Clinical characteristics and follow-up of a newborn with Dubin-Johnson Syndrome: A clinical case report

BACKGROUND

Dubin-Johnson syndrome (DJS) is a rare autosomal recessive liver disorder, characterized by conjugated hyperbilirubinemia. This case report investigates the clinical characteristics and longitudinal outcomes of a neonate diagnosed with DJS.

METHODS

A newborn presented with elevated bilirubin levels and abnormal liver enzyme readings. Comprehensive genetic evaluation was conducted, which included peripheral blood sample collection from the infant and both parents after obtaining informed consent and high-throughput trio exome sequencing was performed. The genetic analysis revealed 2 significant mutations in the ABCC2 gene on chromosome 10: the insertion mutation c.4237(exon30)_c.4238(exon30)ins CT, inherited from the father, and the missense mutation c.517(exon5)G > A, inherited from the mother. Both mutations were classified as pathogenic according to the ACMG 2015 guidelines, indicating a compound heterozygous inheritance pattern. The patient's treatment regimen included phototherapy, which was initiated to address her jaundice upon admission. To support liver function and regulate gut activity, oral ursodeoxycholic acid (20 mg/kg/dose, twice a day) and probiotics were administered. Additionally, a postdischarge medication plan involving a low-dose regimen of phenobarbital (3.5 mg/kg/dose, twice a day) was implemented for 2 weeks.

RESULTS

During a 2-year follow-up after discharge, the infant's bilirubin levels significantly decreased, and liver enzymes, including GGT, progressively normalized.

CONCLUSION

This case report enhances the understanding of DJS in neonates by emphasizing the clinical ramifications of compound heterozygous mutations within the ABCC2 gene and documenting the evolution of the disease. The gradual normalization of liver function tests suggests potential compensatory mechanisms in response to the genetic abnormalities in neonates with DJS. The correlation between the patient's genetic profile of compound heterozygosity and her milder clinical phenotype warrants attention, suggesting that this specific genetic configuration may be associated with less severe manifestations of the disease. The necessity for long-term follow-up is highlighted, recognizing that intercurrent stress conditions could influence the hepatic profile and potentially exacerbate symptoms. Such sustained observation is crucial to further delineate the genomic and clinical landscape of DJS, offering opportunities to refine prognostic and therapeutic approaches.

Genotype-Phenotype Association in ABCC2 Exon 18 Missense Mutation Leading to Dubin-Johnson Syndrome: A Case Report

We report a case of a patient with Dubin-Johnson syndrome confirmed by a genetic study. A 50-year-old woman who had symptoms of intermittent right upper quadrant abdominal pain was diagnosed with calculous cholecystitis at another institute and was presented to our hospital for a cholecystectomy. She had no history of liver disease, and her physical examination was normal. Abdominal computed tomography showed a gallbladder stone with chronic cholecystitis. During a laparoscopic cholecystectomy for cholecystitis, a smooth, black-colored liver was noted, and a liver biopsy was performed. The biopsy specimen showed coarse, dark brown granules in centrilobular hepatocytes via hematoxylin and eosin staining. We performed a genetic study using the blood samples of the patient. In the adenosine triphosphate-binding cassette subfamily C member 2 (ABCC2) mutation study, a missense mutation in exon 18 was noted. Based on the black-colored liver without nodularity, conjugated hyperbilirubinemia, the liver biopsy results of the coarse pigment in centrilobular hepatocytes, and the ABCC2 mutation, Dubin-Johnson syndrome was diagnosed. The patient was managed with conservative care using hepatotonics. One month after follow-up, total bilirubin and direct bilirubin remained in a similar range. Another follow-up was planned a month later, and the patient maintained her use of hepatotonics.

[Genetic analysis of a case with Dubin-Johnson syndrome due to two novel variants of ABCC2 gene]

OBJECTIVE

To explore the genetic etiology and differential diagnosis for a patient with jaundice.

METHODS

Clinical data of the patient and his parents were collected. Genes associated with metabolic liver diseases were subjected to high-throughput sequencing. The pathogenicity of the candidate variants was predicted by using bioinformatics software.

RESULTS

High-throughput sequencing revealed that the proband has harbored two variants of the ABCC2 gene (NM_000392) including c.3011C>T (p.T1004I) and c.3541C>T (p.R1181X), which were respectively inherited from his father and mother. Both variants have been previously unreported and predicted to be pathogenic by bioinformatics analysis.

CONCLUSION

The proband was diagnosed with Dubin-Johnson syndrome due to the compound heterozygous variants of the ABCC2 gene. Genetic testing has enabled accurate differential diagnosis of Dubin-Johnson syndrome in this patient.

Characterization of a novel ABCC2 mutation in infantile Dubin Johnson syndrome

BACKGROUND AND AIMS

The Dubin Johnson Syndrome (DJS) occurs mostly in young adults but an early-onset of the disease has been reported in less common forms (Neonatal DJS and Infantile DJS). In this case, the clinical findings are of limit for the DJS diagnosis. Hence, the genetic testing remains the method of choice to provide an accurate diagnosis. In our study, we aimed to perform a genetic analysis for two siblings presented with an intrahepatic cholestasis before the age of 1 year to provide a molecular explanation for the developed phenotype.

PATIENTS & METHODS

A Tunisian family, having two siblings, manifesting signs of a hepatopathy, was enrolled in our study. A molecular analysis was performed, using a panel-based next generation sequencing, supplying results that were the subject of computational analysis. Then, a clinical follow-up was carried out to assess the evolution of the disease.

RESULTS

The genetic analysis revealed the presence of a novel missense c.4179G > T, (p.M1393I) mutation in ABCC2 gene associated with a substitution c.2789G > A (R930Q) in ATP8B1 gene. Predictive results consolidated the pathogenic effect of both variants. These results confirmed the DJS diagnosis in the studied patients. The clinical course of both patients fit well with the benign nature of DJS.

CONCLUSION

We described here a novel ABCC2 mutation associated with a putative ATP8B1 modifier variant. This finding constituted the first report of a complex genotype in DJS. Hence, genetic analysis by a panel-based next generation sequencing permits an accurate diagnosis and the identification of putative variants that could influence the developed phenotype.

Adult Coats' Disease, Dubin-Johnson Syndrome, and the Search for Targeted Therapies

Coats' disease is nonhereditary retinal vascular disorder characterized by telangiectatic retinal vessels with prominent aneurysmal changes and exudation. A conclusive etiology has not yet been determined. In this retrospective case report and literature review, a 64-year-old male with Dubin-Johnson syndrome presented with unilateral retinal vascular changes and exudation consistent with a diagnosis of adult Coats' disease. The authors conclude that patients with Dubin-Johnson syndrome carry mutations in a multidrug resistance associated protein (MRP). MRPs are also expressed in the retina, retinal pigment epithelium, and vascular endothelium, where they export toxins and metabolites, and may serve as a therapeutic target. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:318-321.].

Dubin-Johnson syndrome with multiple liver cavernous hemangiomas: report of a familial case

Dubin-Johnson syndrome (DJS) is a rare autosomal recessive inheritance disorder of bilirubin metabolism. Herein we reported a complicated but interesting case which is readily resulted in misdiagnosis or an indefinite diagnosis, and this is the first reported familial case of DJS with multiple liver cavernous hemangiomas. A 49-year-old man was referred to our hospital for jaundice and multiple low-density liver masses. Extensive laboratory investigations showed conjugated hyperbilirubinaemia and positive urine bilirubin. Microscopically, lesions were composed of blood-filled vascular channels of various sizes lined by a single layer of flat endothelial cells supported by fibrous tissue. Coarse brown granules presented in the hepatocytes of the liver lobules locating beside the tumor, particularly in the centrilobular hepatocytes, and the granules showed blue-green with Schmorl's reaction lipofuscin staining. Interestingly, one of the patient's six siblings (female) shared the same condition with him. The relationship between DJS and hemangiomas remains unclear, and it might be contributed to some hereditary factors, or probably occurred simultaneously by chance. It was certified that the true reason for the long-term unclear jaundice was DJS, which was presumed clinically to be caused by bile excretion obstacles associated with the hemangiomas. Liver biopsy and histochemical stain may be helpful to identify the reason of jaundice and avoid misdiagnosis or an indefinite diagnosis.

[The Dubin-Johnson syndrome: case report and review of literature]

The Dubin-Johnson syndrome is a hereditary deficiency in the excretion ofconjugated bilirrubin by hepatocytes characterized by chronic hyperbilirubinemia, alteration in coproporphyrin metabolism, and intracellular deposition of a dark melanin-like pigment giving the liver a typical black cast. We report a 28-year-old male patient who presented conjunctival jaundice and conjugated-hyperbilirubinemia without no other alteration in hepatic biochemistry. The diagnosis of this syndrome was perfomed by using the low-risk methods of laparoscopy-facilitated hepatic biopsy and oral cholecystography In contrast, we avoided the classical Bromsulphalein test because of potential severe side effects. We stress here the current importance of these tests for confirming the diagnosis. By using this methodology, we were not able to quantify the isomeric profile of the urinary coproporphyrins nor 99mTc-HIDA cholescintigraphy. In conclusion, we confirm the utility of hepatic biopsy with the aid of laparoscopy and oral cholecystography for the diagnosis of the Dubin-Johnson syndrome on the basis of their effectiveness and relative lack of complications.

[A case with Rotor syndrome in hyperbilirubinemic family]

Rotor syndrome is a rare, benign familial disorder characterized by chronic fluctuating, nonhemolytic and predominantly conjugated hyperbilirubinemia with normal hepatic histology. In contrast to Dubin-Johnson syndrome, there is no liver pigmentation in Rotor syndrome. A 36-year-old man was admitted due to asymptomatic persistent jaundice. His siblings had jaundice with direct hyperbilirubinemia. Physical examination revealed icteric sclerae without hepatosplenomegaly. Laboratory findings showed increased serum bilirubin with direct bilirubinemia. Hepatic uptake and storage capacity of indocyanine green was markedly reduced, while excretion into bile was slightly suppressed. Markedly decreased hepatic uptake and poor visualization of the gallbladder and biliary tract were shown in 99mTc-DISIDA scan. Histology of the liver showed mild steatosis without pigmentation. We report a case with the review of literature.

Dubin-Johnson syndrome with systemic lupus erythematosus: a case report

BACKGROUND

Dubin-Johnson syndrome (DJS) is a rare clinical entity. We describe a case of DJS complicated by systemic lupus erythematosus (SLE).

METHODS

A case of congenital hyperbilirubinemia with SLE was evaluated systematically including review of history, physical examination for the stigmata of chronic liver disease, and other investigations.

RESULT

Liver biopsy revealed a black liver with preserved architecture suggestive of DJS.

CONCLUSIONS

SLE may develop in DJS. The relationship between DJS and SLE in this case is most likely a chance occurrence.

Autopsy case of Dubin-Johnson syndrome with pneumonia and abetalipoproteinemia-like lipid profile

We report the autopsy of a 79-year-old Japanese woman with Dubin-Johnson syndrome accompanied by pneumonia, an abetalipoproteinemia-like lipid profile and acanthocytosis. On admission, physical examination of the patient revealed malnutrition. Blood tests revealed marked inflammatory changes and mild liver dysfunction. Chest X-ray indicated bilateral pneumonia. Total cholesterol, low-density lipoprotein (LDL) cholesterol and triglyceride levels were 89 mg/dL, 5 mg/dL and 6 mg/dL, respectively. Peripheral blood smears revealed numerous acanthocytes. Despite the administration of antibiotics and nutritional support, the patient died. Autopsy revealed a black liver, atrophy of fat tissue on the mesentery, and pneumonia with bilateral pleural effusion. We believe that the abetalipoproteinemia-like lipid profiles in this case were caused by malnutrition and the inflammatory changes rather than the direct effects of Dubin-Johnson syndrome. We base this conclusion on the following three findings: 1) the patient's lipid profile before hospitalization was in the normal range, 2) her serum LDL cholesterol and triglyceride levels gradually increased after nutritional support began, and 3) blood tests revealed marked inflammatory changes (C-reactive protein 9.0 mg/dL; interleukin-6 16.4 pg/mL). This case provides important information that enhances our understanding of lipid metabolism under conditions of malnutrition and inflammation.

A Potential Dubin-Johnson Syndrome Imaging Agent: Synthesis, Biodistribution, and MicroPET Imaging

Dubin-Johnson syndrome (DJS) is caused by a deficiency of the human canalicular multispecific organic anion transporter (cMOAT). A new lipophilic copper-64 complex of 1,4,7-tris(carboxymethyl)-10-(tetradecyl)-1,4,7,10-tetraazadodecane (5) was prepared and evaluated for potential as a diagnostic tool for DJS. The prepared ligand was labeled with (64)Cu citrate in high radiochemical purity. In vivo uptake and clearance of the complex was determined through biodistribution studies using normal Sprague-Dawley rats and mutant cMOAT-deficient (TR(-)) rats. In normal rats, the radioactive copper complex was cleared quickly from the body exclusively through the hepatic pathway. The (64)Cu complex was taken up rapidly by the liver and quickly excreted into the small intestine and then the upper large intestine, whereas <1% ID/organ was found in the kidney at all time points post injection. Whereas activity was accumulated continuously in the liver of TR(-) rats, it was not excreted into the small intestine. MicroPET studies of normal and TR(-) rats were consistent with biodistribution data and showed dramatically different images. This study strongly suggests that cMOAT is involved in excretion of (64)Cu-5. The significant difference between the biodistribution data and microPET images of the normal and TR(-) rats demonstrates that this new (64)Cu complex may allow noninvasive diagnosis of DJS in humans.

Treatment of severe cholestasis in neonatal Dubin-Johnson syndrome with ursodeoxycholic acid

We report a case of Dubin-Johnson Syndrome in a neonate presenting with severe direct hyperbilirubinemia, which failed to respond to phenobarbital treatment. Ursodeoxycholic Acid added to therapy was well tolerated, and resulted in declining bilirubin concentration. We suggest ursodeoxycholic acid in treatment for Dubin-Johnson Syndrome with severe direct hyperbilirubinemia presenting in the neonatal age.

Genes for jaundice

The inheritable causes of jaundice comprise a large group of conditions of varying frequency, from Gilbert's syndrome which is relatively common, to the very rare Crigle-Najjar syndrome. Although these conditions have been well characterized clinically and in some cases biochemically, the underlying molecular defects were unknown because of a lack of knowledge about the process of bile secretion by hepatocytes. The recent cloning of several transporters for bile acids and other organic anions has enabled a greater understanding of this process and allowed correlation of the malfunction of these genes with specific disease processes. This new knowledge will provide for precision in diagnosis, allow antenatal testing and provide opportunities for gene therapy for some of the more serious disorders.

Postoperative management following massive hepatectomy in a patient with Dubin-Johnson syndrome: report of a case

We report herein the case of a 46-year-old man with Dubin-Johnson syndrome (DJS) who was referred to our hospital to undergo a right hepatic lobectomy for hepatocellular carcinoma. His complicated postoperative conjugated hyperbilirubinemia was successfully treated by hemopurification based on the increased level of serum hepatocyte growth factor (HGF). It is considered that hemopurification based on the early postoperative HGF levels has beneficial effects for patients with DJS; however, the specific role of hemopurification in the conjugated hyperbilirubinemia that develops postoperatively in these patients has not been determined.

[Molecular biology analysis: hereditary hemochromatosis, Wilson disease, alpha 1-antitrypsin deficiency and Dubin-Johnson syndrome]

The molecular pathology of hereditary hemochromatosis, Wilson's disease, alpha 1-antitrypsin-deficiency and Dubin-Johnson syndrome could be well characterised during the last years. Diagnosis of hereditary hemochromatosis is reliably confirmed by PCR-augmentation and restriction-analysis. Wilson's disease is a monogenetic disease, which is characterised by over 50 mutations. Molecular diagnosis is complicated by the lack of a single specific mutation. Diagnosis of Dubin-Johnson syndrome and alpha 1-antitrypsin-deficiency is possible by PCR-analysis and hybridisation with specific oligonucleotides.

A case of late onset primary hyperoxaluria type I (PH-I) presented with black liver

A 63-year-old woman who had received hemodialysis therapy since she fell acute on chronic renal failure 4 years ago presented with multiple joint pain. Nephrocalcinosis was not detected by abdominal X-ray when hemodialysis therapy was initiated. Laboratory testing showed azotemia, anemia, hypoproteinemia and mild liver dysfunction but no liver cirrhosis. Biopsied bone tissue demonstrated numerous calcium oxalate crystal depositions. Laparoscopy revealed black liver in macroscopic view. Histological studies showed numerous lipofuscin-like dark brown granules were deposited in hepatocytes. The activity of alanine : glyoxylate aminotransferase (AGT) was less than 0.1 U/g in biopsied patient's liver tissue. Generally, clinical symptoms demonstrated by Japanese primary hyperoxaluria type I (PH-I) patients are milder than those of European patients. Some PH-I patients may successfully avoid urinary tract calcification unless they fall into oliguria by some other causes. The lipofuscin granules are most likely the source of the dark color. Massive deposition of the lipofuscin granules indicated that the duration of the liver metabolic abnormality had lasted for long time. Thus, black liver may be related to a mild form of PH-I.

A case of infantile Dubin-Johnson syndrome with high CT attenuation in the liver

We report a case of Dubin-Johnson syndrome (DJS) with severe infantile cholestasis and elevated computed tomography (CT) attenuation of the liver. Increased levels of urinary coproporphyrin I were found as well as pigment granules in the hepatocytes and hepatosteatosis. The CT attenuation was markedly higher in the liver of this patient at the ages of 3 and 7 months than in the spleen or kidneys. This high attenuation may be a finding specific to infantile DJS and, therefore, abdominal CT may be helpful in the diagnosis.

Neonatal cholestasis in two siblings: a variant of Dubin-Johnson syndrome?

OBJECTIVE

Two Japanese brothers with neonatal cholestasis associated with pigment granules in the hepatocytes and hepatosteatosis were evaluated for the possible role of hepatosteatosis in the Dubin-Johnson syndrome.

METHODOLOGY AND RESULTS

The morphology of pigment accumulation and the laboratory data in these cases were examined. The elevation of urinary coproporphrin isomer I to more than 90% and the presence cholestasis resembled that in the Dubin-Johnson syndrome, but the hypertriglyceridaemia ( > 1.13 mmol/L as triolein) and the hepatosteatosis differed. Both infants were thought to have familial hypertriglyceridaemia. However, this diagnosis was difficult to confirm in the absence of data on the normal values of apolipoprotein and lipoprotein isomer for infants.

CONCLUSIONS

A neonatal variant of the Dubin-Johnson syndrome may account for the unusual findings in these infants.

Rotor's syndrome: report of one case

Rotor's syndrome is a rare hereditary non-hemolytic hyperbilirubinemia. This report concerns an 11-year-old boy who presented with fluctuant jaundice since birth. Liver function tests showed conjugated hyperbilirubinemia with normal serum aminotransferase and globulin level. The diagnosis was confirmed by laboratory workup which included normal liver histology and oral cholecystography and typical sulfobromophthalein excretion curve.

[Dubin-Johnson syndrome. Presentation of 3 cases. Review of the national literature]

Three patients, two male and one female, 42, 64 and 20 years old respectively, with a Dubin-Johnson syndrome are reported. Both men referred jaundice since several years and in the woman's case, the onset of the illness took place during the last term of her second pregnancy. In two patients, liver aspect and it's biopsy were diagnostic. In the other, who was hospitalized because of a myocardial infarction, a hepatic gammagraphy with Tc 99 HIDA was made. No case was associated with biliary lithiasis and only one patient had other members in his family with the illness.

[Hyperbilirubinemia]

A 22-year-old woman had icteric sclerae since childhood. Five years ago of Gilbert-Meulengracht's disease was diagnosed (hyperbilirubinemia, normal other liver laboratory parameters, no evidence of hemolysis). The patient was admitted for re-evaluation. Apart from jaundice of the sclerae no other clinical symptoms were found. Analysis of urine revealed bilirubin and an increased urobilinogen. Serum bilirubin was also elevated. The differentiation of the bilirubin gave evidence of an increase of the direct (conjugated) bilirubin portion. Additional investigations (total coproporphyrin in the urine, isomer I and isomer III coproporphyrin excretion and bromsulphalein test) suggested Rotor's syndrome. Further examinations (oral cholecystography, liver biopsy) were not added because of relative invasiveness, lack of clinical consequences and opposition of the patient. Nevertheless the diagnosis of a Rotor's syndrome is highly probable.

Diagnostic and pathogenetic implications of urinary coproporphyrin excretion in the Dubin-Johnson syndrome

The Dubin-Johnson syndrome (DJS), a hereditary conjugated hyperbilirubinemia, is associated with an impairment of porphyrin metabolism. Total urinary coproporphyrin (CP) excretion and the urinary CP isomer I and III constellation were examined in 15 patients with DJS and 12 unaffected family members, and then compared with 50 unrelated control persons (55 +/- 15 nmol/24 h of total CP: 27 +/- 3% of isomer I; +/- SD). The patients with DJS excreted 80 +/- 7% (+/- SD) of CP isomer I (p less than 0.001). The isomer relation in two young children, 3 and 5 years old, shows an isomer reversal, with isomer I of about 95%. Studies done on four families from our patients with DJS indicate and confirm the autosomal recessive mode of inheritance. Total urinary CP was found to be elevated in subjects with DJS, reaching a mean value of 164 +/- 123 nmol/24 h (upper limit 120 nmol/24 h). Fecal CP isomers I and III were found to be in the usual physiological proportion to each other, but total fecal CP excretion had declined to the lower normal level (10 +/- nmol/g, n = 8). The pathogenetic mechanisms in DJS have not yet been fully worked out. Four possible explanations are currently under discussion: 1. an impaired hepatic excretory function: 2. a uroporphyrinogen III synthase defect; 3. an increase in porphobilinogen deaminase (uroporphyrinogen synthase) activity, or 4. a membrane-associated transport disorder with secondary metabolic changes of the isomer pool and enzyme activities.

A new diagnostic approach to the Dubin-Johnson syndrome

Dubin-Johnson syndrome (DJS), a congenital metabolic disorder of bilirubin excretion, was classically diagnosed by the bromsulfalein (BSP) curve and needle hepatic biopsy methods. We present three cases of DJS and propose a new diagnostic approach which could conceivably become a substitute for more aggressive techniques. The results of the 24-h urine coproporphyrin determination and 99mTc-Disofenin scintigraphy gave, together, enough data for an accurate diagnosis.

[Rotor syndrome: relevance of the determination of coproporphyrin isomers in the urine in comparison with intrahepatic (alcohol-induced) cholestasis]

Porphyrin isomer examinations have been performed in two patients with Rotor syndrome (RS), one patient with Gilbert-Meulengracht syndrome and 12 patients with alcohol toxic cholestasis. Under both conditions, cholestasis and RS, total urinary coproporphyrin excretion as well as coproporphyrin isomer I was relatively and absolutely increased. Despite the different degree of the increase of coproporphyrin isomer I excretion between RS (69 vs. 72%) and cholestasis (47% on average), there are single cases with a coproporphyrin isomer I portion around 60%. In such cases, the differential diagnosis is quite difficult, so that the diagnosis "Rotor syndrome" should never be gained by one distinct examination; it is a diagnosis performed by exclusion of other diseases.

The nicotinic acid test in constitutional conjugated hyperbilirubinemias and effects of corticosteroid

The nicotinic acid test was performed in 5 patients with Dubin-Johnson syndrome, 5 with Rotor syndrome and 13 with Gilbert's syndrome. The increment in serum bilirubin concentration and bilirubin retention 5 hr later differed; the proportion of conjugated bilirubin in the increment of total bilirubin in Dubin-Johnson and Rotor syndromes was greater than in Gilbert's syndrome. These observations suggest that the nicotinic acid test reflects, in part, impaired biliary excretion of conjugated bilirubin. The results did not differentiate the two conjugated hyperbilirubinemias. The nicotinic acid test was also performed before and after corticosteroid treatment in four patients with Dubin-Johnson or Rotor syndrome. Although serum total and unconjugated bilirubin concentrations were reduced by corticosteroids, no significant change occurred in the parameters of the nicotinic acid test, suggesting that corticosteroids may enhance uptake of bilirubin without significantly altering biliary excretion of conjugated bilirubin.