[A case of X-linked alpha-thalassemia/mental retardation (ATR-X) syndrome with repeated apnea attacks due to laryngomalacia].

We report a case of X-linked alpha-thalassemia/mental retardation syndrome (ATR-X) with repeated apnea attacks dating from the patient's 12th year. We initially diagnosed them as obstructive apnea due to upper pharyngeal stenosis and laryngomalacia by polysomnography and laryngo-fiberscopy. However, reevaluation after one and a half years revealed that the boy had central and mixed apnea, as well as obstructive apnea. To date, few reports have been published on the causes of apnea attacks in ATR-X patients. We clinicians should therefore consider laryngomalacia as one cause of apnea attacks in ATR-X patients, and choose the appropriate therapy for a pattern of apnea that can change during its clinical course.

Microchromosomal deletions involving SCN1A and adjacent genes in severe myoclonic epilepsy in infancy.

PURPOSE: Genetic abnormalities of the gene encoding alpha1 subunit of the sodium channel (SCN1A), which can be detected by direct sequencing, are present in more than 60% of patients with severe myoclonic epilepsy in infancy (SMEI) or its borderline phenotype (SMEB). Microchromosomal deletions have been recently reported as additional causes of SMEI. This study examines whether such microdeletions are associated with SMEI as well as with SMEB. METHODS: We recruited patients with SMEI (n = 35) and SMEB (n = 34), who were confirmed previously to have no mutations of SCN1A by direct sequencing. Microdeletions were sought by multiplex ligation-dependent probe amplification (MLPA), and then confirmed and characterized by fluorescence in situ hybridization (FISH) and array-based comparative genomic hybridization (aCGH), respectively. RESULTS: Heterozygous multiple exonic deletions were identified in 7/35 SMEI patients (20%) and 0/34 SMEB patients (0%), with a net frequency of 10.1% (7/69 patients). Deletions were confirmed by FISH and aCGH analysis. The concomitant deletions of adjacent genes were revealed by aCGH. None of the parents who agreed to undergo the analysis had such deletions suggesting that the deletions were de novo. The phenotypes of patients with the deletions were indistinguishable from those of SMEI resulting from point mutations. DISCUSSION: Our findings indicate that microchromosomal deletion, often involving not only SCN1A but also several adjacent genes, is associated with core SMEI. As microchromosomal deletion cannot be anticipated by the phenotypes or detected by conventional methods, genetic abnormalities in SMEI should be carefully sought by techniques that can detect microdeletions.

High molecular weight adiponectin as a predictor of long-term clinical outcome in patients with coronary artery disease.

Adiponectin is an adipocyte-specific secretory protein that is highly and specifically expressed in adipose tissue, and low plasma levels of adiponectin are associated with coronary artery disease (CAD). It has been suggested that high molecular weight (HMW) adiponectin is more important for vascular protection than total amount of adiponectin. To establish the clinical relevance of HMW adiponectin, we measured its serum levels in 149 patients with CAD. The levels were lower in vasospastic angina pectoris (3.4 +/- 2.4 microg/ml, p <0.01), stable angina pectoris (3.3 +/- 2.6 microg/ml, p <0.001), and healed myocardial infarction (3.8 +/- 2.9 microg/ml, p <0.01) than chest pain syndrome (controls) (6.6 +/- 5.4 microg/ml). The levels were also lower in multivessel CAD (3.4 +/- 2.4 microg/dl) compared with single vessel CAD (4.2 +/- 2.7 microg/ml, p <0.05) or no organic stenosis (5.1 +/- 3.5 microg/ml, p <0.01). In univariate analysis, diabetes mellitus (p = 0.03), insulin resistance (p = 0.06), high-sensitivity C-reactive protein levels (p = 0.0012), and low HMW adiponectin levels (p = 0.0001) predicted cardiovascular events during 7 years of follow-up. However, multivariate analysis showed that only HMW adiponectin levels were an independent predictor of cardiovascular events (relative risk 2.79, 95% confidence interval 1.49 to 5.24, p = 0.0014). In conclusion, serum HMW adiponectin levels may serve as a predictor of future cardiovascular events in patients with CAD as well as a marker for severity of CAD.

Comparison of serum high-molecular weight (HMW) adiponectin with total adiponectin concentrations in type 2 diabetic patients with coronary artery disease using a novel enzyme-linked immunosorbent assay to detect HMW adiponectin.

Adiponectin (Acrp30), an adipocyte-derived protein, exists in serum as a trimer, a hexamer, and a high-molecular weight (HMW) form, including 12-18 subunits. Because HMW adiponectin may be biologically active, we measured it in serum using a novel enzyme-linked immunosorbent assay (ELISA) confirmed by gel filtration chromatography that the ELISA detected mainly adiponectin with 12-18 subunits, and we compared HMW with total adiponectin concentration in patients with type 2 diabetes. We next investigated the relationship between serum HMW and coronary artery disease (CAD) in 280 consecutive type 2 diabetic patients, including 59 patients with angiographically confirmed CAD. Total adiponectin was measured in serum by a commercially available ELISA. Like serum total adiponectin, HMW adiponectin correlated positively with HDL cholesterol and negatively with triglyceride, insulin sensitivity, creatinine clearance, and circulating inflammatory markers. Total and HMW adiponectin were significantly higher in women than in men, as was the HMW-to-total adiponectin ratio. Serum HMW and the HMW-to-total adiponectin ratio were significantly lower in men with than without CAD (P < 0.05, respectively). In women, the ratio, but neither total nor HMW adiponectin, tended to be lower when CAD was present. In conclusion, determination of HMW adiponectin, especially relative to total serum adiponectin, is useful for evaluating CAD in type 2 diabetic patients.

Multi-institutional study on the correlation between chromosomal abnormalities and epilepsy.

While there is an abundance of literature describing the association of chromosome aberrations with epilepsy, only a few refer to the detailed features of epilepsy. It is important to investigate the associations between specific chromosome abnormalities and features of epilepsy to identify genes involved in epilepsy and treat them more effectively. We investigated the correlation between specific chromosome aberrations and epilepsy by sending questionnaires to the members of Kyoto Multi-institutional Study Group of Pediatric Neurology. Seventy-six patients were collected from 10 institutions. Chromosome abnormalities included: Down syndrome (n = 19); Angelman syndrome (n = 8); Prader-Willi syndrome (n = 4); 4p- syndrome (n = 3); 1q- syndrome (n = 2); 5p- syndrome (n = 2); Miller-Dieker syndrome (n = 2); 18q- syndrome; (n = 2); Klinefelter syndrome; (n = 2); and 32 other individual chromosomal aberrations. Overall, the severity of mental retardation correlated with the severity of epilepsy. We could abstract characteristic features of epilepsy in some syndromes. In Angelman and Prader-Willi syndromes, febrile seizures occurred frequently, the onset of epilepsy was in early childhood and seizure phenotype was multiple. Paroxysmal discharge of the occipital region and diffuse high voltage slow wave on electroencephalography were characteristic in Angelman syndrome. In Down syndrome, West syndrome and focal epilepsy were common and the prognosis of epilepsy in West syndrome with Down syndrome was good. In 4p- syndrome, febrile seizures were often seen, and unilateral or generalized clonic or tonic-clonic status epilepticus were characteristic. For the other chromosomal aberrations investigated here, the patient numbers were too small to abstract common features of epilepsy.

Cloxazolam treatment for patients with intractable epilepsy.

We examined the antiepileptic effect of cloxazolam on seizures in 23 patients with intractable epilepsy. Most of the patients had central nervous system complications, as well as frequent seizures, and were being treated with polypharmacy. Cloxazolam was administered 1 to 5 mg/day (0.05 to 0.14 mg/kg) at initiation, in two divided doses daily, and gradually increased (1 to 4 mg/day; 0.05 to 0.15 mg/kg) every month at the outpatient clinic. Plasma levels of the main active metabolite, chloro-N-desmethyldiazepam, were measured in 13 patients. Four of 23 patients (17%) became seizure-free, and nine patients (39%) manifested a good response. Both patients with generalized and partial epilepsy manifested a good response. The spectrum of cloxazolam as an antiepileptic was wide. Effective doses were 0.07 to 0.56 mg/kg, and plasma effective levels of chloro-N-desmethyldiazepam were 12.3-115.1 ng/mL. Cloxazolam may be an effective and safe antiepileptic for intractable epilepsy, and should be used as an adjunct to other antiepileptic drugs or administered after other agents.

[Intractable epilepsy (apneic seizure) in an infant with 18q deletion syndrome].

We report here an infant with 18q deletion syndrome, and intractable apneic seizures. He had intrauterine growth retardation and dysmorphic features. Chromosomal analysis demonstrated mosaicism of 18q interstitial deletion (q12.3-q22.3). From the age of 3 months, apneic attacks occurred from once a week to over 10 times a day despite many oral antiepileptic agents, and were diagnosed as complex partial seizures. Ictal electroencephalogram and 18F-fluorodeoxyglucose-positron emission tomography at the age of 10 months identified the epileptic focus in the right parieto-temporal region. He also had severe psychomotor retardation. Head MRI examination revealed diffuse cerebral atrophy and severe white matter dysmyelination, which was caused by the deletion of myelin basic protein gene at the locus of 18q22.3. This locus may be responsible for the clinical manifestations of 18q deletion syndrome. Detailed description of the onset, seizure types, and prognosis of epilepsy associated with 18q deletion syndrome is rare. It was suggested that the locus of 18q21.3-q22.3 was responsible for autonomic seizures in 18q deletion syndrome.

A novel missense mutation in the DKC1 gene in a Japanese family with X-linked dyskeratosis congenita.

The authors report 2 male patients with dyskeratosis congenita (DC) in a Japanese kindred. Sequencing of the complementary DNA of the dyskerin gene (DKC1) revealed a T-to-C transition at nucleotide 1285 in exon 12 that resulted in a novel missense mutation L398P. Despite harboring the same mutation in the DKC1 gene, one patient had significantly milder hematological symptoms than the other, indicating that there may be other factors that determine the severity of DC.

Dichloroacetate therapy in Leigh syndrome with a mitochondrial T8993C mutation.

A 6-year-old female with Leigh syndrome associated with a T-to-C mutation at nucleotide 8993 of mitochondrial deoxyribonucleic acid (T8993C) was treated with dichloroacetate, once during the first acute deterioration after a febrile illness and another time when she demonstrated subacute regression without precipitating events. Dichloroacetate reversed the clinical course on both occasions, and diffuse lesions in the midbrain revealed on magnetic resonance imaging during the second episode disappeared completely. However, dichloroacetate could not prevent the second acute deterioration associated with a febrile illness that occurred during the second treatment. Thus dichloroacetate treatment, although limited, was effective for T8993C-associated Leigh syndrome.

Adenosquamous cell carcinoma arising from the papilla major.

A 47-year-old man was admitted to hospital with complaint of general fatigue. Shortly before the admission a suspected obstructive jaundice was diagnosed at a local hospital. On admission, the physical examination was significant for jaundice; total bilirubin was 6.43 mg/dl. The tumor marker CA19-9 was 2056 U/ml. Endoscopic retrograde cholangiopancreatography (ERCP) was performed and showed dilatation of common bile duct and main pancreatic duct, accompanied with an endoscopic naso-biliary drainage (ENBD) in order to reduce the jaundice. The duodenoscopy showed enlarged and deformed papilla. Hypotonic duodenography showed a filling defect at the medial side of the second portion of the duodenum. Ultrasonography (US) showed a hyperechoic lesion, sized 15 mm in diameter, at the pancreas head with dilatation of biliary tract and main pancreatic duct. An abdominal enhanced CT scan showed a mass sized 15 mm at the lower edge of the common bile duct. A selective hepatic arteriography showed no special finding. We performed a pancreatoduodenectomy with dissection of the lymph nodes. The tumor, sized 22x15x20 mm, was white colored and solid on the papilla. Histopathological inspection of the specimen showed an adenosquamous cell carcinoma of the bile duct in the papilla. The tumor was found to infiltrate the neighboring pancreas and to contain metastasis in lymph nodes in the hepatoduodenal ligament, post pancreaticoduodenal and para-aortic lymph nodes. This is the first report on a case of adenosquamous carcinoma of the papilla major.