Hypospadias in a male patient with 21-hydroxylase deficiency

A 17-day-old Japanese boy was transferred to the hospital because of vomiting and impaired consciousness. His external genitalia was pigmented associated with small penis and penoscrotal hypospadias. He was diagnosed as suffering from adrenal deficiency according to severe electrolyte abnormality, moderate hypoglycemia, metabolic acidosis and extremely elevated 17-OHP and testosterone levels. He turned out to be a compound heterozygote of CYP21A2 mutations by genetic analysis. Through endocrinological evaluation, he seemed to have normal hypophyseal function, intact testosterone production and appropriate 5-alpha-reductase-2 activity. Partial androgen insensitivity could not be ruled out by slight decrease of SHBG in hCG loading test, although mutation was not detected on androgen receptor gene. This is a rare case of a male patient with 21-hydroxylase deficiency accompanied by hypospadias. As the cause of hypospadias in this case has yet to be elucidated, further investigation and careful follow-up are required.

Body mass index in male patients with COPD: correlation with low attenuation areas on CT

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterised by the presence of airflow limitation caused by loss of lung elasticity and/or airway narrowing. The pathological hallmark of loss of lung elasticity is emphysema, and airway wall remodelling contributes to the airway narrowing. Using CT, these lesions can be assessed by measuring low attenuation areas (LAA) and airway wall thickness/luminal area, respectively. As previously reported, COPD can be divided into airway dominant, emphysema dominant and mixed phenotypes using CT. In this study, it is postulated that a patient's physique may be associated with the relative contribution of these lesions to airflow obstruction.

METHODS

CT was used to evaluate emphysema and airway dimensions in 201 patients with COPD. Emphysema was evaluated using percentage of LAA voxels (LAA%) and airway lesion was estimated by percentage wall area (WA%). Patients were divided into four phenotypes using LAA% and WA%.

RESULTS

Body mass index (BMI) was significantly lower in the higher LAA% phenotype (ie, emphysema dominant and mixed phenotypes). BMI correlated with LAA% (rho = -0.557, p<0.0001) but not with WA%. BMI was significantly lower in the emphysema dominant phenotype than in the airway dominant phenotype, while there was no difference in forced expiratory volume in 1 s %predicted between the two.

CONCLUSION

A low BMI is associated with the presence of emphysema, but not with airway wall thickening, in male smokers who have COPD. These results support the concept of different COPD phenotypes and suggest that there may be different systemic manifestations of these phenotypes.

Ultrasound appearance of thyroid tissue in hypothyroid infants

OBJECTIVE

To identify those infants who need a higher starting dose of levothyroxine (l-T4) for early normalization of thyroid-stimulating hormone (TSH) level.

STUDY DESIGN

TSH levels at 2 time points (1 to 3 weeks and 3 to 5 weeks) after l-T4 therapy at a starting dose of 8 to 12 microg/kg/day were evaluated retrospectively in 22 hypothyroid infants screened for congenital hypothyroidism (CH) in terms of etiology as determined by ultrasonography (US), the size of distal femoral epiphysis (DFE), and initial thyroid function.

RESULTS

The infants with a noneutopic thyroid or small DFE exhibited significantly higher posttherapeutic TSH levels compared with the other infants. Eight of the 9 infants who failed to achieve normalized TSH values at 1 to 3 weeks had noneutopic thyroid. All of the infants with eutopic thyroid exhibited normalized TSH at 3 to 5 weeks, and a significantly greater proportion of the infants with eutopic thyroid exhibited normalized TSH at 1 to 3 weeks compared with those with noneutopic thyroid. Stepwise regression analysis demonstrated that US etiology was a significant independent variable for normalization of TSH at 1 to 3 weeks.

CONCLUSIONS

US examination to identify eutopic or noneutopic thyroid provides useful information for determining the starting dose of l-T4 in hypothyroid infants.

p51/p63 Inhibits ultraviolet B-induced apoptosis via Akt activation

The epidermis must be protected against excess apoptotic cell death in response to ultraviolet-B (UV-B) irradiation. p53 is known to be critical for this protection. Although the p53 family member DeltaNp51B/DeltaNp63alpha (an N terminal-deleted form of p51/p63) is abundantly expressed in keratinocytes, its contribution to UV-B-dependent apoptosis is largely unknown. We found that, after a transient increase, DeltaNp51B is downregulated in UV-B-irradiated keratinocytes undergoing apoptosis, whereas p53 is upregulated with delayed kinetics. Furthermore, the reduction of DeltaNp51B by small interfering RNAs augmented UV-B-dependent apoptosis in keratinocytes, indicating that DeltaNp51B blocks keratinocyte apoptosis. Although the exogenous expression of DeltaNp51B in keratinocytes did not further block the UV-B-dependent apoptosis, to our surprise the expression of TAp51B (an isoform with a full NH(2)-terminal transactivation domain that is structurally and functionally similar to p53) decreased apoptosis significantly. The blockade of keratinocyte apoptosis by the p51 was dependent on the phosphorylation of Akt, resulting in the activation of a survival pathway. Thus, in addition to its indispensable roles in epithelial development, p51 acts in adult cells to protect the epidermis against UV-B irradiation by preventing excess depletion of keratinocytes.

p53 homologue, p51/p63, maintains the immaturity of keratinocyte stem cells by inhibiting Notch1 activity

p53 homologue, p51/p63, predominantly expressed in keratinocyte stem cells, is indispensable for the formation of epidermis. Notch1, another such gene indispensable for the process, induces growth arrest and differentiation in keratinocytes. We found that exogenous expression of DeltaNp51B (DeltaNp63alpha), one of the isoforms of p51 specifically expressed in basal keratinocytes, blocked Notch 1-dependent growth arrest and differentiation in mouse keratinocytes by inhibiting p21 expression and maintaining integrins expression. Furthermore, DeltaNp51B by itself was found to have ability to induce expression of integrin alpha6beta4, which promotes attachment of basal cells to basal membrane thereby keeping the cells in immature state. Therefore, we conclude that DeltaNp51B expression warrants integrin expression even under the influence of Notch1 and that DeltaNp51B is a long-sought factor required to maintain basal cell keratinocytes immaturity by inhibiting Notch1 activity. We will postulate a plausible model explaining the maintenance of the squamous epithelium architectures as well as offering mechanistic explanations for pathological features of skin diseases, including cancers, psoriasis along with physiological wound healings.

Kallmann syndrome phenotype in a female patient with CHARGE syndrome and CHD7 mutation

We report on a 14 7/12-year-old Japanese female patient with CHARGE syndrome and CHD7 mutation who also exhibited Kallmann syndrome (KS) phenotype. She had poor pubertal development and apparently impaired sense of smell. A GnRH test showed severely compromised responses of LH (<0.5 --> <0.5 IU/L) and FSH (<0.5 --> 1.2 IU/L), and magnetic resonance imaging delineated hypoplastic olfactory bulbs. Mutation analysis revealed a heterozygous nonsense mutation at exon 33 of CHD7 (7027C>T, Q2343X). The results provide further support for the notion that KS phenotype can be included in the phenotypic spectrum of CHARGE syndrome, and indicate that CHARGE syndrome with KS phenotype is caused by a CHD7 mutation.

Clinical significance of HuR expression, an mRNA-binding protein in non-small cell lung cancer (NSCLC)

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Background: HuR is a nucleo-cytoplasmic shuttling protein that specifically binds to mRNA that has AU rich (ARE) sites at the 3’end and transports the RNA to the cytoplasm for protein translation. In addition to mRNA transportation, HuR plays a role in mRNA stabilization and protein translation. Preclinical studies have shown mRNA’s of several growth factors, cell-cycle regulators, and transcription-regulating proteins have ARE’s at the 3’end and bound by HuR. However, there has been reported no clinical data on HuR expression in NSCLC. Thus, in the present study, we assessed clinical significance of HuR expression in NSCLC. Patients and Methods: A total of 236 patients with completely resected p-stage I-IIIA, NSCLC, were reviewed, and HuR expression was evaluated immunohistochemically. Results (Table): HuR expression was seen in the nucleus and cytoplasm of tumor cells. Cytoplasmic HuR expression was positively correlated with tumor progression (p-stage, P<0.01), especially nodal metastasis, microvessel density (MVD), and COX-2 expression. Enhanced nuclear HuR expression was also correlated with tumor progression and COX-2 expression, but not with MVD. Positive cytoplasmic HuR expression was a significant factor to predict a poor prognosis in all patients (5-year survival rates: 85% for HuR-negative and 43% for HuR-positive patients; P<0.01) and in any p-stage/histology subset patients. Nuclear HuR expression status was also a significant prognostic factor in all patients, but not in all subsets. A multivariate analysis confirmed that cytoplasmic HuR status was an independent prognostic factor (hazard ratio [95% CI], 4.261 [2.109–8.609]; P<0.001). Conclusions: Cytoplasmic HuR expression was correlated with tumor progression, and was a significant and independent prognostic factor in correlation with enhanced COX-2 expression and increased tumor angiogenesis.

[Table: see text]

No significant financial relationships to disclose.

Prevention of Overlooked Bullae During Video-Assisted Thoracic Surgery (VATS) with a Combination of High Frequency Jet Ventilation (HFJV) and Positive End-Expiratory Pressure (PEEP) for Spontaneous Pneumothorax

BACKGROUND

Overlooked bullae have been reported to contribute to the higher incidence of recurrence of pneumothorax following video-assisted thoracic surgery (VATS). In this study, we investigated whether high frequency jet ventilation (HFJV) + positive end-expiratory pressure (PEEP) prevented overlooking of bullae by blowing up the bullae and inflating the lungs moderately during VATS for spontaneous pneumothorax patients.

METHODS

A total of 31 patients with spontaneous pneumothorax who underwent VATS were enrolled in this study. We examined the number, size, and location of bullae with and without HFJV+PEEP during VATS.

RESULTS

More bullae were found with HFJV + PEEP than without HFJV + PEEP in 15 of the 31 patients. Significantly more bullae smaller than 2 cm in diameter were detected with HFJV + PEEP than without HFJV + PEEP. In the patients with 1 - 3 bullae, the detection rate was significantly higher with HFJV + PEEP than without HFJV + PEEP. All bullae confirmed with VATS were detected only in one case (3.2 %) on preoperative chest X-ray, and in two cases (6.5 %) on chest CT. The recurrence rate of pneumothorax following VATS with HFJV + PEEP was 3.3 % (1/31).

CONCLUSION

Our results suggested that VATS combined with HFJV and PEEP might prevent the overlooking of bullae and reduce the postoperative recurrence of spontaneous pneumothorax.

Clinical significance of VEGF-C status in tumour cells and stromal macrophages in non-small cell lung cancer patients

Recent experimental studies have revealed that tumour-associated stromal macrophages as well as tumour cells express vascular endothelial growth factor C (VEGF-C), which plays important roles in lymphangiogenesis, which is a critical factor in the progression of many malignant tumours including non-small-cell lung cancer (NSCLC). However, no clinical study on VEGF-C expression in both stromal macrophages and tumour cells has been reported, and we conducted the present study to address the issue in resected NSCLC. A total of 206 patients with completely resected pathologic stage I-IIIA NSCLC were retrospectively reviewed. Expression of VEGF-C in primary lung tumour was assessed immunohistochemically. Expression of VEGF-C in tumour cells was high in 125 patients (60.7%), and that in stromal macrophages was positive in 136 patients (71.2%). The status of VEGF-C in tumour cells or in stromal macrophages was not correlated with nodal status or angiogenesis. The 5-year survival rate of high tumoral VEGF-C patients (60.7%) was significantly lower than that of low tumoral VEGF-C patients (39.3%) (P=0.046), and a multivariate analysis confirmed that tumoral VEGF-C status was a significant and independent prognostic factor. Moreover, tumour showing high VEGF-A and VEGF-C expression in tumour cells showed the poorest prognosis (5-year survival rate, 45.1%). The status of VEGF-C in stromal macrophages was not correlated with the prognosis. In conclusion, tumoral VEGF-C status, not stromal VEGF-C status, was a significant prognostic factor in resected NSCLC.

Suppression of Postoperative Systemic Inflammatory Response Syndrome with Clarithromycin following Lung Cancer Surgery

We examined whether clarithromycin (CAM), a 14-membered macrolide, can control the postoperative systemic inflammatory response syndrome that occurs following lung cancer surgery. In the control group (n = 16), prophylactic antibiotics (flomoxef) were administered for 4-7 days following surgery. In the CAM group (n = 10), 400 mg/day of CAM were administered orally for 14 days prior to surgery and for 7 days following surgery, in addition to the postoperative administration of flomoxef. The incidence and duration of the systemic inflammatory response syndrome in the CAM group (30%, 0.3 days) were significantly lower than those in the control group (81%, 1.6 days). There were no significant differences between the control and CAM groups in both the amount and frequency of nonsteroidal anti-inflammatory drugs following surgery. In conclusion, our study suggests that CAM may suppress the postoperative systemic inflammatory response syndrome in lung cancer patients.

Subacute thyroiditis in children: patient report and review of the literature

Subacute thyroiditis is extremely rare during childhood. We treated a 10 year-old prepubertal girl who presented with typical clinical features of subacute thyroiditis. Considering this case and previous reports in children, we characterized the clinical features of this disorder as it occurs in childhood. In contrast to the predominance of subacute thyroiditis in adults, the incidence of subacute thyroiditis is lower than that of acute suppurative thyroiditis in children. This may cause difficulty with differential diagnosis, particularly when leukocytosis is present or the lesion is localized to the left lobe. Ultrasonography can be helpful in differentiation.

Hypophosphatemia in juvenile patients with systemic lupus erythematosus

BACKGROUND

Hypophosphatemia is observed in both genetic diseases and acquired disorders, although it has never been described in systemic lupus erythematosus (SLE). The present study reports hypophosphatemia observed in patients with SLE, and investigates whether serum phosphorus (P) concentration is associated with disease activity and some cytokines.

METHODS

Six girls with SLE (age 10 to 16 years) and seven age-matched controls were studied. Relationships between serum P and parameters that represented disease activity were evaluated. Interleukin (IL) 6 and tumor necrosis factor alpha (TNF-alpha) levels were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Two of the patients with SLE developed marked hypophosphatemia during active disease. Their serum P significantly correlated positively with serum complements, red blood cell (RBC) and platelet counts, and negatively with anti-double-stranded DNA antibody (dsDNAab). Three of the remaining four patients showed the same trend, in which their serum P significantly correlated with RBC, platelets, dsDNAab and/or serum complement concentrations. Serum and urinary IL-6 and serum TNF-alpha were higher in active SLE patients than those with inactive disease or in the control group. In addition, the concentrations of these cytokines significantly correlated inversely with serum P. Renal tubular reabsorption of P was significantly lower in patients with active disease both with and without lupus nephritis.

CONCLUSIONS

Hypophosphatemia may be another sign of juvenile SLE, and serum P may represent disease activity. Both TNF-alpha and IL-6 may be related to hypophosphatemia in patients with SLE. Waste of P from renal tubules may be a possible mechanism of hypophosphatemia in SLE.

Compound heterozygous mutations in the cholesterol side-chain cleavage enzyme gene (CYP11A) cause congenital adrenal insufficiency in humans

Cholesterol side-chain cleavage enzyme (P450scc) catalyzes the conversion of cholesterol to pregnenolone in mitochondria, which is the first step in the biosynthesis of all steroid hormones. Until now, no homozygous or compound heterozygous mutations in CYP11A have been described in humans. Here we describe novel compound heterozygous mutations in CYP11A in a patient with congenital adrenal insufficiency born to healthy parents. One mutation, a maternally inherited R353W mutation, resulted in markedly reduced P450scc activity by the single amino acid substitution, indicating that Arg(353) is a crucial amino acid residue for P450scc activity. The other mutation, a de novo A189V mutation in the paternal allele, did not affect the P450scc activity by the single amino acid substitution and turned out to be a splicing mutation, which created a novel alternative splice-donor site. It resulted in a deletion of 61 nucleotides in the open reading frame and thus partially inactivated CYP11A. These experimental data are consistent with the clinical findings indicating that the patient had partially preserved ability to synthesize adrenal steroid hormones. This is the first report of the compound heterozygote for the CYP11A mutations with congenital adrenal insufficiency and the phenotypically normal heterozygote in humans.