Muscular response to the first three months of deflazacort treatment in boys with Duchenne muscular dystrophy

OBJECTIVE

Duchenne muscular dystrophy (DMD) patients are often treated with glucocorticoids; yet their precise molecular action remains unknown.

METHODS

We investigated muscle biopsies from nine boys with DMD (aged: 7,6±2,8 yrs.) collected before and after three months of deflazacort treatment and compared them to eight healthy boys (aged: 5,3±2,4 yrs.). mRNA transcripts involved in activation of satellite cells, myogenesis, regeneration, adipogenesis, muscle growth and tissue inflammation were assessed. Serum creatine kinase (CK) levels and muscle protein expression by immunohistochemistry of selected targets were also analysed.

RESULTS

Transcript levels for ADIPOQ, CD68, CDH15, FGF2, IGF1R, MYF5, MYF6, MYH8, MYOD, PAX7, and TNFα were significantly different in untreated patients vs. normal muscle (p⟨0.05). Linear tests for trend indicated that the expression levels of treated patients were approaching normal values (p⟨0.05) following treatment (towards an increase; CDH15, C-MET, DLK1, FGF2, IGF1R, MYF5, MYF6, MYOD, PAX7; towards a decrease: CD68, MYH8, TNFα). Treatment reduced CK levels (p⟨0.05), but we observed no effect on muscle protein expression.

CONCLUSIONS

This study provides insight into the molecular actions of glucocorticoids in DMD at the mRNA level, and we show that multiple regulatory pathways are influenced. This information can be important in the development of new treatments.

[Phenotypic variability in a family with genetically verified familial hemiplegic migraine type 2]

After playing handball, a 13-year-old girl developed a comatose condition during 7-10 days with hemiparesis and aphasia. From age three to nine she was treated for partial epilepsy. She never had symptoms of migraine. Her father had childhood epilepsy and at the age of 40 and 44 he experienced two attacks with prolonged coma, fever, seizures, hemiparesis and aphasia. His mother had symptoms of severe hemiplegic migraine. Father and daughter were genetically tested and an earlier described mutation in ATP1A2 gene was found. These cases illustrate the phenotypic variability in familial hemiplegic migraine type 2.

[Acute haemorrhagic oedema of infancy]

This is a case report of acute haemorrhagic oedema of infancy. An 11-month-old boy with a prolonged relapsing course within three weeks with fever and an increase in CRP necessitating antibiotic treatment. This disease is a leukocytoclastic vasculitis sharing features with Schönlein-Henoch purpura, but with a more benign self-limiting course with minimal risk of organ involvement. The characteristic distribution and appearance of the cutaneous symptoms often allows a clinical diagnosis of the condition.

[Congenital hemifacially infiltrating lipomatosis]

Congenital infiltrating lipomatosis of the face is a rare condition with congenital facial asymmetry due to localized overgrowth and accumulation of mature lipocytes. We describe a boy, followed from the age of five months to ten years, with left facial overgrowth, ipsilateral macroglossia, ptosis of the left upper lip, typical asymmetric dental eruption and regional macrodontia in the left upper gumma. The hypertrophic asymmetry was proportionally unaltered with growth. Magnetic resonance imaging confirmed diffuse fatty infiltration with overgrowth of regional bony and soft tissue structures. Intracranial structures were normal as was the boy's cognitive development.

[Ramsay Hunt syndrome in a 13-year-old boy]

We describe a formerly healthy 13-year-old boy who was admitted with symptoms of epiphora from his left eye over a period of four days and of left-sided peripheral facial palsy for one day. There was no history of trauma or tick bites. Cutaneous vesicles were observed in the ipsilateral ear. Pleocytosis was found and positive polymerase chain reaction for varicella zoster virus was obtained in samples from the vesicles and the cerebrospinal fluid. A magnetic resonance imaging confirmed neuritis of the left facial nerve. The patient was treated with a combination of aciclovir and prednisolone for ten days. On follow-up one week later, full recovery had been obtained.

[Mowat-Wilson syndrome: a report of three Danish cases]

Mowat-Wilson syndrome (MWS) is an autosomal dominant intellectual disability syndrome characterised by unique facial features and congenital anomalies such as Hirschsprung disease, congenital heart defects, corpus callosum agenesis and urinary tract anomalies. Some cases also present epilepsy, growth retardation and microcephaly. The syndrome is caused by mutations or deletions of the ZEB2 gene at chromosome 2q22-q23. MWS was first described in 1998 and until now approximately 180 cases have been reported worldwide. We report the first three molecularly confirmed Danish cases with MWS.

Reversible magnetic resonance imaging and spectroscopy abnormalities in the course of vigabatrin treatment for West syndrome

Transient magnetic resonance imaging (MRI) hyperintensity of globus pallidi, thalami, dentate nuclei and cerebral peduncles has recently been described in a significant number of young children during treatment with vigabatrin for infantile spasms. We describe two children with infantile spasms treated with vigabatrin, investigated with consecutive MRI as well as magnetic resonance spectroscopy (MRS). Hyperintensity developed during high dose vigabatrin treatment and remitted totally after dose reduction in one case, and cessation in the other. Abnormalities on MRS, suggesting an increase in the glutamine-glutamate complex in the basal ganglia, were found in both cases while on vigabatrin treatment. These changes remitted in the first case after reduction of vigabatrin dose and when seizure free and with a normalized EEG, but persisted in the second case following cessation of vigabatrin without remission of seizure activity.

[Pervasive refusal syndrome in a 12-year-old boy]

We describe a formerly healthy boy aged 12 years with a two-month history of severe coughing and abdominal pain leading to school absence. During admission he became increasingly immobilised and unable to perform activities of daily life, and finally simply adopted the foetal position and needed gastric tube feeding. Gradual restitution was achieved during a 34-month stay as an inpatient at a child psychiatric department. He fulfilled all proposed criteria of the pervasive refusal syndrome. At a follow-up at the age of 20 years, he was pursuing a normal independent life with his girlfriend and was attending higher education.

Splenectomy in two children with autoimmune lymphoproliferative syndrome and massive splenomegaly

Treatment of patients with ALPS has varied but presently there is no consensus about the optimal therapy. Splenectomy is an option but data regarding the postsplenectomy outcome in pediatric ALPS patients remain very limited. We present two children who suffered from anemia and physical discomfort from the large spleen. Both patients underwent uneventful splenectomy and experienced significant improvement in cytopenia, daily activity and well-being. Furthermore the youngest patient showed a significant catch-up growth. We conclude that in selected patients with marked splenomegaly and ALPS, splenectomy may be considered a treatment option.

Four novel PDHA1 mutations in pyruvate dehydrogenase deficiency

The pyruvate dehydrogenase (PDH) complex is a mitochondrial multienzyme that catalyses the irreversible oxidative decarboxylation of pyruvate to acetyl-CoA. We report four novel PDHA1 mutations in patients with pyruvate dehydrogenase deficiency. Analysis of PDH activity showed decreased activity in fibroblasts from all four patients, around 16-52% of mean control, similar to what has been found in previous studies. Two of the mutations were missense mutations: c.616G>A (p.Glu206Lys) and c.457A>G (p.Met153Val), one was a 3 bp in-frame deletion: c.429_431delAGG (p.Gly143del), and one was a 65 bp duplication: c.900-6_958dup65. cDNA analysis of the 65 bp duplication showed a small amount of normal transcript in addition to the transcript corresponding to the duplication. The small amount of normal transcript likely explains the survival of the patient, who was a boy. The duplication and one of the missense mutations were associated with decreased amounts of E(1)α And E(1)β protein on western blot analysis, whereas the other two mutations were associated with normal amounts. This study adds four novel mutations to the around 90 reported mutations in PDHA1 (HGMD PDHA1 mutation database). The phenotypes of patients with PDH deficiency have been divided into three groups: a neonatal form with severe lactic acidosis, a form observed only in males and characterized by episodes of ataxia with relapses associated with hyperlactataemia, and an infantile form with hypotonia, lethargy, onset of seizures or dystonia, psychomotor retardation, in some cases Leigh-like lesions and mild to moderate hyperlactataemia. The four patients reported here all belong to the latter group, which is the largest.

[Neurological symptoms and acute hepatitis associated with parvovirus B19]

The spectrum of symptoms correlated to parvovirus B19 infections has expanded greatly during the past years. We report a case of anaemia, encephalitis-like symptoms and acute hepatitis in a 15-months-old Danish girl associated with parvovirus B19, verified by positive serum IgM og IgG antibodies. She presented with non-febrile seizures and decreased level of consciousness. Later she developed signs of acute hepatitis. The course was benign.

Van der Knaap's vacuolating leukoencephalopathy: two additional cases

We present two new cases with infantile-onset megalencephaly and a characteristic magnetic resonance imaging (MRI) pattern including severe white-matter abnormalities and subcortical cysts. In one of the patients MRI at the early age of 9 months showed pronounced white matter swelling. In another patient the swelling of white matter was less pronounced at 12 years of age.

Childhood hypersensitivity pneumonitis probably caused by cat hair

A case is reported of a 10-y-old boy with hypersensitivity pneumonitis probably caused by his cat. Hypersensitivity pneumonitis caused by animal hairs is reported in furriers, but hypersensitivity pneumonitis in children has only been described as caused by birds, moulds or other fungi. Steroid treatment may interfere with the possibility of finding the causative antigen.

Recrudescence and relapse of meningococcal meningitis and septicaemia

Three cases of recrudescence and relapse of Neisseria meningitidis group B meningitis and septicaemia are reported. The recrudescence and relapses could not be explained by infectious foci, increased bacterial penicillin resistance or immunological defects. As a supplement to antibiotic treatment, all three patients received corticosteroids for the initial 2 days of treatment, and this may have contributed to the unusual course of the disease in our patient.

[Hereditary protein S deficiency and familial thrombosis. A review with description of a Danish family with protein S deficiency]

Protein S is approximately 69,000 Da polypeptide that acts as a co-factor in conjunction with activated protein C, in the natural anticoagulant system of protein C which irreversibly cleaves activated coagulation factors Va and VIIIa on the cell surface. Although synthesis of protein S takes place in several tissues, the hepatic production of protein S is presumably the most important. It has been established that heterozygous deficiency of protein S may be found in families with increased tendency to thrombosis (thrombophilia). The protein S gene, located on chromosome No. 3, consists of a translated gene, denoted PS alpha, and homologous untranslated region, designated PS beta. In inherited protein S deficiency deletions in PS alpha and PS beta have been detected. The present report deals with a Danish family with highly increased tendency to thrombosis, the propositus of which is a male who developed a large deep-vein thrombosis at the age of 18 months. In this family, nine cases with a plasma level of total protein S close to 50% of normal were identified, six of which had experienced one or more incidents of thrombosis in the past. We recommend that young patients who develop spontaneous arterial or venous thrombosis should be tested for the presence of inherited abnormalities of natural anticoagulants like antithrombin-III and proteins S and C.

Combined [99mTc]DMSA kidney scintigraphy and [131I]hippuran renography in children with urinary tract infections

Combined [99mTc]DMSA kidney scintigraphy and [131I]hippuran renography were performed consecutively in 87 children with recurrent urinary tract infections in a retrospective study. This procedure allows a description of renal cortical morphology, split function determination and run-off evaluation. Signs of cortical scarring were found in 41 of 172 kidneys (24%) and were significantly associated with vesico-ureteral reflux (p less than 0.001) and with delayed urinary run-off (p less than 0.01). Split renal function was significantly reduced in kidneys with unilateral scarring (p less than 0.001). The radio-isotope investigations and intravenous urography were performed within 3 months of each other in 56 patients (110 kidneys). Good agreement between the findings was found except for 13 kidneys, where cortical activity defects were revealed by scintiscan despite normal urography. The extended scintigraphic procedure described is considered useful for urological screening of children with urinary tract infections and may thus replace urography as a first-line investigation. It should be followed by micturition cysto-urethrography when evaluation for vesico-ureteral reflux is indicated.