Genetic Analysis of UGT1A1 Polymorphisms Using Preserved Dried Umbilical Cord for Assessing the Potential of Neonatal Jaundice as a Risk Factor for Autism Spectrum Disorder in Children.

Neonatal jaundice has been suggested as a perinatal risk factor for autism spectrum disorder (ASD). We examined UGT1A1 polymorphisms to assess the potential of neonatal jaundice as a risk factor for ASD in children by using DNA extracted from preserved umbilical cord. In total, 79 children with ASD were genotyped for UGT1A1*28 (c.-41-40dup), UGT1A1*6 (c.211 G > A), and UGT1A1*27 (c.686 C > A). The allele frequency of UGT1A1*6 (OR = 1.34, p = 0.26) and UGT1A1*28 (OR = 0.80, p = 0.54) and the prevalence of UGT1A1*28/*6 diplotypes did not differ significantly from those in the control population. No UGT1A1*27 allele was detected in the subjects. ASD symptom assessment scores were not associated with UGT1A1*28/*6/*27 genotypes or UGT1A1*28/*6 diplotypes. These results suggest that neonatal jaundice is not significantly associated with ASD.

Novel BICD2 mutation in a Japanese family with autosomal dominant lower extremity-predominant spinal muscular atrophy-2.

INTRODUCTION: The most common form of spinal muscular atrophy (SMA) is a recessive disorder caused by SMN1 mutations in 5q13, whereas the genetic etiologies of non-5q SMA are very heterogenous and largely remain to be elucidated. We present a father and son with atrophy and weakness of the lower leg muscles since infancy. Genetic studies in this family revealed a novel BICD2 mutation causing autosomal dominant lower extremity-predominant SMA type 2. PATIENTS: The proband was the father, aged 30, and the son was aged 3. Both of them were born uneventfully to nonconsanguineous parents. While the father first walked at the age of 19 months, the son was unable to walk at age 3 years. In both, knee and ankle reflexes were absent and sensation was intact. Serum creatine kinase levels were normal. The son showed congenital arthrogryposis and underwent orthopedic corrections for talipes calcaneovalgus. Investigation of the father at the age of 5 years revealed normal results on nerve conduction studies and sural nerve biopsy. Electromyography showed chronic neurogenic change, and muscle biopsy showed features suggestive of denervation. The father was diagnosed clinically with a sporadic distal SMA. Follow-up studies showed very slow progression. INVESTIGATIONS AND RESULTS: Next-generation and Sanger sequencing revealed a deleterious mutation in BICD2: c.1667A>G, p.Tyr556Cys, in this family. DISCUSSION: BICD2 is a cytoplasmic conserved motor-adaptor protein involved in anterograde and retrograde transport along the microtubules. Next-generation sequencing will further clarify the genetic basis of non-5q SMA.

Congenital Cytomegalovirus Infection in Children with Autism Spectrum Disorder: Systematic Review and Meta-Analysis.

Association of congenital cytomegalovirus (CMV) infection with autism spectral disorder (ASD) has been suggested since 1980s. Despite the observed association, its role as a risk factor for ASD remains to be defined. In the present review, we systematically evaluated the available evidence associating congenital CMV infection with ASD using PubMed, Web of Science, Cochrane Library, and Embase databases. Any studies on children with CMV infection and ASD were evaluated for eligibility and three observational studies were included in meta-analysis. Although a high prevalence of congenital CMV infection in ASD cases (OR 11.31, 95% CI 3.07-41.66) was indicated, too few events (0-2 events) in all included studies imposed serious limitations. There is urgent need for further studies to clarify this issue.

Novel FKRP mutations in a Japanese MDC1C sibship clinically diagnosed with Fukuyama congenital muscular dystrophy.

INTRODUCTION: Fukuyama congenital muscular dystrophy (FCMD), caused by fukutin mutations, is the most common form of Japanese CMD. We followed a Japanese CMD sibship without fukutin mutation, and herein identified new FKRP mutations causing MDC1C rarely reported in Oriental countries. PATIENTS: Two affected siblings, individuals 1 (I-1, male) and 2 (I-2, female), were born uneventfully to unaffected, non-consanguineous parents. Severe hypotonia was soon apparent and serum CK levels were elevated: I-1: 1025 IU/L (normal range <130 IU/L) and I-2: 5350 IU/L. I-1 had neither shown head control, nor said any words until he died of pneumonia at the age of 23months. I-2 learned to sit at 4years and 10months and spoke sentences at 6years and 5months. She had received respiratory support since 9years of age and died at 22years. Both showed a low-density area in the cerebral white matter on CT. MRI of I-2 revealed diffuse hyperintensity in the cerebral white matter on T2-WI, polymicrogyria over the frontal and parietal lobes, and disorganized folia and cysts in the cerebellum. METHODS AND RESULTS: Next generation and Sanger sequencing were performed for I-2. Heterozygous FKRP mutations were identified in exon 4: c.1167_1168delGC, p.Gly391Leufs∗72 and c.501_502GT>CC, p.Arg167Ser, p.Cys168Arg. DISCUSSION: Recently, fukutin and FKRP were identified as sequentially acting ribitol 5-phosphate transferases involved in the post-translational modification of α-dystroglycan. This may explain the clinical similarities between the two disorders.

[Neurological prognosis of floppy infants after health examinations].

OBJECTIVE: The term benign congenital hypotonia is retrospective and refers to infants who are hypotonic at birth or shortly thereafter but later show a normal tone. It encompasses many different pathological processes that affect the brain, motor unit, or both. The majority of affected children have cerebral hypotonia. An increased incidence of mental retardation, learning disabilities, and other sequelae of cerebral abnormality are evident later in life, despite the recovery of a normal muscle tone. We followed floppy infants who were pointed out as showing motor delay on health examinations at 4 or 9 months of age until at least 2 years of age. METHODS: We selected 32 floppy infants (15 males and 17 females) born uneventfully, with no family history, major anomalies, or abnormal findings on brain imaging, and no chromosomal study (G-banding and fluorescence in situ hybridization), serum creatine kinase level, blood lactate and pyruvate level, or blood amino acid abnormalities. RESULTS: All 32 infants achieved head control, but 2 failed to learn to sit unsupported. These two were diagnosed based on gene analysis with Rett syndrome and spinal muscular atrophy, respectively. Although 27 among the 32 patients became ambulant, 18 (67%) showed mental retardation and 5 (19%) also had autism spectrum disorder. Five patients who could not walk were suspected to have congenital myopathy or congenital malformation syndrome. CONCLUSIONS: After learning to walk independently and recovery of the normal muscle tone, many floppy infants showing motor delay on health examinations at 4 or 9 months of age developed mental retardation and autism spectrum disorder. Prospective follow-up is necessary for early diagnosis and intervention. For patients showing no motor and mental development, further laboratory studies including appropriate gene analysis are important for a definite diagnosis.

[Developmental course of patients with Asperger's disorder followed objectively from infancy].

This follow-up study evaluated cognitive and language development in Asperger's disorder (AD) patients diagnosed at the age of 5 to 6 years, with initial complaints of delays in motor or language development in infancy. We evaluated 12 patients (10 males and 2 females) using two intelligence tests:Kyoto Scale of Psychological Development 2001 (K-scale) for those under 6 years, and WISC-III for those over 5-6 years. The cognitive-adaptive area (C-A) of the former test was compared to the performance IQ (PIQ) of the latter test, and the language-social area (L-S) of the former to verbal IQ (VIQ) of the latter. The mean age at the first examination was 3.2 years (range:2.1-4.6 years), and the average age at follow-up was 7.7 years (range:5.3-12.3 years). The average length of follow-up from the initial visit was 5.6 years (range:3.3-8.6 years). During follow-up, the PIQ, VIQ and full scale DQ or IQ (F-DQ/IQ) improved with age. Average scores of the 12 patients at the first examination and last follow-up evaluated by K-scale were:C-A:70.6 (first) and 84.5 (last), L-S:64.8 (first) and 85.8 (last), and F-DQ:68.5 (first) and 84.8 (last). Compared to those with AD, 12 autistic patients with the Kanner type (10 males and 2 females) who visited our clinic during almost the same period, and belonged to almost the same age group, showed average scores at the first examination and last follow-up of:C-A: 61.9 (first) and43.3 (last), L-S:43.0 (first) and43.4 (last), and F-DQ:60.2 (first) and44.5 (last). From these observations, it is apparent that AD patients also showed language delay during infancy, but they improved rapidly between the ages of 4-6 years. This developmental spurt was not seen in autistic patients with the Kanner type.

[Care continuity for patients with myopathy during transition of childhood to adulthood].

Recently, patients with myopathies who had not previously been able to survive after adolescence required long-term follow-up and treatment. We here discussed medical practice after adolescence in child neurology for these patients with myopathies, such as muscular dystrophies, Pompe disease and juvenile dermatomyositis. Major issues encountered in such practice included inpatient facilities and community medical networks, especially for patients who receive long-term home mechanical ventilation, management for cardiomyopathy and/or gastrogavage. A full information transfer system between child specialists and adult specialists is needed for the benefit of maturing patients.

A case of hypertensive encephalopathy with extensive spinal lesions on MRI.

A 14-year-old female had repeated vomiting, headache, abdominal pain, visual field deficit and lethargy at the onset of hypertensive encephalopathy. Cerebrospinal fluid (CSF) test revealed a high level of IgG and protein. MRI demonstrated no supratentorial cerebral lesions but hyperintense lesions were observed from the lower pons to the Th8 level of spinal cord and cerebellar cortex on T2 weighted and FLAIR images without contrast enhancement. The two antihypertensive drugs stabilized to control her blood pressure and improved her clinical symptoms. Reexamination of MRI and cerebrospinal fluid test also revealed clear improvement of the above abnormalities. The abnormal findings on abdominal CT and renography led us to suspect renal infarction. Abdominal angiography demonstrated multifocal stenoses of renal interlobar arteries, which were supposed to supply the renal infarcted regions. These suggested that the renal infarctions due to fibromuscular dysplasia caused systemic hypertension. There have been only two reports that demonstrated spinal cord lesions in reversible posterior leukoencephalopathy syndrome (RPLES). We report extensive spinal lesions on MRI and a high level of IgG in CSF at the subacute phase in a young female with RPLES associated with hypertensive (brainstem) encephalopathy.

Phenotypic spectrum of Fukutinopathy: most severe phenotype of Fukutinopathy.

Fukuyama-type congenital muscular dystrophy (FCMD), Walker-Warburg syndrome (WWS), and muscle-eye-brain (MEB) disease are clinically similar autosomal recessive disorders characterized by congenital muscular dystrophy, cobblestone lissencephaly, and eye anomalies. Among them, WWS is the most severe syndrome. Causative genes for FCMD (Fukutin), WWS (POMT1), and MEB (POMGnT1) have been identified. The vast majority of Japanese FCMD patients carry at least one copy of an ancestral founder insertion mutation. Patients homozygous for this insertion show a milder phenotype than do compound heterozygotes, carrying the insertion in combination with a missense or nonsense mutation on the other allele. No Japanese FCMD patients have been identified with nonfounder mutations on both alleles. A Turkish boy with characteristics of WWS was detected to have a homozygous nonsense mutation in exon 5 of Fukutin. This is the first case worldwide in which a Fukutin mutation has been found outside the Japanese population. Later, another Turkish boy with WWS phenotype was found to have a homozygous nonsense mutation in exon 4 of Fukutin. These two Turkish boys represent the most severe end of the phenotypic spectrum of Fukutin mutations. The Japanese FCMD patients carrying at least one copy of a founder mutation in the noncoding region may produce a lower level of mature Fukutin than normal and generate a relatively mild FCMD phenotype. The homozygous nonsense mutations within the coding region identified in Turkish patients are predicted to cause a total loss of fukutin activity and are likely to produce a more severe phenotype which closely resembles WWS.

Seizure-genotype relationship in Fukuyama-type congenital muscular dystrophy.

Fukuyama-type congenital muscular dystrophy (FCMD) is an autosomal recessive disorder prevalent in Japan, characterized by cobblestone lissencephaly and dystrophic changes in skeletal muscle, resulting in mental retardation, epilepsy and motor impairment. FCMD patients in Japan carry at least one copy of an ancestral founder mutation, a 3 kb insertion in a 3'-untranslated region, that results in a reduction in fukutin mRNA levels. We analyzed 35 patients with FCMD and found 18 patients carried a homozygous founder mutation (homozygotes) and 17 a combined heterozygous between founder mutation and a nonsense or missense mutation (heterozygotes). During an average follow-up of over 10 years, 61% of homozygotes and 82% of heterozygotes developed febrile or afebrile seizures. The ages at onset of febrile and afebrile seizures on average were 5.4 and 4.6 years, respectively, in homozygotes and 3.6 and 3.7 years, respectively, in heterozygotes. Repeated seizures were treated with antiepileptic drugs. While all homozygotes showed good seizure control, four heterozygotes had intractable seizures. Mutations other than the 3 kb insertion were identified in seven of 12 heterozygotes examined. Five patients with a nonsense mutation in exon 3 and one with a missense mutation in exon 5 had a severe phenotype and some showed intractable seizures. On the other hand, one with a nonsense mutation in exon 8 had only one febrile seizure. It was concluded mutational analysis of the FCMD gene could predict seizure prognosis. Heterozygotes usually developed seizures earlier than homozygotes and some heterozygotes showed intractable seizures. Mutational analysis other than of the 3 kb insertion may also help to predict seizure prognosis.

A case of congenital neuromuscular disease with uniform type 1 fibers.

Congenital neuromuscular disease with uniform type 1 fibers is a rare form of congenital nonprogressive myopathy. We report a 3-year-old boy with this disease who showed delayed motor developmental milestones and recurrent acute respiratory failure. He obtained head control at 16 months, crawled at 17 months and sat alone at 20 months, but still could not walk at age 44 months. His mental development was good; he could speak 3-word sentences at 44 months. Scoliosis, bilateral congenital dislocation of the hips, bilateral undescended testes and hemangioma simplex on the right lower limb were also seen. Muscle biopsy at the age of 8 months showed more than 99% of the myofibers were type 1. This is the first case of congenital neuromuscular disease with uniform type 1 fibers accompanied by recurrent acute respiratory failure. This case may be clinically more severe than previously reported cases.

Long-term prognosis of epilepsies and related seizure disorders in Fukuyama-type congenital muscular dystrophy.

Fukuyama-type congenital muscular dystrophy is an autosomal recessive disorder prevalent in Japan that is characterized by congenital muscular dystrophy, cobblestone lissencephaly, and eye anomalies. We examined 46 patients with Fukuyama-type congenital muscular dystrophy and followed their progress for more than 3 years, with special reference to long-term prognosis of seizure disorders and the relationship between seizures and neuropathologic abnormalities. Seizures were observed in 37 patients (80%). The average age at onset was 3 years, 1 month. Initial seizures usually occurred after a febrile episode, although one third of patients had afebrile seizures from the onset. All patients had generalized tonic-clonic convulsions at febrile disorders, and these were followed by complex partial seizures or secondary generalized seizures. Later these seizures developed into Lennox-Gastaut syndrome in three patients. Electroencephalography (EEG) showed paroxysmal discharges in 22 of 37 patients with seizures (59%). The main focus was in the frontal, temporal, or central region. Lesions with marked cortical dysplasia detected by computed tomography, magnetic resonance imaging, or autopsy showed focal paroxysmal discharges on EEG.

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.

[Immunohistochemical studies of a variant of congenital muscular dystrophy].

Three Japanese patients from 2 families had a phenotype indistinguishable from that of Fukuyama-type congenital muscular dystrophy (FCMD). A full mutational analysis of the fukutin gene, however, revealed neither a 3 kb insertion (the Japanese founder mutation) nor a point mutation. A RT-PCR analysis of one of the patients revealed a normal expression of the fukutin transcript, suggesting that they have a new variant of CMD. An immunohistochemical analysis of the muscle of one case showed that the immunoreaction to alpha-dystroglycan (DG) was barely detectable on the surface membranes of muscle fibers. Immunoreactions to beta-DG, dystrophin, laminin alpha-2 chain and sarcoglycan were normal. These findings raise the possibility that the abnormality of alpha-DG is integral to the pathology seen in this variant of CMD. Analysis of POMGnT1 gene, which is causative of muscle-eye-brain disease, revealed no mutation in this case.

Leigh syndrome associated with West syndrome.

Leigh syndrome (LS) (sub-acute necrotizing encephalomyelopathy) is characterized by symmetric brain lesions occurring mainly in the basal ganglia and associated with variable clinical manifestations such as hypotonia, psychomotor retardation, and feeding difficulties. Patients with LS may develop seizures. Only three patients with LS have been identified in the literature as having West syndrome (WS). We have seen 12 children with LS in the past 20 years, and noticed that as many as five of them developed WS. This report discusses five LS children with WS, comparing them with seven LS children without WS. In all five patients, infantile spasms developed after LS had become evident, in addition to other type(s) of seizures. The onset of LS in all the patients with WS was before 10 months of age. Although not statistically proven, early onset of LS, spasticity, nystagmus, apnea, poor feeding, and cardiac problems seemed to be associated with the development of WS. We were not able to conclude that certain types of symptoms or examination results of patients with LS indicated the development of WS. The association of LS with WS did not markedly influence the prognoses of the children. WS may not be a rare complication of LS, especially in infants under 12 months of age. This report is the first review of LS associated with WS.

A new mutation of the fukutin gene in a non-Japanese patient.

Fukuyama-type congenital muscular dystrophy (FCMD), Walker-Warburg syndrome, and muscle-eye-brain disease are clinically similar autosomal recessive disorders characterized by congenital muscular dystrophy, cobblestone lissencephaly, and eye anomalies. FCMD is frequent in Japan, but no FCMD patient with confirmed fukutin gene mutations has been identified in a non-Japanese population. Here, we describe a Turkish CMD patient with severe brain and eye anomalies. Sequence analysis of the patient's DNA identified a homozygous 1bp insertion mutation in exon 5 of the fukutin gene. To our knowledge, this is the first case worldwide in which a fukutin mutation has been found outside the Japanese population. This report emphasizes the importance of considering fukutin mutations for diagnostic purposes outside of Japan.

Reversible vascular changes in children with cerebral infarction.

A case of cerebral infarction in a 4-year-old male is described. The child presented with an acute onset of right hemiplegia, central facial palsy, and dysarthria. He had no predisposing factors for cerebral infarction. A computed tomography scan showed a diffuse low-density area in the territory of the left miiddle cerebral artery. Magnetic resonance angiography disclosed multiple irregular narrowings in the left anterior and middle cerebral arteries. He recovered spontaneously from the stroke with minimal long-term complications, and repeated angiography disclosed a complete regression of the vascular changes 2 months after the stroke. There was no recurrence of stroke after 2-year follow-up. This case demonstrates the importance of longitudinal angiographic follow-up in childhood cerebral infarction of idiopathic origin.

A variant of congenital muscular dystrophy.

We analyzed three Japanese patients (two boys and a girl) from two families with congenital muscular dystrophy (CMD) and brain involvement. One of the two families had two affected siblings of different sexes. Parental consanguinity was not documented in either family. All patients showed generalized hypotonia and weakness from infancy, delayed psychomotor development, facial muscle involvement, and joint contractures. Serum creatine kinase levels were markedly elevated. The histological change seen on muscle biopsy was characteristic of a dystrophic process, although dystrophin and merosin staining were normal. On MR imaging, cortical dysplasia and cerebral white matter abnormalities were observed. Although these clinical, myopathological and neuroradiological findings were typical of Fukuyama-type CMD (FCMD), full mutational analysis of the fukutin gene revealed neither a 3 kb insertion (Japanese founder mutation) nor point mutations. RT-PCR analysis of RNA isolated from lymphoblasts of a patient revealed normal expression of the FCMD transcript. As classification of CMD should be based on genetic background, our present cases with typical clinical, myopathological and neuroradiological findings of FCMD without mutation of the fukutin gene may represent a new variant (or variants) of CMD that is different from FCMD.