Clinical and biochemical consequences of copper-histidine therapy in Menkes disease

Menkes disease (MD) is an X-linked recessively inherited neurodegenerative disorder of copper (Cu) metabolism leading to death in early childhood. Symptoms are attributed to deficient activity of Cu-dependent enzymes. Limited experience has been reported concerning clinical and biochemical consequences of parenteral treatment with copper-(histidine)2-complex (Cu-His) in MD. Cu-His was administered in a 13-week-old boy with MD by daily intramuscular injections. After 6 weeks of therapy, Cu and caeruloplasmin in serum and Cu in CSF were normalized. The excessive dopamine level in CSF was corrected after 3 months of treatment. After 6 weeks of Cu supplementation, complete reduction of epileptic discharges, improved muscular tone and increased motor activities were observed. Developmental regression stopped and was replaced by a slight progression. Death at the age of 19 months was caused by septicaemia due to a fulminant urinary tract infection; there was no evidence of chronic Cu toxicity. These findings suggest that Cu-His supplementation may be a promising palliative treatment in MD.

[Neonatal diabetes mellitus and microcephaly. Indications for autosomal recessive inheritance]

Still, there are a lot of questions about the pathogenesis of neonatal diabetes mellitus. In the author's opinion neonatal diabetes mellitus is a distinct entity which differs from the well-known types of diabetes in children (type 1 diabetes, MODY-diabetes) and transient neonatal hyperglycemia regarding pathogenesis, pathophysiology and prognosis. Casuistics of three children two of whom were sibs are reported in detail to demonstrate the characteristics of neonatal diabetes mellitus. Regarding the reported sibs we suppose genetic origin of the disease. Autosomal-recessive mode of inheritance must be assumed.

[Characteristics of thyroid sonography in infants and children]

In a prospective study the thyroid glands of 598 healthy boys and girls (newborn to 17 years old) were examined by ultrasound. The volume of the normal gland was 1.1 cm3 in neonates, 2 cm3 in 4 year-old-children, and 8.7 cm3 in schoolchildren. The gland of a normal newborn, a girl with congenital hypothyroidism, a girl with inflammation of a median cervical cyst, a girl with insulin-dependent diabetes mellitus and autoimmune thyroiditis, and a girl with an adenoma all showed typical differences in ultrasonic structure from the normal adult gland. Sonography of the thyroid gland discloses valuable information, especially in childhood.

[Ultrasonographically determined thyroid gland volume in children]

The size of the thyroid was evaluated by sonography in 199 boys and 237 girls age one month to 17 years. The volume is 1.2/1.06 ml in boys/girls during the first month, 1.2/1.6 ml at the end of the first year of life, 1.7/2.4 ml at age four, 3.2/3.4 ml with eight years and up to the age of 12 years 5.7/5.7 ml. In juveniles older than 12 years the average volume is 8 ml, sex independently. However, the range appears to be rather wide (1.5-14.5 ml). The right lobe is usually larger than the left one. The rates of the length of the right lobe and the body length, of the total volume and the body weight, and of the total volume and the body surface area are almost independent of age for schoolchildren. There is no significant difference of the thyroid volume between the sexes.

[Macrocephaly as the initial manifestation of glutaryl-CoA-dehydrogenase deficiency (glutaric aciduria type I)]

Glutaric aciduria type I is due to an impaired glutaryl-CoA-dehydrogenase with an increased urinary excretion of glutaric and 3-OH glutaric acid. Typically, the clinical course until the sixth month or even 3rd year of life is symptom free, and only later an encephalopathic crisis develops. The only symptom of our 4 patients was macrocephaly (head circumference greater than 97. percentile) in early infancy. 3 of them suffered from an encephalopathic crisis at 8 months to 3 years of age; during that time they lost already established abilities as sitting, walking and speaking, and developed choereoathetotic movements. One child aged 15 months was normal beside it's macrocephalus. All children were treated with a diet low in lysine (80 mg/kg BW/day), tryptophane (21 mg/kg BW/day), and by supplementation of L-carnitine (200 mg/kg BW/day) and riboflavine (200 mg/day) and the motorically disturbed children received Lioresal 1 mg/kg BW/day. The effect of this treatment cannot be evaluated so far, but there is evidence that the dietetic therapy together with carnitine supplementation may prevent further deterioration in affected, or an encephalopathic crisis in unaffected patients. Therefore we suggest to investigate organic acids in urine in every child or infant with macrocephalus to exclude glutaric aciduria type I.

Glyceryl trinitrate increases platelet cyclic GMP after metabolism in fibroblasts

Glyceryl trinitrate had no direct effect on cyclic GMP levels in platelets. However, in the presence of fibroblasts (RFL-6 cells), glyceryl trinitrate increased platelet cyclic GMP up to 7.8 fold (11.5 fold in the presence of superoxide dismutase). Fibroblasts alone had no effect. Endothelial cells alone increased platelet cyclic GMP up to 4.1 fold (9.6 fold in the presence of superoxide dismutase), but glyceryl trinitrate had no additional effect. Thus fibroblasts, but not endothelial cells, metabolize glyceryl trinitrate to a nitric oxide-like material that stimulates platelet soluble guanylyl cyclase.

Endothelial cyclic GMP and cyclic AMP do not regulate the release of endothelium-derived relaxing factor/nitric oxide from bovine aortic endothelial cells

The present study was designed to investigate whether cyclic GMP or cyclic AMP modulates the release of endothelium-derived relaxing factor/nitric oxide (EDRF/NO) in cultured bovine aortic endothelial cells (BAE cells). BAE cell-conditioned medium was transferred onto rat fetal lung fibroblasts (RFL-6 cells) and the increase in cyclic GMP in these cells was used as a sensitive bioassay of EDRF/NO activity. BAE cells released a material that markedly enhanced cyclic GMP in RFL-6 cells. The synthesis of this substance could be stimulated with bradykinin (10 nM) or Ca++ ionophore A23187 (1 microM) and was completely prevented by treatment of the BAE cells with the EDRF/NO synthesis inhibitors NG-nitro-L-arginine (100 microM) or NG-methyl-L-arginine (1 mM). Addition of hemoglobin (10 microM) or incubation of the RFL-6 detector cells with methylene blue (10 microM) also abolished the cyclic GMP increase in the RFL-6 cells. The release of EDRF/NO by bradykinin and A23187 was accompanied by an approximately 2-fold increase in the cyclic GMP content in the producing BAE cells (in the presence of the cyclic GMP phosphodiesterase inhibitor M&B 22,948, 0.1 mM). Incubation of BAE cells with atrial natriuretic peptide (0.1 microM) or sodium nitroprusside (10 microM) enhanced cyclic GMP content of BAE cells 6.5-fold and 4.1-fold, respectively (in the presence of M&B 22,948, 0.1 mM). These increases in the cyclic GMP levels in BAE cells had no effect on basal or bradykinin- and A23187-stimulated release of EDRF/NO. Bradykinin (10 nM) and A23187 (1 microM) also stimulated prostacyclin production in BAE cells 2.4-fold and 5.6-fold, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of nesidioblastosis in childhood

A review of the literature on the surgical treatment of nesidioblastosis in childhood was made to answer the following questions: age at operation, surgical procedure, pathohistological findings, incidence of recurrence and its treatment, as well as mortality. Primary subtotal pancreatectomy appears to be the method of choice. It should be performed as early as possible following exact diagnosis. Total pancreatectomy is reserved for treatment of a recurrence.

[Efficacy and side effects of differential calcium and phosphate administration in prevention of osteopenia in premature infants]

The prevention of osteopenia and frequency of renal and intestinal side effects of mineral supplementation was studied in 24 preterm infants with birth weight under 1,500 g, prospectively (gestational age 26-34 weeks). Calcium intake varied from 2.5 vs. 3.75 vs. 5 mmol/kg/day, phosphate was offered in dose of 2.5 mmol/kg/day. At the expected birth date 40% of infants with low calcium dose showed an activity of serum alkaline phosphatase greater than five times the maximum adult normal value which is defined as a reliable marker; for osteopenia no infant with medium or high calcium intake reached this critical value (p = 0.03). Medium and high calcium doses resulted in an increased risk for hypercalcuria (25 vs. 50%) (p = 0.03). Half of these infants developed typical signs of nephrocalcinosis on ultrasound examination. No significant difference of fecal fat content was observed with increased calcium intake; but more episodes of abdominal distension occurred during the first days of high calcium supplementation (p = 0.03). We conclude, that a calcium intake of 3.75 mmol/kg/day in combination with phosphate 2.5 mmol/kg/day is sufficient for adequate bone mineralization on a low level of side effects. Calcium excretion in urine has to be observed for early diagnosis of nephrocalcinosis.

[Differences in free amino acid serum levels in premature neonates fed Feminar supplemented with whey proteins]

Free amino acids were examined in plasma of premature infants fed adapted dried milk (15 and 22 infants resp.) and breastfed infants (20). The dried milk was Feminar (casein: whey protein 40:60) where the whey (serum) proteins were prepared either by thermal denaturation (F-TD) or by ultrafiltration (F-U). The concentration of different amino acids in infants fed F-TD were closer to those recorded in breastfed infants, as compared with F-U where greater differences (higher values) were recorded.

[Ultrasonic evaluation of multicystic ovaries in childhood]

High resolution real-time ultrasound showed multicystic pattern of the ovaries in 30 prepubertal infants. In three neonates the cystic abdominal tumour was known since the 33/34 gestational week; the sonographic diagnosis of ovarian cyst was confirmed by the pathologist. The ultrasound study was carried out in 10 patients with suspected idiopathic precocious puberty, whereas in 17 patients, almost 2/3 of the remaining 27 girls, the multicystic ovaries were a fortuitous finding. The maximal diameter of the cysts was 8 mm in multicystic ovaries, one solitary cyst was 13 mm. The follow-up study of 13 patients demonstrated a change in the sonographic pattern. The multicystic structure of the prepubertal ovary is a common finding and must be interpreted as normal.

[Sonography of the thyroid gland in children]

The total volume of the thyroid gland is 1.2/1.0 ccm in male/female newborns; it increases with age up to 7.4 ccm in boys and 7.5 ccm in girls (13-16 years). The relation of total thyroid volume and body surface area is without a significant sex difference 4.5/4.8 ccm/sqm in newborn and about 4.8 ccm/sqm in children aged more than 9 years. Thyroid disorders to be discussed are a cyst, a nodule with an echo-free centre, connatal athyreosis and goitre.

[How sensitive and specific is the determination of gliadin antibodies in the serum of patients with severe damage of small intestine mucosa?]

Serum antigliadin antibodies of the IgG- and IgA-class were investigated by an ELISA-test in healthy children, children suffering from coeliac disease and children with recurrent diarrheas. The sensitivity and specificity of positive antibody-titres for the diagnosis of coeliac disease were evaluated. The investigation of antigliadin antibodies proved to be a useful instrument for the diagnosis of acute coeliac disease as well as for the follow-up of such patients. The limitations of this method are pointed out.

Islet cell antibodies and viral infections

The sera of 127 non-diabetic children after mumps-infection were investigated for the presence of islet cell antibodies and islet cell surface antibodies. The study also included 4 children who developed diabetes mellitus shortly after an active mumps vaccination. 21 of the non-diabetic children and four of the vaccinated children exhibited islet cell cytoplasmic antibodies. Islet cell surface antibodies were observed more frequently, namely in 43 out of 68 patients studied after mumps infection and in 32 out of 44 patients studied after different viral diseases. With one exception, none of the mumps-infected children and none of the other viral infected patients developed diabetes mellitus.

Islet cell antibodies, circulating immune complexes and antinuclear antibodies in diabetes mellitus

Serum samples of patients suffering from diabetes mellitus were tested for complement-fixing and non complement-fixing islet cell antibodies, antinuclear antibodies and circulating immune complexes. There was no correlation between circulating immune complexes or antinuclear antibodies and secondary diabetic complications. A close relationship was found between the ICA titer and complement fixation of ICA. The incidence of ICA at the onset of the disease was higher in the patients under the age of 10 (85%) and decreased with increasing age up to 45% in patients with onset above age 20. In five patients being positive and four patients being negative for ICA at onset of disease, changes and fluctuations in antibody titers were observed over 38 months. Since manifestation of diabetes mellitus is believed to be an endpoint of a long lasting autoimmune process, our observations indicate that the autoimmune phenomena are merely indicators of ongoing autoimmune reactions not necessarily reflecting the state of autoaggression or islet cell destruction.

[Diagnosis and therapy of candidiasis in the premature infant]

Extension of intensive care seems to have increased the risk of systemic candida infection. We report the incidence of systemic candida infection in 8 low-birth-weight infants (gestational age 27-32 weeks, birth weight 710-1,550 g). All infants required respiratory treatment. Various silastic catheters were inserted. Antibiotic therapy was started on the first day of life, usually a combination of ampicillin and gentamycin. Candida septicaemia was diagnosed at the age of 8-69 days of life based on blood and urine cultures, in two children at autopsy. There were no specific clinical symptoms in regard to candida infection. Sonographic technique revealed hydronephrosis in 3 infants due to candida mycelium. Antimycotic therapy included amphotericin B (dosage 0.44-1.0 mg/kg X day) and 5-fluorocytosine (80-100 mg/kg X day) as well as a monotherapy of 5-fluorocytosine (100-200 mg/kg X day). Four children were treated successfully. We like to advice a regular search for candida in urine, blood, tracheal secretion, stool and skin in low-birth-weight infants under intensive care conditions. If antimycotic therapy is started in time, therapy can be successful.

[Carnitine in the treatment of methylmalonic aciduria (MMA)]

Carnitine metabolism was studied and a therapeutic trial with L-carnitine was undertaken in 3 patients with methylmalonic aciduria. Prior to carnitine therapy, the concentration of free carnitine was diminished and the contribution of acylated carnitine to total carnitine was increased in both plasma and urine. During a metabolic crisis, in a patient the intravenous administration of L-carnitine greatly increased, the urinary excretion of acylcarnitine and the plasma concentration of methylmalonic acid fell. In all 3 patients, the chronic oral administration of L-carnitine resulted in the normalisation of the plasma free carnitine concentrations and an increased urinary excretion of carnitine esters. One patient clearly showed clinical improvement under carnitine therapy. The administration of L-carnitine to patients with methylmalonic aciduria results in an increased elimination of toxic propionyl groups and thus to a regeneration of intramitochondrial CoA. In conjunction with appropriate dietary measures, this may improve the metabolic situation of these patients.

[Autoimmunity and viral infections in type-I diabetes mellitus]

Cytoplasmic islet-cell antibodies, insulin antibodies, islet-cell surface antibodies and islet-cell specific cytotoxicity were determined in serum of the following groups: 131 patients with type I diabetes, 19 with type II diabetes, 29 with mumps, 29 with enterovirus infections, 18 with measles and 28 healthy controls. Cytoplasmic islet-cell antibodies were found predominantly in type I diabetics. Islet-cell surface antibodies, on the other hand, were relatively frequently (60-80%) present in sera of both diabetics and patients with various virus infections. Islet-cell specific cytotoxicity in vitro was found not only in sera of diabetics, but also of patients with mumps or enterovirus infections. Sera of five patients with measles, however, had cytotoxic reactions comparable to those of the controls. These results suggest that cytotoxic antibody reactions against islet cells in vitro occur also in sera of non-diabetic patients. Under certain circumstances, infections which induce such immune reactions may be of significance in the pathogenesis of diabetes.

Islet cell antibodies and the development of diabetes mellitus in relation to mumps infection and mumps vaccination

Islet cell antibodies were investigated in 127 non-diabetic children after mumps infection and in four out of seven children who developed diabetes mellitus shortly after active mumps vaccination. Twenty-one of the children who had mumps and all four vaccinated children who were tested had islet cell cytoplasmic antibodies. In contrast, islet cell surface antibodies were detected in 43 out of 68 patients with mumps infection and in 32 out of 44 patients with other viral diseases. All but one mumps-infected child and all the other viral infected patients investigated did not develop diabetes mellitus. The mumps-infected ICA positive children did not show those HLA-frequencies associated with Type 1 diabetes.

Complications of mumps infection, islet-cell antibodies, and HLA

To investigate whether the development of islet-cell antibodies (ICA) in the course of mumps infection is associated with a "diabetes-like" immunogenetic condition, 45 children with mumps complications as well as 56 children with insulin-dependent diabetes mellitus (IDDM) were typed for HLA ABC and DR antigens. ICA were detected in 14 out of 35 mumps patients. In the IDDM group, significant deviations from antigen frequencies of normal controls were observed for HLA Bw39, DR2, DR3, and DR4. In contrast, in ICA positive mumps patients, the frequency of these antigens was normal, but Aw24 was significantly increased. Thus, no immunogenetic similarities of both groups of patients could be detected.