Familial Hypercholesterolemia Variant and Cardiovascular Risk in Individuals With Elevated Cholesterol

Importance

Familial hypercholesterolemia (FH) is a genetic disorder that often results in severely high low-density lipoprotein cholesterol (LDL-C) and high risk of premature coronary heart disease (CHD). However, the impact of FH variants on CHD risk among individuals with moderately elevated LDL-C is not well quantified.

Objective

To assess CHD risk associated with FH variants among individuals with moderately (130-189 mg/dL) and severely (≥190 mg/dL) elevated LDL-C and to quantify excess CHD deaths attributable to FH variants in US adults.

Design, Setting, and Participants

A total of 21 426 individuals without preexisting CHD from 6 US cohort studies (Atherosclerosis Risk in Communities study, Coronary Artery Risk Development in Young Adults study, Cardiovascular Health Study, Framingham Heart Study Offspring cohort, Jackson Heart Study, and Multi-Ethnic Study of Atherosclerosis) were included, 63 of whom had an FH variant. Data were collected from 1971 to 2018, and the median (IQR) follow-up was 18 (13-28) years. Data were analyzed from March to May 2023.

Exposures

LDL-C, cumulative past LDL-C, FH variant status.

Main Outcomes and Measures

Cox proportional hazards models estimated associations between FH variants and incident CHD. The Cardiovascular Disease Policy Model projected excess CHD deaths associated with FH variants in US adults.

Results

Of the 21 426 individuals without preexisting CHD (mean [SD] age 52.1 [15.5] years; 12 041 [56.2%] female), an FH variant was found in 22 individuals with moderately elevated LDL-C (0.3%) and in 33 individuals with severely elevated LDL-C (2.5%). The adjusted hazard ratios for incident CHD comparing those with and without FH variants were 2.9 (95% CI, 1.4-6.0) and 2.6 (95% CI, 1.4-4.9) among individuals with moderately and severely elevated LDL-C, respectively. The association between FH variants and CHD was slightly attenuated when further adjusting for baseline LDL-C level, whereas the association was no longer statistically significant after adjusting for cumulative past LDL-C exposure. Among US adults 20 years and older with no history of CHD and LDL-C 130 mg/dL or higher, more than 417 000 carry an FH variant and were projected to experience more than 12 000 excess CHD deaths in those with moderately elevated LDL-C and 15 000 in those with severely elevated LDL-C compared with individuals without an FH variant.

Conclusions and Relevance

In this pooled cohort study, the presence of FH variants was associated with a 2-fold higher CHD risk, even when LDL-C was only moderately elevated. The increased CHD risk appeared to be largely explained by the higher cumulative LDL-C exposure in individuals with an FH variant compared to those without. Further research is needed to assess the value of adding genetic testing to traditional phenotypic FH screening.

A Novel Variant in the TBC1D24 Lipid-Binding Pocket Causes Autosomal Dominant Hearing Loss: Evidence for a Genotype-Phenotype Correlation

Background: Hereditary hearing loss is a disorder with high genetic and allelic heterogeneity. Diagnostic screening of candidate genes commonly yields novel variants of unknown clinical significance. TBC1D24 is a pleiotropic gene associated with recessive DOORS syndrome, epileptic encephalopathy, myoclonic epilepsy, and both recessive and dominant hearing impairment. Genotype-phenotype correlations have not been established to date but could facilitate diagnostic variant assessment and elucidation of pathomechanisms.

Methods and Results: Whole-exome and gene panel screening identified a novel (c.919A>C; p.Asn307His) causative variant in TBC1D24 in two unrelated Caucasian families with Autosomal dominant (AD) nonsyndromic late-onset hearing loss. Protein modeling on the Drosophila TBC1D24 ortholog Skywalker crystal structure showed close interhelix proximity (6.8Å) between the highly conserved residue p.Asn307 in α18 and the position of the single known pathogenic dominant variation (p.Ser178Leu) in α11 that causes a form of deafness with similar clinical characteristics.

Conclusion: Genetic variants affecting two polar hydrophilic residues in neighboring helices of TBC1D24 cause AD nonsyndromic late-onset hearing loss. The spatial proximity of the affected residues suggests the first genotype-phenotype association in TBC1D24-related disorders. Three conserved residues in α18 contribute to the formation of a functionally relevant cationic phosphoinositide binding pocket that regulates synaptic vesicle trafficking which may be involved in the molecular mechanism of disease.

Histopathology of the Inner Ear in Charcot-Marie-Tooth Syndrome Caused by a Missense Variant (p.Thr65Ala) in the MPZ Gene

Charcot-Marie-Tooth (CMT) syndrome is a clinically and genetically heterogeneous group of neuropathies affecting both peripheral motor and sensory nerves. Progressive sensorineural hearing loss, vestibular abnormalities, and dysfunction of other cranial nerves have been described. This is the second case report of otopathology in a patient with CMT syndrome. Molecular genetic testing of DNA obtained at autopsy revealed a missense variant in the MPZ gene (p.Thr65Ala), pathogenic for an autosomal-dominant form of CMT1B. The temporal bones were also prepared for light microscopy by hematoxylin and eosin and Gömöri trichome stains, and immunostaining for anti-myelin protein zero. Pathology was consistent with a myelinopathy of the auditory, vestibular, and facial nerves bilaterally. The pathophysiology of cranial nerve dysfunction in CMT is unknown. Findings in the current case suggested, at least in cranial nerves 7 and 8, that a myelinopathy may be causative.

CD44 loss in gastric stromal tumors as a prognostic marker

BACKGROUND

The adhesion molecule CD44 (CD44s; CD44H) and its isoforms (CD44v3-6 and v9) are preferentially expressed by different cell types. These transmembrane glycoproteins are involved in cell-cell and cell-matrix interactions and in cell trafficking and, thus, may play a role in tumor metastasis and/or local invasion. The expression pattern of CD44s and variant isoforms, particularly CD44v6 and CD44v9, of some neoplasms, including soft tissue tumors, correlates with clinical course and outcome. The clinical behavior of gastrointestinal stromal tumors (GIST) is site specific; however, other reliable predictors of clinical outcome have not been identified. Thus, the prognostic value of CD44s and isoform expression in GIST were evaluated by immunohistochemistry of tissue microarrays.

DESIGN

Paraffin-embedded formalin-fixed tissue cores (129: 103 GIST and 26 normal stomach smooth muscle) from 33 patients with clinical outcome data were collected and used for the construction of the tissue microarrays. One to five tissue cores from each patient specimen were evaluated (mean = 3 tissue cores/patient). Array slides were stained with anti-CD44s (CD44H) and with antibodies to v3, v4, v5, v6, and v9 isomers. CD44s and isoform expression and staining intensity were scored semiquantitatively without knowledge of patient identity or outcome: 0 = no; 1 = weak; 2 = moderate; 3 = moderate to strong; 4 = strong. The scores of multiple cores from the same GIST were averaged; the nonneoplastic smooth muscle was similarly graded. CD44s and isoform expression and intensity were compared with outcome.

RESULTS

The 33 patients with gastric GIST, 0.8 to 30 cm in size, were followed for 1 to 111 months with a median follow-up of 7 months (mean 17.5 months). The overall median survival was 25 months. Nine of the 33 (27%) patients had metastases, 9 (27%) had recurrent disease, and 9 (27%) died of disease (9-111 months; mean 39 months; median 23 months). All 18 patients with GIST CD44s expression > 2+ were alive at last follow-up (1-62 months; median 3.5 months; mean 11 months). More than half (53%) of patients with GIST CD44s expression < or = 2+ died (9-111 months; median 23 months; mean 38 months); the median follow-up of the surviving patients with CD44 expression < or = 2 was 5 months (2-22 months; mean 6.5 months; log rank P = 0.07). The majority of tumors were variably positive CD44v3 and CD44v4, but there was minimal staining (number of cases and/or expression level) with antibodies directed against the v5, v6, and v9 isomers.

CONCLUSION

These preliminary results suggest that although gastric GISTs variably express CD44s and variants, only the expression of CD44s correlates with clinical outcome with loss of CD44s positivity correlating with poor clinical outcome.

Kikuchi-Fujimoto's disease: report of familial occurrence in two human leucocyte antigen-identical non-twin sisters

Kikuchi-Fujimoto's disease (KFD) is a self-limiting condition usually presenting as cervical lymphadenopathy, with fever and leukopenia, in young adult females. No specific aetiology has been identified yet, although some authors believe that KFD is a 'forme fruste' of systemic lupus erythematosus. Certain human leucocyte antigen (HLA) types have also been associated with KFD. We herein report KFD in two non-twin sisters with HLA-identical phenotype, who presented 10 years apart. Neither patient had evidence of recent infection or connective tissue disease. The familial occurrence emphasizes the possibility of genetic predisposition and calls for a more extensive search for a specific cause of KFD.

Rickets as an unusual initial presentation of abetalipoproteinemia and hypobetalipoproteinemia

OBJECTIVE

Description of rickets as an unexpected initial manifestation in two children with abetalipoproteinemia and hypobetalipoproteinemia, and elucidation of its pathophysiology in these conditions.

METHODOLOGY

Two infants aged two and six months with abetalipoproteinemia and hypobetalipoproteinemia respectively had clinical rickets at presentation, confirmed radiologically and biochemically. Vitamin D intake and serum levels were measured and other causes of rickets were looked for.

RESULTS

Vitamin D intake and laboratory studies levels were suggestive of rickets due to calcium deficiency instead of vitamin D deficiency. Healing of rickets occurred with dietary treatment of the malabsorption, without any dietary calcium or significant vitamin D supplementation.

CONCLUSION

Steatorrhea-induced calcium malabsorption seems to be the most likely cause of rickets in this entity.

Ramichloridium mackenziei brain abscess: report of two cases and review of the literature

We report two cases of brain abscesses caused by Ramichloridium mackenziei, a neurotropic dematiaceous fungus that seems to be geographically restricted to the Middle East. One of the patients had chronic myelomonocytic leukemia but did not receive any chemotherapeutic agents. The other patient was a normal host. Both cases had a fatal outcome despite aggressive antifungal therapy and surgical intervention. Herein, we review all previously described cases in the literature, and discuss the epidemiology, mycology and histopathology of this life-threatening organism.

Polypoid endocervical stromal sarcoma with heterologous elements. Report of a case with review of the literature

A 44 year old woman presented with six recurrent endocervical polyps within the span of 28 months. The last two of these polyps exhibited sarcomatous changes within the endocervical stroma with heterologous cartilagenous elements. Abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. No chemotherapy or radiotherapy was administered. The patient is alive and free of recurrent disease 9 years following surgery.

Adenoid cystic carcinoma of the trachea mimicking asthma

Full text is available as a scanned copy of the original print version.

The spectrum of breast diseases in Saudi Arab females: A 26 year pathological survey at Dhahran Health Center

In an attempt to delineate the spectrum of breast diseases in Saudi Arab females, we carried out a retrospective study of all cases of breast biopsies and mastectomies accessioned in the files of surgical pathology in our laboratory for 26 years (1967-1992). A total of 915 cases were collected. Fibroadenoma was the most common lesion encountered (30.7%), followed by fibrocystic condition (21.1%), carcinoma (14.9%), acute mastitis (7.2%), duct ectasia (4.9%), lactational adenoma (4.8%), intraductal papilloma (2.6%), galactocele (2.4%) and several less frequent lesions. Pathological conditions associated with lactation such as acute mastitis, abscess, granulomatous mastitis, galactocele and lactational adenomas constituted 16.2% of the cases in this series. This high frequency is related to the high fertility rate among Saudi Arab females. The mean age of Saudi Arab females with ductal carcinoma was 47.1 years as compared to 54 years in Western countries. Many patients presented with a large size tumor, skin and/or nipple involvement, as well as a high frequency (61.7%) of axillary nodal metastases in those who underwent axillary nodal dissection. The high frequency of fibroadenoma could be related to the large number of young females in our population. A great increase in the number of cases in the last five years has been observed. This could be related to more awareness among Saudi Arab females of their health problems and the expansion of our medical services.

Aggressive angiomyxoma of the vagina

Aggressive angiomyxoma is a recently described pathological condition which affects mainly the soft tissues of the pelvis and perineum in women. It is neither encapsulated nor circumscribed and has a tendency for local recurrence. We report a 50-year-old woman who presented with a mass arising within the vaginal wall and extending to the perineum which appeared cystic on ultrasound. The mass was excised and there is no evidence of recurrence 40 months after surgery.

Craniofacial duplication (diprosopus): report of a case with a review of the literature

A case of craniofacial duplication (diprosopus) is presented. Details on this rare form of conjoined twins are described, and the proposed theories of its embryogenesis are discussed with brief review of the pertinent literature.

Hydatidosis in Jordan: an epidemiological study of 306 cases

Of the 306 subjects studied, who had had hydatid cysts (Echinococcus granulosus) surgically excised in Jordan, 185 (60%) were female and 121 (40%) male. The liver was the most affected organ (57.8%), followed by the lung (26.4%). The kidneys, spleen, brain, soft tissues of neck, appendix and mesentery were less frequent sites. Multiple-organ infection was seen in 23 patients (7.5%). Over a third of the cases (35.8%) was aged < 21 years and the commonest occupation was housewife, followed by school student. The epidemiology of hydatidosis transmission in Jordan is discussed.

Struma ovarii with pseudo-Meigs' syndrome: report of a case and review of the literature

A case of struma ovarii with ascites and hydrothorax is reported. This unusual rare association is labeled as pseudo-Meigs' syndrome to differentiate it from conventional Meigs' syndrome in which the ovarian tumor is a fibroma. We discuss the diagnostic problems of this condition, and present a brief review of the reported cases in the literature.

Sudden unexpected death due to papillary fibroma of the aortic valve. Report of a case and review of the literature

The case of the sudden unexpected death of a 21-year-old man due to embolization of segments of an aortic valve papillary fibroma to the left main and anterior descending coronary artery is presented. The literature regarding cardiac papillary fibroma is reviewed with particular reference to those cases associated with sudden death.

Diagnostic value of cervical lymph node biopsy: a pathological study of 596 cases

During a 10-year period (1976-1985), a total of 596 cervical lymph node biopsies for diagnostic purposes were performed at our institution. Thirty-five percent of these nodes were involved with malignant lymphoma, and 20.5% showed metastatic deposits. Nondiagnostic reactive hyperplastic changes were noted in 23% of the cases. Several other inflammatory and neoplastic conditions were encountered. Comparison of our data with several series from different countries with review of relevant literature are presented.

Sudden, unexpected death due to cardiac fibroma. Report of a case and review of the literature

A case of cardiac fibroma in a 58-year-old woman with a history of atrioventricular block is described. The patient died suddenly at home 6 days following the insertion of a pacemaker. Review of the pertinent literature is presented.

Mixed mesodermal tumor of the uterus in a 4-year-old girl

A case of malignant mixed mesodermal tumor (MMT) of the uterus in a 4-year-old girl is reported. The patient had a polypoid lesion protruding from the vagina which was initially thought to be a sarcoma botryoides. This is one of the youngest cases of MMT on record. A review of MMT in premenopausal women and children is presented.

Suicide by xylene ingestion. A case report and review of literature

A 27-year-old male committed suicide by ingestion of a large quantity of xylene. The presence of xylene in the tissues of the victim was confirmed by chromatographic and spectrometric techniques. High levels of xylene were detected in blood (11 mg/dl), gastric contents (880 mg/dl), and duodenal contents (3,300 mg/dl). Histological examination of the lungs showed severe congestion and acute pulmonary edema. Review of the relevant literature is presented.

Aneurysmal bone cyst of the ilium associated with pregnancy

A 19-yr-old primigravida presented with a back mass which was found to originate from the right ilium and was associated with oblique fetal lie. Elective caesarean section and excision of the mass were done. Histologically, the lesion proved to be an aneurysmal bone cyst. Review of bone tumors associated with pregnancy is presented, with discussion of the problems related to diagnosis of this condition.

Malignant neoplasms in Jordanian children

Three hundred and seventy-three cases of malignant disease in children were diagnosed in Jordan during the 5-year period 1975-79. Lymphomas (28.7%) were the most frequently encountered tumours, followed by leukaemias (19.6%) and brain tumours (16.1%). One third of the children with lymphoma had Hodgkin's disease. Burkitt's lymphoma accounted for another one third, and lymphocytic lymphoma the remaining third. Abdominal involvement was frequently encountered in children with non-Hodgkin's lymphoma. Our data are similar to those reported from the neighbouring Arab countries, Iraq, Saudi Arabia, Kuwait and Egypt, and contrast with the data available from developed countries in which leukaemias and brain tumours are more frequent than lymphomas.

Burkitt's lymphoma in Jordanian children: epidemiological and clinical study

Twenty-four children with a diagnosis of Burkitt's lymphoma were seen at Jordan University Hospital during a 6 year period (1978-1983). Their median age was 4 years and the male to female ratio was 3:1. A space clustering of cases was evident. Abdominal mass was the commonest presentation being observed in 21 patients, while only two patients presented with jaw masses. Sixteen patients had advanced disease (stages C and D). Chemotherapy was the basic form of therapy given. Twelve children (50%) survived. Advanced stage and poor nutritional status at diagnosis correlated with poor outcome. Our data indicate that Burkitt's lymphoma in Jordanian children presents an intermediate type that shares some similarities with both the endemic (African) and non-endemic types.

Idiopathic subcutaneous and laryngeal fibrosis

A 40-year-old totally deaf male presented with submucosal masses in the subglottic space and multiple subcutaneous nodules in the eyelids, scrotum and thighs. Biopsies of these masses revealed dense fibrosis associated with non-specific chronic inflammation. Although the findings were clinically similar to those of neurofibromatosis, amyloidosis, multifocal fibrosclerosis with cutaneous nodules, and familial multicentric fibromatosis, they did not fit completely with any of the above-mentioned conditions. It is possible that this case represents a peculiar entity of its own.

Breast diseases in Jordanian females: a study of 1000 cases

Pathological data on 1000 breast lesions obtained from Jordanian females were analyzed and compared to data available from other countries or ethnic groups. Ductal carcinoma was the most frequently encountered lesion followed by fibrocystic disease (mammary dysplasia), fibroadenoma and mastitis. The mean age of Jordanian females with ductal carcinoma was 44.5 years, and many patients presented with advanced stage of the disease as evidenced by the high frequency (74.6%) of nodal metastases in the patients who had axillary lymphadenectomy. The frequencies of medullary and mucinous (colloid) carcinoma were not greatly different from those in other countries, but lobular carcinoma had a substantially low rate of occurrence. Many patients with lactation-associated lesions such as mastitis, galactocele and lactating adenomas were noted, which is attributed to the high fertility rate in Jordan.

Patterns of hepatomegaly in Jordanians: a prospective study of 800 cases

Eight hundred Jordanians with liver enlargement were studied: 369 (46%) were males and 431 (54%) females. Ages ranged between 13 and 85 years, with a mean of 47.4%: 766 cases demonstrated a single pathological process while 34 cases showed two or more processes. The most significant findings were: congestion secondary to cardiac failure in 323 cases (38.5%); inflammatory and parasitic processes in 192 cases (22.9%), including acute hepatitis (81 cases), hydatid cyst (63 cases), chronic hepatitis (27 cases), liver abscess (19 cases), brucellosis (one case) and malaria (one case); malignancy in 164 cases (19.6%); liver cirrhosis in 80 cases (9.5%); fatty metamorphosis in 47 cases (5.6%); metabolic and genetic disease in 11 cases (1.3%); miscellaneous conditions in nine cases (1.1%); and 15 apparently normal individuals (1.8%). Cardiac failure was the most frequent cause of hepatomegaly in this sample of Jordanians. Inflammatory processes were the second major cause, followed by malignancy and cirrhosis of the liver.

Polypoid lymphangioma of the tonsil: report of two cases and review of the literature

Benign tumours of the tonsils are uncommon. Among them, lymphangiomas are rare, and only six well-documented cases have been previously reported. We present two additional cases with review of the literature.

Renal amyloidosis in Jordan

Twenty cases of renal amyloidosis were observed among 182 patients who underwent kidney biopsy at Jordan University Hospital (JUH) during the period 1979-1983. Eight cases were classified as primary amyloidosis while the remaining 12 were secondary to various underlying diseases, the most significant one was familial Mediterranean fever (FMF). Comparison of incidence of renal amyloidosis in kidney biopsy series from neighbouring countries is presented.

Gastroduodenal inflammation in patients with non-ulcer dyspepsia. A controlled endoscopic and morphometric study

Proper control and quantitation are important in the accurate evaluation of gastroduodenal inflammation in dyspeptic patients without ulcers or erosions as proved by endoscopy. The endoscopic findings and the gastroduodenal mucosal inflammatory cell count in 31 patients with non-ulcer dyspepsia were compared with an age-matched group of 32 healthy controls. Endoscopy revealed similar mucosal changes and in similar frequency in both groups. Differential mucosal inflammatory cell count showed a statistically significant (P less than 0.001) increase in the neutrophil count in the gastric body, antrum, and duodenal cap of the dyspeptic group, as well as a slight but significant (P less than 0.05) increase in the round cell and eosinophil count of the duodenal mucosa alone. No correlation was found between the endoscopic changes and an increase in neutrophil count above a normal level determined by the healthy controls. However, an endoscopically normal mucosa was more likely to be associated with a normal neutrophil count. Active inflammation of the gastroduodenal mucosa likely accounts for the symptoms in patients with non-ulcer dyspepsia.

Immature teratoma with gliomatosis peritonei associated with pregnancy

Immature teratoma is a malignant form of teratoma that contains immature structures resembling those of the embryo. It is rare and accounts for less than 1% of all ovarian cancers. It occurs most frequently in young women but it is very rarely reported in association with pregnancy.

Synovial sarcoma of the esophagus

The occurrence of synovial sarcoma in sites other than the extremities is rare. Twelve cases in the hypopharynx but none in the esophagus have been described. A case of polypoid synovial sarcoma arising in the upper third of the esophagus in a 25-year-old man is reported. To the authors' knowledge, this is the first report of synovial sarcoma arising in the esophagus. The pathologic findings, ultrastructural studies, and results of surgical management and radiotherapy are discussed.

Hodgkin's disease in Jordanian children: a study of 26 cases

A retrospective review of Hodgkin's disease in 26 children of 14 years of age and below admitted to Jordan University Hospital during the period from 1976 through 1981 was conducted. This review showed a preponderance of males, particularly in the first decade of life, with prominence of the prognostically unfavourable histologic sub-types and advanced clinical stages.

Clear cell sarcoma: report of two cases with ultrastructural observations and review of the literature

Two cases of clear cell sarcoma of tendons and aponeuroses, one with prominent melanogenesis, are reported. One tumour arose in the left buttock of a young male and the other in the left fourth toe of a young female. Both had a rapid fatal course with local and distant metastases. Electron microscopy shows melanosomes in one case, suggesting a melanotic origin.

Therapeutic effect of vincristine, adriamycin and prednisolone (VAP) in angioimmunoblastic lymphadenopathy (AIL)

Five patients, three males and two females, with angioimmunoblastic lymphadenopathy (AIL) are described. The two who received steroids had no response and died 2 and 6 months later. The three patients who received vincristine, adriamycin and prednisolone (VAP) went into remission early and are still in remission with a follow-up of 22-35 months. It is concluded that VAP is effective therapy in AIL.

A case of fatal Lomotil overdosage

A 3 1/2-year-old British girl died in cardio-pulmonary arrest after ingesting an unknown amount of Lomotil® tablets. Chemical analysis by gas-liquid chromatography confirmed the presence of high levels of diphenoxylate in the blood as well as stomach and intestinal contents. No diphenoxylate was found in the urine. At autopsy the intestines were congested, but the main pathology was in the cerebellum, which showed typical changes described by others as ‘respirator brain’. The deceased was not put on a respirator and did not receive naloxone.