Recommendations of the German Central Committee against Tuberculosis (DZK) and the German Respiratory Society (DGP) for the Diagnosis and Treatment of Non-tuberculous Mycobacterioses.

Non-tuberculous mycobacterioses comprise a group of diseases caused by mycobacteria which do not belong to the Mycobacterium (M.) tuberculosis-complex and are not ascribed to M. leprae. These mycobacteria are characterized by a broad variety as to environmental distribution and adaptation. Some of the species may cause specific diseases, especially in patients with underlying immunosuppressive diseases, chronic pulmonary diseases or genetic predisposition, respectively. Worldwide, a rising prevalence and significance of non-tuberculous mycobacterioses is recognized. The present recommendations summarise current aspects of epidemiology, pathogenesis, clinical aspects, diagnostics - especially microbiological methods including susceptibility testing -, and specific treatment for the most relevant species. Diagnosis and treatment of non-tuberculous mycobacterioses during childhood and in HIV-infected individuals are described in separate chapters.

A homoallelic FECH mutation in a patient with both erythropoietic protoporphyria and palmar keratoderma.

BACKGROUND: Erythropoietic protoporphyria (EPP) is a hereditary disorder caused by the deficiency of ferrochelatase (FECH) in the haem biosynthetic pathway. In the majority of families, EPP is transmitted as a pseudodominant trait. Autosomal recessive form of EPP is found in only about 3% of the families. OBJECTIVES: In this study, we describe a 6-year-old boy who suffered from both EPP and palmar keratoderma. METHODS AND RESULTS: A novel homoallelic missense mutation (p.Ser318Tyr) was identified in the FECH gene. In addition, a region of homozygosity of approximately 6.8 Mb was observed in chromosome 18 of the patient by both microsatellite and SNP array. The parents of the patient, both of Palestinian (Jordanian) origin, were heterozygous for the S318Y mutation, although no history of consanguinity was known. Microsatellite genotyping identified a partial haplotype from each parent that corresponds to the region of homozygosity in the patient. Assuming S318Y is a founder mutation, the number of generations separating the two parents from their common ancestor from whom they inherited S318Y was estimated as 21.7 (95% CI 3.42­69.7). CONCLUSION: EPP was therefore inherited as an autosomal recessive trait in the family. This study confirms the association between palmar keratoderma and autosomal recessive EPP.

Awareness is the name of the game: clinical and biochemical evaluation of a case of a girl diagnosed with acute intermittent porphyria associated with autism.

Neuroporphyrias, a heterogeneous group of metabolic diseases, are diagnosed less often than their true prevalence justifies. Lack of awareness of porphyrias and their protean clinical and biochemical manifestations, is the most significant hurdle to their recognition and diagnosis. These points are reflected in the unusual case reported here, which highlights the potential damage that inappropriate management may cause when the diagnosis is missed over a long period. We diagnosed heterozygous Acute Intermittent Porphyria (AIP) in a 15 yr old girl, who first presented with autism at the age of 4 years. This phenotypic association has not been previously reported. In addition to the unrecognized phenotype, her normal urinary aminolevulinic acid and porphobilinogen, findings which are not compatible with symptomatic porphyria according to well established criteria, could also have led to a missed diagnosis of neuroporphyria. However, the diagnosis of AIP was established on the basis of a 64% reduction in erythrocyte hydroxymethylbilane synthase (HMBS) activity and the finding of a known causative AIP mutation (p.D178N). We therefore recommend that porphyria should be considered in autistic children especially when there is an atypical course or unexpected abreaction to medications. The biochemical and genetic data should be carefully evaluated in a specialized porphyria center.

Variations in the length of poly-C and poly-T tracts in intron 3 of the human ferrochelatase gene.

The third intron of human ferrochelatase (FECH) gene contains according to NCBI, a poly-C (11) and a poly-T (24) tracts which are located approximately 900 bp upstream from the known splice modulating SNP IVS3-48 c/t. Ferrochelatase catalyses the last step in heme biosynthesis and a deficiency of this enzyme results in the hereditary disorder of erythropoietic protopoprhyria (EPP). During the course of mutation analysis in the FECH gene among EPP patients, we observed variations in the length of the poly-C and poly-T tracts. To study these variations, we analyzed a total of 54 individuals of Swiss and Israeli origins. Among them, 37 were control subjects (23 individuals with the genotype t/t and 14 with the genotype c/t), 10 were unrelated EPP patients (genotype c/M) and 7 were unrelated asymptomatic mutation carriers (genotype t/M). The length of poly-C tract varied from 10 to 16, that of poly-T tract from 22 to 24 in the study cohort. Statistic analysis showed that the low-expressed FECH allele (IVS3-48c) is associated with poly-C12, C13 and C15 and poly-T22. In addition, the segregation of poly-C and poly-T tracts was studied in two Israeli EPP families. Instabilities, as seen by both insertion and deletion of one nucleotide between two generations, were observed only in the poly-T tract. The function of the poly-C and poly-T tracts are yet to be explored.

Biochemical and molecular diagnosis of erythropoietic protoporphyria in an Ashkenazi Jewish family.

Erythropoietic protoporphyria (EPP) is a rare hereditary disorder due to a partial deficiency of ferrochelatase (FECH). The genotype of EPP patients features a mutation on one allele of the FECH gene and a common hypomorphic FECH IVS3-48c on the other allele (M/c). The resulting enzyme activity in patients is ∼35% of that in normal individuals. Ferrochelatase deficiency results in the accumulation of protoporphyrin in the skin, which is responsible for the clinical symptom of cutaneous photosensitivity in patients. In this study, we report the identification of a novel FECH mutation delT23 in an 11-member EPP family of Jewish origin. Two EPP siblings shared an identical genotype of delT23/IVS3-48c (M/c). They were both photosensitive and showed highly increased erythrocyte protoporphyrin. The genotype of the patients' mother, who did not present with any EPP clinical symptoms, was delT23/IVS3-48t (M/t). The patients' father, an offspring of consanguineous parents, was homozygous IVS3-48 c/c. He exhibited a mild photosensitivity, and an increase of 4-fold in erythrocyte protoporphyrin. His FECH mRNA amount was 71% of that of genotype t/t. It is the first reported case of an individual with c/c genotype who exhibits both biochemical and clinical indications of EPP. These results suggest that IVS3-48c is a functional variant of ferrochelatase. The clinical symptoms and biochemical abnormalities in the patients' father could be the result of an interaction between genetic and environmental factors. In addition, the frequency of IVS3-48c in the Ashkenazi Jewish population was estimated at 8%, which is similar to that in the European populations.

Individualized workup: a new approach to the biochemical diagnosis of acute attacks of neuroporphyria.

Porphyria experts concur that acute attacks of AIP, VP and HCP, are invariably associated with increases in urinary PBG. Reports differ, however, as to the amount of increase indicative of an acute attack. Some authors consider excretion of at least 25-fold the upper level of normal, as indicative, whereas others regard a 10-fold or even a 2-fold increase, as sufficient indication. An additional diagnostic difficulty arises from the fact that in many individuals known to have inherited one of the acute porphyrias, PBG is persistently raised also during remission. It may be markedly elevated even in asymptomatic carriers. In the absence of a universally accepted standard for interpreting PBG results, attribution of neurovisceral or neuropsychiatric symptoms in porphyrics to an acute attack of porphyria rather than to other causes, depends largely on clinical assessment. The aim of this work was to identify reliable criteria, which will enable establishing or excluding an acute attack, on a biochemical basis. The study summarizes and interprets data obtained during classical neurovisceral acute attacks and latent phases in 20 patients (10 with AIP, 6 with VP, and 4 with HCP). Calculated increases in urinary PBG, with the upper limit of normal excretion, (8.8 micromol/24 h), defined as 100 %, revealed an overlap between values in the acute and latent phases, (1 to 18.5-fold and 2.3 to 51-fold, respectively). This overlap indicates that the workup in each case needs to be individualized. We achieved this goal, by using another method of calculation, in which the PBG value measured during an acute attack in a particular patient was divided by the PBG value measured in that patient's latent phase. Increases of 2.3 to 50.5-fold were obtained, leading to the conclusion that any increase, calculated as above, of 2.3-fold and higher, may be taken as indicative of an acute attack. An additional finding, demonstrated in the study, which might be useful for supporting the diagnosis of an acute attack, is the distinct emission peak observed at 404/621 nm, in the plasma fluorometric scan of AIP and HCP patients, during an acute attack. We conclude that comparison of the urinary PBG level and plasma fluorometric scan in the acute phase to those of the latent phase in the individual patient is the key to correct, accurate and reliable biochemical diagnosis of an acute attack in a patient previously diagnosed as a porphyric. The additional tests required for confirming a patient's first acute attack, having no data to compare with, are discussed.

The effect of beta-adrenergic blocking agents on experimental porphyria induced by 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC) in vivo and in vitro.

The effect of DL-propranolol on 3',5'-diethoxycarbonyl-1,4-dihydrocollidine-induced experimental porphyria was studied. DL-Propranolol, a beta-adrenergic blocking agent with non-specific membrane effects, partially inhibited 3',5'-diethoxycarbonyl-1,4-dihydrocollidine-induced delta-aminolevulinate synthetase activity both in rats and in chick embryo liver cells in culture. In rats, DL-propranolol decreased urinary delta-aminolevulinate and porphobilinogen but no change occurred in the 24-h urinary excretion of total porphyrins and in the concentration of porphyrins in the liver. In cultured chick embryo liver cells treated with 3',5'-diethoxycarbonyl-1,4-dihydrocollidine, DL-propranolol decreased accumulation of porphyrins in the medium. D-Propranolol, oxprenolol and quinidine acted like DL-propranolol in chick embryo liver cells in culture treated with 3',5'-diethoxycarbonyl-1,4-dihydrocollidine. Pindolol, practolol and lidocaine had no effect. Phenobarbitone had a synergistic effect on the induction of delta-aminolevulinate synthetase by 3',5'-diethoxycarbonyl-1,4-dihydrocollidine in cultures of chick embryo liver cells. This induction was partially inhibited by propranolol. However, the increased accumulation of porphyrins in the medium caused by 3',5'-diethoxycarbonyl-1,4-dihydrocollidine was inhibited by the addition of phenobarbitone. This inhibited induction was further decreased by propranolol. Most of our results indicate that the drugs tested act mainly by their effects on membranes.

The effects of succinylacetone (4,6-dioxoheptanoic acid) on delta-aminolevulinate synthase activity and the content of heme in monolayers of chick embryo liver cells.

Succinylacetone was shown to inhibit aminolevulinate dehydratase (5-aminolevulinate hydro-lyase (adding 5-aminolevulinate and cyclizing), EC 4.2.1.24) to reduce cellular heme and porphyrins and to induce delta-aminolevulinate synthase (succinyl-CoA:glycine C-succinyltransferase (decarboxylating), EC 2.3.1.37) in monolayers of chick embryo liver cells. Marked synergistic effects on delta-aminolevulinate synthase activity were obtained by combining succinylacetone with levulinate and porphyrogenic drugs. The time course of delta-aminolevulinate synthase activity showed a delayed synergistic response.

L-Alanine: 4,5-dioxovalerate transaminase does not regulate heme synthesis in rat liver.

L-Alanine: 4,5-dioxovalerate transaminase (ADT) was determined in liver homogenates of rats treated by either inducers of porphyrin synthesis or the repressor, hemin. ADT activity was not induced by the porphyrinogenic agents nor reduced by hemin, indicating that ADT probably has no regulatory role in the heme synthesis pathway. The same conclusion was drawn from similar experiments performed in monolayers of chick embryo liver cells.

Cutaneous photosensitivity induced by paclitaxel and trastuzumab therapy associated with aberrations in the biosynthesis of porphyrins.

BACKGROUND: Paclitaxel and trastuzumab are new treatments for patients with metastatic breast cancer. CASE REPORT: We describe here a 40-year-old female patient with metastatic breast cancer who developed a photosensitive rash 1 month after initiation of paclitaxel and trastuzumab therapy. The eruption appeared on the dorsal aspect of her hands, forearms, legs and face and consisted of erythema, edema and vesicles, and was associated with distal onycholysis. Aberrations in various parameters of the metabolism of porphyrins were observed in urine and erythrocytes. Sun avoidance and withdrawal of paclitaxel was followed by resolution of the rash and a return to the normal pattern of porphyrins biosynthesis. CONCLUSION: The combination of paclitaxel and trastuzumab treatment and sun exposure may induce a photosensitive reaction, associated with changes in various parameters of porphyrins biosynthesis.

Effects of fish-oil ingestion on cardiovascular risk factors in hyperlipidemic subjects in Israel: a randomized, double-blind crossover study.

Effects of a daily fish-oil supplement on serum lipids, apolipoproteins, and some platelet functions and hemorheologic variables were examined in 27 hyperlipidemic subjects in a randomized, controlled, double-blind, crossover fashion with an identically encapsulated vegetable oil serving as the control treatment. Despite the habitual high linoleic acid intake of the study population, significant incorporation of n-3 (omega-3) fatty acids into the serum, platelet, and erythrocyte lipids was observed after the fish-oil supplement. Ingestion of fish oil resulted in a 40% decrease in the triglyceride concentration, a 12% increase in HDL cholesterol, and a significant decrease in plasma viscosity, whereas the vegetable-oil placebo had no significant effect. We conclude that a moderate intake of fish oil (15 g/d) is a feasible treatment for hypertriglyceridemia even in patients with a background of high linoleic acid intake and that it may have a beneficial effect on several cardiovascular risk factors.

The heme biosynthetic pathway in lymphocytes of patients with malignant lymphoproliferative disorders.

The metabolism of heme is impaired in lymphocytes of patients with malignant lymphoproliferative disorders (MLPO). Two of the enzymes of the heme biosynthetic pathway, delta-aminolevulinic acid dehydrase (ALAD) (EC 4.2.1.24) and ferrochelatase (FC) (EC 4.99.1.1) are markedly reduced. The activity of porphobilinogen deaminase (PBGD) (EC 4.3.1.8) is increased. The rate-limiting enzyme of heme biosynthesis in the liver, aminolevulinate synthase (ALAS) (EC 2.3.1.37) remains unchanged although the concentration of total heme in the lymphocytes is markedly reduced. This might reflect a lack of negative feedback inhibition by heme on ALAS activity in this system.

Evidence of abnormality of lymphocyte uroporphyrinogen synthase in family members of patients with lymphoproliferative diseases.

Patients with active lymphoproliferative diseases (LPD) were shown to have high activity of lymphocyte uroporphyrinogen synthase (L-UROS), the enzyme which converts porphobilinogen to uroporphyrinogen. The mean L-UROS activity of 64 first-degree relatives of patients with LPD was significantly higher than that of a control group and 45% of these relatives had pathological values of L-UROS. L-UROS activity was also determined in the spouses of 2 patients and was pathologically elevated in both. The pattern of pathological values among family members may indicate the presence of a communicable agent.

The influence of propranolol on the concentration of heme and on the activity of delta aminolevulinate synthase in monolayers of chick embryo liver cells.

The addition of propranolol to monolayers of chick embryo liver cells caused a rapid increase in cellular heme, followed by an equally rapid decrease. Subsequently the concentration of heme rose at a relatively slower rate. About 10 hr after addition of propranolol to the medium a plateau level was reached at +/- 35% above control values. Changes in the activity of delta-aminolevulinate synthase (ALAS) were negatively correlated with those of cellular heme. Cycloheximide prevented the above phenomenon. ALAS activity was not clearly correlated with the rapid, partial inhibition of protein synthesis, caused by propranolol. These observations are related to the beneficial influence of administration of hemin or of propranolol to patients with acute attacks of hepatic porphyria.

Evidence relating the inhibitory effect of cobalt on the activity of delta-aminolevulinate synthase to the intracellular concentration of porphyrins.

This study shows that the inhibition of ALAS activity caused by cobalt is directly correlated with the intracellular porphyrin concentration, thus indicating that cobalt exerts its inhibitory effect on ALAS activity as a result of the formation of cobalt-protoporphyrin.

The effects of metalloporphyrins, porphyrins and metals on the activity of delta-aminolevulinic acid synthase in monolayers of chick embryo liver cells.

The effect of various metals, porphyrins and metalloporphyrins on the activity of delta-aminolevulinate synthase (ALAS) was measured in monolayers of chick embryo liver cells in order to determine whether the metal moiety of heme or heme itself is the regulator of ALAS activity. Iron, magnesium, zinc, copper, manganese and nickel did not decrease ALAS activity in non-induced and in cells induced by allyl-isopropylacetamide (AIA). Cobalt decreased both non-induced and induced activity. Porphyrins inhibited ALAS, apparently only after having been converted into metalloporphyrins. Almost all the metalloporphyrins examined decreased ALAS activity. None of the substances, at the concentrations used, was toxic to the cells. These observations indicate that probably heme and not iron is the regulator of ALAS activity in monolayers of chick embryo liver cells.

MRI and CT in the differential diagnosis of pleural disease.

STUDY OBJECTIVE: To explore the role of MRI in the differential diagnosis of pleural disease. PATIENTS: Forty-two patients with pleural disease were included. METHOD: Retrospective study. All patients were examined with both CT and MRI. The morphologic features of pleural lesions and magnetic resonance signal intensity on T1-weighted, T2-weighted, and contrast-enhanced T1-weighted images were evaluated. RESULTS: Mediastinal pleural involvement, circumferential pleural thickening, nodularity, irregularity of pleural contour, and infiltration of the chest wall and/or diaphragm were most suggestive of a malignant cause both on CT and MRI. Pleural calcification on CT was suggestive of a benign cause. Contrary to what has been previously reported in the literature, neither on CT nor on MRI, pleural thickness >1 cm revealed significant difference between malignant and benign pleural disease (p>0.05, chi(2) test). High signal intensity in relation to intercostal muscles on T2-weighted and/or contrast-enhanced T1-weighted images was significantly suggestive for a malignant disease. Using morphologic features in combination with the signal intensity features, MRI had a sensitivity of 100% and a specificity of 93% in the detection of pleural malignancy. CONCLUSION: When signal intensity and morphologic features are assessed, MRI is more useful and therefore superior to CT in differentiation of malignant from benign pleural disease.

Impairment of induction of delta-aminolevulinic acid synthase by gluconeogenic amino acids and carbohydrates in vitro.

This study was undertaken in a system of chick embryo liver cells incubated in Earle's Basal Salt Solution with hormones. Impairment of induction of delta-aminolevulinic acid synthase (ALAS) by allyl-isopropylacetamide (AIA) was observed in the presence of glucose. Fructose and various gluconeogenic substances including gluconeogenic amino acids had a similar effect. Leucine, which is purely ketogenic, did not influence induction of ALAS. SH-containing amino acids increased induction of ALAS by AIA. The glucose analogues 3-O-methylglucose and 2-deoxyglucose did not impair induction of ALAS by AIA. The inhibitory effect of glycerol, fructose, and glycine was not affected by 3-O-methylglucose but was reversed by 2-deoxyglucose. The results indicate that the salutary effects of proteins on acute attacks of hepatic porphyria are probably caused by their gluconeogenic properties and that glucose-6-phosphate, or metabolite of glucose-6-phosphate that is not in the glycolytic pathway, is the active agent that leads to the glucose-like effect.

Laminin fragment P1 in the sera of patients with pulmonary sarcoidosis.

Laminin is a noncollagenous component of the extracellular matrix in the alveolar wall and may play a role in the development of fibrotic lung disease. Serum levels of laminin fragment P1 as well as procollagen III peptide were determined in 28 patients with pulmonary sarcoidosis and 10 healthy controls using specific radioimmunoassays. The patients' results were compared with the clinical appearance, lung function values (vital capacity, total lung capacity, FEV1, transfer coefficient (KCO), and alveolar-arterial oxygen difference during exercise) and serum concentrations of angiotensin converting enzyme and soluble interleukin 2 receptor. Laminin levels in patients were significantly higher than in controls but always remained within normal limits. Although there was a tendency towards higher values in patients with active disease and with radiographic involvement, no significant correlation was found between laminin concentration and clinical, functional or biochemical data. In contrast, procollagen III N-terminal peptide concentrations were elevated in 19 of 28 patients and showed a weak but significant inverse correlation with parameters of restriction with significantly higher values in patients with active disease. In conclusion, serum levels of laminin fragment P1 are not elevated in pulmonary sarcoidosis and do not correlate with other parameters of the disease. Yet serum levels of procollagen III N-terminal peptide were associated with the degree of parenchymal involvement as expressed by functional disturbance and with active disease.

Clinical findings in 715 patients with newly detected pulmonary sarcoidosis--results of a cooperative study in former West Germany and Switzerland. WATL Study Group. Wissenschaftliche Arbeitsgemeinschaft für die Therapie von Lungenkrankheitan.

BACKGROUND AND AIM OF WORK: Clinical appearance of sarcoidosis depends on the methods of case finding and geographical factors. In a further effort to clarify clinical characteristics of pulmonary sarcoidosis, we examined a larger population of consecutive pulmonary sarcoidosis cases throughout former West Germany and Switzerland. METHODS: In a prospective multicenter study from January 1982 to December 1984, 715 patients with newly-diagnosed pulmonary sarcoidosis were studied for their clinical appearance, roentgenological and laboratory findings and pulmonary function. RESULTS: The group consisted of 366 male and 349 female patients with a median age of 33 years (range 14 to 76). 35% presented with roentgenological stage I disease, 51% with stage II and 14% with stage III. Extrapulmonary manifestations were found in 16%. Angiotensin converting enzyme was elevated in 62% of the cases. Lung function tests revealed a restrictive pattern in 19% and airway obstruction in 4%; 2% showed a combined ventilation disturbance. 66% of our patients were symptomatic in contrast to reports from former East Germany, a country with mass X-ray screening where only 18 to 35% of the patients presented with symptoms and 51 to 74% were in stage I. CONCLUSIONS: Differences between our findings and data from East Germany underline the importance of case finding methods for the patterns of clinical appearance of sarcoidosis.