A man with type III glycogenosis associated with cirrhosis and portal hypertension

Type III glycogenosis, an inherited disorder of glycogen metabolism that results from reduced or absent activity of the enzyme amylo-1,6-glycosidase (debranching enzyme), has not been frequently associated with cirrhosis and portal hypertension in adults. An adult Caucasian man with well-document type IIIa glycogenosis, who presented with a variceal hemorrhage secondary to hepatic cirrhosis, is described here. No other cause of cirrhosis was found.

Polymerase chain reaction-based detection of B-cell monoclonality in cytologic specimens

Thirty-seven cytologic cell blocks were evaluated for B-cell monoclonality by polymerase chain reaction (PCR), 16 of them cytologically positive for lymphoma, and 21 suspicious for lymphoma but morphologically nondiagnostic. Of 37 specimens, 13 (35%) showed B-cell monoclonality, including six of 16 cytologically positive samples and seven of 21 cytologically suspicious ones. Of these 13 positive samples, seven were positive using crude lysates as substrates, and six additional positive samples were identified only when DNAs were purified and concentrated. Analysis of the DNAs further revealed poor polymerase chain reaction amplifiability and low DNA yield in many samples, indicating that cell block materials are suboptimal for this assay. We concluded that B-cell monoclonality can be detected in ethanol-fixed cytologic samples, and usage of unembedded material will likely improve the sensitivity. In specimens cytologically suspicious for lymphoma, polymerase chain reaction-based identification of monoclonal B-cell population supports the diagnosis of B-cell lymphoma and is a potentially useful test in solving this diagnostic dilemma.

[Computerized tomography of liver in alveolar echinococcosis treated with albendazole]

Eleven cases of alveolar echinococcosis were examined by using computerized tomographic (CT) scanning of liver 2-7 years after long-term continuous albendazole therapy. In seven cases the hepatic lesion was almost completely calcified and cured in three cases incomplete calcification of the peripheral margin of the hepatic lesion was observed. CT scanning of the remaining in effective case showed active lesion with heterogenous hypodense areas in the liver without calcification on the peripheral margin. Long-term continuous albendazole therapy can be lethal to the parasite.

Opioids in myocardial ischaemia: potentiating effects of dynorphin on ischaemic arrhythmia, bradycardia and cardiogenic shock following coronary artery occlusion in the rat

The endogenous opioid peptide (EOP) dynorphin and opioid receptors have been found in the heart. This opioid system plays important roles in cardiovascular regulation and is involved in the pathophysiology of shock, heart failure and myocardial ischaemia. The aim of this study was to evaluate whether the EOP dynorphin modulates or potentiates ischaemia-induced arrhythmias and whether its effects are prevented by the opiate antagonist naloxone. Following coronary artery occlusion, all rats in the control group developed ischaemia-induced arrhythmias, bradycardia and hypotension, which were significantly potentiated by pre-treatment with dynorphin and attenuated by treatment with naloxone. The results clearly indicate that EOPs may be released when myocardial ischaemia occurs, thus causing arrhythmias, bradycardia and hypotension. Dynorphin and naloxone, by virtue of their opioid agonistic and antagonistic actions, respectively, potentiate and attenuate these fatal complications secondary to myocardial ischaemia. This suggests that EOPs play an important part in ischaemic heart disease.

Large, isolated, congenital aneurysm of the anterior descending coronary artery

A large congenital aneurysm, arising from the first diagonal branch of the left anterior descending artery in a 52 year old woman was diagnosed by transoesophageal echocardiography, computed tomography, and magnetic resonance imaging. Surgical closure of the aneurysm was successful.

Expression and localization of two low molecular weight GTP-binding proteins, Rab8 and Rab10, by epitope tag

Small GTP-binding proteins of the YPT/SEC4/Rab family have been shown to play an essential role in intracellular membrane trafficking. In mammals, Rab8 and Rab10 are the two small GTP-binding proteins identified so far that are closest to SEC4, an essential gene product involved in post-Golgi constitutive secretion in the yeast Saccharomyces cerevisiae. To study the localization of Rab proteins, we have expressed the cDNAs with an influenza virus hemagglutinin (HA) epitope tag at the N terminus. The feasibility of this method was tested by using yeast SEC4. HA-tagged SEC4 functionally complemented a temperature-sensitive sec4 mutant similarly to wild-type SEC4, indicating that the modified protein retained functional integrity. Monoclonal antibody 12CA5, raised against the HA tag, was used to determine the expression and localization of HA-tagged proteins after transfection. In stably transfected CHO and Swiss 3T3 cells, HA-tagged Rab8 was localized to the cell periphery, with the highest concentration in the ruffling areas. In contrast, epitope-tagged Rab10 expressed in CHO and BHK cells was concentrated on membranes in the perinuclear region. By light microscopy, the staining partially overlapped with that of a Golgi marker, beta-COP. Thus, despite the high degree homology of Rab8 and Rab10 (66% identity), the two proteins are localized to distinct cellular compartments. This approach should provide a general tool for the analyses of other members of the YPT/SEC4/rab gene family.

Pulmonary venous flow: its relationship to left atrial and mitral valve motion

The factors affecting pulmonary venous flow were studied in a group of 50 patients divided into four groups. Group 1 consisted of 14 normal subjects. Group 2 consisted of 10 patients with pure mitral stenosis and normal sinus rhythm. Group 3 consisted of 15 patients with pure mitral stenosis and atrial fibrillation. Group 4 consisted of 11 patients with atrial fibrillation alone. Pulmonary venous flow, atrial septal motion, and mitral valve flow were obtained by transesophageal echocardiography. Pulmonary wedge pressure or left atrial pressure was measured invasively in all patients. We observed that pulmonary venous flow had a reversed flow during atrial contraction and a biphasic flow in the ventricular phase. The first phase of flow occurred during ventricular systole, corresponding to the beginning of atrial relaxation. The second phase of flow, during ventricular diastole, occurred consistently after the rapid filling wave of mitral flow. The beginning of the second phase, corresponding to maximal relaxation of the atrial septum, reached a maximum corresponding to the beginning of atrial contraction. Results of the present study also indicate that decrease or absence of reversed atrial flow and decrease in the first phase of ventricular flow were noticeable in patients in Groups 2, 3, and 4. The second phase of pulmonary venous flow was significantly decreased in patients with mitral obstruction (Groups 2 and 3), but was maintained when the mitral valve was normal (Group 4). In six patients undergoing percutaneous mitral valvuloplasty, the ventricular phase of pulmonary venous flow increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of abnormal esophageal motility and gastroesophageal reflux in patients with angina-like chest pain by a radionuclide esophageal transit test

A modified radionuclide esophageal transit test including the esophageal mean transit time (MTT), residual fraction (RF) and retrograde index (RI), was carried out to evaluate esophageal motility and to detect gastroesophageal reflux in three groups: (A) 25 patients (13 males, 12 females, age: 45-65 years) with angina-like chest pain but normal coronary angiogram; (B) 31 patients (14 males, 17 females, age: 42-63 years) with coronary artery disease (CAD) demonstrated by abnormal coronary angiographic findings and intractable angina-like chest pain even after treatment; and (C) 25 normal volunteers (10 males, 15 females, age: 39-67 years). In groups A and B abnormal results were found in 60% (15/25) and 39% (12/31) for MTT; in 28% (7/25) and 39% (12/31) for RF and in 36% (9/25) and 58% (18/31) for RI (i.e., higher than the mean +/- 2 SD of normal values; MTT: 5.72 +/- SD 0.91, RF: 0.129 +/- SD 0.057, RI: 0.055 +/- SD 0.054), respectively. We conclude that the causes of non-cardiac chest pain in group A patients with normal coronary arteries were primarily esophageal dysmotility or spasm (prolonged MTT). However, in group B patients decreased pressure of the lower esophageal sphincter due to the side effects of anti-angina drugs induced delayed cleaning of the esophagus (higher RF) or gastroesophageal reflux (higher RI).

99mTc-sestamibi can improve the inferior attenuation of TL-201 myocardial spect imaging

Tl-201 myocardial scintigraphy (Tl study) tends to be attenuated by soft tissues (such as the diaphragm) due to its low energy emission. 99mTc-sestamibi (2-methoxy isobutyl isonitrile) is a relatively new agent with a higher energy emission and this characteristic accounts for the higher quality of 99mTc-sestamibi images. The purpose of this study is to evaluate the ability of 99mTc-sestamibi in alleviating the inferior attenuation of Tl studies. 99mTc-sestamibi SPECT myocardial scintigraphy was performed on 13 patients with inferior wall perfusion defects as determined by Tl study (but with normal coronary artery as evidenced by cardiac catheterization). All patients underwent Tl SPECT study using a standard procedure. Same-day protocol (rest-stress sequence) was used for 99mTc-sestamibi SPECT imaging. All images were analyzed by two independent observers. The results of our study reveal that 99mTc-sestamibi produced better images. The inferior wall perfusion defects in the T1 study were noted in one case only (1/13) in the 99mTc-sestamibi study. Our study suggests that 99mTc-sestamibi can remarkably reduce the inferior attenuation of Tl study.

Computer tomography of liver in alveolar echinococcosis treated with albendazole

Fourteen cases of alveolar echinococcosis were examined by computed tomographic (CT) scanning of the liver, including 3 cases before treatment and 11 cases 2.0-7.5 years after long-term continuous albendazole therapy. In 7 cases the hepatic lesions were almost completely calcified and cured, while in 3 cases incomplete calcification of the peripheral margin of the hepatic lesions was observed. CT scanning of the one uncured case and the 3 cases before treatment showed active lesions with heterogeneous hypodense areas in the liver without calcification on the peripheral margin. Long-term continuous albendazole therapy can result in parasitological cure with death of the parasite.

Medium-chain acyl-CoA dehydrogenase (MCAD) deficiency: diagnosis by acylcarnitine analysis in blood

Medium-chain acyl-coenzyme A dehydrogenase (MCAD) deficiency is a disorder of fatty acid catabolism, with autosomal recessive inheritance. The disease is characterized by episodic illness associated with potentially fatal hypoglycemia and has a relatively high frequency. A rapid and reliable method for the diagnosis of MCAD deficiency is highly desirable. Analysis of specific acylcarnitines was performed by isotope-dilution tandem mass spectrometry on plasma or whole blood samples from 62 patients with MCAD deficiency. Acylcarnitines were also analyzed in 42 unaffected relatives of patients with MCAD deficiency and in other groups of patients having elevated plasma C8 acylcarnitine, consisting of 32 receiving valproic acid, 9 receiving medium-chain triglyceride supplement, 4 having multiple acyl-coenzyme A dehydrogenase deficiency, and 8 others with various etiologies. Criteria for the unequivocal diagnosis of MCAD deficiency by acylcarnitine analysis are an elevated C8-acylcarnitine concentration (> 0.3 microM), a ratio of C8/C10 acylcarnitines of > 5, and lack of elevated species of chain length > C10. These criteria were not influenced by clinical state, carnitine treatment, or underlying genetic mutation, and no false-positive or false-negative results were obtained. The same criteria were also successfully applied to profiles from neonatal blood spots retrieved from the original Guthrie cards of eight patients. Diagnosis of MCAD deficiency can therefore be made reliably through the analysis of acylcarnitines in blood, including presymptomatic neonatal recognition. Tandem mass spectrometry is a convenient method for fast and accurate determination of all relevant acylcarnitine species.

[Experimental and clinical study on cryptosporidiasis. III. Ultrastructural observation on Cryptosporidium in immunosuppressed mice]

The ultrastructure of Cryptosporidium parvum, which parasitized on the surface of the intestine of the immunosuppressed mice, was studied by transmission electron microscopy. The parasite was enveloped by the parasitophorous vacuole developed from the host epithelial cell. An electron dense band was found at the attachment site between the Cryptosporidium and the host cell. At the attachment site, the cytoplasma membrane of Cryptosporidium appeared in the form of many membranous folds, and contacted closely with the plasma membrane of the epithelial cell. Rhoptry-like structure and small electron dense granules were found in the merozoite, but their effects on the development of Cryptosporidium are still unknown (Figs. 1-5).

Type I glycogen storage disease: nine years of management with cornstarch

Long-term effects of cornstarch (CS) therapy on biochemical values and physical growth in children with type I glycogen storage disease (GSD I) were compared to those of children receiving continuous nocturnal nasogastric glucose feedings (CNG). Only patients who had received more than 5 years of dietary therapy (either CS or CNG) were evaluated. Six patients (five female, age 13.5 years +/- 1.3, range 11.7-16.5 years) received CS (1.75-2.5 g/kg, four times daily) and seven patients (five female, age 9.6 +/- 2.5 years, range 7.3-14.8 years) received CNG. Blood glucose, lactate, cholesterol and triglyceride levels were not significantly different between the two methods of treatment. All patients maintained linear growth rates normal for their age. The standard deviation score of height after 6.7 +/- 1.6 years (range 5-9 years) of CS treatment was -1.29 +/- 0.59 and after 8.8 +/- 2.4 years (range 7-14 years) of CNG was -1.24 +/- 0.63. These values did not differ significantly from each other or from the target height, an estimate of genetic potential for height as determined from parental heights. With the exceptions of diarrhea, increased flatulence and excess weight gain, there were no adverse effects of CS after 9 years of treatment. Our data suggests that cornstarch is a simple, effective and safe therapy for GSD I.

Beneficial effects of the opiate antagonist naloxone on hemodynamics and ventricular function following coronary artery occlusion and reperfusion in the dog

It has been shown that endogenous opioid peptides (EOP) subserve important roles in cardiovascular regulation and are involved in the pathophysiology of myocardial ischemia, contributing to the deleterious effects. The aim of this study was to evaluate the effects of the opiate antagonist naloxone on the hemodynamics and ventricular function following coronary artery occlusion and reperfusion in the dog, utilizing the technique of cardiac catheterization. During myocardial ischemia and reperfusion, it was found that in the control group, there was reduction in the aortic, left ventricular, right atrial, pulmonary arterial and wedge pressures, and in the left ventricular dP/dt. The reduction in the aortic, left ventricular and pulmonary arterial pressures, and left ventricular dP/dt were significantly attenuated by pretreatment with naloxone. The results indicate a regulatory role of EOP in the cardiovascular function and suggest a possible involvement of EOP in myocardial ischemia and reperfusion causing detrimental effects such as arrhythmias, bradycardia, hypotension and, as shown in this study, impaired hemodynamics and ventricular function. The beneficial effects of naloxone on circulatory dynamics may have clinical implications in the prevention and treatment of ischemic heart disease.

[Continuous albendazole therapy in alveolar echinococcosis--evaluation of therapeutic effect with computerized tomography and ultrasonography]

Fifteen cases of alveolar echinococcosis were treated with albendazole in a dosage of 20 mg/kg/d x 30 days for 12-60 courses (25.8 courses in average) and were followed up 1-7 years (48 months in average) with computerized tomography and ultrasonography. Abdominal pain in all the cases, jaundice in 4 and hemoptysis in disappeared 2. In 13 of the 15 cases, the hepatic lesions reduced in size. Among 9 cases examined with computerized tomography, the hepatic lesions were completely calcified in 5 and enclosed with calcified walls in 3. Only one patient with huge and extensive hepatic lesions showed no apparent improvement. No severe adverse reaction was observed. Evidently albendazole was effective in the treatment of alveolar echinococcosis.

Unbalanced translocation 46,XY,-15,+der(22)t(15;22)(q13;q11)pat: case report and review of the literature

We present a boy with a rare unbalanced translocation 46,XY,-15,+der(22),t(15;22)(q13;q11) pat. Previous reports of similar chromosome findings mention only the Prader-Willi phenotype. At birth, his manifestations included severe hypotonia and lethargy, (typical of deletion of 15pter----q13); hypertelorism, down-slanting small palpebral fissures, preauricular tags, long philtrum (typical of duplication of 22pter----q11); severe laryngotracheomalacia, and proximal implantation of the thumb. In a review of the literature on chromosome abnormalities involving duplication of 22q11 the associated clinical phenotype consists of mild mental retardation, microcephaly, hypotonia, hypertelorism, down-slanting palpebral fissures, a long philtrum, cleft or highly arched palate, and ear abnormalities. Preauricular pits or tags are common. Cardiovascular defects, renal and genital problems and dislocated hips are frequently present. Anal atresia and colobomata are mainly seen in cat-eye syndrome, the phenotype associated with idic 22q11. Our findings indicate that patients with unbalanced t(15;22) can have manifestations of the dup 22q11, in addition to the previously reported Prader-Willi phenotype, even if the duplicated segment is small.

Pericardiocentesis: a 20 patients study

Emergency pericardiocentesis, guided by a two-dimensional echocardiography, was performed on twenty patients with symptomatic pericardial effusion of various types and causes. There were fourteen men and six women. The underlying causes were: primary lung cancer (6 cases), metastatic cardiac tumors (3 cases), tuberculosis (4 cases), complicated interventional procedures with cardiac chamber or vessel perforations (2 cases), dissecting aortic aneurysm (1 case), systemic lupus erythematous (1 case), idiopathic pericarditis (1 case), bacterial pericarditis (1 case), and myxedema heart disease (1 case). Seventeen cases were performed through the left xipho-sternal approach and 3 cases through the apical approach. None of the patients died as a result of these procedures. A two-dimensional echocardiogram is useful in diagnosing cardiac tamponade as well as in guiding pericardiocentesis, and obtaines highly positive results (20/20). The positive rate of pericardial fluid cytology for malignant cells was 89% (8/9), however, pericardial fluid cultures or direct smear for tuberculosis were negative (0/4). In cancer patients, the mean survival time following pericardiocentesis was 4.2 months (range, 1-7.8 months). We concluded that neoplastic involvement of the pericardium is the most frequent cause of symptomatic pericardial effusion. Pericardiocentesis assisted by a two-dimensional echocardiogram is safe and easy. In addition, pericarditis caused by TB is still significant and must be considered in every case in our nation.

Naloxone reversal of ischemic arrhythmia is stereospecific and suggests role of endogenous opioid peptides in ischemic heart disease

The effects of the stereoisomers of naloxone during myocardial ischemia were studied. (-)-Naloxone (but not the (+)-isomer naloxone) attenuated the ischemia-induced cardiac arrhythmias, hypotension, and bradycardia that result from coronary artery occlusion in anesthetized rats. From these findings, it may be inferred that endogenous opioid peptides may play a role in the pathophysiology of myocardial ischemia. It is also suggested that naloxone may have therapeutic value in the prevention and treatment of ischemic heart disease.

Assignment of the human glycogen debrancher gene to chromosome 1p21

Glycogen debranching enzyme is a monomeric protein containing two independent catalytic activities of glycantransferase and glucosidase that are both required for glycogen degradation. Its deficiency causes type III glycogen storage disease. A majority of the patients with this disease have deficient enzyme activity in both liver and muscle (type IIIa) but approximately 15% of them lack enzyme activity only in the liver (type IIIb); however, the enzyme is a monomer and appears to be identical in all the tissues. The cDNA coding for the complete human muscle debranching enzyme has recently been isolated. Using the cDNA clones, the debrancher gene was localized to human chromosome 1 by somatic cell hybrid analysis. Regional assignment to chromosome band 1p21 was determined by in situ hybridization. Mapping of the debrancher gene to a single chromosome site is consistent with our hypotheses that a single gene encodes both liver and muscle debrancher protein.

Transesophageal echocardiography in adults with a continuous precordial murmur

In order to assess the ability of echocardiography in the detection of intracardiac and extracardiac shunts, we studied 11 patients (aged 22-64 yr) with a continuous precordial murmur using transthoracic and transesophageal echocardiography, and correlated the results with the subsequent angiographic and surgical findings. We found that only in 5 of 6 patients with a patent arterial duct could the continuous flow pattern be detected in pulmonary artery using transthoracic echocardiography, whereas it could be readily and accurately identified by transesophageal echocardiography in all patients. The diameters of the patent arterial duct were also measured and found to be in good correlation with subsequent surgical findings (r = 0.98, p less than 0.05). In 2 patients with a ruptured aneurysm of sinus of Valsalva which originated from the right coronary sinus and perforated into the right ventricle, transesophageal echocardiography gave a better image than transthoracic echocardiography. In 2 patients with coronary artery fistula, the origin and site of drainage of the coronary artery could be imaged using transesophageal echocardiography, but the course of coronary artery fistula was more easily detected by transthoracic echocardiography. In one patient with aortopulmonary window, the defect between ascending aorta and main pulmonary artery could readily be imaged by transesophageal echocardiography. We therefore recommend transesophageal echocardiography when evaluating patients with precordial continuous murmur in whom intracardiac and extracardiac shunts or defects are suspected.

Glycogen storage disease type III (glycogen debranching enzyme deficiency): correlation of biochemical defects with myopathy and cardiomyopathy

OBJECTIVE

To determine whether a specific subtype of glycogen storage disease type III is associated with myopathy and cardiomyopathy.

DESIGN

Case series.

SETTING

Three referral medical centers.

PATIENTS

All patients with glycogen storage disease type III who were followed in 1990 and for whom both immunoblot analysis and clinical data were available.

MAIN OUTCOME MEASURES

Evaluation for myopathy and cardiomyopathy included determinations of serum creatine kinase activity; muscle strength testing; ischemic exercise testing; nerve conduction studies; and electromyographic, electrocardiographic, and echocardiographic studies.

RESULTS

Three patients with deficient debranching enzyme activity and deficient immunoreactive material in liver but normal debranching enzyme activity in muscle (glycogen storage disease IIIb) had no clinical evidence of myopathy or cardiomyopathy. Serum creatine kinase activity, muscle strength, ischemic exercise testing, electrocardiograms, and echocardiograms were normal in these patients. These studies and electromyograms were abnormal in seven patients with total debranching enzyme deficiency and an absence of immunoreactive material in both liver and muscle (glycogen storage disease IIIa) and in three patients who had debranching enzyme transferase deficiency but normal glucosidase activity in both liver and muscle (glycogen storage disease IIId). All 10 of these patients had progressive myopathy, and 6 had progressive cardiomyopathy.

CONCLUSION

Clinical features of glycogen storage disease type III correlate with the particular biochemical defect seen with the disorder. Assessments of debranching enzyme or debranching enzyme transferase activity in muscle can be used to predict whether patients with glycogen storage disease type III will develop myopathy and cardiomyopathy.

Molecular cloning and nucleotide sequence of cDNA encoding human muscle glycogen debranching enzyme

cDNA comprising the entire length of the human muscle glycogen debranching enzyme was cloned and its nucleotide sequence determined. The debrancher mRNA includes a 4545-base pair coding region and a 2371-base pair 3'-nontranslated region. The calculated molecular mass of the debrancher protein derived from cDNA sequence is 172,614 daltons, consistent with the estimated size of purified protein (Mr 165,000 +/- 500). A partial amino acid sequence (13 internal tryptic peptides with a total of 213 residues) determined on peptides derived from purified porcine muscle debrancher protein confirmed the identity of the cDNA clone. Comparison of the amino acid sequence predicted from the human glycogen debrancher cDNA with the partial protein sequence of the porcine debrancher revealed a high degree (88%) of interspecies sequence identity. RNA blot analysis showed that debrancher mRNA in human muscle, lymphoblastoid cells, and in porcine muscle are all similar in size (approximately 7 kilobases). Two patients with inherited debrancher deficiency had a reduced level of debrancher mRNA, whereas two other patients had no detectable abnormality in RNA blots. The isolation of the debrancher cDNA and determination of its primary structure is an important step toward defining the structure-function relationship of this multifunctional enzyme and in understanding the molecular basis of the type III glycogen storage disease.