Lethal neonatal respiratory failure due to biallelic variants in BBS1 and monoallelic variant in TTC21B.

BACKGROUND: Bardet-Biedl syndrome (BBS) is a rare, autosomal recessive ciliopathy characterized by early onset retinal dystrophy, renal anomalies, postaxial polydactyly, and cognitive impairment with considerable phenotypic heterogeneity. BBS results from biallelic pathogenic variants in over 20 genes that encode key proteins required for the assembly or primary ciliary functions of the BBSome, a heterooctameric protein complex critical for homeostasis of primary cilia. While variants in BBS1 are most frequently identified in affected individuals, the renal and pulmonary phenotypes associated with BBS1 variants are reportedly less severe than those seen in affected individuals with pathogenic variants in the other BBS-associated genes. CASE-DIAGNOSIS: We report an infant with severe renal dysplasia and lethal pulmonary hypoplasia who was homozygous for the most common BBS1 pathogenic variant (c.1169 T > G; p.M390R) and also carried a predicted pathogenic variant in TTC21B (c.1846C > T; p.R616C), a genetic modifier of disease severity of ciliopathies associated with renal dysplasia and pulmonary hypoplasia. CONCLUSIONS: This report expands the phenotypic spectrum of BBS with the first infant with lethal neonatal respiratory failure associated with biallelic, pathogenic variants in BBS1 and a monoallelic, predicted pathogenic variant in TTC21B. BBS should be considered among the ciliopathies in the differential diagnosis of neonates with renal dysplasia and severe respiratory failure.

Genetic variation in MKL2 and decreased downstream PCTAIRE1 expression in extreme, fatal primary human microcephaly.

The genetic mechanisms driving normal brain development remain largely unknown. We performed genomic and immunohistochemical characterization of a novel, fatal human phenotype including extreme microcephaly with cerebral growth arrest at 14-18 weeks gestation in three full sisters born to healthy, non-consanguineous parents. Analysis of index cases and parents included familial exome sequencing, karyotyping, and genome-wide single nucleotide polymorphism (SNP) array. From proband, control and unrelated microcephalic fetal cortical tissue, we compared gene expression of RNA and targeted immunohistochemistry. Each daughter was homozygous for a rare, non-synonymous, deleterious variant in the MKL2 gene and heterozygous for a private 185 kb deletion on the paternal allele, upstream and in cis with his MKL2 variant allele, eliminating 24 CArG transcription factor binding sites and MIR4718. MKL1 was underexpressed in probands. Dysfunction of MKL2 and its transcriptional coactivation partner, serum response factor (SRF), was supported by a decrease in gene and protein expression of PCTAIRE1, a downstream target of MKL2:SRF heterodimer transcriptional activation, previously shown to result in severe microcephaly in murine models. While disruption of the MKL2:SRF axis has been associated with severe microcephaly and disordered brain development in multiple model systems, the role of this transcription factor complex has not been previously demonstrated in human brain development.

Synergism between gamma interferon and lipopolysaccharide for synthesis of factor B, but not C2, in human fibroblasts.

Four different human fibroblast cell lines synthesized C2 and factor B. Factor B synthesis was increased 12.1-fold by 50 ng/ml LPS and 7.1-fold by 100 U/ml IFN-gamma. C2 synthesis was increased only 2.1-fold by LPS, but 6.4-fold by IFN-gamma. Both LPS and IFN-gamma increased levels of factor B mRNA. LPS induced a 4.7-fold greater increase in factor B protein than in factor B mRNA, whereas IFN-gamma stimulated comparable increases in protein and mRNA. These data suggest that LPS acts to increase factor B synthesis at both pretranslational and translational sites, while IFN-gamma acts primarily at a pretranslational level. In contrast to factor B, increases in C2 protein and C2 mRNA were comparable for both stimuli. A synergistic effect between the two stimuli was observed for factor B only: protein synthesis was increased 54.5-fold or 2.8-fold greater than the additive effects of the stimuli separately. The rate of synthesis in the presence of LPS and IFN-gamma together could not be achieved by increasing concentrations of, or the times of incubation with, either stimulus separately. The synergism was not the result of an increased sensitivity of the cells to either stimulus and was not reproduced by preincubation with one stimulus before incubation with the other stimulus. Several lines of evidence suggest that the synergism, like the stimulation of factor B synthesis by LPS, was dependent on both translational and pretranslational regulation of factor B mRNA. C2 and factor B synthesized in human fibroblasts may play a role in host defense in inflammatory reactions before increases in vascular permeability and recruitment of other complement producing cells.

Surfactant protein-C promoter variants associated with neonatal respiratory distress syndrome reduce transcription.

Dominant mutations in coding regions of the surfactant protein-C gene, SFTPC, cause respiratory distress syndrome (RDS) in infants. However, the contribution of variants in noncoding regions of SFTPC to pulmonary phenotypes is unknown. By using a case-control group of infants > or =34 weeks gestation (n = 538), we used complete resequencing of SFTPC and its promoter, genotyping, and logistic regression to identify 80 single nucleotide polymorphisms (SNPs). Three promoter SNPs were statistically associated with neonatal RDS among European descent infants. To assess the transcriptional effects of these three promoter SNPs, we selectively mutated the SFTPC promoter and performed transient transfection using MLE-15 cells and a firefly luciferase reporter vector. Each promoter SNP decreased SFTPC transcription. The combination of two variants in high linkage dysequilibrium also decreased SFTPC transcription. In silico evaluation of transcription factor binding demonstrated that the rare allele at g.-1167 disrupts a SOX (SRY-related high mobility group box) consensus motif and introduces a GATA-1 site, at g.-2385 removes a MZF-1 (myeloid zinc finger) binding site, and at g.-1647 removes a potential methylation site. This combined statistical, in vitro, and in silico approach suggests that reduced SFTPC transcription contributes to the genetic risk for neonatal RDS in developmentally susceptible infants.

Pretranslational regulation of the synthesis of the third component of complement in human mononuclear phagocytes by the lipid A portion of lipopolysaccharide.

The third component of complement (C3) is a plasma glycoprotein with a variety of biologic functions in the initiation and maintenance of host response to infectious agents. While the hepatocyte is the primary source of plasma C3, mononuclear phagocytes contribute to the regulation of tissue availability of C3. Lipopolysaccharide (LPS), a constituent of cell walls of gram-negative bacteria, consists of a polysaccharide moiety (core polysaccharide and O antigen) covalently linked to a lipid portion (lipid A). Using metabolic labeling with [35S]methionine, immunoprecipitation, and SDS-polyacrylamide gel electrophoresis, we examined the effects of LPS on synthesis of C3 by human mononuclear phagocytes as well as synthesis of the second component of complement (C2), factor B, lysozyme, and total protein. LPS increased C3 synthesis 5-30-fold without affecting the kinetics of secretion of C3 or the synthesis of C2, lysozyme, or total protein. Factor B synthesis was consistently increased by LPS. Experiments with lipid A-inactivated LPS (alkaline treated), LPS from a polysaccharide mutant strain, and lipid X (a lipid A precursor) indicated that the lipid A portion is the structural element required for this effect. Northern blot analysis demonstrated at least a fivefold increase in C3 mRNA in LPS-treated monolayers, which suggests that the regulation of the increase in C3 synthesis is pretranslational. C2 mRNA and factor B mRNA were increased approximately twofold. The availability of specific gene products in human mononuclear phagocytes that respond to LPS should permit understanding of the molecular regulation of more complex functions of these cells elicited by LPS in which multiple gene products are coordinately expressed.

Perinatal hypophosphatasia: tissue levels of vitamin B6 are unremarkable despite markedly increased circulating concentrations of pyridoxal-5'-phosphate. Evidence for an ectoenzyme role for tissue-nonspecific alkaline phosphatase.

"Perinatal" hypophosphatasia is the most severe form of this inborn error of metabolism, which is characterized by deficient activity of the tissue-nonspecific (liver/bone/kidney) isoenzyme of alkaline phosphatase (ALP) (TNSALP). We report that autopsy tissue from three affected subjects, which was profoundly low in ALP activity, had essentially unremarkable levels of pyridoxal-5'-phosphate (PLP), pyridoxal, and total vitamin B6 content despite markedly elevated plasma PLP levels (5,800, 14,500, and 98,500 nM; adult norm, 5-109 nM). Our findings help to explain the general absence of symptoms of vitamin B6 excess or deficiency in hypophosphatasia, and provide evidence that TNSALP acts as an ectoenzyme to regulate extracellular rather than intracellular concentrations of PLP (the cofactor form of vitamin B6) and perhaps other phosphate compounds.

Respiratory failure in a term infant with cis and trans mutations in ABCA3.

A full-term female neonate presented with persistent respiratory failure and radiologic studies consistent with surfactant deficiency. Sequencing of the ATP-binding cassette transporter A3 gene (ABCA3) revealed three mutations: R280C, V1399M and Q1589X. The infant underwent bilateral lung transplantation at 9 months of age and is alive at 3 years of age. Parental sequencing demonstrated that two of the mutations (R280C and Q1589X) were oriented on the same allele (cis), whereas V1399M was oriented on the opposite allele (trans). As more than one mutation in ABCA3 can be present on the same allele, parental studies are needed to determine allelic orientation to inform clinical decision making and future reproductive counseling.

Phenylalanine hydroxylase activity in preterm infants: is tyrosine a conditionally essential amino acid?

To assess the production of the nonessential amino acid tyrosine in preterm infants, we estimated the activity of phenylalanine hydroxylase (PAH) in three groups of infants by measuring the conversion of phenylalanine to tyrosine, using a model based on a primed constant 200-min intravenous infusion of [2H5]phenylalanine. We determined the isotopic enrichments of [2H5]phenylalanine and [2H4]tyrosine by selected-ion-monitoring gas chromatography-mass spectrometry (GCMS). Group 1 (n = 7, mean gestational age 29.7 +/- 1.5 wk, mean birth weight 1.4 +/- 0.4 kg) was studied during the first 4 d of life before initiation of amino acid nutrition. Group 2 (n = 7, mean gestational age 29.7 +/- 1.5 wk, mean birth weight 1.4 +/- 0.4 kg) was studied at 4-6 d of life after receiving amino acid nutrition. Group 3 (n = 4, mean gestational age 28.5 +/- 0.9 wk, mean birth weight 1.1 +/- 0.1 kg) was studied during the first 4 d of life after receiving amino acid nutrition. Calculated from the observed enrichments, phenylalanine conversion to tyrosine was 5.9 +/- 2.6, 19.4 +/- 8.8 and 11 +/- 1.8 mumol.kg-1l.h-1 in groups 1, 2, and 3, respectively. The rate of conversion of phenylalanine to tyrosine increased significantly after initiation of amino acid nutrition. We conclude that preterm infants are capable of converting phenylalanine to tyrosine. Provision of phenylalanine in the context of parenteral amino acid nutrition solution accelerated PAH conversion of phenylalanine to tyrosine, suggesting that the enzyme system is capable of responding normally to provision of substrate.(ABSTRACT TRUNCATED AT 250 WORDS)

A controlled clinical trial of local anesthesia for lumbar punctures in newborns.

To evaluate the efficacy of subcutaneous administration of lidocaine for reducing physiologic instability in acutely ill newborns during clinically required procedures, 81 neonates who required lumbar punctures within the first month of life were stratified by birth weight and respiratory support and randomly assigned to an experimental or a control group. The experimental group received an injection of 0.1 mL/kg of 1% lidocaine prior to the lumbar puncture. The control group received a nonanesthetized lumbar puncture without placebo. Changes in heart rate, respiratory rate, transcutaneous oxygen and carbon dioxide tensions, and heart rate variability from baseline, preparatory (positioning/handling), lumbar puncture, and recovery periods were measured. The administration of lidocaine did not minimize physiologic instability in response to the lumbar puncture nor was it associated with any detectable adverse effects other than prolonging the duration of the lumbar puncture. Although significant physiologic changes were observed in response to preparatory procedures, few additional changes beyond those occurred in response to lumbar punctures in either the experimental or control group. It is concluded that local anesthesia failed to influence manifestations of physiologic instability during neonatal lumbar punctures and that preparatory procedures were more destabilizing than either the administration of lidocaine or the lumbar puncture itself. The results suggest that the management of newborns requires emphasis on minimizing the destabilizing effects of required and frequent handling procedures.

Population-based estimates of surfactant protein B deficiency.

OBJECTIVE: Surfactant protein B deficiency is a lethal cause of respiratory distress in infancy that results most commonly from a homozygous frameshift mutation (121ins2). Using independent clinical ascertainment and molecular methods in different populations, we sought to determine allele frequency. STUDY DESIGN: Using clinical characteristics of the phenotype of affected infants, we screened the Missouri linked birth-death database (n = 1 052 544) to ascertain potentially affected infants. We used molecular amplification and restriction enzyme digestion of DNA samples from a metropolitan New York birth cohort (n = 6599) to estimate allele frequency. RESULTS: The point estimate and 95% confidence interval of the 121ins2 allele frequency in the Missouri cohort are 1/1000 individuals (.03-5.6/1000) and in the New York cohort are.15/1000 (. 08-.25/1000). These estimates are not statistically different. CONCLUSIONS: The close approximation of these independent estimates suggests accurate gene frequency (approximately one 121ins2 mutation per 1000-3000 individuals) despite its rare occurrence and that this mutation does not account for the majority of full-term infants with lethal respiratory distress.

School-based AIDS education for adolescents.

PURPOSE: To describe a program which utilizes medical students and persons with AIDS (PWAs) to provide for adolescents school-based education about acquired immunodeficiency syndrome (AIDS). METHODS: Two 1.5 hour classroom sessions were conducted by medical students and persons with AIDS for seventh and eighth grade students (n = 1,161 students) at two urban middle schools. In addition, a two hour informational session was provided for parents. A 49 question student health survey was used to evaluate adolescents' HIV knowledge, tolerance of persons with AIDS, and intentions to engage in human immunodeficiency virus (HIV) safe behaviors. RESULTS: Significant (p < 0.01) increases in HIV knowledge and tolerance of persons with AIDS were observed, which persisted for three months. A significant (p < 0.01) improvement in intention to engage in HIV-safe behaviors was observed but did not persist for three months. CONCLUSIONS: Medical students and persons with AIDS can provide school-based AIDS education to early adolescents.

Umbilical cord ulceration as a cause of hypoxic-ischemic encephalopathy: report of a case and review of the literature.

We report a case of hypoxic-ischemic injury caused by acute hemorrhage from an umbilical cord ulceration in a newborn infant with an antenatal diagnosis of small bowel obstruction. Recognition of the association between umbilical cord ulceration and small bowel obstruction may alter obstetric and delivery room management.

Alveolar capillary dysplasia with misalignment of pulmonary veins and anterior segment dysgenesis of the eye: a report of a new association and review of the literature.

The association of alveolar capillary dysplasia with misalignment of pulmonary veins (ACD-MPV) and ocular abnormalities has not been previously reported. We present a case of ACD-MPV and anterior segment dysgenesis of the eye in a full-term infant as well as a review of the relevant literature.

Increased risk for respiratory distress among white, male, late preterm and term infants.

OBJECTIVE: To determine whether race/ethnicity and sex independently increase risk of respiratory distress syndrome (RDS) in late preterm and term infants. STUDY DESIGN: Using a cohort design, we studied the risk of RDS associated with race/ethnicity and sex in infants with gestational age (GA) 34 to 42 weeks born between 1 January 2000 and 31 December 2009 (n=286 454) within 12 hospitals in the Northern California Kaiser Permanente Medical Care Program. RESULT: Male sex (adjusted odds ratio (aOR) 1.68; 95% confidence interval 1.45 to 1.93) and White race/ethnicity (vs Asians (aOR 0.57; 95% confidence interval 0.47 to 0.70), Blacks (aOR 0.66; 95% confidence interval 0.50 to 0.87), and Hispanics (aOR 0.76; 95% confidence interval 0.64 to 0.90)) independently increase risk for RDS regardless of GA. A GA <39 weeks, operative delivery, maternal diabetes, and chorioamnionitis also increased RDS risk in this cohort. CONCLUSION: Male sex and White race/ethnicity independently increase risk for RDS in late preterm and term infants. Timing of elective delivery should acknowledge these risks.

Surfactant therapy failure identifies infants at risk for pulmonary mortality.

OBJECTIVE: To characterize the clinical features of infants who do not respond to surfactant therapy. DESIGN: Patient series, chart review. SETTING: Academic referral neonatal intensive care unit. PATIENTS/SELECTION: Ninety-nine consecutive infants with respiratory distress syndrome who received surfactant therapy and 107 infants from the 2 years prior to initiation of surfactant therapy matched for birth weight, race, sex, gestational age, chronological age, and disease severity. MEASUREMENTS/RESULTS: Oxygen index was used to quantitate response to surfactant therapy. A 25% decrease in oxygen index 6 hours after the first surfactant dose was significantly different from that of the matched historical cohort (P = .04). Oxygen index decreased 25% or more in 49 infants, the response group, while oxygen index decreased less than 25% or increased following therapy in the remaining 50 infants, the nonresponse group. Pulmonary interstitial emphysema occurred more frequently in the nonresponse group. The only deaths from pulmonary causes at 10 days of age or younger occurred in the nonresponse group (n = 11). CONCLUSIONS: Pulmonary processes unresponsive to surfactant therapy contribute to morbidity and mortality in newborn respiratory distress syndrome. Classifying respiratory distress syndrome as "surfactant responsive" or "surfactant unresponsive" offers a scheme by which to investigate alternative explanations and interventions for newborn respiratory distress syndrome.

Regulation of the synthesis of the third component of complement and factor B in cord blood monocytes by lipopolysaccharide.

We compared the regulation of C3 and factor B synthesis in cord blood and adult monocytes by using techniques for identification and quantification of newly synthesized proteins, lipopolysaccharide (LPS) from several Gram-negative organisms, and precursors of LPS. Synthesis of C3 and factor B in cord blood monocytes was unaffected by lipid A (the active moiety of LPS extracted by the Westphal procedure). In contrast, adult monocytes increased C3 synthesis by 11.5-fold and factor B synthesis by 3.1-fold in response to LPS. This difference in cord blood monocyte response to LPS was specific in that other LPS-induced monocyte functions (superoxide production and phagocytosis) were stimulated comparably in both cord blood and adult monocytes by LPS. To characterize further this regulatory difference, the roles of LPS precursors, arachidonic acid metabolites, and of factor(s) released by adult monocytes were examined. Precursors of the lipid portion of LPS (lipid X and lipid Y), LPS isolated by trichloroacetic acid extraction, and endotoxin-associated protein (EAP) increased C3 and factor B synthesis in cord blood monocytes. Inhibitors of the lipoxygenase pathway (dexamethasone, ETYA) but not of the cyclooxygenase pathway (indomethacin) abrogated the response of adult monocytes to lipid A and EAP and of cord blood monocytes to EAP. Finally, co-incubation of adult monocytes and cord blood monocytes in LPS-containing medium resulted in enhancement of C3 and factor B synthesis in cord blood monocytes. These data suggest that the difference in LPS response between cord blood and adult monocytes may result from differences in lipid processing or protein recognition of LPS, differences in the production of lipoxygenase pathway products, and/or one or more regulatory factors. The availability of human mononuclear phagocytes which exhibit distinct differences in biosynthetic responsiveness to LPS should permit investigation of the molecular mechanism(s) by which LPS affects C3 and factor B gene expression.

Energy expenditure, lipolysis, and glucose production in preterm infants treated with theophylline.

Theophylline is administered to preterm infants with pulmonary disease to improve pulmonary function and reduce apneic episodes. Because it potentially mediates both alpha- and beta-receptor-effector mechanisms, we tested the hypothesis that it increases lipolysis, gluconeogenesis from glycerol, and energy expenditure in 16 preterm infants, eight of whom were treated therapeutically with theophylline for apnea of prematurity (T) and eight of whom were controls (C). Mean +/- SD postnatal ages were 4.8 +/- 1.9 wk (T) and 2.4 +/- 0.9 wk (C) (p < 0.01). Corrected gestational ages were 35 +/- 1.6 wk (T) and 34 +/- 0.5 wk (C) (p = NS). Body weights were 1.69 +/- 0.13 kg (T) and 1.70 +/- 0.23 kg (C) (p = NS). All infants were clinically stable, breathing room air, fed enterally, and receiving no diuretics, steroids, or antibiotics. Lipolysis, hepatic glucose production, and gluconeogenesis from glycerol were measured using [2-13C]glycerol and [6,6-3H2] glucose tracers. Body water and energy expenditure were measured by the 2H2(18)O method. Body water volumes were 68.5 +/- 3.4% body weight (T) and 70.2 +/- 3.4% (C) (p = NS), suggesting fat was 10-13% of body weight in both groups. Mean daily energy expenditure was 65 +/- 22 kcal/kg body weight/d (T) versus 59 +/- 5 kcal/kg body weight/d (C) (p = NS). Between 4 and 6 h after a feeding, glucose production rates were 40.5 +/- 4.3 mumol/kg/min (T) and 37.6 +/- 4.8 mumol/kg/min (C) (p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

A circulating anticoagulant in lepromatous leprosy.

We observed a patient with lepromatous leprosy and a circulating anticoagulant. Intrinsic pathway inhibition was demonstrated by prolongation of the activated partial thromboplastin time. Extrinsic pathway inhibition was demonstrated by prolongation of the prothrombin time when performed with diluted thromboplastin. A plasma co-factor was required for inhibition. Immunoadsorption with specific antisera and Sephadex G-200 fractionation suggested that the anticoagulant was an IgM immunoglobulin. The similarities between this patient's anticoagulant and those associated with other disease states are discussed.