Conocimiento de las enfermedades genéticas raras en la práctica clínica diaria

En este número, nos complace presentar 4 trabajos multidisciplinarios que incluyen disciplinas como la Genética Pediátrica, la Hematología, y Nefrología.  Estos trabajos de gran calidad representan el esfuerzo de meses de los colegas especialistas en el área de la genética clínica multidisciplinaria. Cada contribución representa una herramienta para la educación y la docencia a múltiples niveles del aprendizaje médico. (provisto por Infomedic International)

In this issue, we are pleased to present 4 multidisciplinary papers that include disciplines such as Pediatric Genetics, Hematology, and Nephrology. These high quality papers represent the efforts of months of specialist colleagues in the area of multidisciplinary clinical genetics. Each contribution represents a tool for education and teaching at multiple levels of medical learning. (provided by Infomedic International)

Características epidemiológicas y microbiológicas de los episodios de Neutropenia Febril (NF) en niños con cáncer en el Hospital del Niño - Dr. José Renán Esquivel (HNJRE)

Introducción: La neutropenia febril (NF) constituye una complicación frecuente, considerada una urgencia infectológica en los pacientes con cáncer que reciben tratamiento mielosupresor. Metodología: Se realizó un estudio retrospectivo descriptivo a través de la revisión de los expedientes de todos los episodios de NF secundarios a quimioterapia ingresados en el Hospital del Niño - Dr. José Renán Esquivel durante el periodo de enero a diciembre de 2017. Resultados: El estudio consistió en la evaluación de características epidemiológicas e identificación de agentes infecciosos en 49 casos de NF, y 104 eventos febriles. Se observó que el 51% de los casos eran varones, con una edad promedio de 7 años, y recuperación de NF en los primeros 7 días del 68%. La mayoría de las hospitalizaciones (53,8%) duraron de 1 a 7 días, con una relación directa con los días de fiebre y la presencia de neutropenia. La letalidad registrada fue de 6.1%. Los agentes etiológicos más frecuentes fueron la Pseudomonas aeruginosa, los Estafilococos coagulasa negativos y Staphylococcus aureus meticilino sensible. Conclusión: Los hallazgos permiten conocer la epidemiología actual de los pacientes con NF que se admiten al hospital, con el fin de optimizar el tratamiento para reducir la tasa de letalidad. (provisto por Infomedic International)

Introduction: Febrile neutropenia (NF) constitutes a frequent complication, considered an infectious emergency in cancer patients receiving myelosuppressive treatment. Methodology: A descriptive retrospective study was conducted by reviewing the records of all episodes of NF secondary to chemotherapy admitted to the Hospital del Niño - Dr. José Renán Esquivel during the period from January to December 2017. Results: The study consisted of the evaluation of epidemiological characteristics and identification of infectious agents in 49 cases of NF, and 104 febrile events. It was observed that 51% of the cases were male, with a mean age of 7 years, and recovery from NF in the first 7 days of 68%. Most hospitalizations (53.8%) lasted from 1 to 7 days, with a direct relationship with the number of days of fever and the presence of neutropenia. The case fatality rate was 6.1%. The most frequent etiological agents were Pseudomonas aeruginosa, coagulase-negative Staphylococci and methicillin-sensitive Staphylococcus aureus. Conclusion: The findings provide insight into the current epidemiology of patients with NF admitted to the hospital, in order to optimize treatment to reduce the case-fatality rate. (provided by Infomedic International)

Síndrome de Insensibilidad Androgénica: presentación de un caso de discordancia entre ecografía pre y postnatal y estudios genéticos moleculares

Introducción: El síndrome de insensibilidad androgénica es un desorden genético y un tipo de trastorno del desarrollo sexual. Es la feminización de los genitales externos evaluados al nacimiento cuando el genotipo es 46, XY. Objetivo: Presentar la clínica, estudios moleculares, ultrasonidos durante el embarazo y del recién nacido con trastorno de diferenciación sexual. Caso Clínico: Femenina de 35 años con tercer embarazo, feto único, con resultado de cribado genético prenatal no invasivo ampliado de aneuploidías cromosómicas y determinación del sexo fetal a la semana 11 de gestación con sexo genético masculino, ultrasonido con ángulo del tubérculo genital de menos de 30° indicativo de sexo fenotípico femenino y ecografía postnatal con sexo gonadal masculino. Panel molecular genético con una variante patogénica para el Gen AR, en hemicigosis, asociado a Síndrome de Insensibilidad Androgénica. Conclusión: La discordancia sexual fenotipo-genotipo puede indicar una condición genética, cromosómica o bioquímica subyacente. El manejo conjunto interdisciplinario y el consejo genético permite el diagnóstico molecular neonatal temprano de la condición. (provisto por Infomedic International)

Introduction: Androgen insensitivity syndrome is a genetic disorder and a type of sexual development disorder. It is characterized by the evident feminization of the external genitalia at birth in an individual with the 46, XY genotype. Aim: To present the clinic, molecular studies, obstetric ultrasonography of the first trimester and ultrasound of the newborn with sexual differentiation disorder. Clinic case: 35-year-old female with third pregnancy, singleton fetus, with extended non-invasive prenatal genetic screening for chromosomal aneuploidies and fetal sex determination at week 11 of gestation with male genetic sex, ultrasound with genital tubercle angle less than 30° indicative of female phenotypic sex and postnatal ultrasound with male gonadal sex. Genetic molecular panel with a pathogenic variant for the AR gene, in hemi zygosis. Conclusion: Early detection of phenotype-genotype sexual discordance is important as it may indicate an underlying genetic, chromosomal, or biochemical condition, allowing timely critical counseling and postnatal treatment. (provided by Infomedic International)

Neuroendocrine tumors in Panama: A nationwide database analysis.

Neuroendocrine tumors (NETs) comprise a heterogenous group of rare malignancies, which are increasing in incidence worldwide. To further understand the epidemiology of NETs in the Republic of Panama, the present study used two study groups, which included patients from several hospitals and clinics throughout the country, who were referred to the three largest national reference centers: The Complejo Hospitalario Metropolitano, Hospital Santo Tomas and Instituto Oncologico Nacional. These two groups comprised a retrospective cohort, which included cases reported between 2016 and 2017, and a second cohort, which was retrospective, but data were continuously collected from patients diagnosed with NETs between 2018 and 2019. Data from 157 patients with NETs reported that 83% of patients were in the 40-80 years old age group. The majority of cases (46%) presented as grade G1 tumors, while 29% were G3. Computerized tomography scans with contrast, and analysis of the Ki-67 biomarker and immunohistology markers (chromogranin A and synaptophysin) was performed in the majority of the cases. The results revealed that the most frequent anatomical sites for the primary tumor were the colorectum (17.2%), pancreas (12.7%) and stomach (12.1%), and the most frequent organ with metastasis was the liver, accounting for 34% of all cases. In conclusion, the present study is the first comprehensive study of NET in Panama to the best of our knowledge, which provides evidence of the demographic characteristics of the population, clinical features and overall survival for the affected population in this Central American country.

Estudio multicéntrico retrospectivo de los aspectos epidemiológicos, clínicos y terapéuticos de la enfermedad de Kawasaki en niños de Panamá

Resumen Antecedentes: La enfermedad de Kawasaki (EK) representa la principal causa de cardiopatía pediátrica adquirida en muchos países; sin embargo, hay pocos estudios publicados en Latinoamérica. Objetivo: Describir la epidemiología, los aspectos clínicos y el tratamiento de EK en niños en Panamá como parte del estudio de vigilancia de REKAMLATINA-2 en Latinoamérica. Pacientes y Métodos: Estudio retrospectivo, descriptivo, de pacientes internados con diagnóstico de EK, atendidos en tres hospitales pediátricos de Panamá del 1-enero-2009 al 31-diciembre-2013. Resultados: Se analizaron 111 pacientes, 61(54,9%) eran hombres. Todos fueron hospitalizados, siendo la media de hospitalización de 5,8 (4-7) días. La mediana de edad al ingreso fue de 28,9 (12-38) meses. Un 63,9% recibió antimicrobianos recientemente por otros posibles diagnósticos. Recibieron inmunoglobulina intravenosa (IGIV) 105 (94,6%) pacientes; de éstos, 10 (9,5%) fueron resistentes. Un 11,7% tuvo alteraciones cardiovasculares en el ECO inicial, de las cuales las lesiones coronarias se detectaron en 3 (2,9%) pacientes. Conclusiones: Los datos sugieren que EK en Panamá tiene una incidencia cercana a 2,05 x 100,000 bajo 15 años de edad y una frecuencia 2,6 veces mayor bajo 3 años de edad. Se observó un alto porcentaje de uso de antimicrobianos ambulatoriamente antes de la confirmación diagnóstica, lo cual sugiere reconocimiento tardío de EK en Panamá.

Abstract Background: Kawasaki disease (KD) is the leading cause of pediatric acquired heart disease in many countries, however, there are few published studies from Latin America (LA). Aim: To describe the epidemiology, clinical aspects, and treatment of KD in children from Panama as part of the REKAMLATINA-2 in LA. Methods: Retrospective descriptive review of hospitalized patients diagnosed with KD, attended at three main pediatric hospitals of Panama from January-1-2009 to December-31-2013. Results: 111 patients were analyzed, 61(54.9 %) were male. All children were hospitalized, and had a mean length of hospitalization of 5.8 (4-7) days. Median age at admission was 28.9 (12-38) months. Prior to KD final diagnosis, 63.9% patients received antibiotics for other presumed diagnoses. 105 (94.6%) patients received IGIV, 10 (9.5%) were resistant. On initial echocardiogram, 11.7% of cardiovascular complications were reported, of which coronary artery lesions (CALs) were detected in 3 (2.9 %) patients. Conclusion: The data suggest that KD in Panama has an incidence of about 2.05 x 100,000 in children under 15 years of age, and with a frequency 2.6 times higher in children under 3 years. A high rate of antibiotic misuse on outpatient prior to diagnostic confirmation was observed, suggesting KD unawareness and late recognition in Panamá.

Medidas Mínimas de Bioseguridad en instalaciones de salud ante Pandemia por SARS­CoV­2 / Recomendaciones mínimas de Bioseguridad para Instalaciones de salud traba ja ndo con muestras de SARS­CoV­2 Desarrollado por la Organización Mundial de la Salud. Resumen ejecutivo: Entorno laboratoria / Minimum Biosafety Measures in healthcare facilities during SARS­CoV­2 Pandemic

El SARS­CoV­2 es un nuevo virus, causante de la actual pandemia que nos afecta. Dada su virulencia y nuestro desconocimiento de su biología, representa una real amenaza para la población. Además de las medidas epidemiológicas, el personal de salud, clínico, técnico y administrativo son el frente para el diagnóstico y tratamiento de nuestra población. Es de suma importancia que nuestro personal pueda implementar medidas básicas para minimi­ zar la exposición y contagio de este virus. Se ha revisado las recomendaciones generales de la Organización Mundial de Salud para personal de salud sobre requerimientos mínimos que debemos cumplir en tal entorno. También hemos provisto de rótulos que deben ser co­ locados en toda instalación que maneja muestras de SARS­CoV­2. Es necesario que esta información sea de fácil acceso para todo profesional de salud, y así pueda revisarla e inter­ nalizarla para su protección, la de sus pacientes, y familiares. Esperamos que sea de gran utilizad para fortalecer nuestras capacidades de bioseguridad en nuestro país, y utilizar esta información como herramienta educativa y de capacitación básica.

SARS­CoV­2 is a new virus, causing the current pandemic affecting us. Given its virulence and our lack of understanding of its biology, it represents a real threat to the population. Ad­ ditionally to the epidemiological measures, the clinical, technical and administrative person­ nel are at the front in the battle to diagnose and treat our population. It is of utmost importance that our staff can know and implement basic safety measures to minimize the exposure and spread of this virus. We have reviewed the general recommendations of the World Health Organization for healthcare personnel of the minimum requirements that we must meet in such an environment. Here, it has also been provided banners to be displayed in every facility processing SARS­CoV­2 samples. This guide must be easily accessible for all health professional to be reviewed and internalized for their safety, of their patients, and their families. We hope it will be of great use in our country to strengthen our biosafety capa­ bilities and to use this information for educational and training purposes.

[Multicenter retrospective study about the epidemiological, clinical and therapeutic aspects of Kawasaki disease in children from Panama]. / Estudio multicéntrico retrospectivo de los aspectos epidemiológicos, clínicos y terapéuticos de la enfermedad de Kawasaki en niños de Panamá.

BACKGROUND: Kawasaki disease (KD) is the leading cause of pediatric acquired heart disease in many countries, however, there are few published studies from Latin America (LA). AIM: To describe the epidemiology, clinical aspects, and treatment of KD in children from Panama as part of the REKAMLATINA-2 in LA. METHODS: Retrospective descriptive review of hospitalized patients diagnosed with KD, attended at three main pediatric hospitals of Panama from January-1-2009 to December-31-2013. RESULTS: 111 patients were analyzed, 61(54.9 %) were male. All children were hospitalized, and had a mean length of hospitalization of 5.8 (4-7) days. Median age at admission was 28.9 (12-38) months. Prior to KD final diagnosis, 63.9% patients received antibiotics for other presumed diagnoses. 105 (94.6%) patients received IGIV, 10 (9.5%) were resistant. On initial echocardiogram, 11.7% of cardiovascular complications were reported, of which coronary artery lesions (CALs) were detected in 3 (2.9 %) patients. CONCLUSION: The data suggest that KD in Panama has an incidence of about 2.05 x 100,000 in children under 15 years of age, and with a frequency 2.6 times higher in children under 3 years. A high rate of antibiotic misuse on outpatient prior to diagnostic confirmation was observed, suggesting KD unawareness and late recognition in Panamá.

SPI-1 is a missing host-range factor required for replication of the attenuated modified vaccinia Ankara (MVA) vaccine vector in human cells.

Modified vaccinia virus Ankara (MVA) is the leading poxvirus vector for development of vaccines against diverse infectious diseases. This distinction is based on high expression of proteins and good immunogenicity despite an inability to assemble infectious progeny in human cells, which together promote efficacy and safety. Nevertheless, the basis for the host-range restriction is unknown despite past systematic attempts to identify the relevant missing viral gene(s). The search for host-range factors is exacerbated by the large number of deletions, truncations and mutations that occurred during the long passage history of MVA in chicken embryo fibroblasts. By whole genome sequencing of a panel of recombinant host-range extended (HRE) MVAs generated by marker rescue with 40 kbp segments of vaccinia virus DNA, we identified serine protease inhibitor 1 (SPI-1) as one of several candidate host-range factors present in those viruses that gained the ability to replicate in human cells. Electron microscopy revealed that the interruption of morphogenesis in human cells infected with MVA occurred at a similar stage as that of a vaccinia virus strain WR SPI-1 deletion mutant. Moreover, the introduction of the SPI-1 gene into the MVA genome led to more than a 2-log enhancement of virus spread in human diploid MRC-5 cells, whereas deletion of the gene diminished the spread of HRE viruses by similar extents. Furthermore, MRC-5 cells stably expressing SPI-1 also enhanced replication of MVA. A role for additional host range genes was suggested by the restoration of MVA replication to a lower level relative to HRE viruses, particularly in other human cell lines. Although multiple sequence alignments revealed genetic changes in addition to SPI-1 common to the HRE MVAs, no evidence for their host-range function was found by analysis thus far. Our finding that SPI-1 is host range factor for MVA should simplify use of high throughput RNAi or CRISPR/Cas single gene methods to identify additional viral and human restriction elements.

Identification of Poxvirus Genome Uncoating and DNA Replication Factors with Mutually Redundant Roles.

Genome uncoating is essential for replication of most viruses. For poxviruses, the process is divided into two stages: removal of the envelope, allowing early gene expression, and breaching of the core wall, allowing DNA release, replication, and late gene expression. Subsequent studies showed that the host proteasome and the viral D5 protein, which has an essential role in DNA replication, are required for vaccinia virus (VACV) genome uncoating. In a search for additional VACV uncoating proteins, we noted a report that described a defect in DNA replication and late expression when the gene encoding a 68-kDa ankyrin repeat/F-box protein (68k-ank), associated with the cellular SCF (Skp1, cullin1, F-box-containing complex) ubiquitin ligase complex, was deleted from the attenuated modified vaccinia virus Ankara (MVA). Here we showed that the 68k-ank deletion mutant exhibited diminished genome uncoating, formation of DNA prereplication sites, and degradation of viral cores as well as an additional, independent defect in DNA synthesis. Deletion of the 68k-ank homolog of VACV strain WR, however, was without effect, suggesting the existence of compensating genes. By inserting VACV genes into an MVA 68k-ank deletion mutant, we discovered that M2, a member of the poxvirus immune evasion (PIE) domain superfamily and a regulator of NF-κB, and C5, a member of the BTB/Kelch superfamily associated with cullin-3-based ligase complexes, independently rescued the 68k-ank deletion phenotype. Thus, poxvirus uncoating and DNA replication are intertwined processes involving at least three viral proteins with mutually redundant functions in addition to D5.IMPORTANCE Poxviruses comprise a family of large DNA viruses that infect vertebrates and invertebrates and cause diseases of medical and zoological importance. Poxviruses, unlike most other DNA viruses, replicate in the cytoplasm, and their large genomes usually encode 200 or more proteins with diverse functions. About 90 genes may be essential for chordopoxvirus replication based either on their conservation or individual gene deletion studies. However, this number may underestimate the true number of essential functions because of redundancy. Here we show that any one of three seemingly unrelated and individually nonessential proteins is required for the incompletely understood processes of genome uncoating and DNA replication, an example of synthetic lethality. Thus, poxviruses appear to have a complex genetic interaction network that has not been fully appreciated and which will require multifactor deletion screens to assess.

Molluscum Contagiosum Virus Transcriptome in Abortively Infected Cultured Cells and a Human Skin Lesion.

UNLABELLED: Molluscum contagiosum virus (MOCV), the only circulating human-specific poxvirus, has a worldwide distribution and causes benign skin lesions that may persist for months in young children and severe infections in immunosuppressed adults. Studies of MOCV are restricted by the lack of an efficient animal model or a cell culture replication system. We used next-generation sequencing to analyze and compare polyadenylated RNAs from abortive MOCV infections of several cell lines and a human skin lesion. Viral RNAs were detected for 14 days after MOCV infection of cultured cells; however, there was little change in the RNA species during this time and a similar pattern occurred in the presence of an inhibitor of protein synthesis, indicating a block preventing postreplicative gene expression. Moreover, a considerable number of MOCV RNAs mapped to homologs of orthopoxvirus early genes, but few did so to homologs of intermediate or late genes. The RNAs made during in vitro infections represent a subset of RNAs detected in human skin lesions which mapped to homologs of numerous postreplicative as well as early orthopoxvirus genes. Transfection experiments using fluorescent protein and luciferase reporters demonstrated that vaccinia virus recognized MOCV intermediate and late promoters, indicating similar gene regulation. The specific recognition of the intermediate promoter in MOCV-infected cells provided evidence for the synthesis of intermediate transcription factors, which are products of early genes, but not for late transcription factors. Transcriptome sequencing (RNA-seq) and reporter gene assays may be useful for testing engineered cell lines and conditions that ultimately could provide an in vitro replication system. IMPORTANCE: The inability to propagate molluscum contagiosum virus, which causes benign skin lesions in young children and more extensive infections in immunosuppressed adults, has constrained our understanding of the biology of this human-specific virus. In the present study, we characterized the RNAs synthesized in abortively infected cultured cells and a human skin lesion by next-generation sequencing. These studies provided an initial transcription map of the MOCV genome, suggested temporal regulation of gene expression, and indicated that the in vitro replication block occurs prior to intermediate and late gene expression. RNA-seq and reporter assays, as described here, may help to further evaluate MOCV gene expression and define conditions that could enable MOCV replication in vitro.

Genome sequence of erythromelalgia-related poxvirus identifies it as an ectromelia virus strain.

Erythromelagia is a condition characterized by attacks of burning pain and inflammation in the extremeties. An epidemic form of this syndrome occurs in secondary students in rural China and a virus referred to as erythromelalgia-associated poxvirus (ERPV) was reported to have been recovered from throat swabs in 1987. Studies performed at the time suggested that ERPV belongs to the orthopoxvirus genus and has similarities with ectromelia virus, the causative agent of mousepox. We have determined the complete genome sequence of ERPV and demonstrated that it has 99.8% identity to the Naval strain of ectromelia virus and a slighly lower identity to the Moscow strain. Small DNA deletions in the Naval genome that are absent from ERPV may suggest that the sequenced strain of Naval was not the immediate progenitor of ERPV.