Diagnostic and management challenges in paediatric Cushing's syndrome.

OBJECTIVE: Cushing syndrome (CS) is the result of chronic exposure to glucocorticoid excess. CS in children is most often caused by the administration of exogenous steroids. Endogenous CS is rare in the paediatric population and is caused mainly by tumours of the pituitary and adrenal glands, with ectopic sources being extraordinarily rare before the age of 18 years. In addition, children and young adults with CS present with different epidemiology, management issues, prognosis and outcomes than older adult patients. This complex disorder needs early diagnosis and management to avoid the significant morbidity and even mortality that can result from chronic untreated CS. METHODS: In this review, we present the complex case of a 7-year-old boy with CS that highlights the diagnostic and management challenges of paediatric CS patients, including the considerations for genetic predisposition and life-long consequences of CS in children and young adults. RESULTS: The diagnostic protocols for the evaluation of CS have been devised for adults and tested predominantly on adults. In this review, we discuss necessary modifications so that the testing can be adjusted for use in children. Additionally, pituitary adenomas in children are generally smaller and thus more difficult to recognize on pituitary imaging. CONCLUSIONS: The management of the case and its complexities underline the need for children with CS to be managed in a centre with experienced paediatric endocrinologists and skilled neurosurgeons both for their initial diagnosis and treatment as well as for their long-term follow-up and management.

Continuous glucose monitoring has an increasing role in pre-symptomatic type 1 diabetes: advantages, limitations, and comparisons with laboratory-based testing.

Type 1 diabetes (T1D) is well-recognised as a continuum heralded by the development of islet autoantibodies, progression to islet autoimmunity causing beta cell destruction, culminating in insulin deficiency and clinical disease. Abnormalities of glucose homeostasis are known to exist well before the onset of typical symptoms. Laboratory-based tests such as the oral glucose tolerance test (OGTT) and glycated haemoglobin (HbA1c) have been used to stage T1D and assess the risk of progression to clinical T1D. Continuous glucose monitoring (CGM) can detect early glycaemic abnormalities and can therefore be used to monitor for metabolic deterioration in pre-symptomatic, islet autoantibody positive, at-risk individuals. Early identification of these children can not only reduce the risk of presentation with diabetic ketoacidosis (DKA), but also determine eligibility for prevention trials, which aim to prevent or delay progression to clinical T1D. Here, we describe the current state with regard to the use of the OGTT, HbA1c, fructosamine and glycated albumin in pre-symptomatic T1D. Using illustrative cases, we present our clinical experience with the use of CGM, and advocate for an increased role of this diabetes technology, for monitoring metabolic deterioration and disease progression in children with pre-symptomatic T1D.

Genetic Variants in SRD5A2 in a Spectrum of DSD Patients from Australian Clinics Highlight Importance of Genetic Testing alongside Typical First-Line Investigations.

INTRODUCTION: Steroid 5-alpha reductase deficiency (5α-R2D) is a rare condition caused by genetic variants that reduce the activity of the enzyme that converts testosterone into dihydrotestosterone. The clinical spectrum of 5α-R2D is known to overlap with other 46,XY differences of sex development (DSD) such as androgen insensitivity or gonadal dysgenesis. However, the clinical trajectories of the aetiologies can differ, with 5α-R2D presenting its own challenges. METHODS: In this study, we have collated clinical information for five individuals with variants in SRD5A2 identified using research genetic testing in an Australian paediatric setting. RESULTS: We describe how a genetic finding resolved or confirmed a diagnosis for these individuals and how it guided clinical management and family counselling. CONCLUSION: This work highlights the importance of early genetic testing in children born with 46,XY DSD where it complements traditional first-line testing.

Redefining response in wet AMD to anti VEGF therapy based on non-OCTA versus OCTA evaluation.

PURPOSE: Anti vascular endothelial growth factor (anti VEGF) has been the mainstay of treatment in wet age-related macular degeneration (AMD). Subsequent decision to continue anti VEGF therapy depends on the treatment response quantified by functional (visual acuity) and morphological (optical coherence tomography) parameters then categorized from good to poor. METHODS: This study evaluates the agreement between OCT angiography (OCTA) and non-OCTA (logMAR VA plus OCT) to decide anti-VEGF treatment's continuity. After an anti VEGF treatment, on a follow up visit, a patient underwent non-OCTA evaluation (decision A) then OCTA evaluation (decision B) to judge the necessity of future anti VEGF application. RESULTS: Out of 129 eyes, on 72 eyes (49%), there were agreements on both decision arms, but on 55 eyes (42%) there was disagreement. Particularly, disagreement on 47/55 eyes was important, where OCTA advised "continue anti VEGF" and non-OCTA advised "Stop anti VEGF" therapy. Cohen's Kappa for probability of agreement to continue anti VEGF was fair (0.33) and to stop anti VEGF therapy was none (0.1). CONCLUSIONS: Based on resulting disagreements between the two modalities on deciding the continuity of anti VEGF, we conclude that OCTA must be considered in the conventional decision making algorithm in patients with wet AMD under anti VEGF therapy.

Vitamin D Status of School-Age Children in North India.

Information on vitamin D deficiency in prepubertal children is scarce. The authors studied calcium intake, sunlight exposure, serum calcium, alkaline phosphatase, 25-hydroxyvitamin (25OHD), and intact parathormone (iPTH) in the children (N = 135) attending the pediatric endocrinology clinic (declared normal after evaluation) and their healthy siblings. Serum 25OHD < 12 ng/mL was frequent (55.6%) and median (IQR) 25OHD lower [10.1 (11.4) ng/mL] in pubertal (n = 36) versus prepubertal (n = 99) children [36.4% (p < 0.05), 15.5 (13.2) ng/mL (p < 0.001)]. Girls had lower 25OHD [12.33 (10.32)] vs. [15.83 (13.37) ng/mL, p < 0.05], calcium intake [517.20 (405.5) vs. 623.6 (430.5) mg, p < 0.05], and minutes of sunlight exposure [MSE, 38.55 (42.86) vs. 63.4 (66.8) min, p < 0.01] than boys. MSE and body surface area (BSA) exposed were significant associations of 25OHD in a multivariate model. Vitamin D deficiency in children, both pubertal and prepubertal, assumes public health importance in the authors' region. Girls are at higher risk. Duration of sunlight exposure and BSA are modifiable factors.

Modeling Type 1 Diabetes Using Pluripotent Stem Cell Technology.

Induced pluripotent stem cell (iPSC) technology is increasingly being used to create in vitro models of monogenic human disorders. This is possible because, by and large, the phenotypic consequences of such genetic variants are often confined to a specific and known cell type, and the genetic variants themselves can be clearly identified and controlled for using a standardized genetic background. In contrast, complex conditions such as autoimmune Type 1 diabetes (T1D) have a polygenic inheritance and are subject to diverse environmental influences. Moreover, the potential cell types thought to contribute to disease progression are many and varied. Furthermore, as HLA matching is critical for cell-cell interactions in disease pathogenesis, any model that seeks to test the involvement of particular cell types must take this restriction into account. As such, creation of an in vitro model of T1D will require a system that is cognizant of genetic background and enables the interaction of cells representing multiple lineages to be examined in the context of the relevant environmental disease triggers. In addition, as many of the lineages critical to the development of T1D cannot be easily generated from iPSCs, such models will likely require combinations of cell types derived from in vitro and in vivo sources. In this review we imagine what an ideal in vitro model of T1D might look like and discuss how the required elements could be feasibly assembled using existing technologies. We also examine recent advances towards this goal and discuss potential uses of this technology in contributing to our understanding of the mechanisms underlying this autoimmune condition.

A Rare Etiology of Hypocalcemic Seizures in Adulthood: Clues to Diagnosis from Facial Dysmorphism.

We report a 40-year-old male who presented with seizures due to hypocalcemia. Biochemical evaluation revealed the diagnosis of hypoparathyroidism. The symptom complex of dysmorphic facies and intellectual disability along with hypoparathyroidism led to a suspicion of 22q11.2 microdeletion syndrome (22q11.2DS), which was confirmed by multiplex ligation-dependent probe amplification (MLPA) analysis showing 22q11.2.21 microdeletion.

Neonatal Diabetes Mellitus: Novel Mutations.

OBJECTIVE: To describe the spectrum of neonatal diabetes mellitus (NDM), document new mutations, and review published Indian literature on the etiology of NDM. METHODS: Retrospective analysis of the clinical and genetic profile of 12 NDM patients. RESULTS: Eight patients presented with NDM before the age of 6 mo. Three other patients, including 2 siblings presented in later part of infancy. An additional patient was diagnosed at age 5 y with the same etiology as her infant sibling. Four patients had transient diabetes [TNDM:1 each with a mutation in KCNJ11 and INS gene, 2 with ABCC8 mutation], 7 had permanent diabetes [PNDM: 2 siblings with complete glucokinase deficiency, 2 siblings with thiamine responsive megaloblastic anemia (TRMA), 1 with Immune dysregulation, Polyendocrinopathy, Enteropathy, X-linked (IPEX) syndrome and 2 with Wolcott Rallison syndrome, (WRS)]. Four patients had 5 novel mutations. Genetic etiology could not be established in 1 patient with features of insulin resistance. Poorly controlled blood glucose in the TRMA patient led to hyperglycemia-induced hemichorea-hemiballismus, a rare manifestation in children. CONCLUSIONS: The authors describe 5 novel mutations, in the EIF2AK3, ABCC8, and GCK genes, a homozygous mutation at the ABCC8 locus presenting as TNDM, an obscure phenotype of the GCK gene mutation, and hyperglycemia-induced hemichorea-hemiballismus in a patient with TRMA. In India, PNDM is most commonly due to WRS similar to Middle Eastern countries with high consanguinity rates.

Efficacy and tolerability of fenfluramine in patients with Dravet syndrome: A systematic review and meta-analysis.

BACKGROUND: Dravet syndrome (DS) is an infantile-onset developmental and epileptic encephalopathy syndrome with limited treatment options. We aimed to evaluate the efficacy and tolerability of fenfluramine in patients with Dravet syndrome using meta-analytical techniques. METHODS: We searched for relevant randomized controlled trials and non-randomized studies involving children with Dravet syndrome on fenfluramine therapy in MEDLINE, CENTRAL, EMBASE, Google Scholar and Web of Science database (31 July 2020). The primary outcome for the efficacy of fenfluramine was reduction in monthly convulsive seizure frequency. We carried out a random effect meta-analysis focusing on efficacy and safety variables. Only Randomized Controlled Trials (RCT) were included in the meta-analysis. The risk of bias was assessed for each study, and GRADE was used to assess the quality of evidence for each outcome. RESULTS: Of 61 publications initially screened, 12 were reviewed as full-text. Seven articles including 2 RCTs, 4 uncontrolled studies (3 prospective and one retrospective study), and one case report described responses to fenfluramine in 144 DS patients (54 % male, mean age of 8.8 years, median dose of 0.4 mg/kg/day). Fenfluramine was found to be more efficacious than placebo, in terms of mean convulsive and total seizure frequency reduction (mean difference: -45.3 % (95 % CI: -48.1 %, -42.4 %, p < 0.00001) and -39.7 % (-46.7 %, -32.7 %, p < 0.00001)). A greater proportion of patients in the fenfluramine arm achieved >25 %, >50 %, >75 % and 100 % seizure reductions (odds ratios: 6.5 (3.7, 11.5, p < 0.00001), 10.6 (5.3, 21.3, p < 0.00001), 22.7(6.9, 75.3, p < 0.00001) and 9.3(1.7, 51.4, p = 0.01) respectively). The incidence of serious adverse events was not greater in the fenfluramine groups (OR: 1.02 (0.5, 2.19, p = 0.96)). CONCLUSION: Fenfluramine appears to be a safe and efficacious antiseizure medication in patients with Dravet syndrome.

Clinical spectrum of KIAA2022/NEXMIF pathogenic variants in males and females: Report of three patients from Indian kindred with a review of published patients.

BACKGROUND: In the last two decades, with the advent of whole-exome and whole-genome sequencing, supplemented with linkage analysis, more than 150 genes responsible for X-linked intellectual disability have been identified. Some genes like NEXMIF remain an enigmatic entity, as often the carrier females show wide phenotypic diversity ranging from completely asymptomatic to severe intellectual disability and drug-resistant epilepsy. METHODS: We report three patients with pathogenic NEXMIF variants from an Indian family. All of them had language predominant developmental delay and later progressed to moderate intellectual disability with autistic features. We also reviewed the previously published reports of patients with pathogenic NEXMIF variants. RESULTS: Together with the presented cases, 45 cases (24 symptomatic females) were identified from 15 relevant research items for analysis. Males have demonstrated a more severe intellectual disability and increasingly delayed walking age, autistic features, central hypotonia, and gastroesophageal reflux. In contrast, females have shown a predominant presentation with drug-resistant epilepsy and mild to moderate intellectual impairment. Notably, the affected females demonstrate a higher incidence of myoclonic, absence, and atonic seizures. The majority of the variants reported are nonsense or frameshift mutations, causing loss of function of the NEXMIF gene, while a considerable proportion possesses chromosomal translocations, microdeletions, and duplications. CONCLUSIONS: NEXMIF gene mutations should be suspected in all cases of X-linked ID and autism cases in males or even in refractory epilepsy cases in females.

Consumptive Hypothyroidism Due to Diffuse Hepatic Hemangiomas Treated With Propranolol Therapy.

Infantile hepatic hemangioma (IHH)-related consumptive hypothyroidism is rare and occurs as a result of excess thyroid hormone inactivating enzyme, type-3 iodothyronine deiodinase. We present an infant with IHH-related hypothyroidism, in whom treatment with propranolol led to regression of tumor and subsequent euthyroid status.

Quadrantic vortex vein decompression with subretinal fluid drainage for manangement of Nanophthalmic choroidal effusions- a review of literature and case series.

BACKGROUND: Uveal effusion syndrome is a rare entity of idiopathic exudative detachments of uveal tissues and retina. Medical treatments with systemic steroids and antimetabolites have been tried but with variable results. Scleral windows or vortex decompressions are usually performed and surgeons usually perform partial sclerectomy in all the quadrants. CASE PRESENTATION: For the first time, we report 2 cases of nanophthalmic uveal effusion syndrome managed with our technique. CONCLUSION: Quadrantic vortex vein decompression with external drainage for nanophthalmic uveal effusion can provide immediate and stable gain in vision.

Induced pluripotent stem cell macrophages present antigen to proinsulin-specific T cell receptors from donor-matched islet-infiltrating T cells in type 1 diabetes.

AIMS/HYPOTHESIS: Type 1 diabetes is an autoimmune disorder characterised by loss of insulin-producing beta cells of the pancreas. Progress in understanding the cellular and molecular mechanisms underlying the human disease has been hampered by a dearth of appropriate human experimental models. We previously reported the characterisation of islet-infiltrating CD4+ T cells from a deceased organ donor who had type 1 diabetes. METHODS: Induced pluripotent stem cell (iPSC) lines derived from the above donor were differentiated into CD14+ macrophages and tested for their capacity to present antigen to T cell receptors (TCRs) derived from islet-infiltrating CD4+ T cells from the same donor. RESULTS: The iPSC macrophages displayed typical macrophage morphology, surface markers (CD14, CD86, CD16 and CD11b) and were phagocytic. In response to IFNγ treatment, iPSC macrophages upregulated expression of HLA class II, a characteristic that correlated with their capacity to present epitopes derived from proinsulin C-peptide to a T cell line expressing TCRs derived from islet-infiltrating CD4+ T cells of the original donor. T cell activation was specifically blocked by anti-HLA-DQ antibodies but not by antibodies directed against HLA-DR. CONCLUSIONS/INTERPRETATION: This study provides a proof of principle for the use of iPSC-derived immune cells for modelling key cellular interactions in human type 1 diabetes.

Novel mutations and spectrum of the disease of NR0B1 (DAX1)-related adrenal insufficiency in Indian children.

Background X-linked adrenal hypoplasia congenita (AHC), due to mutations in the nuclear receptor superfamily 0, group B, member 1 (NR0B1)/dosage-sensitive sex reversal, AHC, critical region on the X chromosome, gene 1 (DAX1) gene, usually presents with a salt-wasting adrenal crisis in infancy and hypogonadotropic hypogonadism (HH) in adolescents. Genetic reports in the literature from patients of diverse ethnicity are limited. We describe the atypical clinical characteristics and molecular genetic results in six Indian patients. Methods Both exons and flanking intronic sequences of the NR0B1 gene were amplified and sequenced in five patients. In the sixth patient, suspected to have a large deletion, multiplex ligation-dependent probe amplification (MLPA) and chromosomal microarray analysis were performed. Results Sequencing revealed three novel mutations: a nonsense mutation (c.776C > A), a deletion (c.298del), both causing loss of domains which are highly conserved among nuclear receptor families, and a missense mutation (c.1112T > C). In-silico analysis by structure-based protein modeling predicted a de-stabilizing effect of the novel missense mutation. Two previously reported mutations were seen in patients with atypical manifestations such as late-onset adrenal insufficiency and precocious puberty. One patient had a 7.15-Mb contiguous deletion involving the NR0B1, Duchenne muscular dystrophy (DMD), glycerol kinase (GK) and melanoma antigen, family B, 16 (MAGEB16) genes. Conclusions Our report emphasizes the wide clinical spectrum of AHC, including rare manifestations, and enumerates unique mutations in the NR0B1 gene.

Reviving the lost art of scleral buckling surgery for rhegmatogenous retinal detachment: evaluation of risk factors of detachments, poor physiological outcomes, and perspective from a developing country.

PURPOSE: To evaluate the primary anatomic and physiological success of scleral buckling surgery for rhegmatogenous retinal detachment and factors influencing its outcomes. METHODS: This is a prospective analytical study of 92 eyes that underwent scleral buckling at the Lumbini Eye Institute and Research Center, in Lumbini, Nepal. Parameters evaluated which could influence the outcome of the surgery included the lens status, duration of symptoms, locations of breaks, the extent of retinal detachment, and preoperative proliferative vitreoretinopathy. RESULTS: A total of 92 eyes from 88 patients with rhegmatogenous retinal detachment were evaluated; 68 (74%) eyes were of male and 24 (26%) were of female. The mean time of presentation was 4.71 ± 8.45 months. The overall primary anatomical and physiological success was achieved in 79 (84.9%) and 68 (73.9%) of the cases at 6 months. Sixteen cases developed re-detachment (mean duration of 2.8 ± 1.8 months). Eleven of the cases had a successful anatomical outcome and five of the patients had persistent detachment despite second surgery. In phakic patients, the primary success rate was 92.7% whereas in pseudophakic it was 71.4%. Proliferative vitreoretinopathy 10 (63%) was the most common cause of surgical failure. Bilateral buckling at the same setting was done to two patients-both achieving primary success. CONCLUSION: Scleral buckling is a very good surgical option for rhegmatogenous retinal detachment and represents a surgical technique worth being trained, performed, practiced, and continued despite advancements in modern vitreoretinal surgical devices and preference for vitrectomy and tamponade agents. It may also be successfully tried in cases of bilateral rhegmatogenous retinal detachment if a doubt regarding compliance for follow-up and surgery for the fellow eye exists.