Frequency of vitamin D deficiency in children with iron deficiency anaemia and factors associated with vitamin D deficiency.

Objective: To evaluate vitamin D deficiency in children with iron-deficiency anaemia, and to identify the risk factors for such deficiency. METHODS: The cross-sectional study was conducted at the Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan, from October 2021 to March 2022, and comprised children aged 1-5 years who had been diagnosed with iron-deficiency anaemia. Quantitative variables, like age, height, weight, gender, socioeconomic status and sibling status, were controlled by stratification. Data was compared to assess the risk factors of vitamin D deficiency among the subjects. Data was analysed using SPSS 22. RESULTS: Of the 236 children with iron-deficiency anaemia, 159(67.5%) also had vitamin D deficiency; 95(59%) girls and 65(41%) boys. Overall, 104(65.4%) subjects were aged 4-5 years and 55(34.6%) were aged 1-3 years. Vitamin D deficiency had significant association with female gender, older age, height and weight <5th centiles, educated parents, low to middle socioeconomic status, urban residence and higher number of siblings (p<0.05). CONCLUSIONS: The prevalence of vitamin D deficiency among children with iron-deficiency anaemia was found to be high.

Mutational spectrum of CFTR in cystic fibrosis patients with gastrointestinal and hepatobiliary manifestations.

BACKGROUND: Cystic fibrosis (CF) is a rare and debilitating autosomal recessive disorder. It hampers the normal function of various organs and causes severe damage to the lungs, and digestive system leading to recurring pneumonia. Cf also affects reproductive health eventually may cause infertility. The disease manifests due to genetic aberrations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. This study aimed to screen for CFTR gene variants in Pakistani CF patients representing variable phenotypes. METHODS: Clinical exome and Sanger sequencing were performed after clinical characterization of 25 suspected cases of CF (CF1-CF25). ACMG guidelines were followed to interpret the clinical significance of the identified variants. RESULTS: Clinical investigations revealed common phenotypes such as pancreatic insufficiency, chest infections, chronic liver and lung diseases. Some patients also displayed symptoms like gastroesophageal reflux disease (GERD), neonatal cholestasis, acrodermatitis, diabetes mellitus, and abnormal malabsorptive stools. Genetic analysis of the 25 CF patients identified deleterious variants in the CFTR gene. Notably, 12% of patients showed compound heterozygous variants, while 88% had homozygous variants. The most prevalent variant was p. (Met1Thr or Met1?) at 24%, previously not reported in the Pakistani population. The second most common variant was p. (Phe508del) at 16%. Other variants, including p. (Leu218*), p. (Tyr569Asp), p. (Glu585Ter), and p. (Arg1162*) were also identified in the present study. Genetic analysis of one of the present patients showed a pathogenic variant in G6PD in addition to CFTR. CONCLUSION: The study reports novel and reported variants in the CFTR gene in CF patients in Pakistani population having distinct phenotypes. It also emphasizes screening suspected Pakistani CF patients for the p. (Met1Thr) variant because of its increased observance and prevalence in the study. Moreover, the findings also signify searching for additional pathogenic variants in the genome of CF patients, which may modify the phenotypes. The findings contribute valuable information for the diagnosis, genetic counseling, and potential therapeutic strategies for CF patients in Pakistan.

Mutational analysis in different genes underlying severe combined immunodeficiency in seven consanguineous Pakistani families.

BACKGROUND: Severe Combined Immunodeficiency (SCID) is an autosomal recessive inborn error of immunity (IEI) characterized by recurrent chest and gastrointestinal (GI) infections and in some cases associated with life-threatening disorders. METHODOLOGY AND RESULTS: This current study aims to unwind the molecular etiology of SCID and also extended the patients' phenotype associated with identified particular variants. Herein, we present 06 disease-causing variants identified in 07 SCID-patients in three different SCID related genes. Whole Exome Sequencing (WES) followed by Sanger Sequencing was employed to explore genetic variations. The results included identification of two previously reported heterozygous variants in homozygous form for the first time in RAG1gene [(p.Arg410Gln);(p.Arg737His)], followed by a recurrent variant (p.Trp959*) in RAG1, a novel variant in IL2RG (p.Asp48Lfs*24), a recurrent variant in IL2RG (p.Gly271Glu) and a recurrent variant in DCLRE1C (p.Arg191*) gene. CONCLUSION: To conclude, the immune-profiling and WES revealed two novel, two as homozygous state for the first time, and two recurrent disease causing variants contributing valuably to our existing knowledge of SCID.

Identification of novel homozygous variants in FOXE3 and AP4M1 underlying congenital syndromic anophthalmia and microphthalmia.

BACKGROUND: Anophthalmia and microphthalmia are severe developmental ocular disorders that affect the size of the ocular globe and can be unilateral or bilateral. The disease is found in syndromic as well as non-syndromic forms. It is genetically caused by chromosomal aberrations, copy number variations and single gene mutations, along with non-genetic factors such as viral infections, deficiency of vitamin A and an exposure to alcohol or drugs during pregnancy. To date, more than 30 genes having different modes of inheritance patterns are identified as causing anophthalmia and microphthalmia. METHODS: In the present study, a clinical and genetic analysis was performed of six patients with anophthalmia and microphthalmia and/or additional phenotypes of intellectual disability, developmental delay and cerebral palsy from a large consanguineous Pakistani family. Whole exome sequencing followed by data analysis for variants prioritization and validation through Sanger sequencing was performed to identify the disease causing variant(s). American College of Medical Genetics and Genomics (ACMG) guidelines were applied to classify clinical interpretation of the prioritized variants. RESULTS: Clinical investigations revealed that the affected individuals are afflicted with anophthalmia. Three of the patients showed additional phenotype of intellectual disability, developmental delays and other neurological symptoms. Whole exome sequencing of the DNA samples of the affected members in the family identified a novel homozygous stop gain mutation (NM_012186: c.106G>T: p.Glu36*) in Forkhead Box E3 (FOXE3) gene shared by all affected individuals. Moreover, patients segregating additional phenotypes of spastic paraplegia, intellectual disability, hearing loss and microcephaly showed an additional homozygous sequence variant (NM_004722: c.953G>A: p.Arg318Gln) in AP4M1. Sanger sequencing validated the correct segregation of the identified variants in the affected family. ACMG guidelines predicted the variants to be pathogenic. CONCLUSIONS: We have investigated first case of syndromic anophthalmia caused by variants in the FOXE3 and AP4M1. The present findings are helpful for understanding pathological role of the mutations of the genes in syndromic forms of anophthalmia. Furthermore, the study signifies searching for the identification of second variant in families with patients exhibiting variable phenotypes. In addition, the findings will help clinical geneticists, genetic counselors and the affected family with respect to prenatal testing, family planning and genetic counseling.

Epidemiology and clinical spectrum of pediatric patients with human immunodeficiency virus (HIV) infection: A 15 years' experience.

Objective: To view the different patterns of presentation of HIV in pediatric population along with mode of transmission and associated co infections and co morbidities. Methods: It was a retrospective study conducted at Pakistan Institute of Medical Sciences, Islamabad, in which we evaluated the records of pediatric patients diagnosed with HIV from 2005 to 2020. All the data like age, gender, area, presenting complaints, examination findings at the time of diagnosis, mode of transmission, co infection and co morbidities were recorded. Descriptive analysis was done to calculate frequencies and means of the variables. SPSS 20 was used for data analysis. Results: Ninety four participants were evaluated with male to female ratio as 1.8:1 and mean age of 5.2 years. Majority of patients (44%) were below 4 years. Fever (55%) was the most reported symptom followed by cough (39%), diarrhoea (29%), pallor (27%), shortness of breath (26%), weight loss (23%) and failure to thrive (22%). Co infection with TB was present in (16%). Eight (9%) patients were thalassaemic. Mother to child transmission (60%) was the commonest mode of transmission followed by blood transfusion (23%) and parenteral transmission (6%). Conclusion: In children HIV is more prevalent in males especially under 4 years with fever, cough, diarrhea and pallor being the common symptoms at presentation. Tuberculosis is the commonest co infection as we are endemic for TB and mother to child transmission is the commonest mode of transmission as there was no outbreak in our area.

Whole exome sequencing identified a novel splice donor site variant in interleukin 2 receptor alpha chain.

Interleukin 2 receptor alpha chain (IL-2Rα or CD25) deficiency (OMIM #606367) is an immune dysregulation disorder segregating in autosomal recessive form. The disease is caused by biallelic variants in the IL-2Rα gene encoding IL-2Rα also known as CD25 protein. IL-2Rα combines with γ and ß chains of interleukin 2 receptor to form a functional interleukin 2 receptor (IL-2R). In the present study, we identified a Pakistani family presenting a unique presentation of IL-2Rα deficiency. Clinical whole exome sequencing revealed a novel splice donor site variant (NM_001378789.1 (NP_001365718); c.64 + 1G > A) in the IL-2Rα gene. American College of Medical Genetics (ACMG) guidelines interpreted the identified variant as likely pathogenic. The IL-2Rα gene mutation usually presents with autoimmunity and immunodeficiency but in our patient, it presents with congenital diarrhea, metabolic crisis, and strong family history of death in infancy due to the similar complications. Her congenital diarrhea is attributed to autoimmunity in the form of autoimmune enteropathy and eczema. The laboratory findings revealed severe metabolic acidosis hypokalemia and elevated lactate and ammonia levels. This is a new presentation of IL-2Rα gene mutation. The present study highlights the importance of clinical whole exome sequencing in the correct diagnosis of congenital disorders. The study will also help clinical geneticists for genetic counseling and prevention of the disease in the affected family.

Extensively Drug-Resistant Enteric Fever In Children: Surging Threats Of Antimicrobial Resistance And Possible Solutions.

BACKGROUND: Enteric fever is an infectious disease caused by Salmonella enterica including Salmonella Typhi and Paratyphi A and is associated with potentially serious outcomes, especially in developing countries. The study was conducted with the aim to present the clinical features, laboratory characteristics and antibiotic susceptibility in patients with culture-proven extensively drug-resistant (XDR) enteric fever and to explore drug combinations as a possible solution for the growing problem of antimicrobial resistance. METHODS: This descriptive cross-sectional study was conducted in the Paediatric unit of Ayub teaching hospital. Patients admitted with culture-proven XDR enteric fever were included. Patient characteristics were documented on a predesigned proforma. Response to antimicrobial agents including ceftriaxone and levofloxacin, azithromycin and meropenem and meropenem alone was assessed. Data was entered and analyzed using SPSS version 26. RESULTS: A total of 53 patients participated in this study. The majority of patients 36 (67.9%) were male and above 5 years of age(n=38,71.7%). The mean age of the participants was 7.08±3.02 years. The major presenting features included fever, anorexia and pain abdomen in 53 (100%), 51 (96.2%) and 41 (77.4%) respectively. The mean duration of symptoms prior to hospitalization was 8.92±3.361 days. Of the total patients, 32(60.4%) responded to the initial therapy with ceftriaxone and levofloxacin, 11(20.8%) patients responded to meropenem alone and 10 (18.9%) patients responded to meropenem and azithromycin in combination. There was no statistically significant difference in mean duration to show response in patients receiving either of the treatments (p=0.484). CONCLUSIONS: Paediatric patients with XDR enteric fever mainly presented with fever, anorexia and pain abdomen and showed good response to therapy with the combination of ceftriaxone and levofloxacin inspite of the apparent resistance on blood culture and sensitivity.

Primary Antibiotic Resistance And Effectiveness Of Clarithromycin Vs Metronidazole Based Therapy For Helicobacter Pylori Infection In Children.

BACKGROUND: NASPGHAN guidelines recommend regional antibiotic susceptibility profiling for H. pylori eradication treatment. Profiling local antibiotic resistance patterns is mandatory for successful H. pylori eradication in children. The aim of our study was to determine primary resistance to Clarithromycin and Metronidazole, most commonly used in the eradication regimens in children presenting with symptomatic H. pylori infection. This study was conducted at Children Hospital PIMS Islamabad from June 2020 to August 2021. METHODS: The children of either gender age 2-14 years having symptomatic H. pylori infection (hematemesis, chronic abdominal pain) underwent stool for H. pylori Antigen. Children requiring urgent diagnostic endoscopy underwent rapid urease tests. Biopsies were taken from children having positive stool H. pylori Ag and rapid urease test for histological examination. The biopsy specimens were cultured and subsequently tested for antibiotic sensitivity. RESULTS: Out of 54 children having H. pylori infection 40/54 (74.074%) children had strains susceptible to antimicrobials and 14/54 (25.92%) were having resistance to antimicrobials. According to the pattern of antimicrobial sensitivity, they were further grouped into three (a) Clarithromycin and Metronidazole sensitive group (18/40, 45%) (b) Clarithromycin sensitive and Metronidazole resistant group (12/40, 30%) (c) Metronidazole sensitive group (10/40 25%). CONCLUSIONS: Clarithromycin and Metronidazole cannot be used as1stline treatment for H. pylori eradication in children and can only be used with known antimicrobial susceptibility.

Exome Sequencing Revealed a Novel Splice Site Variant in the CRB2 Gene Underlying Nephrotic Syndrome.

Background and Objectives: Nephrotic syndrome (NS) is a kidney disease where the patient has a classic triad of signs and symptoms including hypercholesterolemia, hypoalbuminemia, proteinuria (>3.5 g/24 h), and peripheral edema. In case of NS, the damaged nephrons (structural and functional unit of the kidney) filter unwanted blood contents to make urine. Thus, the urine contains unwanted proteins (proteinuria) and blood cells (hematuria), while the bloodstream lacks enough protein albumin (hypoalbuminemia). Nephrotic syndrome is divided into two types, primary NS, and secondary NS. Primary NS, also known as primary glomerulonephrosis, is the result of a glomerular disease that is limited to the kidney, while secondary NS is a condition that affects the kidney and other parts of the body. The main causes of primary NS are minimal change disease, membranous glomerulonephritis, and focal segmental glomerulosclerosis. In the present study we recruited a family segregating primary NS with the aim to identify the underlying genetic etiology. Such type of study is important in children because it allows counseling of other family members who may be at risk of developing NS, predicts risk of recurrent disease phenotypes after kidney transplant, and predicts response to immunosuppressive therapy. Materials and Methods: All affected individuals were clinically evaluated. Clinical examination, results of laboratory tests, and biopsy investigations led us to the diagnosis. The next-generation sequencing technique (whole-exome sequencing) followed by Sanger sequencing identified a novel homozygous splice site variant (NM_173689.7: c.941-3C>T) in the CRB2 gene. The variant was present in a homozygous state in the affected individuals, while in a heterozygous state in phenotypically normal parents. Results: The study expanded the spectrum of the mutations in the gene CRB2 responsible for causing NS. Conclusions: In addition, the study will also help in genetic counseling, carrier testing, and prenatal and/or postnatal early diagnosis of the disease in the affected family.

Clinical and genetic characterization of patients segregating variants in KPTN, MINPP1, NGLY1, AP4B1, and SON underlying neurodevelopmental disorders: Genetic and phenotypic expansion.

Neurodevelopmental disorders (NDDs) are heterogeneous genetic conditions of the central nervous system (CNS). Primary phenotypes of NDDs include epilepsy, loss of developmental skills, abnormal movements, muscle weakness, ocular anomalies, hearing problems, and macro- or microcephaly. NDDs occur due to variants in genes encoding proteins involved in the structure and function of CNS, thus interrupting its normal physiological role. In the study presented here, four consanguineous families (A-D), with members showing neurodevelopmental symptoms, were recruited for clinical and genetic characterization of the phenotypes. Clinical examinations, including Seguin Form Board Test (SFBT), Vineland Social Maturity Scale (VSMS), brain Magnetic Resonance Imaging (MRI), Electroencephalogram (EEG), Electromyography (EMG), Nerve Conduction Velocity (NCV), and Magnetic Resonance Spectroscopy, were employed to characterize the disease phenotypes. Whole exome sequencing (WES) followed by Sanger sequencing was employed to search for the genetic basis of the neurological symptoms observed in four families (A-D). Two of these families (A, B) were of Saudi Arabian origin, and two others (C, D) were of Pakistan origin. Two homozygous missense (KPTN: NM_007059.4:c.301T>G: NP_008990.2; p.(Phe101Val) and MINPP1:NM_001178118.2:c.1202G>A: NP_001171588.1; p.(Arg401Gln)) variants in families A and B, respectively, and two homozygous nonsense (NGLY1:NM_018297.3:c.1534_1541dup: NP_060767.2; p.(Ser515LysfsTer51) and AP4B1:NM_001253852:c.1668G>A: NP_001240781.1; p.(Trp556X)) variants in families C and D, respectively, were identified. Interestingly, additional heterozygous nonsense variant in SON: NM_138927.2: c.5753_5756del: NP_620305.3; p.(Val1918GlufsTer87) and a homozygous variant in FLG (FLG: NM_002016.2:c.7339C>T: NP_002007.1; p.(Arg2447X) were detected in families A and D, respectively. Further, we determined the deleteriousness of each variant through computational approaches. The present study expands the phenotypic and genetic spectrum of NDD-associated genes (KPTN, MINPP1, NGLY1, and AP4B1). Moreover, additional nonsense variants (SON: c.5753_5756del and FLG: c.7339C>T) identified in two families segregating with the phenotype might explain the phenotypic variability and severity in our patients.

Comparison Of Efficacy Of Yogurt Versus Probiotics For The Management Of Acute Diarrhoea.

BACKGROUND: The advantages of probiotic administration for acute diarrhoea are mainly shorter duration of symptoms as well as reduced number of stools per day while use of traditional yogurt has similar results. So, this study was conducted to compare the efficacy of yogurt with probiotic in children with acute gastroenteritis. METHODS: This randomized controlled trial was conducted at department of Paediatrics, Children Hospital, Pakistan Institute of Medical Sciences, Islamabad over 1 year. A total of nine hundred and thirty (930) children between 1-5 years of age presenting with acute diarrhoea were enrolled and equally randomized to Group-A (yogurt) and Group-B (lactobacillus rhamnosus) with ORS. The primary outcome was mean frequency of diarrhoea in first 24 hours after initiation of treatment in both the groups. RESULTS: Gender distribution revealed that out of 930 patients, 643 (69.1%) were male and 287 (30.9%) were female while the mean age was 3.14±1.18 years. Mean duration of disease was 4.23±2.02 days. Mean no. of stools in first 24 hours after treatment in Group-A (yogurt) was 3.25±1.64 and 3.29±1.74 in Group-B (probiotics). Student t-test for independent samples was applied and no significant difference was found between the two groups (p=0.713). CONCLUSIONS: Mean frequency of diarrhoea in first 24 hours after treatment with traditional yogurt and commercially available probiotics was not statistically significant in this study.

A novel nonsense variant in EXOC8 underlies a neurodevelopmental disorder.

Human exocyst complex is an evolutionary conserved multimeric complex composed of proteins encoded by eight genes EXOC1-EXOC8. It is known that the exocyst complex plays a role in ciliogenesis, cytokinesis, cell migration, autophagy, and fusion of secretory vesicles. Recently, loss of function variants in EXOC7 and EXOC8 has been associated with abnormalities of cerebral cortical development leading to a neurodevelopmental phenotype. Neurodevelopmental disorders are a huge group of clinically and genetically heterogeneous disorders. In the present study, we recruited a large consanguineous family segregating a neurodevelopmental disorder in an autosomal recessive form. We performed clinical phenotyping by imaging the patient's brain followed by whole exome sequencing examining DNA from two affected individuals. The clinical phenotypes of the disease were suggestive of brain atrophy. Clinical examination revealed intellectual impairment with hypertonia and brisk reflexes. WES followed by Sanger sequencing revealed a novel homozygous nonsense mutation [EXOC8; NM_175876.5; c.1714G > T; p.(Glu572Ter)] in the DNA of affected individuals. Both parents of the patients were heterozygous for the identified mutation. All the pathogenicity prediction softwares predicted the identified variant as disease causing. This study reports a second protein-truncating variant in EXOC8. The findings confirm that loss of function variants in EXOC8 underlies a neurodevelopmental disorder. The identification of a protein-truncating variant in EXOC8 in the current study can be helpful in establishing genotype-phenotype correlations. Our results also provide new insights into genetic counseling and clinical management for the affected individuals.

Exome sequencing reveals the first intragenic deletion in ABCA5 underlying autosomal recessive hypertrichosis.

BACKGROUND: Hereditary hypertrichosis (HH) is characterized by excessive hair growth on various body areas, which is independent of the individual's age. This rare hair disorder has been classified by its origin (genetic or acquired), age of onset, breadth of hair distribution (universal or localized) and the affected body areas. HH is often linked to several additional congenital abnormalities involving teeth, heart and bones. Human HH is associated with heterozygous genomic duplications and deletions in the chromosomal region 17q24.2-q24.3, containing genes such as ABCA5, ABCA6, ABCA10 and MAP2K6. Recently, a homozygous splice-site variant in ABCA5 has been reported to cause autosomal recessive congenital generalized hypertrichosis terminalis (CGHT; OMIM 135400). AIM: To investigate the clinical and genetic basis of autosomal recessive hypertrichosis in a large consanguineous Pakistani family. METHODS: In the present study, we characterized a family of Pakistani origin segregating CGHT in an autosomal recessive pattern, using whole exome sequencing followed by Sanger sequencing. RESULTS: We identified a novel 2-bp intragenic deletion [NM_172232.4(ABCA5);c.977_978delAT] causing a frameshift variant (p.His326ArgfsTer5) in ABCA5. CONCLUSIONS: To our knowledge, this is the first intragenic deletion in ABCA5 underlying CGHT. The findings further validate the involvement of ABCA5 in hair development. The study will facilitate genetic counselling of families carrying CGHT-related features in Pakistani and other populations.

A case of multisystem inflammatory syndrome in children presenting as systemic onset juvenile idiopathic arthritis.

Multisystem inflammatory syndrome in children (MIS-C) is a rare and serious COVID-19 manifestation characterised by generalised inflammatory response including inflammation of the heart, blood vessels, lungs, kidneys, brain, skin, eyes and gastrointestinal system. Children usually present with fever lasting for 24 hours or more along with other symptoms such as abdominal pain, vomiting, diarrhoea, skin rash, red eyes, and swelling of the lips, tongue, hands and feet. Children with MIS-C usually have negative results for a current infection with COVID-19 but positive antibody results indicating that these children were infected with the COVID-19 virus in the past. We present the case of a 12-month-old girl with multisystem inflammatory syndrome presenting as systemic-onset juvenile idiopathic arthritis (SoJIA) and positive Covid-19 PCR. She was treated successfully with Dexamethasone and Naproxen.

Risk factors for mortality among admitted children with complications of measles in Pakistan: An observational study.

OBJECTIVE: To identify the vaccination status and risk factors for mortality in children admitted with complications of measles. METHODS: The retrospective study was conducted at Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and comprised data of children admitted with complications of measles between 2013 and 2017. Information on vaccination history, complications of measles, anthropometry, hospital stay and outcome within 15 days of admission was retrieved from hospital records. Data was analysed using Stata 14. RESULTS: Of the 307 children admitted, 79(26%) were aged <9 months and were excluded. Of the remaining 228 subjects, 109(47.8) were unvaccinated. Risk factors significantly associated with mortality were an unvaccinated state of measles vaccine, being stunted, and encephalitis in comparison with pneumonia (p<0.05). A total of 39(17%) children died within 15 days of admission. CONCLUSIONS: Encephalitis, non-vaccination and under-nutrition were significantly associated with mortality in children with complications of measles.

Clinical and genetic characterization of congenital lipoid adrenal hyperplasia.

Disorders of steroid synthesis are a group of anomalies caused by defects in any step of conversion of cholesterol into steroid hormones. The disorders are characterized by defects leading to abnormalities of salt-water balance and/or sexual differentiation. Congenital lipoid adrenal hyperplasia (CLAH) is the most severe form of steroid synthesis disorder caused by the accumulation of cholesterol in the outer mitochondrial membrane due to steroidogenic acute regulatory protein (StAR) deficiency. Pathogenic sequence variants in the gene STAR encoding StAR protein leads to CLAH. In the present study, a Pakistani family was clinically diagnosed with the LAH phenotype. Sanger sequencing of STAR in the family revealed a novel homozygous nonsense mutation [c.295G>T, p.(Glu99*)] in the living affected individual. The study was designed to assist in carrier testing and prenatal diagnosis within the affected family. In addition, searching for common variants in the STAR gene would help in designing low-cost targeted variation testing in other patients.

Sequence variants in three genes underlying leukodystrophy in Pakistani families.

Leukodystrophies (LDs) are a heterogeneous group of rare and progressive genetic diseases that affect brain, spinal cord, and often the peripheral nerves. They are characterized by abnormal development or destruction of the myelin sheath of the brain. This study was aimed to search for the causative variants in three unrelated consanguineous families presented with LD. Detailed clinical investigations were carried out on probands in three unrelated consanguineous families of Pakistani origin. Targeted gene sequencing and Whole Exome Sequencing (WES) were performed for variant identification. Candidate variants were checked for co-segregation with the phenotype using Sanger sequencing. Public databases including ExAC, gnomAD, dbSNP, and the 1,000 Genome Project were searched to determine frequencies of the alleles. Conservation of the missense variants was ensured by aligning orthologous protein sequences from diverse vertebrate species. Targeted gene sequencing identified a novel homozygous missense mutation [c.2135G > A, p.(Arg712His) in the ATP Binding Cassette Subfamily D Member 1 (ABCD1; OMIM# 300371) in three affected siblings in family A.WES followed by validation by Sanger sequencing revealed previously reported homozygous missense variants [c.162C > A; p.(Asn54Lys)] in ASPA (OMIM# 608034) in family B and [c.361G > C,p.(Gly121Arg)] in ARSA (OMIM# 607574) in family C. Investigation of three families underlies importance of WES as an amazing diagnostic tool for conclusive determination of a specific type of LD. Further, the study would assist in carrier testing and prenatal diagnosis of the affected families. In addition, searching for common variants in the genes causing LD would help in designing low-cost targeted variation testing in patients.

Hereditary Hemorrhagic Telangiectasia - Early Childhood Presentation with Hepatic Failure.

Hereditary hemorrhagic telangiectasia (HHT) is a vascular dysplasia in which capillary bed is absent with direct draining of arterial blood into venous circulation. Due to increased pressure there is increased risk of bleeding. The classical triad consists of telangiectasias, epistaxis and a positive family history. This defect can involve any organ system, especially lungs, brain and liver; but hepatic vascular malformations in HHT usually remain silent until fifth or sixth decade of life. However, if symptomatic, it usually results in only mild liver dysfunction in adults. Herein, we report a rare case showing extensive hepatic involvement in HHT leading to hepatic failure at a younger age. Hepatic screening is traditionally not recommended at early age while pulmonary and cerebral screening must be done. Based on this case, we recommend hepatic screening even in a young patient with HHT.

Frequency of acute bacterial meningitis in children with first episode of febrile seizures.

OBJECTIVE: To determine the frequency of acute bacterial meningitis in children with first episode of febrile seizures. METHODS: This cross-sectional study was conducted at the Polyclinic, Postgraduate Medical Institute, Islamabad, Pakistan, from December 2012 to August 2013, and comprised patients with first episode of fever and seizure. SPSS 10 was used for data analysis. RESULTS: Of the157 patients, 12(7.6%) were diagnosed to have acute bacterial meningitis with 5(41.6%) in the age group of 6-12 months, 4(33.3%) in 13-18 months and 3(25%) in the age group of 19-60 months. CONCLUSIONS: Clinicians evaluating children after a febrile seizure should direct their attention toward identifying the cause of the child's fever.

Frequency of hyponatraemia and hypokalaemia in malnourished children with acute diarrhoea.

OBJECTIVE: To determine the frequency of hyponatraemia and hypokalaemia in malnourished children with acute diarrhoea. METHODS: This cross-sectional study was carried out at the Military Hospital, Rawalpindi, Pakistan, from September 2013 to March 2014, and comprised acute diarrhoea patients whose ages ranged from six months to five years. Blood samples for serum sodium and potassium were examined at the Armed Forces Institute of Pathology. Patients were labelled as having hyponatraemia, hypokalaemia, both or having normal serum sodium and potassium levels. RESULTS: Of the 80 patients, 49(61.3%) were boys and 31(38.7%) were girls with an overall mean age of 1.9±1.4 years. Besides, 41(51.3%) were aged below one year. The mean duration of diarrhoea was 3.2±1.7 days, with 53(66%) patients having the illness for 1-3 days. Hyponatraemia was observed in 26(32.5%) patients and hypokalaemia in 44(55%), whereas 10(12.5%) had no electrolyte imbalance. None of the participants had hypernatraemia or hyperkalaemia. CONCLUSIONS: Electrolyte disturbances among malnourished children may not be clinically evident, but diarrhoeal illness aggravated these imbalances.