Atypical juvenile generalized scleroderma presenting as polyarthritis and failure to thrive

In this Grand Round, two children are described with atypical generalized scleroderma and severe failure to thrive. Neither had Raynaud's phenomenon nor evidence of gastrointestinal (GI) disease. Treatment with non-steroidal anti-inflammatory drugs, prednisone, D-penicillamine, alpha and gamma interferon was unsuccessful in reversing the sclerodermatous changes and growth arrest. Dietary intake analysis and extensive GI investigation were performed in both. In one case, resting energy expenditure (Ee) was repeatedly measured. His intake did not meet requirements for growth. Supplemental tube feeding (900 kcal in 6 h) was commenced, causing an increase in weight from 11 to 16 kg. The other patient refused supplementary tube feeding and no weight gain has been observed for 5 yr. In conclusion, early-onset generalized scleroderma in the absence of visceral involvement, but with growth failure, may represent an atypical form of systemic sclerosis. The response of the two patients to conventional therapy was disappointing. However, the rapid catch-up growth induced by tube feeding observed in one patient underlines the importance of adequate dietary management.

Hepatic GVHD after HLA-haploidentical bone marrow transplantation in children with severe combined immunodeficiency: the effect of ursodeoxycholic acid

We describe two children with a severe combined immune deficiency (SCID) with B cells. Following a T-cell-depleted haploidentical bone marrow transplantation (BMT), they both developed a chronic graft-versus-host disease (GVHD) of the skin and a severe persisting hyperbilirubinaemia and elevated liver enzymes. The diagnosis of a vanishing bile duct syndrome was confirmed by liver biopsies. Because corticosteroids and cyclosporin A induced only a partial response, ursodeoxycholic acid (UDCA) was added to their treatment schedule. Serum bilirubin and liver enzymes returned to normal within months. A control liver biopsy showed normal and proliferating bile ducts without cholestatic damage. We conclude that UDCA was well tolerated and may be of value as an additional treatment for hepatic GVHD in SCID.

Endocrine autoimmune diseases

A considerable proportion of endocrine disorders (Graves' disease, primary hypothyroidism, type 1 diabetes, Addison's disease, and some forms of ovarian failure) are due to aberrant reactions of the immune system, viz. exaggerated reactions towards self-structures (autoantigens). Autoreactive T-cells are mainly responsible for the elicitation of destructive inflammatory responses in the target endocrine glands. Autoantibodies play a minor role in such reactions, but are useful in clinical practice as markers of the disease. A special type of autoantibody is formed by those autoantibodies that have endocrine functional activity, viz. autoantibodies capable of stimulatory or blocking the hormone synthesis and/or the growth of endocrine cells. These autoantibodies interfere with receptors, e.g. the TSH receptor or the IGF-I receptor. Antibodies stimulating the TSH receptor are responsible for the hyperthyroidism of Graves' disease.

Deficiency of the beta subunit of the eighth component of complement presenting as arthritis and exanthem

A 13-year-old boy presented with juvenile chronic arthritis of 6 months' duration. Antinuclear antibodies, anti-double-stranded DNA antibodies, and rheumatoid factor were not detected. Western blotting showed a deficiency of the beta subunit of the eighth component of complement. The same deficiency was present in the patient's sister. C8 beta deficiency is usually detected in individuals who survive meningococcal disease. There was no such history in this family. Juvenile chronic arthritis has not previously been described in patients with C8 beta deficiency.

Prevalence of circulating immune complexes in patients with cystic fibrosis and arthritis

We report the clinical and laboratory characteristics of eight patients with cystic fibrosis (CF) and arthropathy. Five patients had frequently relapsing, episodic arthritis; one had chronic arthritis with high titers of rheumatoid factors that could not be distinguished from juvenile chronic arthritis. In two patients the arthropathy did not relapse. Forty-six patients with CF but without arthropathy, seen during the same 1-year period, served as control subjects. Results of lung function tests and sputum cultures were similar in both groups. The sera of six of the eight patients with CF-arthropathy had high levels of circulating immune complexes, measured both by C1q-binding and the indirect granulocyte phagocytosis test, whereas only 1 of 12 control patients tested had positive C1q binding (p < 0.023). Serum complement levels were normal in both groups. Synovial biopsies, performed in three patients, showed only scanty lymphocytic infiltrates; immunofluorescent staining showed deposits of IgM, IgG, and components of complement C1q, C3, and C4. These findings suggest that the arthropathy found in CF is an immune-mediated phenomenon.

Failure to thrive is an early symptom of the imerslund Gräsbeck syndrome

PURPOSE

The Imerslund-Gräsbeck syndrome (IGS) is a rare inherited disorder characterized by a megaloblastic anemia due to a selective vitamin B12 malabsorption in association with a mild proteinuria. Usually recurrent infections, gastrointestinal complaints, and pallor are presenting symptoms. We report two cases of IGS with an unusual presentation.

PATIENTS AND METHODS

Two girls are described with the Imerslund-Gräsbeck syndrome who had a failure to thrive as a presenting symptom without infections or gastrointestinal complaints. The diagnosis of IGS was based on marked macrocytic anemia, very low serum vitamin B12 levels, abnormal Schilling urinary excretion test results, and mild proteinuria. When parenteral vitamin B12 was started, a rapid catch-up growth was seen in both girls.

CONCLUSIONS

The absence of well-known causes of failure to thrive, such as recurrent infections and gastrointestinal complaints, favors the concept that the metabolic disturbances caused by an isolated cobalamin deficiency as seen in IGS causes a failure to thrive.

[Erroneous diagnosis 'neonatal hypoglycemia' due to incorrect preservation of blood samples]

The high frequency of neonatal hypoglycaemia found in the St. Catherine's Hospital, Eindhoven [corrected], (8.2% of all newborn infants had values of 1.8 mmol/l glucose or less) promoted us to test the effects of the different conditions of blood preservation before measuring in a consecutive series of 18 newborn infants at risk for hypoglycaemia. When blood was preserved in microtest tubes coated with sodium fluoride (NaF) and measured after 1 hour at room temperature, the glucose level decreased by 7 to 36%. Storage on melting ice for one hour prevented this decline completely. In our hospital sodium fluoride coated microtest tubes are used. They were found to contain various concentrations of NaF, ranging from 0.85 to 2.65 mg/ml. In a 2nd experiment with cord blood from 8 patients, we proved that a concentration of 16 mg/ml sodium fluoride was necessary to inhibit glycolysis and to prevent a fall of plasma glucose. The rapid determination of blood glucose values, i.e. within 10 minutes after the blood sample is taken, decreased, as expected, the frequency of hypoglycaemia in the newborn at risk.

Autoimmune involvement in Cushing syndrome due to primary adrenocortical nodular dysplasia

Cushing syndrome due to primary adrenocortical nodular dysplasia was diagnosed in two patients, aged 3 years 9 months and 9.5 years. Subsequently, adrenalectomy was performed and followed by steroid replacement. In both cases, the adrenals were normal or only slightly enlarged and showed adrenocortical nodular dysplasia histologically. Small lymphocytic infiltrates consisting of T-cells and class II MHC positive macrophages were present in adrenal specimens of both the patients. Samples of protein A sepharose purified serum immunoglobulins from both children stimulated adrenocortical DNA synthesis and cortisol production in cultured guinea-pig adrenal segments in vitro in a dose dependent fashion. Adrenal stimulating immunoglobulins were also demonstrated in serum specimens of both patients' mothers. However, none of them had overt signs of adrenal disease. Our data support the view that autoimmune mechanisms may be involved in primary adrenocortical nodular dysplasia.

Familial Cushing's syndrome due to nodular adrenocortical dysplasia is an inherited disease of immunological origin

Circulating immunoglobulins may be involved in the pathogenesis of familial Cushing's syndrome due to nodular adrenocortical dysplasia. The disease may also be part of a complex including cutaneous and cardiac myxomas, spotty pigmentation of the skin, and other signs of endocrine overactivity. In the present study of two sisters treated by complete adrenalectomy for Cushing's syndrome due to nodular adrenocortical dysplasia, and of their first-degree relatives, no evidence of associated disorders was present. However, the serum of both girls and of their mother contained immunoglobulins capable of stimulating adrenal DNA synthesis and cortisol production in vitro. The study supports the theory that familial Cushing's syndrome due to adrenocortical dysplasia is an inherited disease of immunological origin.

Immunoglobulins of patients with idiopathic Addison's disease block the in vitro action of adrenocorticotropin

The presence of serum immunoglobulins (Ig) blocking ACTH-induced adrenal DNA synthesis and/or cortisol production was studied in 25 patients with idiopathic Addison's disease. For this purpose guinea pig adrenal segments kept in organ culture were exposed to ACTH and graded concentrations of patient IgG. After a 5-h culture period the cortisol present in the culture fluid was measured by RIA, and DNA synthesis in the adrenal cells was measured using Feulgen densitometry on frozen sections of the cultured adrenal segments. Addition of ACTH alone in concentrations of 0.1-10 pmol/L to the culture system stimulated in vitro cortisol secretion; the maximal stimulation was 63 +/- 35% (+/- SD; n = 5) at a concentration 0.1 pmol/L. ACTH also increased (in concentrations of 1 fmol/L to 1 pmol/L) the percentage of fasciculata cells in S-phase from 0-4% (nonstimulated) to 5-12%. IgG preparations from all but 2 of the 25 patients with idiopathic Addison's disease blocked these in vitro ACTH-induced adrenal responses in a dose-dependent fashion. IgG from 2 patients with tuberculous adrenalitis, 1 patient with secondary adrenal insufficiency, and 7 normal subjects had no blocking activity. Among 5 non-Addisonian autoimmune endocrinopathy patients who had adrenal cytoplasmic autoantibodies, 4 had no ACTH-blocking IgGs. Two of 9 patients with miscellaneous adrenal disorders (Cushing's disease, pigmented adrenal micronodular dysplasia, and adrenal nodules) had ACTH-blocking activity. These results demonstrate the existence of IgGs blocking the in vitro effects of ACTH and suggest their involvement in the pathogenesis of idiopathic Addison's disease.

Immunoglobulins of patients with Cushing's syndrome due to pigmented adrenocortical micronodular dysplasia stimulate in vitro steroidogenesis

The putative stimulation of adrenal steroid production by immunoglobulins (Igs) of five patients with pigmented adrenocortical micronodular dysplasia and clinical Cushing's syndrome was investigated. Ascorbate depletion, a process linked to steroid production, was measured by a cyto-chemical bioassay employing guinea pig adrenal explants in organ culture and exposed to IgG from the patients and normal subjects. We also measured cortisol production by these segments during a 5-h culture period using a RIA. For positive reference values we studied the effects of ACTH-(1-39), ACTH-(1-24), ACTH-(11-24), and ACTH-(18-39) on in vitro ascorbate depletion and cortisol production. Both ACTH-(1-39) and ACTH-(1-24) depleted ascorbate and stimulated cortisol production in adrenal cells. The dose-response kinetics of the peptides were bell-shaped; maximal responses were reached in both instances at 1 fmol/L to 10 pmol/L. In all tests, stimulation of in vitro cortisol production was paralleled by ascorbate depletion. ACTH-(18-39) also stimulated ascorbate depletion and cortisol production, but at one concentration only (100 fmol/L), and TSH and LH had no effect. Protein-A-Sepharose-purified IgG preparations of the five patients stimulated ascorbate depletion and/or cortisol production in a dose-dependent fashion; however, the responses occurred over a narrow concentration range (15-150 micrograms IgG/mL culture fluid). These observations support the hypothesis that the hypercortisolism of the syndrome of pigmented adrenocortical micronodular dysplasia is due to circulating Igs that stimulate adrenal steroidogenesis.

Effects of ACTH and ACTH fragments on DNA synthesis in guinea-pig adrenal segments kept in organ culture

Stimulation of adrenal DNA synthesis by ACTH and its fragments ACTH (Synacthen) and ACTH was investigated. Synthesis of DNA was measured as the increase in the percentage of cells in S-phase (Feulgen densitometry) in guinea-pig adrenal explants kept in organ culture and exposed to the peptides for 5 h at 37 degrees C. ACTH and its C-terminal fragment ACTH (corticotrophin-like intermediate lobe peptide) were found to be potent stimulators of in-vitro adrenal DNA synthesis. The dose-response kinetics were biphasic and optimal responsiveness was reached in both instances at 1 fmol/1-10 pmol/1 (this biological effect of ACTH has hitherto not been described). The N-terminal fragment ACTH gave only minimal responses. Thyrotrophin and LH, tested as controls, did not induce adrenal DNA synthesis. Epidermal growth factor was a potent stimulator of adrenal DNA synthesis in vitro. Our data suggest a trophic action of the C-terminal part of the corticotrophic molecule. Clear trophic effects were also found for the N-terminal part of the pro-opiomelanocortin molecule N-POC (optimum 0.1 nmol/l) and N-POC(51-62) (optimum 0.1 pmol/l). The latter observations support earlier concepts that this part of the pro-opiomelanocortin molecule has a stimulatory effect on adrenal DNA synthesis.

Frequency and coordination of ciliary beat after cryopreservation of respiratory epithelium

The effect of cryopreservation on human nasal mucosal biopsies was evaluated by determining the frequency and coordination of the ciliary beat. Samples were cryopreserved in a medium containing 80% Gey's balanced salt solution, 10% dimethyl sulfoxide, and 10% fetal calf serum. After thawing, the samples were put in a solution of 90% Gey's balanced salt solution and 10% fetal calf serum. Video recordings of the samples before and after cryopreservation were compared using a semiquantitative method. All the frequencies and coordination patterns seen before cryopreservation could be found in the sample after cryopreservation. It is concluded that ciliated epithelial biopsies can be stored in liquid nitrogen with the maintenance of ciliary beat frequency. In the recorded ciliated cells the ciliary beat coordination was slightly reduced; a lack of coordination was present in 20% of cells after cryopreservation as compared to 10% before cryopreservation.

Bone marrow mitotic index: a methodological study

The mitotic index (MI) of bone marrow specimens is assessed in 3 different ways: method I determines the number of mitotic figures per 1,000 nucleated cells; method II counts the number of mitoses seen per 1,000 nucleated cells belonging to the proliferative pool, and method III is the same as method I, but excludes all lymphoid cells. 30 Giemsa-stained bone marrow smears from 6 children were screened by 3 independent investigators. MI of method II is found to be approximately twice as high as the MI of method I. The results of method III indicate that the size of the lymphoid population introduces a bias, which renders method I less reliable. It is concluded that method II is the method of choice for a reliable assessment of bone marrow MI.