ester for 30 min resulted in an accumulation of cystine in excess to that naturally occurring in cystinotic skin fibroblasts. These equal levels of cystine accumulation achieved in both cystinotic and normal cells, permitted comparative experiments to look for differences in cystine disposal between normal and cystinotic cells. Cystinotic fibroblasts demonstrated very low cystine clearance with a lower ratio of cysteine-N-ethylmaleimide to cystine than normal. The results on cystinotic fibroblasts are consistent with those observed in leucocytes, suggesting that fibroblasts can be useful in further studies to elucidate the clearance defect of cystine in cystinosis as well as its potential in antenatal diagnosis.

Hypernatremic dehydration as a sign leading to the diagnosis of glucose-galactose malabsorption in breast-fed neonates

Hypernatremic dehydration is described in a case of a breast-fed infant with glucose-galactose malabsorption. Hypernatremic dehydration in general is uncommon in normal breast-fed infants. The finding of hypernatremic dehydration in breast-fed infants with watery diarrhea and sugar in the stool should lead to the consideration of monosaccharide intolerance such as glucose-galactose malabsorption.

Comparative study of cystine clearance in cystinotic and I-cell fibroblasts upon exposure to cystine dimethyl ester

I-cell fibroblasts can accumulate cystine at levels comparable to those seen in homozygous cystinotic fibroblasts. Cystine accumulation in cystinosis is accounted for cystine clearance defect in situ. To unravel the question whether the same clearance defect or two different mechanisms cause cystine accumulation in I-cell disease, we used the cystine loading technique upon exposure of skin fibroblasts to radioactive cystine dimethyl ester. Normal, cystinotic and I-cell fibroblasts were exposed to radioactive cystine dimethyl ester, and the clearance of the generated radioactive cystine was measured. Cystinotic cells showed a marked defect in cystine clearance in situ, as compared to normal fibroblasts. In I-cell fibroblasts, we observed slow hydrolysis of cystine dimethyl ester to cystine, indicating low esterase activity, but no defect in clearance of the generated cystine. Cysteine production from the exogenous cystine dimethyl ester, presumably by cytoplasmic hydrolysis of the generated cystine, is normal in I-cell fibroblasts. Thus, our results indicate that, unlike cystinosis, there is no cystine clearance defect in situ for cystine in I-cell disease, and probably unrelated mechanisms cause cystine storage in cystinosis and I-cell disease.

Effects of cysteamine and other thiols on cystine egress from isolated lysosome-rich fractions of cystinotic and normal leucocytes

After loading isolated normal and cystinotic white blood cell lysosomes with radioactive amino acid methyl esters, egress of the corresponding amino acids was measured in the presence or absence of reducing agents. Cysteamine greatly enhanced disposal of cystine- and, to a lesser extent, cysteine-loaded lysosomes, resulting in final similar rates of radioactive clearance. Cysteamine did not alter leucine egress. Cysteamine comparably accelerated cystine egress from normal and cystinotic lysosomes. Reduced glutathione, ascorbic acid, coenzyme A and acetylcoenzyme A, which are much less effective cystine-depleting agents on intact cystinotic cells than cysteamine, failed to increase egress rates from isolated lysosomes loaded with cystine. We believe this in vitro system can help in the future in evaluating drug efficacy in reducing cystine content in cystinotics in addition to the already existing tissue culture technique.

Cystine accumulation and clearance by normal and cystinotic leukocytes exposed to cystine dimethyl ester

Upon exposure to 0.25 mM cystine dimethyl ester, normal and cystinotic leukocytes accumulate substantially more intracellular cystine than is present endogenously in cystinotic cells. Leukocytes loaded by exposure to cystine dimethyl ester may have abnormally lucent and distended lysosomes, and the cystine is compartmentalized within the granular fraction of the cells. After the cells are exposed to cystine dimethyl ester, cystine clearance from normal leukocytes is much faster than from cystinotic cells. The ratios of labeled cysteine-N-ethylmaleimide to cystine are also greater in normals than in cystinotics 60 min after termination of loading. No overlap in ranges of cystine clearance half-times or cystine-N-ethylmaleimide to cystine ratios was observed in normal compared to cystinotic leukocytes. Limited experiments with fibroblasts exposed to cystine dimethyl ester suggest a correspondingly prolonged cystine clearance for cystinotic cells. These experiments provide evidence for defective clearance of cystine from cystinotic lysosomes in situ.

Patterns of amino acid efflux from isolated normal and cystinotic human leucocyte lysosomes

This study describes the first direct measurements of amino acid efflux from human lysosomes. Isolated leucocyte lysosomes can be loaded with radioactive amino acids by exposure to low concentrations of the corresponding labeled amino acid methyl esters. Efflux of amino acid from the loaded lysosomes can then be determined. Conditions during loading are adjusted for each ester to permit its adequate intralysosomal hydrolysis and subsequent accumulation of the free amino acid. Relative rates of efflux were leucine approximately equal to phenylalanine greater than methionine greater than tryptophan much greater than cystine. Efflux of leucine, tryptophan, or cystine was independent of exogenous cation, ATP, or amino acid concentrations under the conditions tested. Leucine efflux was similar in normal and cystinotic lysosomes, providing strong evidence that isolated cystinotic lysosomes do not manifest a generalized defect in amino acid efflux. In both normal and cystinotic lysosomes, cystine efflux was much slower than efflux of leucine or other amino acids from human or rat liver lysosomes. Significant differences in mean cystine efflux between isolated normal and cystinotic lysosomes were not apparent in the present test system, although the possibility of differences in rats could not be excluded.

Association of certain human leukocyte antigens with nephropathic cystinosis in the absence of linkage between these loci

The HLA phenotypes of 41 patients (22 males and 19 females) with classical nephropathic cystinosis were analyzed and compared with those reported from a control group of 1,465 Americans of Caucasian origin. There was a significantly increased association of cystinosis with HLA B7, and a reduced association with A9. The calculated A3B7 and A1B7 haplotypes were also significantly increased in cystinosis. Lod score analysis of five families indicated that linkage between the gene(s) for cystinosis and the HLA loci is unlikely. While associations of other genetic diseases with specific HLA types should be sought, such relationships, as documented here, do not imply true genetic linkage.

Reduced chronic hemolysis during high-dose vitamin E administration in Mediterranean-type glucose-6-phosphate dehydrogenase deficiency

The observation that high-dose oral vitamin E supplementation (800 IU per day) improved red-cell survival in two rare disorders associated with increased red-cell susceptibility to oxidative stress prompted a similar trial in 23 patients with Mediterranean glucose-6-phosphate dehydrogenase (G6PD) deficiency. Three months of vitamin E administration resulted in decreased chronic hemolysis as evidenced by improved red-cell life span (P less than 0.025), with an improvement in red-cell half-life from 22.9 +/- 0.7 days to 25.1 +/- 0.6 days (mean +/- S.E.M.), increased hemoglobin concentration (P less than 0.001), and decreased reticulocytosis (P less than 0.001) as compared with base-line values. Evaluation after one year of vitamin E administration demonstrated sustained improvement in all these indexes. Controlled clinical trials of vitamin E supplementation may be warranted to examine its efficacy in ameliorating acute hemolytic crises or in reducing morbidity from neonatal jaundice in this relatively common genetic disorder.

The radiographic manifestations of bone changes in copper deficiency

The bone changes in infants with copper deficiency are typified by osteopenia and the symmetrical appearance of sickle-shaped metaphyseal spurs. Four examples are demonstrated and the differential diagnosis is extensively discussed.