Three Cases of Joubert Syndrome in a Consanguineous Syrian Family and a Interesting Case of Multinational Collaboration.

Joubert syndrome (JS) is a rare congenital, autosomal recessive disorder characterized by a distinctive brain malformation, developmental delay, ocular motor apraxia, breathing abnormalities, and high clinical and genetic heterogeneity. We are reporting three siblings with JS from consanguineous parents in Syria. Two of them had the same homozygous c.2172delA (p.Trp725Glyfs*) AHI1 mutation and the third was diagnosed prenatally with magnetic resonance imaging. This pathogenic variant is very rare and described in only a few cases in the literature. Multinational collaboration could be of benefit for the patients from undeveloped, low-income countries that have a low-quality health care system, especially for the diagnosis of rare diseases.

Differential DNA Methylation of the IMMP2L Gene in Families with Maternally Inherited 7q31.1 Microdeletions is Associated with Intellectual Disability and Developmental Delay.

Most copy number variations (CNVs) in the human genome display incomplete penetrance with unknown underlying mechanisms. One such mechanism may be epigenetic modification, particularly DNA methylation. The IMMP2L gene is located in a critical region for autism susceptibility on chromosome 7q (AUTS1). The level of DNA methylation was assessed by bisulfite sequencing of 87 CpG sites in the IMMP2L gene in 3 families with maternally inherited 7q31.1 microdeletions affecting the IMMP2L gene alone. Bisulfite sequencing revealed comparable levels of DNA methylation in the probands, healthy siblings without microdeletions, and their fathers. In contrast, a reduced DNA methylation index and increased IMMP2L expression were observed in lymphocytes from the healthy mothers compared with the probands. A number of genes were upregulated in the healthy mothers compared to controls and downregulated in probands compared to mothers. These genes were enriched in components of the ribosome and electron transport chain, as well as oxidative phosphorylation and various degenerative conditions. Differential expression in probands and mothers with IMMP2L deletions relative to controls may be due to compensatory processes in healthy mothers with IMMP2L deletions and disturbances of these processes in probands with intellectual disability. The results suggest a possible partial compensation for IMMP2L gene haploinsufficiency in healthy mothers with the 7q31.1 microdeletion by reducing the DNA methylation level. Differential DNA methylation of intragenic CpG sites may affect the phenotypic manifestation of CNVs and explain the incomplete penetrance of chromosomal microdeletions.

A Familial Small Supernumerary Marker Chromosome 15 Associated with Cryptic Mosaicism with Two Different Additional Marker Chromosomes Derived de novo from Chromosome 9: Detailed Case Study and Implications for Recurrent Pregnancy Loss.

We report a case of familial small supernumerary marker chromosome 15 in a phenotypically normal female with 4 recurrent spontaneous abortions and a healthy child. The initial karyotype showed a small, bisatellited, apparently metacentric marker chromosome, 47,XX,+idic(15)(q11.1), maternally inherited. The proband's mother was mosaic for the idic(15)(q11.1) without pregnancy loss. Reexamination of the proband's karyotype revealed cryptic mosaicism for 1 ring and 1 minute chromosome derived de novo from chromosome 9 in 2% of the metaphases. In FISH analysis, the patient's karyotype was mos 47,XX,+idic(15)(q11.1)mat[100]/49,XX,+idic(15)(q11.1)mat,+r(9;9;9;9),+der(9)dn[2]. The second spontaneous abortion had trisomy 9 (47,XX,+9); the third had mosaic trisomy 9 in 21% of the nuclei and isodicentric chromosome 15 in 36% of the nuclei (mos 48,XN,+9,+idic(15)(q11.1)/47,XN,+9/47,XN,+idic(15)(q11.1)/46,XN). The first and fourth abortions were not cytogenetically studied. The cause of the spontaneous abortions in this patient is likely the cryptic mosaicism for ring and minute chromosomes 9, and gonadal mosaicism is most probable, due to the 2 abortions.

Distal arthrogryposis with variable clinical expression caused by TNNI2 mutation.

Distal arthrogryposis (DA) is a clinically and genetically heterogeneous disorder with multiple joint contractures. We describe a female DA patient with hand and foot deformities, and right-sided torticollis. Using exome sequencing, we identified a novel TNNI2 mutation (c.485>A, p.Arg162Lys) in the patient and her father. The father has no typical DA but hip dysplasia. This may explain the clinical features of DA2B in this family, but with variable clinical expression.

Positive reproductive family history for spontaneous abortion: predictor for recurrent miscarriage in young couples.

OBJECTIVE: The etiology of recurrent spontaneous abortions (RSA) in chromosomally normal parents is still unexplained. It is unclear whether or not some factors, such as spontaneous abortions (SA), which occur among extended family members can create a predisposition to RSA. Therefore, this study comprises two parts: (a) an epidemiological part, to evaluate the relationship between RSA in 567 couples and the frequency of SA among their first (I), second (II) and third (III) generation relatives, and (b) a genetic part, investigating whether parental and fetal chromosomal status may predispose to the occurrence of RSA. STUDY DESIGN: Couples (567) having one or more SA were analyzed in this retrospective case-control study. The family reproductive history data was collected from their medical charts. RESULTS: The total number of SA found in 567 couples was 1174, and the largest number occurred at 8-10 weeks of gestation. The majority of spouses had normal karyotypes (88.5% and 91%). Of the remainder, 65% of females and 76% of males expressed constitutional chromosomal variation, mostly pericentric inversion of chromosome 9. Cytogenetic analysis of aborted material showed some type of change in 40% of cases. The family reproductive history data indicated that SA among the couples' I, II and III generation relatives happened with a frequency two to three times higher than that of the general population (55.5, 47.6 and 32.6% for female relatives, and 45.8, 44.1 and 15.1% for male relatives). CONCLUSION: Positive reproductive family history for SA might be the causal factor for RSA and can also predetermine women that are of greater susceptibility to preterm pregnancy.

Down syndrome: parental origin, recombination, and maternal age.

The aims of the present study were to assess (1) the parental origin of trisomy 21 and the stage in which nondisjunction occurs and (2) the relationship between altered genetic recombination and maternal age as risk factors for trisomy 21. The study included 102 cases with Down syndrome from the Croatian population. Genotyping analyses were performed by polymerase chain reaction using 11 short tandem repeat markers along chromosome 21q. The vast majority of trisomy 21 was of maternal origin (93%), followed by paternal (5%) and mitotic origin (2%). The frequencies of maternal meiotic I (MI) and meiotic II errors were 86% and 14%, respectively. The highest proportion of cases with zero recombination was observed among those with maternal MI derived trisomy 21. A higher proportion of telomeric exchanges were presented in cases with maternal MI errors and cases with young mothers, although these findings were not statistically significant. The present study is the first report examining parental origin and altered genetic recombination as a risk factor for trisomy 21 in a Croatian population. The results support that trisomy 21 has a universal genetic etiology across different human populations.

Full trisomy 5 in a sample of spontaneous abortion and Arias Stella reaction.

BACKGROUND: Historically, 50% of spontaneously expelled abortuses have been thought to be chromosomally abnormal; about 60% are trisomies. In general, trisomy 16 is the most frequent chromosomal abnormality, followed by trisomy 21 and trisomy 22. So far only 1 case of a female fetus with multiple congenital malformations associated with full trisomy 5 has been described. REPORT: We present a case of de novo full trisomy 5 in a spontaneous abortion sample. A young couple with normal constitutional karyotype experienced the second spontaneous abortion at 9 weeks of gestation, with the cytogenetic formula 47,XX,+5 in all analyzed cells. CONCLUSIONS: The routine cytogenetic analysis of miscarriages is still an uncommon practice, but it can have a great impact on the management of couples with repeated pregnancy wastage. Besides of the obvious cost benefit for health care, such analysis would help the physician to decide about future patient management, as well as planning the genetic counseling.

[Vitamin B12 deficiency in children--underestimated danger in the light of new knowledge]. / Manjak vitamina B12 u djece --podcijenjena opasnost u svjetlu novih spoznaja.

Vitamin B12 (cobalamin) has two active forms, adenosylcobalamin and methylcobalamin which have a key role in two important metabolic pathways in humans and their deficiency is responsible for clinical problems. Cobalamin is essential during whole life, but its sufficient amount is extra important in fetal and neonatal period, when it is essential for normal child growth and development as well as for normal development of the central nervous system. Because of very complex transport and metabolism, its deficiency can be manifested in numerous congenital and acquired disorders. Vitamin B12 deficiency mostly has non-specific clinical features, it carries a great risk of permanent consequences, but most frequently it is easily curable if diagnosed on time. In Croatia cobalamin deficiency in children has been diagnosed too rarely. Accordingly, the aim of this paper is to point to the recently gained knowledge on cobalamin metabolism, present typical case reports and to provide guidelines for rapid and proper diagnostic and therapeutic approach.

Angiomyomatous hamartoma of the popliteal lymph nodes in a patient with Klippel-Trenaunay syndrome: case report.

We present a case of angiomyomatous hamartoma (AMH) in the popliteal region of a patient with Klippel-Trenaunay syndrome. A 14-year-old boy with a right popliteal mass and recurrent edema of the right leg was admitted to a local hospital where a diagnosis of Klippel-Trenaunay syndrome was made. Three lymph nodes in the right popliteal fossa were removed. Histopathologic examination showed angiomyomatous hamartomas. Postoperatively, the patient was followed for 6 years. He had occasional mild edema of the right leg, but no signs of inflammation or recurrence of the angiomyomas. Our case is the first reported case of angiomyomatous hamartoma in a patient with Klippel-Trenaunay (KT) syndrome.

Tyrosinemia type II (Richner-Hanhart syndrome): a new mutation in the TAT gene.

In the present study we report the clinical features and the molecular genetic investigation of the tyrosine aminotransferase (TAT) gene in a young girl from Croatia with Richner-Hanhart syndrome, mainly suffering from photophobia, hyperkeratosis of the palmes and soles and slight neurological abnormalities. Sequencing analysis of the TAT gene revealed a novel homozygous missense mutation c.1250G>A (p.R417Q) in exon 12, and herewith confirmed the clinical diagnosis. Showing the first symptoms in babyhood, at the age of 8 years it was for the first time clinically diagnosed that the patient suffers from tyrosinemia type II and a therapy with tyrosine and phenylalanine reduced diet has been started successfully. All symptoms disappeared within 2-4 weeks. Since that time, we have been following the girl until today for more than ten years. She is in a good condition, and attends the normal high school program.

The ophthalmic anomalies in children with Down syndrome in Split-Dalmatian County.

UNLABELLED: Our aim was to present the ophthalmic anomalies in patients with Down syndrome in Split-Dalmatia County born from 1992 until 2009 year. It was a cross-sectional study. 153 children with Down syndrome aged 0-18 years from the Split-Dalmatia County were examined. One hundred twelve participants were borne in Split, 13 in Vrgorac,16 in Makarska, 12 in Sinj. All enrolled children underwent a complete ophthalmological examination (anterior segment, ocular motility, refractive status, fundus, measuring intraocular pressure (IOP). Of 89.5% percent of responders with refractive errors, 48.1% had myopia, 35.0% had hypermetropia, astygamtism in 16.7%, 28.7% strabismus, nystagmus (8.4%), cataracts (1.3%), glaucoma (1.9%), supernumerary optic disc vessels (24.1%) and keratoconus (1.3%). CONCLUSION: In patients with Down syndrome the prevalence of refractive errors (myopia prevalence), as well as other ophthalmological diseases was determined.

Common acute lymphoblastic leukemia Ph+ following Langerhans cell histiocytosis in a multi-malformed child with INV (9) (p12;q13) (mat): case report.

The occurrence of Langerhans cell histiocytosis (LCH) and another malignancy in the same patient is infrequent but has been recognized. The genetic changes that could be responsible for LCH and/or concomitant leukemia development are obscure. To the best of our knowledge, this is the first description of constitutional maternally derived inv (9) (p12;q13) in an LCH patient, and also of the development of common ALL Ph after LCH diagnosis and therapy. The potential significance of these findings [inv (9)+LCH+ALL Ph+] and their mutual relationship are unknown. Therefore, cooperative studies of large numbers of patients are needed to identify the common risk factors, if any.

Genitourinary diseases prior spontaneous abortion as a risk factor for recurrent pregnancy loss.

The etiology of recurrent spontaneous abortion (RSA) is still unexplained. Many couples do not find the cause of their RSA at all. The purpose of this research was to evaluate the association between recurrent pregnancy loss and previous (cured prior to pregnancy) acute/chronic genitourinary infections in both parents. Couples (226) having two or more (up to six) spontaneous abortions were analyzed in this retrospective case-control study. The control group consisted of 124 couples with neither miscarriages nor complicated pregnancies in their past. The data (serum immunological markers, karyotype, flow cytometry data, PHD) were collected from their medical charts. It was found that there was no statistically significant difference in average weeks of pregnancy in which the second, third and fourth abortion occurred. There was a statistically significant difference in previously experienced genitourinary infections between women from the RSA group and the control group, as well as for men from the RSA group and the control group. It can be concluded that past infections of the maternal and/or paternal genitourinary system may be the causal factor for recurrent pregnancy loss and can also pre-determine women that are of greater susceptibility to preterm pregnancy. Therefore the genetic counseling of couples should include thorough medical and family history of both partners and their first- and second-degree relatives in conjunction with typical medical examination.

De novo NEMO gene deletion (delta4-10)--a cause of incontinentia pigmenti in a female infant: a case report.

Incontinentia pigmenti (IP) is a rare, inherited, multisystem genodermatosis. It is transmitted as an X-linked dominant trait. The disorder is a consequence of mutations in the NEMO gene (Xq28) that completely abolish expression of the NF-kappaB essential modulator. Here we present a female infant of healthy nonconsanguinous, young parents with a clinically evident first phase of IP. PCR analysis of patient's peripheral blood lymphocytes DNA was done for detection of NEMO delta4-10 deletion. Skin changes present at birth appertain to first inflammatory stage. However, a pathohistological feature of the skin biopsy showed second phase of disease. Genetic testing of diseased child revealed delta4-10 in NEMO gene. However, the assumption that the female child has familial IP was rejected as PCR performed on the mother's leukocytes did not record the presence of the same mutation. Moreover, the existence of a healthy male infant of the same mother as well as the lack of any phenotypic signs of the disease in other family members additionally support that IP was not inherited, but it was a consequence of de novo NEMO gene mutation. In conclusion, here we describe a Croatian female with clinical IP phenotype having de novo genomic rearrangements in the NEMO gene.

The MECP2 gene mutation screening in Rett syndrome patients from Croatia.

Rett syndrome (RTT) is an X-linked dominant neurodevelopmental disorder almost exclusively affecting females and is usually sporadic. Mutations in MECP2 gene have been found in more than 80% of females with typical features of RTT. In this study, we analyzed 15 sporadic cases of RTT. In 7 of 15 patients (47%), we detected pathogenic mutations in the coding parts of MECP2 fourth exon. We found two missense (T158M, R133C), two nonsense (R168X, R270X), two frameshift mutations (P217fs and a double deletion of 28-bp at 1132-1159 and 10-bp at 1167-1176), and one in-frame deletion (L383_E392del10). To our knowledge, the last two mutations have not been reported yet. We also detected one previously described polymorphism (S194S). In conclusion, these results show that the fourth exon should be the first one analyzed because it harbors most of the known mutations. Moreover, mutation-negative cases should be further analyzed for gross rearrangements. This is the first study of its kind in Croatia and it enabled us to give the patients an early confirmation of RTT diagnosis.

Treatment of post-traumatic trabecular mashwork thrombosis and secondary glaucoma with intracameral tissue plasminogen activator in previously unrecognized sickle cell anemia.

Intracameral tissue plasminogen activator (t-PA) application in a child with previously unrecognized sickle cell anemia, post-traumatic hyphema, thrombosis in trabecular mashwork and consecutive acute glaucoma showed positive results. Thirteen year-old boy, son of African father and Caucasian mother, was admitted to hospital, with symptoms of acute glaucoma and partial hyphema after right eye trauma. Visual acuity of affected eye was 0.5 and intraocular pressure (IOP) 46 mm Hg. Despite a common therapy three days later clinical condition of patient's right eye was getting worst. Visual acuity was only hand motion (HM) and IOP 53 mmHg. At this point rose suspicion of sickle cell disease (SCD) and decision about injecting t-PA (20 microg) into anterior chamber was made. Cytological examination of aqueous humor revealed 10% sickled erythrocytes. Hemoglobin electrophoresis discovered hemoglobin S so that diagnosis of SCD was confirmed. Intraocular application of t-PA showed excellent results in post-traumatic hyphema with trabecular mashwork thrombosis in the patient with sickle cell anemia. Two-years follow up confirmed permanent normalisation of IOP and visual acuity. Successful outcome with anterior chamber paracentesis and intracameral injection of t-PA is promising novel approach, which we recommend in treatment of post-traumatic hyphema in SCD.

Disseminated BCG infection resembling langerhans cell histiocytosis in an infant with severe combined immunodeficiency: a case report.

We present a very rare congenital immunologic disease, severe combined immunodeficiency syndrome (SCID) in 6-months-old-boy with prolonged mucocutaneous candidiasis, severe anaemia, skin rash similar to the infiltrative eczema of Langerhans cell histiocytosis (LCH) and subcutaneous nodules with histiocytic infiltration. Laboratory findings show profound absence of humoral and cell-mediated immunity. Pathology specimens analysis of subcutaneous nodule revealed numerous S-100 protein and Cd1a negative histiocytes, occupied by BCG intracellular growth. Histopathology and immunohistochemistry confirmed the diagnosis of BCG dissemination. BCG vaccination in infants with SCID can lead to life threatening dissemination, resembling to the infiltrative eczema of LCH and may mislead the clinician.

Anti-CD20 monoclonal antibody (Rituximab) for therapy of mediastinal CD20-positive large B-cell non-Hodgkin lymphoma with a local tumor extension into the lung of a 10-year-old girl.

Intravenous therapy with the anti-CD20 antibody Rituximab has been recently approved for the treatment of CD20 positive non-Hodgkin's lymphoma (NHL) in adults but not in children. The authors present the benefits of its application for mediastinal NHL CD 20+ with a local extension into the lung of a 10-year-old-girl. Receiving the chemotherapy according to study NHL-BFM-95 for high-risk lymphoma the girl did not reach complete remission. Before the last chemotherapy block was started, a computed tomography scan of the thorax showed residue in the right lung. Twenty-five days after the last chemotherapy she received Rituximab at a dose of 375 mg/m(2) by intravenous infusion once a week for a total of four doses without the adverse reactions. Complete remission was achieved. The patient was high risk with lung involvement of lymphoma suggesting a pure prognosis. The results suggest that Rituximab may improve the outcome in high-risk patients and appeared to be safe and effective in children also.