Three novel point mutations of the CYP21 gene detected in classical forms of congenital adrenal hyperplasia due to 21-hydroxylase deficiency

Congenital adrenal hyperplasia (CAH) [OMIM 201 910] is a group of autosomal recessive disorders most commonly due to 21-hydroxylase deficiency and presenting with a wide range of clinical manifestations. A limited number of inactivating pseudogene-derived mutations account for the majority of 21-hydroxylase gene ( CYP21) mutations, additional rare mutations can be found in single families and small populations. We found three novel CYP21 mutations in CAH patients suffering from the classical form of the disease, of which one is a frameshift mutation (1353-1354insA) leading to a premature termination codon (K277K, Q228A...E294X), one results in a premature stop codon (2551C>T, R444X), and one is a missense mutation (2609T>C; P463L). The frameshift and premature stop mutations can be predicted to result in a CYP21 protein without any residual enzyme activity. To determine the functional consequences of the P463L mutation, the IN VITRO enzyme activity was studied in COS-7 cells and revealed a reduced 21-hydroxylase activity of 2.6+/-0.8 (SD)% for the conversion of 17-hydroxyprogesterone (17OHP) to 11-deoxycortisol and of 3.0+/-0.5 % for the conversion of progesterone to 11-deoxycorticosterone (DOC). We conclude that functional analyses of unknown mutations provide information on the disease severity and should be always performed when novel CYP21 mutations are detected. Knowledge of the residual 21-hydroxylase function improves both genetic counselling and individual clinical management in CAH patients.

A new and accurate prediction model for growth response to growth hormone treatment in children with growth hormone deficiency

OBJECTIVE

To identify parameters which predict individual growth response to recombinant human GH (rhGH) therapy and to combine these parameters in a prediction model.

DESIGN

Fifty-eight prepubertal patients with GH deficiency (17 females) participated in this prospective multicenter trial with 1 year of follow-up.

METHODS

Auxological measurements, parameters of GH status and markers of bone metabolism were measured at baseline and at 1, 3 and 6 months after the start of rhGH treatment. Correlations with height velocity during the first 12 months of treatment (HV+12) were calculated. Prediction models were derived by multiple regression analysis.

RESULTS

The model which best predicted HV+12 combined the following parameters: pretreatment bone age retardation as a fraction of chronological age, pretreatment serum levels of IGF-I, urinary levels of deoxypyridinoline (a marker of bone resorption) after 1 month of treatment and height velocity after 3 months of treatment. This model explained 89% of the variation in HV+12 with a standard deviation of the residuals of 0.93 cm/year. Defining successful rhGH therapy as a doubling of pretreatment height velocity, the model had a specificity of 90% and a sensitivity of 100% in predicting therapeutic success.

CONCLUSIONS

This model is an accurate and practicable tool to predict growth response in GH-deficient children. It may help to optimize rhGH therapy by individual dose adjustment and contribute to improved overall outcomes.

High cure rates and reduced long-term toxicity in pediatric Hodgkin's disease: the German-Austrian multicenter trial DAL-HD-90. The German-Austrian Pediatric Hodgkin's Disease Study Group

PURPOSE

To further reduce therapy-related late effects in patients with pediatric Hodgkin's disease (HD) while maintaining the high cure rates achieved with vincristine, prednisone, procarbazine, and doxorubicin (OPPA) or OPPA/cyclophosphamide, vincristine, prednisone, and procarbazine (COPP) chemotherapy and involved-field radiotherapy. The risk of testicular dysfunction was addressed by substituting etoposide for procarbazine (OEPA) in the induction therapy for boys. Radiation doses and fields were further reduced.

PATIENTS AND METHODS

Three hundred nineteen boys and 259 girls younger than 18 years with previously untreated HD, enrolled onto the study between 1990 and 1995, were allocated to treatment group (TG)1 (early stages), TG2 (intermediate stages), or TG3 (advanced stages). All groups underwent two cycles of OEPA (boys) or OPPA (girls) for induction chemotherapy. TG2 and TG3 continued on additional two or four cycles, respectively, of COPP. Low-dose radiotherapy was given to the initially involved sites, ie, reduced involved fields.

RESULTS

Initial response to OPPA or OEPA induction was virtually identical. Eight of 578 patients experienced early progression of HD. Thirty-seven relapses, three secondary tumors, and no secondary leukemias have been recorded, with a median follow-up duration of 5.1 years (maximum, 8.1 years). Thirteen of 578 patients died. The probability of 5-year event-free survival/overall survival is 91%/98% in the total group, 94%/97% with OPPA, and 89%/98% with OEPA induction therapy. Risk factor analysis showed two significant prognostic factors: histologic subtype NS2 and "B" symptoms. OEPA induction therapy, large mediastinal tumor, and age were not significant. Preliminary studies of testicular function indicate a lower risk of germ cell damage than previously documented with OPPA.

CONCLUSION

OEPA is a satisfactory alternative to OPPA. Radiotherapy can be confined to involved sites when combined with appropriate chemotherapy. The DAL-HD-90 regimen represents a comprehensive treatment program for all stages of pediatric HD and offers a favorable benefit/risk ratio, combining excellent disease control, moderate acute toxicity, and reduced long-term toxicity.

Familial clustering of infantile cirrhosis in Northern Germany: A clue to the etiology of idiopathic copper toxicosis

Two cases of infantile liver cirrhosis of unknown origin occurred in a circumscribed rural area of Northern Germany. Both children had increased dietary copper exposure. The search for additional cases of what appeared to be idiopathic copper toxicosis (ICT) revealed a cluster of affected infants in this region, raising questions about the relative importance of genetic and environmental factors that are considered to be etiologic. We gathered clinical and pathologic data concerning the patients, analyzed the pedigrees of affected families, and searched for possible environmental factors contributing to the pathologic process. We encountered 8 cases of infantile liver cirrhosis in 5 families in Emsland, a circumscribed and predominantly rural area of Northern Germany; ICT was definitely proven in 2 cases. Clinical presentation and liver pathology in 6 additional cases were consistent with the diagnosis of ICT. Pedigrees of affected families revealed complex relationships with occasional consanguinity of parents, suggesting autosomal recessive inheritance. The households were served by private wells with water of low pH flowing through copper pipes, suggesting the possibility of increased alimentary copper exposure. These findings support earlier conclusions that ICT develops when an infant with a genetic predisposition is exposed to a copper-enriched diet.

Ultrastructural localization of IgG and TPO in autoimmune thyrocytes referring to the transcytosis of IgG and the antigen presentation of TPO

While autoantibodies against thyroid peroxidase (TPO) are known to produce cytotoxicity in vitro, their in vivo effects are still obscure. In addition, the mechanism of TPO autoantibody creation needs to be disclosed because the localization of TPO on thyrocytes is considered to be restricted to the apical membrane, which is not in contact with immunocompetent cells. In order to study these crucial processes in the pathogenesis of thyroid autoimmunity, the ultrastructural localization of TPO and IgG was determined and quantified in thyrocytes of normal thyroid gland and thyroid tissue of patients suffering from Graves' disease. This was done by using ultrathin frozen sections and the immunogold method. IgGs were detected in the follicular lumen, close to the apical membrane, in transport vesicles, the endoplasmic reticulum, and the Golgi apparatus of thyrocytes from patients with Graves' disease. The labeling of TPO in the basolateral membrane was distinctly lower than that of the apical membrane, but was significant in comparison to the plasma membrane labeling of fibroblasts present in the same sections. These data indicate that thyroid autoantibodies may perform their cytotoxic function in intracellular compartments besides the plasma membrane. TPO molecules on the basolateral membrane of HLA class II antigen-positive thyrocytes may initiate antigen presentation of TPO as well as the formation and uptake of TPO autoantibodies.

Sonographic features of Hashimoto thyroiditis in childhood

Fifty-seven sonograms of 18 children with Hashimoto thyroiditis were retrospectively assessed. Thirty-three examinations (in 12 patients) showed thyroid glands which were more reflective than adjacent strap muscles, 22 studies (in eight patients) demonstrated glands of equal reflectivity and two examinations (in one child) depicted thyroid glands of lower reflectivity than muscle. The most frequent ultrasound appearance consisted of 2-5 mm echopenic lesions generally distributed throughout large poorly-defined hyperreflective glands. In serial examinations no correlation was found between laboratory indexes of thyroid status and sonographic findings.

Different concentrations of thyroid peroxidase and thyroglobulin in the nuclear envelope and the endoplasmic reticulum throughout the cytoplasm

Thyroid peroxidase (TPO) and thyroglobulin (TG) represent two major glycoproteins of thyroid follicular cells performing biological functions such as iodination, transcytosis of thyroglobulin, and formation of thyroid hormones. They are involved in thyroid autoimmunity and thyroid inborn metabolic disorders. Studying these processes at a molecular level includes the determination of their precise intracellular distribution. An evaluation of the relative concentrations of TG and TPO in different subcellular compartments was carried out in stimulated human follicular cells using thin-frozen sections and the immunogold technique. It is documented that TG is transported from the endoplasmic reticulum and the Golgi apparatus to the follicular lumen by transport vesicles; most of it being present in the expanded endoplasmic reticulum throughout the cytoplasm. On the other hand, gold particles indicating TPO are adjacent to the membranes of the exocytotic pathway. They do not label the basolateral membrane but show the strongest density in the nuclear envelope and the apical membrane. The labeling density of TPO is about four times higher in the nuclear envelope than in the endoplasmic reticulum throughout the cytoplasm. In contrast, TG is concentrated three times higher in the rough endoplasmic reticulum throughout the cytoplasm than in the nuclear cisternae. Our results give the first quantitative evidence that TPO and TG are concentrated in different subcompartments of the endoplasmic reticulum. Because previous studies demonstrated the nuclear envelope as the site where the synthesis of endogenous peroxidase (Brökelmann, J., D. W. Fawcett, Biol. Reprod. 1, 59-71 (1969)) begins, we suggest that synthesis of these functionally related proteins happens in specialized parts of the endoplasmic reticulum.(ABSTRACT TRUNCATED AT 250 WORDS)

[MR findings in patients with idiopathic panhypopituitarism]

High-resolution MR imaging was performed in seven patients with pituitary dwarfism and panhypopituitarism. In five cases MR-findings included absence of the infundibulum and of the normal intrasellar posterior pituitary bright spot, and the presence of a small nodule at the median eminence. The absence of diabetes insipidus in these patients and the signal characteristics of the nodule at the median eminence suggest that the latter may represent a functioning ectopic posterior pituitary lobe. This complex of findings was only observed in patients with complications in the perinatal period (breech delivery) and appears to be the end result of an ischemic or traumatic injury of the infundibular stem. The infundibular defect would explain both the permanent hormone deficiency of the anterior pituitary gland through a disruption of the hypothalamic-hypophyseal portal system and the absence of diabetes insipidus through an ectopic regeneration of the neurohypophysis at the median eminence.

[Acne fulminans following high-dose testosterone treatment in tall boys]

In three boys, aged 12.5, 14 and 16 years, respectively, acne of the fulminans type developed after eight to twelve months' administration of 250 mg testosterone weekly or 500 mg every second week. Numerous deep and painful pustules grew, dominantly on the chest and back, in one of the boys also in the face. In addition fever and fatiguability set in, as well as bone and joint pains in some. Erythrocyte sedimentation rate and leukocyte counts were raised. Testosterone was at once discontinued and isotretinoin, in one boy also antibiotics, administered, this treatment lasting for 8 to 13 months. All three boys were left with disfiguring scars. Before testosterone is given to arrest growth in tall boys both patient and parents should be told of these potentially severe side effects.

[Significance of procarbazine in the chemotherapy of Hodgkin's disease--a report of the Cooperative Therapy Study DAL-HD-85]

It was the objective of the DAL study HD-85 to examine the possibility of a reduction of chemotherapy, compared to the study HD-82 which had applied a combined treatment strategy resulting in a relapse rate of only 2.5% after 4 years, and a proportion of intercurrent deaths of 1.5%, in a total of 203 patients. Procarbazine was eliminated in the OPPA-therapy (OPA) and replaced by methotrexate in the COPP-cycles (COMP). Chemotherapy consisted in 2 cycles of OPA for stage I/IIA (group 1), 2 cycles of OPA and 2 cycles of COMP for stage IIB/IIIA (including IEA/IIEA) (group 2), and 2 cycles of OPA and 4 cycles of COMP for stage IIIB/IV (group 3). The subsequent radiotherapy was limited to the initially involved fields, the dosage of 35, 30 or 25 Gy depending on the extent of chemotherapy. Regions showing incomplete tumor regression after chemotherapy received another 5 Gy, in patients of groups 2 and 3. Between Jan. 1985 to Nov. 1986, 103 children with Hodgkin's disease from 42 participating hospitals were enrolled in this study. 98 patients were treated according to protocol (59 boys, 39 girls). A specific strategy for the selective indication of laparotomy and splenectomy was applied. With this strategy no laparotomy was performed in 39/98 patients (40%). 67 patients (68%) retained their spleen. 4 patients showed progression of the disease under chemotherapy, all others achieved remission. 16 patients relapsed before Dec. 31, 1987. So far no child of this study has died.(ABSTRACT TRUNCATED AT 250 WORDS)

Acne of the fulminans type following testosterone therapy in three excessively tall boys

Ulcerative acne was observed in three boys who underwent long-term treatment with high doses of testosterone for excessively tall stature. Even after withdrawal of testosterone therapy, this devastating type of acne still persisted for several months. After starting isotretinoin treatment, two cases progressed to full-blown acne fulminans with systemic manifestations. In these two cases, oral isotretinoin therapy induced multiple lesions of hyperproliferative granulation tissue resembling pyogenic granuloma. Topical steroid treatment proved to be beneficial for this adverse effect. Systemic corticosteroid treatment was administered in one case. High testosterone levels during puberty may be an important trigger mechanism of acne fulminans and may explain why this disease almost exclusively affects male adolescents.

Radiological findings in patients with mucopolysaccharidosis I H/S (Hurler-Scheie syndrome)

The development of radiological changes in two patients with mucopolysaccharidosis (MPS) Type I H/S is described. Radiological findings reveal enlargement of the sella in one patient, impression of the basilar skull in the other patient. Sclerosis and thickening of the base of skull was observed in both patients. The mandibular necks were short with striking flattening of the superior surfaces of the condyles, when the patients reached adult age. At the age of 12, hypertelorism and spaced teeth were already present in both patients. In addition, they showed early costal, clavicular and scapular changes, irregularities of the acromial joints and acetabulae, hypoplasia of the inferior portion of the iliac bones and flared iliac wings. The flat femurs had short metaphyses and were held in valgus position. Development of dentigerous cysts as well as mandibular changes seem to be rather specific for this variant of alpha-L-iduronidase deficiency. In contrast to the classical form of MPS I, skeletal changes of the spine and hands are minimal.

Prediction of splenic involvement in children with Hodgkin's disease. Significance of clinical and intraoperative findings. A retrospective statistical analysis of 154 patients in the German therapy study DAL-HD-78

In 154 splenectomized children and adolescents with histologically proven Hodgkin's disease in the therapy study DAL-HD-78, the incidence of splenic involvement was 39%. In single-parameter analyses 6 of 16 examined pre- and intraoperative findings showed significant correlation to splenic involvement: B-symptoms, palpable splenic enlargement, mediastinal/lung hilus involvement, nodular changes of splenic surface, enlarged lymph nodes at splenic hilus/pancreatic tail, or enlargement of other upper-abdominal lymph nodes. The results of multivariant analyses (Cox regression model) of these six parameters showed that the two most significant intraoperative parameters--changes of splenic surface and enlargement of lymph nodes at splenic hilus/pancreatic tail-gave almost all of the information which can be obtained about splenic involvement. With these two parameters, an intraoperative decisional strategy for selective splenectomy has been developed which allows the omission of splenectomy in about two thirds of children with Hodgkin's disease while still obtaining detailed information about infradiaphragmatic spread of disease. Since minor splenic involvement remains undetected in about 10% of the nonsplenectomized patients (i.e., 6% of all patients), this method should be used only in combination with chemotherapy.

[Combined treatment strategy in over 200 children with Hodgkin's disease: graduated chemotherapy, involved field irradiation with low dosage and selective splenectomy. A report of the cooperative therapy study DAL-HD-82]

It was the aim of the cooperative therapy study HD-82 for children with Hodgkin's disease to reduce chemo- and radiotherapy and to investigate of a strategy for selective splenectomy previously developed in the Hodgkin study HD-78. Between December 1981 and December 1984 207 patients (131 boys and 76 girls) below 16 years of age were enrolled in this study. In 174 out of 207 patients (84.1%) the criteria for selective splenectomy were applied i.e. the spleen was only removed when the splenic surface was nodular or when the lymphnodes at the splenic hilus and/or the pancreatic tail were enlarged. 69 out of 174 patients (39.7%) had a splenectomy. 50 of the removed 69 spleens (72%) showed histological evidence of Hodgkin's disease. These results were comparable to the 36% and 73% predicted from the retrospective analysis in the HD-78 study. According to the stage of Hodgkin's disease three different treatment groups with 2, 4 and 6 cycles of OPPA/COPP were formed (stage I/IIA, IIB/IIIA and IIIB/IV). Radiation therapy was given as involved field irradiation with a total dose of 35, 30 and 25 Gy depending on the extent of the chemotherapy. 203 patients were treated according to the protocol. Until the 30th of November 1985 3 patients died from intercurrent disease during a follow-up period of 11 to 47 months (median 29 months). 5 patients relapsed. The probability for disease-free survival after 3 1/2 years is 96% for the total group and 99%, 96% and 87% for the three treatment groups including 100, 53 and 50 patients in each group respectively.

CONCLUSIONS

1. The OPPA/COPP chemotherapy eliminates reliably occult microfoci. 2. The radiation doses in combination with the chemotherapy are sufficient to prevent local recurrences. 3. The decisional model for selective splenectomy has proved to be extremely valuable prospectively.

[Therapy of pituitary dwarfism with recombinant human growth hormone. A multicenter study]

During the period from 1982 to 1985, biosynthetic growth hormone (methionyl-hGH) was administered to 55 children with pituitary growth deficiency, 49 with idiopathic, six with other forms of the disorder. Preparations with a relatively high content of Escherichia coli polypeptides (ECP) were given to 32 children (group I), those with a markedly reduced ECP content to 12 (group II), while 11 children received almost ECP-free preparations (group III). The treatment achieved an intensive rise of growth acceleration in all three groups. At the same time, somatomedin C, biological somatomedin activity and alkaline phosphatase rose steeply, reaching a maximum after six months and remaining at high concentrations even thereafter. High antibody titres against ECP and hGH (with high binding capacity) were demonstrated in group I children, significantly lower titres with little binding capacity in those of group II, while most of those in group III had no measurable antibodies. Even in high concentrations the antibodies did not have any inhibiting effect on growth. No positive correlation between antibody titre and growth velocity was demonstrable. An exception was a boy with an allergy in group I, who had a maximal antibody titre and, at the same time, a high serum concentration of IgE. He had marked delay in growth which, however, quickly became normal on administration of extractive hGH.

[Malignant testicular tumors in children and adolescents: concept of the MAHO 82 cooperative therapeutic study of the Society for Pediatric Oncology]

The German Society of Pediatric Oncology (GPO) designed a cooperative study to improve the outlook of patients with malignant (testicular) germ cell tumors. According to stage and histology of the tumor different surgical approaches to retroperitoneal lymphadenectomy are suggested. Local radiotherapy is not recommended. Adjuvant chemotherapy with Vinblastine, Bleomycin and Cis-Platinum according to stage of disease, histologic classification and age of the patient is outlined. For non-responders or patients with only partial response an alternative aggressive chemotherapy with VP 16, Ifosfamide and Cis-Platinum is guidelined.

[Treatment strategy in non-testicular malignant germ cell tumors in children and adolescents--concept of the MAKEI 83 cooperative therapeutic study of the Society for Pediatric Oncology]

In December 1982 the German Society of Pediatric Oncology (GPO) has initiated a cooperative study for non-testicular malignant germ cell tumors with initial vinblastine, bleomycin and cisplatinum chemotherapy depending on stage and histological grading, followed by ifosfamide, cisplatinum and VP 16 chemotherapy. Dysgerminoma patients with advanced disease are also treated with primary chemotherapy including vinblastine, bleomycin and cisplatinum; radiotherapy is limited to current disease. Patients with more differentiated teratomas receive combination chemotherapy with vinblastine, actinomycin D and cyclophosphamide.

[Results of preventive management of the central nervous system in 275 children with acute lymphoblastic leukemia]

From 1970 to 1979, two subsequent BFM studies were performed with different modalities of systemic chemotherapy and preventive central nervous system (CNS) therapy. Eighteen out of 275 children experienced isolated CNS relapses within 2 years after diagnosis. The present analysis should clarify the following questions: 1. Could the risk for CNS relapse be assessed by initial diagnostic findings? 2. Is the CNS relapse rate influenced by more intensive systemic chemotherapy? 3. Is the CNS relapse rate altered by different doses of radiation therapy? The risk for relapse was assessed using a risk index (RI) based on findings at diagnosis. All patients were treated with an 8 weeks induction and consolidation chemotherapy protocol. In part, children with increased risk for relapse (RI greater than = 3) received an additional 6 weeks reinduction protocol within the first six months after diagnosis. Preventive treatment to the CNS consisted of radiotherapy at doses of less than = 18 Gy or 24 Gy and intrathecal methotrexate given during the consolidation phase. The results are as follows: 1. The RI proved to be predictive also for the risk of CNS relapse. However, CNS relapse rates were not substantially higher in children with RI greater than = 3 when they had been exposed to radiation doses of 24 Gy instead of less than = 18 Gy. 2. Intensive systemic reinduction therapy did not influence the CNS relapse rate in children with RI greater than = 3. 3. Three percent of children with RI less than = 2 experienced CNS relapses, irrespectively of lower or higher radiation doses. In patients with RI greater than = 3, however, irradiation at doses of less than = 18 Gy instead of 24 Gy led to a 3-4 fold higher incidence of CNS relapses, irrespectively of chemotherapy. We conclude that radiation doses of less than = 18 Gy are capable of preventing CNS relapses effectively in children with RI less than = 2. The exposure of patients with RI greater tha = 3 to doses of 24 Gy is justified.

Evaluation of surgically treated Nelson's syndrome

In 17 primary transnasal operations on Nelson tumours long-term results are assessed measuring ACTH plasma levels and performing regular neuroradiological controls. In small intrasellar adenomas only one recurrent ACTH elevation near to pretreatment levels without symptoms from tumour growth was observed after 10 years. ACTH normalization was rarely achieved in large tumours, but only in one patient was a relapse visible in CT scan after three years. Thus selective tumour removal seems to be advisable at an early stage when sellar enlargement occurs. Interpretation of ACTH plasma levels has to include completeness of adrenalectomy, cystic tumour necrosis, and corticoid replacement which reduces ACTH levels. Elevation of ACTH plasma levels over 5,000 pg/ml has been regularly accompanied by extrasellar tumour extension. In large adenomas with definitely elevated ACTH levels, additional radiation therapy should be considered.

[Treatment of malignant tumours of the genitalia in young girls (author's transl)]

This is a report about three cases of malignant tumours in young girls (botryoid sarcoma--rhabdomyosarcoma and an endodermal sinus tumour). The surgical treatment consisted of radical excision of the tumour with subsequent lymphadenectomy. The ovaries remained in place. Chemotherapy has resulted in an improvement of 5 years survival of malignant tumours in children. Ultraradical surgery, the treatment of choice until 5 years ago seams to dispensable.

[Concordant leukemia in identical twins (author's transl)]

We report female monozygous twins who developed acute lymphoblastic leukemia at the age of 5 1/2 years. The diagnosis in the first twin was made after pallor, lethargy, and petechiae developed. The diagnosis in the second twin was made two days later when a whole blood count was taken. The lymphoblasts of both patients showed with the exception of the PAS-reaction identical morphological, cytochemical, and immunological results. The PAS-reaction was positive in 55% of the lymphoblasts in one twin, negativ in the lymphoblasts of the other twin. Both patients are in continuous complete remission 14 months after diagnosis. The risk of leukemia is high in the other monozygous twin when one of the twins has already developed leukemia. In the literature it is estimated to be 1 : 5. The diagnosis after the second year of life is rarely made at the same time. There is only one previous report of this occuring in a case of acute myeloblastic leukemia in 4 1/2 year old monozygous twins.