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Al Shidhani A, Al Hinai A, Al Thihli K, Al Mandhari H, Al Yaarubi S, Ullah I, Al-Hashmi N, Al Murshedi F. Congenital Hyperinsulinism and Maple Syrup Urine Disease: A Challenging Combination. J Clin Res Pediatr Endocrinol 2023; 15:302-306. [PMID: 34738771 PMCID: PMC10448551 DOI: 10.4274/jcrpe.galenos.2021.2021.0173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/28/2021] [Indexed: 12/01/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycemia in infancy. CHI is a challenging disease to diagnose and manage. Moreover, complicating the course of the disease with another metabolic disease, in this case maple syrup urine disease (MSUD), adds more challenges to the already complex management. We report a term neonate who developed symptomatic, non-ketotic hypoglycemia with a blood glucose (BG) level of 1.9 mmol/L at 21-hours of life. A critical sample at that time showed high serum insulin and C-peptide levels confirming the diagnosis of CHI. Tandem mass spectrometry done at the same time was suggestive of MSUD which was confirmed by high performance liquid chromatography. The diagnosis of both conditions was subsequently confirmed by molecular genetic testing. His hypoglycemia was managed with high glucose infusion with medical therapy for CHI and branched chain amino acids (BCAA) restricted medical formula. At the age of four months, a near-total pancreatectomy was done, due to the failure of conventional therapy. Throughout his complicated course, he required meticulous monitoring of his BG and modified plasma amino acid profile aiming to maintain the BG at ≥3.9 mmol/L and levels of the three BCAAs at the disease therapeutic targets for his age. The patient is currently 29 months old and has normal growth and development. This patient is perhaps the only known case of the co-occurrence of CHI with MSUD. Both hypoglycemia and leucine encephalopathy can result in death or permanent neurological damage. The management of CHI and MSUD in combination is very challenging.
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Affiliation(s)
- Azza Al Shidhani
- Sultan Qaboos University Hospital, Department of Child Health, Muscat, Oman
| | | | - Khalid Al Thihli
- Sultan Qaboos University Hospital, Department of Genetics, Muscat, Oman
| | - Hilal Al Mandhari
- Sultan Qaboos University Hospital, Department of Child Health, Muscat, Oman
| | - Saif Al Yaarubi
- Sultan Qaboos University Hospital, Department of Child Health, Muscat, Oman
| | - Irfan Ullah
- Sultan Qaboos University Hospital, Department of Child Health, Muscat, Oman
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Rafei MA, Harikrishna B, Al Thihli K, Al-Mujaini AS, Ganesh A. Ophthalmic findings as clues for early diagnosis of Vici syndrome in a neonate. Ophthalmic Genet 2021; 42:780-783. [PMID: 34264147 DOI: 10.1080/13816810.2021.1952621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM To report the earliest diagnosis of Vici syndrome in a three-week-old Omani girl. METHODS A three-week-old baby girl with blond hair and agenesis of the corpus callosum was born to consanguineous parents. An older sibling with similar findings had died at the age of six months with recurrent seizures and aspiration pneumonia without a diagnosis of the underlying systemic condition. After a standard ophthalmic and comprehensive systemic evaluation, full sequencing of the EPG5 gene was carried out. RESULTS The findings of bilateral anterior polar cataracts and oculocutaneous albinism in the child with agenesis of corpus callosum raised a suspicion of Vici syndrome. Immunology, neurology, cardiology, and genetic consultations were requested and revealed the presence of immunodeficiency, psychomotor retardation, and hypertrophic cardiomyopathy. Full sequencing of the EPG5 gene led to the detection of a homozygous c.6084 G > A (Trp2028Ter) mutation, confirming the diagnosis of Vici syndrome. Parental heterozygosity was confirmed. On follow-up, progressive microcephaly, failure to thrive, and significant developmental delay were noted, and a clinical decision not to resuscitate was made at the age of 22 months. CONCLUSIONS We report the earliest diagnosis of Vici syndrome in the literature. Ophthalmic findings are a cardinal feature of this condition. The diagnosis should be considered in infants with hallmark features of oculocutaneous albinism, cataracts, and agenesis of the corpus callosum. Vici syndrome has a very poor prognosis due to progressive neuroregression superimposed on the neurodevelopmental anomaly.
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Affiliation(s)
| | | | - Khalid Al Thihli
- Department of Genetics and Developmental Medicine, Sultan Qaboos University, Muscat, Oman
| | - Abdullah S Al-Mujaini
- Department of Ophthalmology, Sultan Qaboos University, Muscat, Oman.,Department of Ophthalmology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Anuradha Ganesh
- Department of Ophthalmology, Sultan Qaboos University, Muscat, Oman
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Jumah MA, Muhaizea MA, Rumayyan AA, Saman AA, Shehri AA, Cupler E, Jan M, Madani AA, Fathalla W, Kashyape P, Kodavooru G, Thihli KA, Bastaki L, Megarbane A, Skrypnyk C, Zamani G, Tuffery-Giraud S, Urtizberea A, Ortez González CI. Current management of Duchenne muscular dystrophy in the Middle East: expert report. Neurodegener Dis Manag 2019; 9:123-133. [PMID: 31166138 PMCID: PMC6609894 DOI: 10.2217/nmt-2019-0002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Aim: Duchenne muscular dystrophy (DMD) is a severe and rare X-linked neuromuscular childhood disorder that results in functional decline, loss of ambulation and early death due to cardiac or respiratory failure. The objective of this paper is to address different aspects of the current management of DMD in the Middle East, north Africa (MENA) region, and to gather experts’ recommendations on how to optimally diagnose and treat patients suffering from this disease. Methods: A group of experts (neuromuscular medicine, neuropediatricians and geneticists) convened to discuss the diagnosis and management of DMD in the MENA region. A list of practical statements was prepared by the chair of the meeting to guide the discussions around critical aspects relating to the current and future management of DMD. Results & conclusion: Ideally, DMD management should be a multidisciplinary approach. Nevertheless, few tertiary care hospitals in the region are currently able to provide the full spectrum of medical expertise and services needed by DMD patients. Clinical practice in the region remains heterogeneous. Specific guidelines for diagnosis and treatment are needed in the MENA region to improve outcomes. Disease awareness among the general public and the medical community is lacking. Now that mutation-specific therapies are being developed and more widely studied, general education programs regarding early signs and symptoms, a standardized referral and diagnosis pathway, patient registries and support groups will significantly improve the management of the disease.
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Affiliation(s)
| | | | | | | | - Ali Al Shehri
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Edward Cupler
- King Faisal Specialist Hospital & Research Centre, Tihamah, Saudi Arabia
| | | | | | | | | | | | | | | | | | - Cristina Skrypnyk
- Center of Princess Al-Jawhara (ACMID), Arabian Gulf University, Bahrain
| | - Gholamreza Zamani
- Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Andoni Urtizberea
- Hôpital Marin de Hendaye, Route de la Corniche, 64700 Hendaye, France
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Byrne S, Jansen L, U-King-Im JM, Siddiqui A, Lidov HGW, Bodi I, Smith L, Mein R, Cullup T, Dionisi-Vici C, Al-Gazali L, Al-Owain M, Bruwer Z, Al Thihli K, El-Garhy R, Flanigan KM, Manickam K, Zmuda E, Banks W, Gershoni-Baruch R, Mandel H, Dagan E, Raas-Rothschild A, Barash H, Filloux F, Creel D, Harris M, Hamosh A, Kölker S, Ebrahimi-Fakhari D, Hoffmann GF, Manchester D, Boyer PJ, Manzur AY, Lourenco CM, Pilz DT, Kamath A, Prabhakar P, Rao VK, Rogers RC, Ryan MM, Brown NJ, McLean CA, Said E, Schara U, Stein A, Sewry C, Travan L, Wijburg FA, Zenker M, Mohammed S, Fanto M, Gautel M, Jungbluth H. EPG5-related Vici syndrome: a paradigm of neurodevelopmental disorders with defective autophagy. Brain 2016; 139:765-81. [PMID: 26917586 PMCID: PMC4766378 DOI: 10.1093/brain/awv393] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/31/2015] [Accepted: 11/12/2015] [Indexed: 01/07/2023] Open
Abstract
Vici syndrome is a progressive neurodevelopmental multisystem disorder due to recessive mutations in the key autophagy gene EPG5. We report genetic, clinical, neuroradiological, and neuropathological features of 50 children from 30 families, as well as the neuronal phenotype of EPG5 knock-down in Drosophila melanogaster. We identified 39 different EPG5 mutations, most of them truncating and predicted to result in reduced EPG5 protein. Most mutations were private, but three recurrent mutations (p.Met2242Cysfs*5, p.Arg417*, and p.Gln336Arg) indicated possible founder effects. Presentation was mainly neonatal, with marked hypotonia and feeding difficulties. In addition to the five principal features (callosal agenesis, cataracts, hypopigmentation, cardiomyopathy, and immune dysfunction), we identified three equally consistent features (profound developmental delay, progressive microcephaly, and failure to thrive). The manifestation of all eight of these features has a specificity of 97%, and a sensitivity of 89% for the presence of an EPG5 mutation and will allow informed decisions about genetic testing. Clinical progression was relentless and many children died in infancy. Survival analysis demonstrated a median survival time of 24 months (95% confidence interval 0-49 months), with only a 10th of patients surviving to 5 years of age. Survival outcomes were significantly better in patients with compound heterozygous mutations (P = 0.046), as well as in patients with the recurrent p.Gln336Arg mutation. Acquired microcephaly and regression of skills in long-term survivors suggests a neurodegenerative component superimposed on the principal neurodevelopmental defect. Two-thirds of patients had a severe seizure disorder, placing EPG5 within the rapidly expanding group of genes associated with early-onset epileptic encephalopathies. Consistent neuroradiological features comprised structural abnormalities, in particular callosal agenesis and pontine hypoplasia, delayed myelination and, less frequently, thalamic signal intensity changes evolving over time. Typical muscle biopsy features included fibre size variability, central/internal nuclei, abnormal glycogen storage, presence of autophagic vacuoles and secondary mitochondrial abnormalities. Nerve biopsy performed in one case revealed subtotal absence of myelinated axons. Post-mortem examinations in three patients confirmed neurodevelopmental and neurodegenerative features and multisystem involvement. Finally, downregulation of epg5 (CG14299) in Drosophila resulted in autophagic abnormalities and progressive neurodegeneration. We conclude that EPG5-related Vici syndrome defines a novel group of neurodevelopmental disorders that should be considered in patients with suggestive features in whom mitochondrial, glycogen, or lysosomal storage disorders have been excluded. Neurological progression over time indicates an intriguing link between neurodevelopment and neurodegeneration, also supported by neurodegenerative features in epg5-deficient Drosophila, and recent implication of other autophagy regulators in late-onset neurodegenerative disease.
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Affiliation(s)
- Susan Byrne
- 1 Department of Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
| | - Lara Jansen
- 2 Department of Basic and Clinical Neuroscience, IoPPN, King's College London, London, UK
| | - Jean-Marie U-King-Im
- 3 Department of Neuroradiology, Evelina's Children Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
| | - Ata Siddiqui
- 3 Department of Neuroradiology, Evelina's Children Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
| | - Hart G W Lidov
- 4 Department of Pathology, Boston Children's Hospital, Boston MA 02115, USA
| | - Istvan Bodi
- 5 Department of Clinical Neuropathology, King's College Hospital, London, UK
| | - Luke Smith
- 6 Randall Division for Cell and Molecular Biophysics, Muscle Signalling Section, King's College, London, UK
| | | | - Thomas Cullup
- 8 Regional Molecular Genetics Laboratory, Great Ormond Street Hospital, London, UK
| | - Carlo Dionisi-Vici
- 9 Division of Metabolism, Department of Paediatric Medicine, Bambino Gesù Children's Research Hospital, Rome
| | - Lihadh Al-Gazali
- 10 Departments of Paediatrics, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE
| | - Mohammed Al-Owain
- 11 College of Medicine, Alfaisal University, Riyadh, Saudi Arabia 12 Department of Medical Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Zandre Bruwer
- 13 Genetic and Developmental Medicine Clinic, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Khalid Al Thihli
- 13 Genetic and Developmental Medicine Clinic, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | | | - Kevin M Flanigan
- 15 Center for Gene Therapy, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kandamurugu Manickam
- 16 Center for Human and Molecular Genetics at The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Erik Zmuda
- 16 Center for Human and Molecular Genetics at The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Wesley Banks
- 16 Center for Human and Molecular Genetics at The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ruth Gershoni-Baruch
- 17 Institute of Human Genetics, Rambam Health Care Campus and the Technion Faculty of Medicine, Haifa, Israel
| | - Hanna Mandel
- 18 Metabolic Disease Unit, Meyer Children's Hospital, Rambam Health Care Campus and the Technion Faculty of Medicine, Haifa, Israel
| | - Efrat Dagan
- 19 Department of Nursing, University of Haifa, Haifa, Israel
| | - Annick Raas-Rothschild
- 20 Institute of Rare Diseases, Institute of Genetics; Sheba Medical Centre, Tel Hashomer and the Sackler school of Medicine Tel Aviv University Ramat Aviv, Israel
| | - Hila Barash
- 20 Institute of Rare Diseases, Institute of Genetics; Sheba Medical Centre, Tel Hashomer and the Sackler school of Medicine Tel Aviv University Ramat Aviv, Israel
| | - Francis Filloux
- 21 Division of Pediatric Neurology, University of Utah School of Medicine and Primary Children's Medical Centre, Salt Lake City, Utah, USA
| | - Donnell Creel
- 22 University of Utah School of Medicine, Moran Eye Centre, Salt Lake City, Utah, USA
| | - Michael Harris
- 23 Innovation Center for Biomedical Informatics, Georgetown University Medical Center, Washington DC, USA
| | - Ada Hamosh
- 24 McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, USA
| | - Stefan Kölker
- 25 Division of Child Neurology and Metabolic Medicine, University Children's Hospital, Heidelberg, Germany
| | - Darius Ebrahimi-Fakhari
- 25 Division of Child Neurology and Metabolic Medicine, University Children's Hospital, Heidelberg, Germany
| | - Georg F Hoffmann
- 25 Division of Child Neurology and Metabolic Medicine, University Children's Hospital, Heidelberg, Germany
| | - David Manchester
- 26 Department of Pediatrics, Section of Clinical Genetics and Metabolism, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, USA
| | - Philip J Boyer
- 27 Department of Pathology, East Carolina University, Brody School of Medicine, Brody Medical Sciences Building, Greenville, NC 27834, USA
| | | | | | - Daniela T Pilz
- 30 Institute of Medical Genetics, University Hospital of Wales, Cardiff, UK
| | - Arveen Kamath
- 30 Institute of Medical Genetics, University Hospital of Wales, Cardiff, UK
| | - Prab Prabhakar
- 31 Department of Paediatric Neurology, Great Ormond Street Children's Hospital, London, UK
| | - Vamshi K Rao
- 32 University of Nebraska Medical Center and Childrens Hospital and Medical Center, Omaha, Nebraska, USA
| | - R Curtis Rogers
- 33 Greenwood Genetic Center, Greenville, South Carolina, USA
| | - Monique M Ryan
- 34 Departments of Neurology, Royal Children's Hospital and Paediatrics, University of Melbourne, and Murdoch Childrens Research Institute, Melbourne Australia
| | - Natasha J Brown
- 35 Victorian Clinical Genetics Services, Murdoch Childrens Research Institute Parkville, Australia 36 Department of Paediatrics, University of Melbourne, Parkville, Australia 37 Department of Clinical Genetics, Austin Health, Australia
| | | | - Edith Said
- 39 Department of Anatomy and Cell Biology, University of Malta, Msida, Malta 40 Section of Medical Genetics, Mater dei Hospital, Msida, Malta
| | - Ulrike Schara
- 41 Pediatric Neurology, University Childrens Hospital, University of Duisburg-Essen University of Duisburg-Essen, Essen, Germany
| | - Anja Stein
- 42 Department of Neonatology, University Childrens Hospital, University of Duisburg-Essen, Essen, Germany
| | - Caroline Sewry
- 43 Dubowitz Neuromuscular Centre, Institute of Child Health and Great Ormond Street Hospital, 30 Guilford Street, London WC1N 1EH, UK
| | - Laura Travan
- 44 Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Trieste, Italy
| | - Frits A Wijburg
- 45 Department of Paediatrics, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Martin Zenker
- 46 Institute of Human Genetics, University Hospital Magdeburg, Germany
| | - Shehla Mohammed
- 47 Department of Clinical Genetics, Guy's Hospital, London, UK
| | - Manolis Fanto
- 2 Department of Basic and Clinical Neuroscience, IoPPN, King's College London, London, UK
| | - Mathias Gautel
- 6 Randall Division for Cell and Molecular Biophysics, Muscle Signalling Section, King's College, London, UK
| | - Heinz Jungbluth
- 1 Department of Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK 6 Randall Division for Cell and Molecular Biophysics, Muscle Signalling Section, King's College, London, UK 48 Department of Basic and Clinical Neuroscience, IoPPN, King's College London, London, UK
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