Sudden death of an infant with cardiac, nervous system and genetic involvement--a case report.

We present a case of sudden death of a 1-month-old male infant with heart, brainstem and genetic polymorphism involvement. Previously considered quite healthy, the child died suddenly and unexpectedly during sleep. The autopsy protocol included an in-depth anatomopathological examination of both the autonomic nervous system and the cardiac conduction system, and molecular analysis of the serotonin transporter gene promoter region, in which a specific genetic condition seems to be associated with sudden infant death. Histological examination revealed the presence of congenital cardiac alterations (hypertrophic cardiomyopathy and an accessory Mahaim fiber in the cardiac conduction system), severe hypodevelopment of all the raphe nuclei and a heterozygous genotype L/S related to the serotonin transporter gene. The sudden death of this infant was the unavoidable outcome of a complex series of congenital anomalies, each predisposing to SIDS. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/3480540091031788.

Reduction of serotonergic neurons in the dorsal raphe due to chronic prenatal administration of a tryptophan-free diet.

Serotonin (5-HT) is a widely studied neurotransmitter which plays an important role in the development and proper functioning of the organism throughout life. The appearance of 5-HT system early in ontogeny suggests the hypothesis that 5-HT plays a regulatory role in neurodevelopment. This study investigated the effect of administration of a tryptophan deficient diet during prenatal development on the morphology and cell population of the dorsal raphe. The experimental diet, containing balanced amounts of carbohydrates, lipids and proteins, was provided to a time-mated group of rats from gestational day 5 until delivery. Control groups were fed with (i) the experimental diet formulation with 0.2% tryptophan added to the mixture, or (ii) a regular chow diet. At delivery, five pups per dam were euthanized. Body and brain weight was measured and brain sections were processed for immunohistochemistry for tryptophan hydroxylase (TrpH) and whole brain 5-HT analysis. Sections containing dorsal raphe were photographed with a light microscope and TrpH positive neurons quantified. Brain weights in the tryptophan deprived group showed no difference as compared with controls while body weights were reduced by 25%. Total numbers of serotonergic neurons at the dorsal raphe in the prenatal tryptophan deficient pups were reduced by 35%. A regional analysis of the dorsal raphe indicated a marked cellular reduction in the medial and caudal sections of the nucleus, which contains the majority of serotonergic neurons, in the tryptophan deprived condition. Quantitative 5-HT analysis showed that the brain concentration was similar among conditions. In conclusion, gestational tryptophan deprivation exerts adverse effects on the development of the 5-HT system, particularly in the dorsal raphe, manifested by decreased numbers of serotonergic neurons as well as altered topography in this important nucleus.

Embryonic exposure to thimerosal, an organomercury compound, causes abnormal early development of serotonergic neurons.

Even though neuronal toxicity due to organomercury compounds is well known, thimerosal, an organomercury compound, is widely used in pediatric vaccine preservation. In the present study, we examined whether embryonic exposure to thimerosal affects early development of serotonergic neurons. Thimerosal (1mg Hg/kg) was intramuscularly administered to pregnant rats on gestational day 9 (susceptible time window for development of fetal serotonergic system), and fetal serotonergic neurons were assessed at embryonic day 15 using anti-serotonin antibodies. A dramatic increase in the number of serotonergic neurons localized to the lateral portion of the caudal raphe was observed in thimerosal group (1.9-fold increase, p<0.01 compared to control). These results indicate that embryonic exposure to thimerosal affects early development of serotonergic neurons.

Prenatal stress induces anxiety-like behavior together with the disruption of central serotonin neurons in mice.

Most pregnant women are at risk of showing some emotional abnormality, since some biological functions such as hormonal systems may dramatically change in pregnancy. Some of them may be exposed to strong stress as hesitation of positive drug therapies because of worries regarding adverse effects on the embryo. A growing body of evidence suggests that prenatal stress increases the vulnerability to neuropsychiatric disorders, including depression and anxiety. However, the mechanisms involved are still unknown. To clarify the influence of exposure to prenatal stress on emotional development, we examined behavioral responses in offspring exposed to weak- or strong-prenatal restraint stress. We found that offspring that had been exposed to strong stress displayed anxiety-like behavior as determined by the elevated plus-maze test. It has been widely accepted that central serotonin (5-hydroxytryptamine; 5-HT) neurons play a critical role in emotional behaviors. Immunohistochemical studies showed that exposure to strong-prenatal restraint stress increased the expression of 5-HT-positive cells in the dorsal raphe nuclei in mice. Moreover, under these conditions, tryptophan hydroxylase-like immunoreactivities were also dramatically increased. In contrast, these behavioral and neurochemical abnormalities were not observed in offspring that had been exposed to weak-prenatal restraint stress. These findings indicate that exposure to excessive prenatal stress induces anxiety-like behavior together with disruption of the development of 5-HT neurons in mice.

Diffusion tensor imaging demonstrates brainstem and cerebellar abnormalities in congenital central hypoventilation syndrome.

Congenital central hypoventilation syndrome (CCHS) patients show reduced breathing drive during sleep, decreased hypoxic and hypercapnic ventilatory responses, and autonomic and affective deficits, suggesting both brainstem and forebrain injuries. Forebrain damage was previously described in CCHS, but methodological limitations precluded detection of brainstem injury, a concern because genetic mutations in CCHS target brainstem autonomic nuclei. To assess brainstem and cerebellar areas, we used diffusion tensor imaging-based measures, namely axial diffusivity, reflecting water diffusion parallel to fibers, and sensitive to axonal injury, and radial diffusivity, measuring diffusion perpendicular to fibers, and indicative of myelin injury. Diffusion tensor imaging was performed in 12 CCHS and 26 controls, and axial and radial diffusivity maps were compared between groups using analysis of covariance (covariates; age and gender). Increased axial diffusivity in CCHS appeared within the lateral medulla and clusters with injury extended from the dorsal midbrain through the periaqueductal gray, raphé, and superior cerebellar decussation, ventrally to the basal-pons. Cerebellar cortex and deep nuclei, and the superior and inferior cerebellar peduncles showed increased radial diffusivity. Midbrain, pontine, and lateral medullary structures, and the cerebellum and its fiber systems are injured in CCHS, likely contributing to the characteristics found in the syndrome.

A report of two cases with dolichosegmental intracranial arteries as a new feature of PHACES syndrome.

BACKGROUND: We describe two previously unreported cases with complete or incomplete expression of PHACES syndrome, a rare congenital syndromal pediatric disorder, which is characterized by posterior cranial fossa malformations, large facial hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, abnormalities of the eye, sternal and supraabdominal raphe defects. CASE REPORTS: These two children exhibited a feature not reviewed extensively in the literature, namely, segmental elongation and dilatation of intracranial arteries associated with intracranial occlusive arterial disease, predominantly on the anterior division of the internal carotid artery (ICA) and on the P2 segment of the posterior cerebral artery. This dolichoectasia was found at the distal cervical internal carotid artery, the intradural segment of the ICA before the division, the trigeminal artery, and the posterior division of the ICA. We presume that the different forms of arterial involvement in PHACES syndrome (arterial stenoses, segmental agenesis of vessels, and the dolichoectasia described in this study) constitute a spectrum of angiogenetic dysfunctions related to an embryonic event involving several cephalic neural crest segments of the dorsal aorta.

Immunohistochemical and microarray analyses of a mouse model for the smith-lemli-opitz syndrome.

The Smith-Lemli-Opitz syndrome is a mental retardation/malformation syndrome with behavioral components of autism. It is caused by a deficiency in 3beta-hydroxysteroid-Delta7-reductase (DHCR7), the enzyme required for the terminal enzymatic step of cholesterol biosynthesis. The availability of Smith-Lemli-Opitz syndrome mouse models has made it possible to investigate the genesis of the malformations associated with this syndrome. Dhcr7 gene modification (Dhcr7-/-) results in neonatal lethality and multiple organ system malformations. Pathology includes cleft palate, pulmonary hypoplasia, cyanosis, impaired cortical response to glutamate, and hypermorphic development of hindbrain serotonergic neurons. For the current study, hindbrain regions microdissected from gestational day 14 Dhcr7-/-, Dhcr7+/- and Dhcr7+/+ fetuses were processed for expression profiling analyses using Affymetrix oligonucleotide arrays and filtered using statistical significance (S-score) of change in gene expression. Of the 12,000 genes analyzed, 91 were upregulated and 98 were downregulated in the Dhcr7-/- hindbrains when compared to wild-type animals. Fewer affected genes, representing a reduced affect on these pathways, were identified in heterozygous animals. Hierarchical clustering identified altered expression of genes associated with cholesterol homeostasis, cell cycle control and apoptosis, neurodifferentiation and embryogenesis, transcription and translation, cellular transport, neurodegeneration, and neuronal cytoskeleton. Of particular interest, Dhcr7 gene modification elicited dynamic changes in genes involved in axonal guidance. In support of the microarray findings, immunohistochemical analyses of the netrin/deleted in colorectal cancer axon guidance pathway illustrated midline commissural deficiencies and hippocampal pathfinding errors in Dhcr7-/- mice. The results of these studies aid in providing insight into the genesis of human cholesterol-related birth defects and neurodevelopmental disorders and highlight specific areas for future investigation.

Abnormal serotonergic development in a mouse model for the Smith-Lemli-Opitz syndrome: implications for autism.

The Smith-Lemli-Opitz syndrome (SLOS) is a malformation/mental retardation syndrome resulting from an inborn error in 3beta-hydroxysteroid Delta7-reductase (DHCR7), the terminal enzyme required for cholesterol biosynthesis. Using a targeting strategy designed to virtually eliminate Dhcr7 activity, we have created a SLOS mouse model that exhibits commissural deficiencies, hippocampal abnormalities, and hypermorphic development of serotonin (5-HT) neurons. The latter is of particular interest with respect to current evidence that serotonin plays a significant role in autism spectrum disorders and the recent clinical observation that 50% of SLOS patients present with autistic behavior. Immunohistochemical analyses have revealed a 306% increase in the area of 5-HT immunoreactivity (5-HT IR) in the hindbrains of mutant (Dhcr7-/-) mice as compared to age-matched wild type animals. Amount of 5-HT IR was measured as total area of IR per histological section. Additionally, a regional increase as high as 15-fold was observed for the most lateral sagittal hindbrain sections. In Dhcr7-/- mice, an expansion of 5-HT IR into the ventricular zone and floor plate region was observed. In addition, the rostral and caudal raphe groups exhibited a radial expansion in Dhcr7-/- mice, with 5-HT IR cells present in locations not seen in wild type mice. This increase in 5-HT IR appears to represent an increase in total number of 5-HT neurons and fibers. These observations may help explain the behavioral phenotype seen in SLOS, and provide clues for future therapeutic interventions that utilize pharmacological modulation of the serotonergic system.

Effects of in utero ethanol exposure and maternal treatment with a 5-HT(1A) agonist on S100B-containing glial cells.

This laboratory previously showed that in utero ethanol exposure severely impairs the development of the cell bodies and projections of serotonin (5-HT) neurons, and that maternal treatment with a 5-HT(1A) agonist prevents many of these abnormalities. Others demonstrated that stimulation of fetal astroglial 5-HT(1A) receptors increases production and release of S100B, a glial trophic factor that is essential for the development of 5-HT neurons. The present study investigated a potential mechanism by which ethanol hinders development of 5-HT neurons, and by which maternal 5-HT(1A) agonist treatment prevents this damage. This study tested the hypothesis that in utero ethanol exposure reduces the number of S100B immunopositive glia and that maternal 5-HT(1A) agonist treatment prevents ethanol-associated changes in S100B. To test our hypothesis, we determined the effects of in utero ethanol exposure and maternal treatments with the 5-HT(1A) agonists ipsapirone and buspirone on S100B immunopositive glial cells. On gestation day 20 (G20), S100B immunopositive cells were quantified in the midline raphe glial structure (MRGS), a large transient structure that contains substantial numbers of S100B-positive glial cells and that spans the dorsal raphe, median raphe, and B9 complex of 5-HT neurons. S100B immunopositive glial cells were also determined in an area proximal to the dorsal raphe in postnatal day 2 (PN2) rats. In utero ethanol exposure significantly reduced S100B immunopositive glial cells in the MRGS at G20 and in the dorsal raphe at PN2. In addition, treatment of pregnant rats with a 5-HT(1A) agonist between G13 and G20 prevented the ethanol-associated reduction in S100B immunopositive glial cells. These studies demonstrated that part of ethanol's damaging effects on developing 5-HT neurons is mediated by a reduction of S100B and that some of the protective effects of maternal 5-HT(1A) agonist treatment are related to the actions of these drugs on glial cells.

To shunt or not to shunt: hydrocephalus and dysraphism.

Objective criteria are available for decision making in children with ventriculomegaly and spina bifida cystica. Figure 29.7 is the evaluation algorithm used in the Hydrocephalus/Myelodysplasia Clinic at Rainbow Babies and Children's Hospital. In children without serious neurosurgical complications such as the Chiari crisis or problems with wound healing, we rely on three reasonably objective measurements for decision making. Head circumference: Measured daily while in hospital and at each visit. If the pattern of head growth crosses multiple percentile lines indicating that the child will be severely megalencephalic, a shunt will be performed. Ultrasonography: Ultrasound determinations are made in the first few days of life, prior to discharge, at 6 weeks of age, and each 6 weeks of age until 6 months. Some measurements of ventricular size (usually CT scan because of a small anterior fontanelle) should be made at age 1 year. Denver Developmental Testing (DDST): These are performed at age 6 weeks and each 6 weeks thereafter. If the child shows significant ventriculomegaly, a shunt is performed. When the results are questionable the decision is delayed and the test repeated in 6 weeks. Whether a shunt is or is not placed in an infant with ventriculomegaly and myelodysplasia, follow-up must remain compulsive. Following shunting, not only should the head circumference stabilize, but the cortical mantle should increase. Often children shunted in this situation fail to show signs of increased intracranial pressure with shunt malfunction and must be followed with serial head circumference measurements as well as ultrasounds and CT scans. If the decision is made not to shunt the child the work of Hall et al. (10) would suggest the possibility that later in life shunts may be needed to prevent scoliosis secondary to hydromyelia. More information is needed as the aggressively treated population become adults.

Ultrastructure of the neural basal lamina in loop-tail mice.

Ultrastructural features of the neural basal lamina were studied by means of the tannic acid and ruthenium red techniques in normal and abnormal dysraphic loop-tail mice at 9-11 days of gestation. With ruthenium red, the configuration of the neural basal lamina is similar in both normal and abnormal embryos at 9-11 days. However, differences were detected in the abnormal 9-day embryos processed with tannic acid, as compared with normal littermates. These include irregularities in the lamina rara externa, as well as differences in the staining pattern of the neuroepithelial cell plasma membrane. By 11 days of gestation, the lamina rara externa of the normal embryos shows features similar to those observed in the 9-day abnormal embryos.