FBXL4 defects are common in patients with congenital lactic acidemia and encephalomyopathic mitochondrial DNA depletion syndrome.

Mutations in FBXL4 have recently been recognized to cause a mitochondrial disorder, with clinical features including early onset lactic acidosis, hypotonia, and developmental delay. FBXL4 sequence analysis was performed in 808 subjects suspected to have a mitochondrial disorder. In addition, 28 samples from patients with early onset of lactic acidosis, but without identifiable mutations in 192 genes known to cause mitochondrial diseases, were examined for FBXL4 mutations. Definitive diagnosis was made in 10 new subjects with a total of 7 novel deleterious variants; 5 null and 2 missense substitutions. All patients exhibited congenital lactic acidemia, most of them with severe encephalopathic presentation, and global developmental delay. Overall, FBXL4 defects account for at least 0.7% (6 out of 808) of subjects suspected to have a mitochondrial disorder, and as high as 14.3% (4 out of 28) in young children with congenital lactic acidosis and clinical features of mitochondrial disease. Including FBLX4 in the mitochondrial diseases panel should be particularly important for patients with congenital lactic acidosis.

Pathologic Variants of the Mitochondrial Phosphate Carrier SLC25A3: Two New Patients and Expansion of the Cardiomyopathy/Skeletal Myopathy Phenotype With and Without Lactic Acidosis.

Variants in the SLC25A3 gene, which codes for the mitochondrial phosphate transporter (PiC), lead to a failure of inorganic phosphate (Pi) transport across the mitochondrial membrane, which is required in the final step of oxidative phosphorylation. The literature described two affected sibships with variants in SLC25A3; all cases had skeletal myopathy and cardiomyopathy (OMIM 610773). We report here two new patients who had neonatal cardiomyopathy; one of whom did not have skeletal myopathy nor elevated lactate. Patient 1 had a homozygous splice site variant, c.158-9A>G, which has been previously reported in a Turkish family. Patient 2 was found to be a compound heterozygote for two novel variants, c.599T>G (p.Leu200Trp) and c. 886_898delGGTAGCAGTGCTTinsCAGATAC (p.Gly296_Ser300delinsGlnIlePro). Protein structure analysis indicated that both variants are likely to be pathogenic. Sequencing of SLC25A3 should be considered in patients with isolated cardiomyopathy, even those without generalized skeletal myopathy or lactic acidosis.

Thirteen Patients with MAT1A Mutations Detected Through Newborn Screening: 13 Years' Experience.

BACKGROUND: Methionine adenosyltransferase I/III (MATI/III) deficiency is the most common genetic cause of persistent isolated hypermethioninemia. Patients and Methods : This is a retrospective data analysis of 62 newborns with elevated methionine detected by newborn screening between January 2000 and June 2013. The clinical, biochemical, and molecular findings of a subset of these children with MAT1A mutations associated with MATI/III deficiency are presented. RESULTS: Of the 62 newborns with elevated methionine, 12 were identified as having classical homocystinuria; 37 were false-positives; and 13 were found to have isolated persistent hypermethioninemia in the absence of biochemical markers of homocystinuria, abnormal liver function studies, or other causes of elevated methionine. These 13 individuals underwent genetic testing for changes in the MAT1A gene, associated with MATI/III deficiency. Three of 13 were found to have the common autosomal dominant R264H mutation, one was found to be a compound heterozygote for two novel pathogenic mutations, and three were found to be heterozygotes for previously reported mutations shown to cause autosomal recessive MATI/III deficiency when present in homozygous or a compound heterozygous configuration. The remaining six patients had variants of unknown clinical significance or novel mutations. For the majority of individuals, methionine persisted above the normal range but trended downward over time. None of these 13 individuals was started on a low-methionine diet, and all have age-appropriate growth and development. CONCLUSION: These cases show that individuals with even single changes in the MAT1A gene may have elevations in methionine identified by newborn screening, which may persist for months after birth without any clinical consequences.

Effect of three different doses of ketamine prior to general anaesthesia on postoperative pain following Caesarean delivery: a prospective randomized study.

BACKGROUND: Ketamine is an analgesic suitable for the induction of anesthesia during Caesarean delivery. This double blind, randomized trial examined the effect of intravenous ketamine used before the induction of general anesthesia on morphine consumption, immediate and long term postoperative pain after Cesarean delivery. METHODS: One hundred and forty term pregnant women undergoing elective Cesarean delivery were randomized into four groups (N.=35 each), placebo (0.9% normal saline), ketamine 0.25, 0.5, or 1 mg kg(-1) intravenously. In all patients 2-2.5 mg kg(-1) propofol was used for the induction of anesthesia, 0.6 mg kg(-1) rocuronium to facilitate the tracheal intubation and 50% oxygen in N2O and sevoflurane (end-tidal concentration of 1.2-1.3 %) for the maintenance of anesthesia. Postoperative analgesia was provided with intravenous morphine chloride patient-controlled analgesia (PCA) and rescue analgesia with intramuscular diclofenac sodium in the postoperative period. Apgar scores of the neonates and hemodynamic variables of the mothers were recorded during anaesthesia. Groups were compared regarding the cumulative morphine consumption and pain scores assessed with a numerical rating (0-10) scale at 2, 6, 12, 18, 24, and 48 h postoperatively. Postoperative side effects were recorded. Patients were evaluated for persistent postoperative pain at 2 weeks, 1 and 6 months, and 1 year. RESULTS: The cumulative morphine consumption at 48 hours after the surgery was the primary outcome of the study. There was no significant difference in terms of acute pain at 2 (P=0.3), 6 (P=0.7), 12 (P=0.4), 18 (P=0.4), 24 (P=0.8), and 48 (P=0.5) hours postoperatively. Cumulative morphine consumption obtained at 2 (P=0.9), 6 (P=0.5), 12 (P=0.4), 18 (P=0.4), 24 (P=0.1), and 48 (P=0.2) hours was also similar among the groups. Prolonged postoperative pain evaluated 2 weeks (P=0.3), 1 month (P=0.7), 6 months (P=0.1) and 1 year (P=0.3) after the operation was also similar among the groups. There was no significant difference in side effects among the groups during the postoperative 48 hours. Apgar scores at 1 min (P=0.5) and 5 mins (P=0.5) were similar among the groups. Maternal intraoperative hemodynamic parameters were similar among the groups. CONCLUSION: There was no difference regarding early and late postoperative pain and morphine consumption with ketamine at doses of 0.25, 0.5, and 1 mg kg(-1) in women undergoing Caesarean delivery under general anaesthesia, compared with the control group.

Comparision of reproductive outcome of the women with hypogonadotropic hypogonadism and tubal factor infertility.

OBJECTIVE: To evaluate the outcome of women with hypogonadotropic hypogonadism (HH) undergoing in-vitro fertilization (IVF). MATERIALS AND METHODS: Data from 13 cycles often hypogonadotropic patients treated with in vitro fertilization from the period January 2006 to January 2008 were analyzed and compared with treatment results from 20 patients with tubal factor infertility (TI). All patients underwent ovarian hyperstimulation for IVF/ICSI at the same center. HH patients initiated the treatment by receiving daily injections of hMG. The patients in the control group were given the same dosage of recombinant FSH. RESULTS: Demographic characteristics of the patients were comparable. Mean duration of stimulation was 13 days in the HH group and nine days in the TI group; the difference was significant (p < 0.001). Significantly more gonadotropins were used for the stimulation of HH patients (p < 0.05). Peak serum E2 concentration was found to be higher in the TI group. We evaluated the proportion of metaphase II (MII) oocytes to total oocytes retrieved in HH patients and found the number was similar to the TI group. Despite that fertilization and implantation rates were similar in both groups, the cancellation rate was higher in the HH group (23.1% vs 0). However pregnancy and live birth rates were similar. CONCLUSIONS: The present study showed that HH women undergoing IVF/ICSI are good responders. The treatment of HH women with IVF/ICSI did not increase multiple pregnancies and OHSS rates over the TI group.

Argininosuccinate lyase deficiency: longterm outcome of 13 patients detected by newborn screening.

Argininosuccinate lyase deficiency is a urea cycle disorder which can present in the neonatal period with hyperammonemic encephalopathy, or later in childhood with episodic vomiting, growth and developmental delay. Abnormal hair, hepatomegaly, and hepatic fibrosis are unique features of this disorder. Twelve patients with argininosuccinate lyase deficiency were ascertained between 4 and 6 weeks of age by urine amino acid screening. One infant in a previously identified family was diagnosed shortly after birth. Diagnosis was confirmed by enzyme assay in red blood cells and/or skin fibroblasts. At the time of last follow-up, patients had been followed for 13-33 years. All patients were asymptomatic at detection, 7 had slightly increased blood ammonia, and all were initially treated with low-protein diet. Utilization of (14)C-citrulline by intact skin fibroblasts measured by (14)C incorporation into macromolecules was 74-135% of the control mean for 7 of the 8 patients studied. Nine patients had normal development, 4 had learning disability, 6 had EEG abnormalities, 3 had seizure disorder. None had any episodes of hyperammonemic coma. None had hepatomegaly. Patients detected by screening had higher enzyme activity measured by the (14)C-citrulline incorporation assay than comparison groups of patients with neonatal-onset and with late-onset detected by clinical disease. The ability to utilize (14)C-citrulline by intact fibroblasts seems to correlate with clinical outcome and may have prognostic value. It is likely that early diagnosis and treatment contributed to the relatively mild clinical course of the study group.

Very long-chain acyl-CoA dehydrogenase deficiency: the effects of accidental fat loading in a patient detected through newborn screening.

Very long-chain acyl-CoA dehydrogenase deficiency (VLCADD) is an autosomal recessive disorder of fatty acid oxidation. The majority of patients with VLCADD can be detected through newborn screening (NBS) with elevated levels of the tetradecanoyl carnitine species. An 11-month-old infant, diagnosed with late-onset VLCADD (genotype: T848C/G1322A) through newborn screening at birth, was admitted with emesis, severe lethargy, limpness in extremities, loss of muscle tone and an elevated CK level. He was mistakenly given Ketocal formula (about 8 g/kg per day long-chain fat-over six times his usual intake) instead of his usual Monogen formula for 2.5 days before being admitted. Once admitted, he was started on Monogen and IV (10% dextrose) fluids. He was discharged home after four days in the hospital without any sequelae of this accidental fat loading event. The report highlights several important points about this particular case and more generally about patients with VLCADD detected through NBS: (1) the amount of time in which patients might become severely symptomatic and the nature of these symptoms after fat loading; (2) the time frame for complete recovery after beginning of treatment; (3) the importance of alerting home-care companies and families about formula delivery errors and their repercussions.

FDG-PET findings in patients with galactosaemia.

Despite treatment with a galactose-restricted diet, many galactosaemia patients develop lifelong cognitive impairment, speech abnormalities and a gamut of neurological problems including cognitive impairment and tremors. No study has explored changes in cerebral glucose metabolism in patients with galactosaemia. Five patients with galactosaemia had ages ranging from 20 to 40 years (mean age 28 years) and eight similarly aged controls received brain [(18)F]fluorodeoxyglucose (FDG) positron emission tomography (PET) scans. PET scans were analysed using a previously validated template methodology of regions of interest (ROIs). Count ratios for each anatomical ROI were compared between the galactosaemic patients and the healthy controls. Statistical parametric mapping (SPM) software was also used to further analyse the data. ROI analysis showed that galactosaemic patients had significant bilateral decreases in cerebral glucose metabolism in the superior temporal gyrus, medial occipital lobe, parietal lobe, cerebellum, calcarine cortex, superior frontal cortex, and superior parietal cortex when compared with controls. Significant increases were seen in the cingulate gyrus and temporal poles, bilaterally. SPM analysis revealed foci of decreased glucose metabolism in the caudate, cerebellum, precentral gyrus and cerebellar tonsils of galactosaemic patients. SPM also showed increased glucose metabolism in the subcallosal gyrus and claustrum. The results show significant abnormalities in cerebral function in patients with galactosaemia, particularly with widespread decreases in cortical metabolism. These abnormalities appear to be in brain regions that may be associated with the neuropsychological deficits in these patients. PET brain scans may be of value in galactosaemia patients to evaluate for dysfunction.

Mutations of the E1beta subunit gene (PDHB) in four families with pyruvate dehydrogenase deficiency.

Pyruvate dehydrogenase complex (PDC) deficiencies are a major cause of primary lactic acidosis. Most cases result from mutations of the gene for the pyruvate dehydrogenase E1alpha subunit (PDHA1), with fewer cases resulting from mutations in genes for E3, E3-binding protein, E2, and the E1beta subunit (PDHB). We have found four cases of PDHB mutations among 83 analyzed cases of PDC deficiency. In this series, PDHB mutations were found to be about 10% as frequent as PDHA1 mutations. All cases were diagnosed by low PDC activity, with normal E2 and E3 activities. These included a 6.5-year-old male (consanguineous, homozygous R36C); a neonatal female who died soon after birth, (compound heterozygous C306R/D319V), a 26-year-old female (heterozygous I142M/W165S), and a 13month old female (consanguineous, homozygous Y132C) who is a sibling of a previously published case. Their ethnic background is diverse (Caucasian, Arab, and African American descent). All cases had lactic acidosis and developmental delay. Three cases had agenesis of the corpus callosum, seizures, and hypotonia; one died within the first year of life. These clinical findings are similar to those of PDHA1 deficiency, except that ataxia was more frequent in PDHA1 cases and consanguinity was found only in PDHB families. PDC activity in lymphocytes from six parents is normal, who all are heterozygous carriers for the respective mutations. Immunoreactivity of E1beta was markedly reduced in one case and showed a slightly larger form of E1beta in one case. Computer analysis predicts that: R36C affects the interaction of several amino acids resulting in conformational change, C306R affects interaction of the two beta subunits, D319 is in the interface of E1 and E2, I142M affects conformation around a K ion affecting stability of the beta subunit, W165S affects hydrophobic interaction between the beta subunits, and Y132C affects interaction between the beta subunits. All of these residues are conserved in E1beta across species, and Y132 is also conserved in other TPP-requiring enzymes. These observations support the conclusion that these are pathogenic mutations.

Clinical and molecular features of mitochondrial DNA depletion due to mutations in deoxyguanosine kinase.

Published mutations in deoxyguanosine kinase (DGUOK) cause mitochondrial DNA depletion and a clinical phenotype that consists of neonatal liver failure, nystagmus and hypotonia. In this series, we have identified 15 different mutations in the DGUOK gene from 9 kindreds. Among them, 12 have not previously been reported. Nonsense, splice site, or frame-shift mutations that produce truncated proteins predominate over missense mutations. All patients who harbor null mutations had early onset liver failure and significant neurological disease. These patients have all died before 2-years of age. Conversely, two patients carrying missense mutations had isolated liver disease and are alive in their 4th year of life without liver transplant. Five subjects were detected by newborn screening, with elevated tyrosine or phenylalanine. Consequently, this disease should be considered if elevated tyrosine is identified by newborn screening. Mitochondrial DNA content was below 10% of controls in liver in all but one case and modestly reduced in blood cells. With this paper a total of 39 different mutations in DGUOK have been identified. The most frequent mutation, c.763_c.766dupGATT, occurs in 8 unrelated kindreds. 70% of mutations occur in only one kindred, suggesting full sequencing of this gene is required for diagnosis. The presentation of one case with apparent viral hepatitis, without neurological disease, suggests that this disease should be considered in patients with infantile liver failure regardless of the presence of neurological features or apparent infectious etiology.

Anterior meningocele misdiagnosed as an ovarian cyst.

OBJECTIVE: An undiagnosed anterior meningocele may mimic an ovarian cyst. Careful evaluation and consultation must be the mainstay of surgery for adnexal masses. RESULTS: A patient initially diagnosed as having an adnexal mass was discovered to have an anterior meningocele at surgery. In vitro fertilization plans were delayed to prevent complications during procedures.

Spontaneous uterine rupture during preterm labor in the second trimester of a twin IVF pregnancy without any apparent risk factor.

Uterine rupture is a rare complication of pregnancy. It can cause severe problems for the mother and child if not immediately diagnosed and treated. Some certain risk factors play a major role for occurrence. Multiple pergnancies, grand multiparity, previous cesarean sections or myomectomy operations, hysteroscopic manipulations and corrective uterine surgery, etc. are the main predisposing factors. In this case we report the successful management of a spontaneous uterine rupture in a primigravid female an the 29th week of a twin pregnancy after IVF treatment.

Well differentiated mesothelioma complicating endometrial carcinoma; a case report.

Peritoneal mesothelioma is a rare cancer of the abdominal cavity which has low malignant potential. Peritoneal mesothelioma can mimic other types of gynecologic malignancies. Careful clinical and pathologic evaluation is essential for an accurate diagnosis and treatment.

Cardiomyopathy and hypotonia in a 5-month-old infant with malonyl-coa decarboxylase deficiency: potential for preclinical diagnosis with expanded newborn screening.

Malonyl-CoA decarboxylase deficiency is an inborn error of metabolism that may cause hypotonia and a fatal cardiomyopathy in infancy. Newborn metabolic screening programs do not include this disorder, although there is a possibility that presymptomatic treatment may attenuate the development of cardiomyopathy. We report a case of malonyl-CoA decarboxylase deficiency in a 5-month-old boy who presented with cardiomyopathy and hypotonia. Retrospective analysis of the newborn screening test showed an elevation in the concentration of malonylcarnitine at age 3 days. Unfortunately, this perturbation was missed because the screening test did not routinely measure malonylcarnitine in the newborn blood. Our experience confirms the possibility of screening for malonyl-CoA decarboxylase deficiency with tandem mass spectrometry. This finding should enable studies to determine if presymptomatic treatment could change the outcome in this often fatal disorder.

Two newborns with nutritional vitamin B12 deficiency: challenges in newborn screening for vitamin B12 deficiency.

Vitamin B12 deficiency causes decreased Methionine Synthase and L-Methylmalonyl-CoA Mutase activity and results in accumulation of Homocysteine, Methylmalonic acid and Propionylcarnitine. Propionylcarnitine is included in tandem mass spectrometry-based newborn screening programs for detection of certain inborn errors of metabolism. We report two asymptomatic newborns with Vitamin B12 deficiency due to maternal deficiencies. One was detected incidentally at 3 weeks of age; the second on supplemental newborn screening based on elevated Propionylcarnitine at 2 days of age. This illustrates the potential for false negative results for Vitamin B12 deficiency screening by acylcarnitine profiling in newborn screening. Homocysteine and Methylmalonic acid may be better markers of Vitamin B12 deficiency. In conclusion, we suggest measuring Methylmalonic acid, Propionylcarnitine and Homocysteine levels in blood spots in expanded newborn screening in order to detect asymptomatic newborns with Vitamin B12 deficiency. Further studies are needed to establish the sensitivity of these three markers in screening for Vitamin B12 deficiency.

High local endometrial effect of vaginal progesterone gel.

Our objective was to investigate the first-pass effect to the uterus of progesterone gel administered vaginally. This was a prospective, randomized study of 32 postmenopausal women, attending our menopause clinic. All women used transdermal estradiol (50 microg/day, a patch each week) for 2 weeks. They used either vaginal progesterone gel or intramuscular progesterone in oil 50 mg after 24 h to oppose the transdermal estradiol. Serum progesterone levels and endometrial tissue progesterone levels were determined. Serum progesterone levels were higher in women who used the intramuscular rather than the vaginal route. Although serum progesterone levels in the vaginal group were lower than in the intramuscular group, the endometrial tissue concentration of progesterone was higher. It is concluded that progesterone gel, used vaginally, has a high local effect on the endometrium, without any systemic side-effects due to high plasma progesterone levels.

Relationship between semen quality and seminal plasma total carnitine in infertile men.

This study was designed to determine any correlation between infertility and semen quality with concentrations of total carnitine in human seminal plasma. Seminal plasma total carnitine concentrations were determined in 79 men. The seminal plasma of 65 infertile men and 14 men as a control group with proved fertility were investigated. The concentrations of total carnitine were reduced significantly in the infertile group compared to the control group (31.52 +/- 20.77 vs. 45.52 +/- 10.73 mg/l, P<0.05). The 65 infertile men were divided into five groups according to their sperm analysis: normospermia (n=42), oligospermia (n=23), asthenospermia (n=40), teratospermia (n=44) and oligoasthenospermia (n=10). Total seminal plasma carnitine concentration differed significantly between controls and the patient groups (P<0.05). There was a statistically significant positive correlation between seminal plasma total carnitine concentration with total sperm count and the percentage of normal forms (P<0.05 and P<0.01, respectively). Total carnitine concentration was found to be low in the asthenospermia group when compared with the group of patients, whose total motile sperm percentage was 51 (P<0.05). These findings suggest that the determination of seminal carnitine levels may be a useful test in evaluation of male infertility.

The role of inhibin B as a basal determinant of ovarian reserve.

Our objective was to compare inhibin B and conventional basal determinants in designating the ovarian reserve in patients receiving assisted reproductive treatment. A total of 58 women, aged 19-47 years, who were accepted for assisted reproductive treatment at the Zeynep Kamil Women and Children's Hospital, Department of Assisted Reproductive Technologies, were included in the study. The age, body mass index, basal levels of follicle stimulating hormone, estradiol and inhibin B, volume of the ovary and number of antral follicles were compared prospectively. When the number of oocytes collected was > or = 5, this was accepted as a sufficient ovarian response. Serum inhibin B (cut-off level 56 pg/ml), as a basal determinant of ovarian reserve, had the highest sensitivity (81%) and specificity (81%). The usefulness of serum inhibin B measurement as a basal determinant of ovarian reserve is supported.

Basal hormone levels in women with recurrent pregnancy loss.

The potential role of endocrine abnormalities during the follicular phase in women with unexplained recurrent pregnancy loss was investigated in a retrospective study. Eighty women with recurrent pregnancy loss underwent routine work-up to exclude known associations with the condition. Following investigation, 58 women failed to reveal an identifiable cause, and were therefore classified as having unexplained recurrent pregnancy loss. The control group consisted of women with known causes of abortions, such as uterine septum and parental chromosomal abnormalities. Mean age, gravidity, parity, presence of infertility, previous number of miscarriages and duration of marriage were similar in both groups. Day-3 serum levels of follicle stimulating hormone (FSH), estradiol, luteinizing hormone (LH) prolactin, total testosterone, dehydroepiandrosterone sulfate (DHEAS) and thyroid stimulating hormone (TSH) were compared in the two groups. FSH, estradiol, LH, prolactin and DHEAS concentrations were significantly higher in the unexplained recurrent pregnancy loss group than in the explained recurrent pregnancy loss group, although serum concentrations of all hormones were within the normal range (p < 0.01). TSH and total testosterone levels were similar in the two groups (p > 0.05). There were no differences in the frequency of abnormal levels of hormones between the two groups (p > 0.05). We conclude that endocrine abnormalities in the follicular phase are not associated with recurrent pregnancy loss.

Doppler evaluation of the uterine, intraovarian, stromal and spiral arteries on the day of human chorionic gonadotrophin administration in controlled ovarian hyperstimulation.

The aim of this prospective study was to investigate the ability of transvaginal power Doppler ultrasonography to assess the relationship between the pulsatility indices (PI) of uterine, spiral and ovarian arteries and endometrial thickness on the day of, but just before, human chorionic gonadotrophin administration and the relationship to pregnancy outcome. Fifty-seven patients were recruited to the study. The mean PI values of the uterine arteries demonstrate significant differences between the women who conceived and those who did not. The mean PI values of the intraovarian flow also demonstrated significant differences between the left and right PI values and between the PI of the women who conceived and those who did not. Mean PI values of the spiral arteries and endometrial thickness did not demonstrate any significant difference between the women who conceived and those who did not. The parameters used currently in colour Doppler assessment of ovarian stromal, uterine and spiral artery perfusion are clinically helpful in discriminating prospectively which patients will and will not become pregnant in controlled ovarian hyperstimulation, insemination programme.