Unfavorable neuroblastoma prognostic factor NLRR2 inhibits cell differentiation by transcriptional induction through JNK pathway.

The novel human gene family encoding neuronal leucine rich repeat (NLRR) proteins were identified as prognostic markers from our previous screening of primary neuroblastoma (NB) cDNA libraries. Of the NLRR gene family members, NLRR1 and NLRR3 are associated with the regulation of cellular proliferation and differentiation, respectively. However, the functional regulation and clinical significance of NLRR2 in NB remain unclear. Here, we evaluated the differential expression of NLRR2, where high expressions of NLRR2 were significantly associated with a poor prognosis of NB (P = 0.0009), in 78 NBs. Enforced expression of NLRR2 in NB cells enhanced cellular proliferation and induced resistance to retinoic acid (RA)-mediated cell growth inhibition. In contrast, knockdown of NLRR2 exhibited growth inhibition effects and enhanced RA-induced cell differentiation in NB cells. After RA treatment, NLRR2 expression was increased and correlated with the upregulation of c-Jun, a member of the activator protein-1 (AP-1) family in NB cells. Moreover, the expressions of NLRR2 and c-Jun were suppressed by treatment with a JNK inhibitor, which ameliorated the promoter activity of the NLRR2 gene while knockdown of c-Jun reduced NLRR2 expression. We then searched AP-1 binding consensus in the NLRR2 promoter region and confirmed c-Jun recruitment at a consensus. Conclusively, NLRR2 must be an inducible gene regulated by the JNK pathway to enhance cell survival and inhibit NB cell differentiation. Therefore, NLRR2 should have an important role in NB aggressiveness and be a potential therapeutic target for the treatment of RA resistant and aggressive NB.

A hypermorphic missense mutation in PLCG2, encoding phospholipase Cγ2, causes a dominantly inherited autoinflammatory disease with immunodeficiency.

Whole-exome sequencing was performed in a family affected by dominantly inherited inflammatory disease characterized by recurrent blistering skin lesions, bronchiolitis, arthralgia, ocular inflammation, enterocolitis, absence of autoantibodies, and mild immunodeficiency. Exome data from three samples, including the affected father and daughter and unaffected mother, were filtered for the exclusion of reported variants, along with benign variants, as determined by PolyPhen-2. A total of eight transcripts were identified as possible candidate genes. We confirmed a variant, c.2120C>A (p.Ser707Tyr), within PLCG2 as the only de novo variant that was present in two affected family members and not present in four unaffected members. PLCG2 encodes phospholipase Cγ2 (PLCγ2), an enzyme with a critical regulatory role in various immune and inflammatory pathways. The p.Ser707Tyr substitution is located in an autoinhibitory SH2 domain that is crucial for PLCγ2 activation. Overexpression of the altered p.Ser707Tyr protein and ex vivo experiments using affected individuals' leukocytes showed clearly enhanced PLCγ2 activity, suggesting increased intracellular signaling in the PLCγ2-mediated pathway. Recently, our laboratory identified in individuals with cold-induced urticaria and immune dysregulation PLCG2 exon-skipping mutations resulting in protein products with constitutive phospholipase activity but with reduced intracellular signaling at physiological temperatures. In contrast, the p.Ser707Tyr substitution in PLCγ2 causes a distinct inflammatory phenotype that is not provoked by cold temperatures and that has different end-organ involvement and increased intracellular signaling at physiological temperatures. Our results highlight the utility of exome-sequencing technology in finding causal mutations in nuclear families with dominantly inherited traits otherwise intractable by linkage analysis.

Mutations in proteasome subunit ß type 8 cause chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature with evidence of genetic and phenotypic heterogeneity.

OBJECTIVE: Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE syndrome) is an autoinflammatory syndrome recently described in children. We undertook this study to investigate the clinical phenotype, genetic cause, and immune dysregulation in 9 CANDLE syndrome patients. METHODS: Genomic DNA from all patients was screened for mutations in PSMB8 (proteasome subunit ß type 8). Cytokine levels were measured in sera from 3 patients. Skin biopsy samples were evaluated by immunohistochemistry, and blood microarray profile and STAT-1 phosphorylation were assessed in 4 patients and 3 patients, respectively. RESULTS: One patient was homozygous for a novel nonsense mutation in PSMB8 (c.405C>A), suggesting a protein truncation; 4 patients were homozygous and 2 were heterozygous for a previously reported missense mutation (c.224C>T); and 1 patient showed no mutation. None of these sequence changes was observed in chromosomes from 750 healthy controls. Of the 4 patients with the same mutation, only 2 shared the same haplotype, indicating a mutational hot spot. PSMB8 mutation-positive and -negative patients expressed high levels of interferon-γ (IFNγ)-inducible protein 10. Levels of monocyte chemotactic protein 1, interleukin-6 (IL-6), and IL-1 receptor antagonist were moderately elevated. Microarray profiles and monocyte STAT-1 activation suggested a unique IFN signaling signature, unlike in other autoinflammatory disorders. CONCLUSION: CANDLE syndrome is caused by mutations in PSMB8, a gene recently reported to cause "JMP" syndrome (joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced childhood-onset lipodystrophy) in adults. We extend the clinical and pathogenic description of this novel autoinflammatory syndrome, thereby expanding the clinical and genetic disease spectrum of PSMB8-associated disorders. IFN may be a key mediator of the inflammatory response and may present a therapeutic target.

Elevated levels of plasma Big endothelin-1 and its relation to hypertension and skin lesions in individuals exposed to arsenic.

Chronic arsenic (As) exposure affects the endothelial system causing several diseases. Big endothelin-1 (Big ET-1), the biological precursor of endothelin-1 (ET-1) is a more accurate indicator of the degree of activation of the endothelial system. Effect of As exposure on the plasma Big ET-1 levels and its physiological implications have not yet been documented. We evaluated plasma Big ET-1 levels and their relation to hypertension and skin lesions in As exposed individuals in Bangladesh. A total of 304 study subjects from the As-endemic and non-endemic areas in Bangladesh were recruited for this study. As concentrations in water, hair and nails were measured by Inductively Coupled Plasma Mass Spectroscopy (ICP-MS). The plasma Big ET-1 levels were measured using a one-step sandwich enzyme immunoassay kit. Significant increase in Big ET-1 levels were observed with the increasing concentrations of As in drinking water, hair and nails. Further, before and after adjusting with different covariates, plasma Big ET-1 levels were found to be significantly associated with the water, hair and nail As concentrations of the study subjects. Big ET-1 levels were also higher in the higher exposure groups compared to the lowest (reference) group. Interestingly, we observed that Big ET-1 levels were significantly higher in the hypertensive and skin lesion groups compared to the normotensive and without skin lesion counterpart, respectively of the study subjects in As-endemic areas. Thus, this study demonstrated a novel dose-response relationship between As exposure and plasma Big ET-1 levels indicating the possible involvement of plasma Big ET-1 levels in As-induced hypertension and skin lesions.

A multi-population-based genomic analysis uncovers unique haplotype variants and crucial mutant genes in SARS-CoV-2.

BACKGROUND: COVID-19 is a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Rigorous detection and treatment strategies against SARS-CoV-2 have become very challenging due to continuous evolutions to the viral genome. Therefore, careful genomic analysis is sorely needed to understand transmission, the cellular mechanism of pathogenicity, and the development of vaccines or drugs. OBJECTIVE: In this study, we intended to identify SARS-CoV-2 genome variants that may help understand the cellular and molecular foundation of coronavirus infections required to develop effective intervention strategies. METHODS: SARS-CoV-2 genome sequences were downloaded from an open-source public database, processed, and analyzed for variants in target detection sites and genes. RESULTS: We have identified six unique variants, G---AAC, T---AAC---T, AAC---T, AAC--------T, C----------T, and C--------C, at the nucleocapsid region and eleven major hotspot mutant genes: nsp3, surface glycoprotein, nucleocapsid phosphoprotein, ORF8, nsp6, nsp2, nsp4, helicase, membrane glycoprotein, 3'-5' exonuclease, and 2'-O-ribose methyltransferases. In addition, we have identified eleven major mutant genes that may have a crucial role in SARS-CoV-2 pathogenesis. CONCLUSION: Studying haplotype variants and 11 major mutant genes to understand the mechanism of action of fatal pathogenicity and inter-individual variations in immune responses is inevitable for managing target patient groups with identified variants and developing effective anti-viral drugs and vaccines.

Persistent mullerian duct syndrome: A 24-year experience.

BACKGROUND: Persistence of mullerian duct derivatives in otherwise normal male child is a very rare disorder. This may lead to diagnostic as well as management dilemma. MATERIALS AND METHODS: The medical record of 27 cases of persistent mullerian duct syndrome (PMDS) operated in three teaching hospitals more than a period of 24years is retrieved and analyzed for demography, clinical presentation, investigations, and treatment. RESULTS: There were a total of twenty seven male children with PMDS. The age was ranged between 3months and 19years. Ten patients presented with isolated bilateral UDT, six patients with bilateral UDT and unilateral inguinal hernia (4 left and 2 right sided inguinal hernia), and eight patients presented with right inguinal hernia and left sided UDT. Eight of 27 patients showed familial trends i.e. four pairs of brothers had PMDS in our series. In 21 patients, the diagnosis was made incidentally while operating for UDT and inguinal hernia. At operation 5 patients had female type of PMDS and 22 patients had male type PMDS. In 6 patients (male type), the PMDS was associated with transverse testicular ectopia. In 18 patients the initial operation was performed through inguinal incision with excision of mullerian remnants in the same settings in 12 patients. In 4 patients, straightforward laparotomy performed (familial cases) to excise mullerian remnants. In 5 patients, the PMDS was diagnosed on laparoscopy; initially biopsy of these remnants and gonads was done followed by excision of remnants by laparotomy approach. Biopsies taken from gonads in each patient revealed testicular tissue with variable degree of immaturity and dysplasia. The biopsy of mullerian remnants did not reveal any malignancy. All patients were genotypically male. CONCLUSION: Isolated undescended testes, left UDT and right inguinal hernia, bilateral UDT and unilateral inguinal hernia are the main presenting features of PMDS. About 30% of the patients showed familial tendency. Inguinal exploration for UDT or inguinal hernia, and laparoscopy for UDT reveal incidental findings of mullerian remnants. PMDS can be managed as single stage procedure however two stage procedure including gonadal biopsies in first stage followed by mullerian remnants excision and orchidopexy in the second stage can be opted if there is doubt about gonads and genotype.

Additive loss-of-function proteasome subunit mutations in CANDLE/PRAAS patients promote type I IFN production.

Autosomal recessive mutations in proteasome subunit ß 8 (PSMB8), which encodes the inducible proteasome subunit ß5i, cause the immune-dysregulatory disease chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE), which is classified as a proteasome-associated autoinflammatory syndrome (PRAAS). Here, we identified 8 mutations in 4 proteasome genes, PSMA3 (encodes α7), PSMB4 (encodes ß7), PSMB9 (encodes ß1i), and proteasome maturation protein (POMP), that have not been previously associated with disease and 1 mutation in PSMB8 that has not been previously reported. One patient was compound heterozygous for PSMB4 mutations, 6 patients from 4 families were heterozygous for a missense mutation in 1 inducible proteasome subunit and a mutation in a constitutive proteasome subunit, and 1 patient was heterozygous for a POMP mutation, thus establishing a digenic and autosomal dominant inheritance pattern of PRAAS. Function evaluation revealed that these mutations variably affect transcription, protein expression, protein folding, proteasome assembly, and, ultimately, proteasome activity. Moreover, defects in proteasome formation and function were recapitulated by siRNA-mediated knockdown of the respective subunits in primary fibroblasts from healthy individuals. Patient-isolated hematopoietic and nonhematopoietic cells exhibited a strong IFN gene-expression signature, irrespective of genotype. Additionally, chemical proteasome inhibition or progressive depletion of proteasome subunit gene transcription with siRNA induced transcription of type I IFN genes in healthy control cells. Our results provide further insight into CANDLE genetics and link global proteasome dysfunction to increased type I IFN production.

Protective effects of Moringa oleifera Lam. leaves against arsenic-induced toxicity in mice.

OBJECTIVE: To evaluate the protective role of leaves of Moringa oleifera (M. oleifera) Lam. against arsenic-induced toxicity in mice. METHODS: Swiss albino male mice were divided into four groups. The first group was used as non-treated control group while, the second, third, and fourth groups were treated with M. oleifera leaves (50 mg/kg body weight per day), sodium arsenite (10 mg/kg body weight per day) and sodium arsenite plus M. oleifera leaves, respectively. Serum indices related to cardiac, liver and renal functions were analyzed to evaluate the protective effect of Moringa leaves on arsenic-induced effects in mice. RESULTS: It revealed that food supplementation of M. oleifera leaves abrogated the arsenic-induced elevation of triglyceride, glucose, urea and the activities of alkaline phospatase, aspartate aminotransferase and alanine aminotransferase in serum. M. oleifera leaves also prevented the arsenic-induced perturbation of serum butyryl cholinesterase activity, total cholesterol and high density lipoprotein cholesterol. CONCLUSIONS: The results indicate that the leaves of M. oleifera may be useful in reducing the effects of arsenic-induced toxicity.

Multiple associated anomalies in patients of duodenal atresia: a case series.

Duodenal atresia has been reported in association with various malformations and syndromes common being Down syndrome, malrotation, and annular pancreas. Its association with multiple anomalies is rare and scarcely reported in literature. Herein 3 cases of duodenal atresia associated with multiple congenital anomalies are being reported.

Eventration of diaphragm with hiatal hernia: a case report.

A 25-day-old female baby having eventration of diaphragm associated with a big hiatal hernia is being reported here. This is the second report describing the rare association.

Mortality in a case of crystal gel ball ingestion: an alert for parents.

Decorative crystal gel balls are used for decoration purpose. Due to their attractive appearance they may be ingested by children. This may result in grave complications. A case of decorative crystal ball ingestion is being reported in a 6 months old infant who presented with sub acute intestinal obstruction and was operated. Crystal gel balls were causing obstruction of jejunum. Enterotomy and removal of the mass of jelly balls was done with primary closure. The patient was re-operated for anastomotic disruption on 6th postoperative day. Baby developed septicemia, and succumbed after 2 days of second operation.

Congenital pouch colon: a preliminary report from pakistan.

BACKGROUND: Congenital pouch colon (CPC) is a rare entity in patients of anorectal malformations (ARM) requiring special consideration as to the management. This study is aimed at evaluating the presentation, management, and the outcome of initial surgery in patients with CPC. MATERIALS AND METHODS: This retrospective study was conducted in the department of Pediatric Surgery of our institute during May 2007- May 2010. The Information about the demography, clinical features, investigations, management, and the outcome of initial surgery was retrieved and analyzed. RESULTS: There were 21 patients of CPC managed during the study period. Sixteen (76%) were males and five (24%) females (M:F 3.2:1). Mean age of presentation was 4.8 days with a range of 12 hours to 45 days. In 18 (85.7%) patients, CPC was found with high ARMs, whereas, in 3 (14.3%) patients it was associated with low ARMs. Imperforate anus with moderate to massive abdominal distension was the presentation in 16 (76%) patients. Abdominal radiographs helped in preoperative diagnosis in 8 patients. Two patients had pneumoperitoneum on abdominal radiographs. At operation, type I CPC was found in 9 (42.8%) patients, type II in 5 (23.8%), type III in 2 (9.5%) patients, and type IV CPC in 5 (23.8%) patients. In 11 (52.4%) patients, pouch was emptied and retained with proximal enterostomy. In 7 (33.3%) patients, end enterostomy with pouch excision was done. In two patients, a window colostomy was formed. In one patient, pouch was disconnected from the normal bowel and Hartmann's pouch with end ileostomy was formed. There were 2 (9.5%) deaths in our series. CONCLUSION: CPC is a rare malformation. Massive abdominal distension with imperforate anus is the common presentation. Optimum management can reduce the morbidity and mortality.

Gastric volvulus in children: our experience.

Gastric volvulus is an extremely rare disorder in the pediatric age group. It is a complex entity as to the etiology and management. The study was conducted to evaluate etiology, mode of presentation, management, and outcome in our patients with gastric volvulus. It was a retrospective study of 10 patients with gastric volvulus managed during May 2006 and October 2010. The medical record of these patients including history, clinical examination, investigations, operative notes, and the outcome was reviewed. Of the ten patients, seven were males and three females. The mean age of presentation was 2.87 years. Half (50 %) of the patients showed typical Borchardt triad whereas in other patients the presentation was variable. In eight patients, the diagnosis was precisely made with the help of radiological investigations. At operation, three patients had primary gastric volvulus, and seven had secondary gastric volvulus. The predisposing factors leading to secondary gastric volvulus were eventration of diaphragm, hiatus hernia, congenital diaphragmatic hernia, malrotation, and traumatic diaphragmatic rupture. Seven patients had organoaxial volvulus and three showed mesenterioaxial. Gastropexy was performed in three patients (primary gastric volvulus). In seven patients (secondary gastric volvulus), the predisposing anatomical defects were corrected without adding gastropexy in the regime. One patient with traumatic rupture of the diaphragm died. There was no recurrence in any patient over a mean follow up of 3.7 years (SD ± 1.27). Secondary gastric volvulus is prevalent with diaphragmatic defects sharing major contribution in the etiology. Classical Borchardt triad is seen in 50 % cases of pediatric gastric volvulus. Correction of predisposing factors alone is sufficient to manage secondary gastric volvulus in children.

Congenital right hemidiaphragmatic agenesis.

Congenital diaphragmatic hernia is a congenital defect of the diaphragm through which intestine and other viscera herniate into the chest. In extreme form of diaphragmatic maldevelopment, there might be a complete agenesis of diaphragm. A 45-day old male infant was presented with fever, cough and respiratory distress for a week. Chest radiograph showed right-sided congenital diaphragmatic hernia. The patient underwent surgical exploration and found to have an unusual and large defect of right hemidiaphragm. The diaphragm was absent on anterior and lateral aspects of the chest wall and only a small rim of diaphragm was present on posterior aspect. The defect was identified as agenesis of right hemidiaphragm and successfully managed by suturing the posterior rim of diaphragm to the intercostal muscles and ribs. This report describes successful management of hemidiaphragmatic agenesis without incorporating a prosthetic material.

A case of fetus in fetu.

Fetus in fetu is a rare developmental aberration, characterized by encasement of partially developed monozygotic, diamniotic, and monochorionic fetus into the normally developing host. A 4-month-old boy presented with abdominal mass. Radiological investigations gave the suspicion of fetus in fetu. At surgery a fetus enclosed in an amnion like membrane at upper retroperitoneal location was found and excised. The patient is doing well after the operation.

Laparoscopic management of 128 undescended testes: our experience.

BACKGROUND: To describe different laparoscopic procedures in the management of impalpable undescended testes (UDT) and their outcome. Descriptive study. MATERIALS AND METHODS: The medical records of all the patients, managed laparoscopically for impalpable UDT between January 2008 to March 2011 at the department of Pediatric surgery, the Children's Hospital and The Institute of Child Health Lahore, Pakistan were reviewed for demography, history and clinical examination, investigations, operative notes, complication and outcome. RESULTS: There were a total of 90 patients (128 testes) with impalpable UDT managed laparoscopically. The mean age of presentation was 4.25 years (SD±3.47). In 38 (42.2%) patients, UDT were bilateral, whereas in 33 (36.7%), these were right sided and in 19 (21%), these were left sided. Laparoscopic findings revealed 65 (50.8%) testes lying higher up in the abdomen, 26 (20.3%) testes at internal ring, vas and vessel going into the deep ring in 22 (17%) cases and 15 (11.7%) atrophied/vanishing testes. Laparoscopic 2-Stage Fowler-Stephen (FS) orchidopexy was performed in 65 testes, laparoscopic orchidopexy was performed in 26 testes, laparoscopy followed by inguinal exploration and orchidopexy in 19 testes (3 testes were atrophied) and orchidectomy was performed in 9 testes. There were three conversions to laparotomy, one for external iliac iatrogenic injury and two for adhesions of the testes with the intestine. During follow-up at 6 months, 2 patients had testicular atrophy and the parents of 5 patients where testes could be brought to the scrotum neck were worried for the location. CONCLUSION: Laparoscopic management of impalpable UDT is an effective way of managing every kind of impalpable UDT. It is safe and its complications are very few.

Pheochromocytoma: a rare cause of childhood hypertensive encephalopathy.

Pheochromocytomas are rare neuroendocrine tumours of chromaffin tissues. They are catecholamine secreting tumours which cause severe hypertension and other systemic disturbances. Of all the causes of childhood hypertension, pheochromocytoma constitutes less than 1%. We report the case of a 12 years old child who presented with hypertensive encephalopathy, confirmed histologically to be secondary to pheochromocytoma, and cured with meticulous critical care and surgical resection.

Acute gastric volvulus secondary to malrotation of gut in a child with cerebral palsy.

Acute gastric volvulus secondary to malrotation of gut is a rare surgical emergency. We report a case of an eight years old cerebral palsy (CP) child who presented to us with sudden upper abdominal distension and non productive retching. X-ray abdomen revealed a huge gas shadow on left side of abdomen with paucity of distal gas shadows. On exploration organoaxial gastric volvulus with gastric ischemia, secondary to malrotation of gut, was found. Volvulus derotated and Ladd's procedure was done. Gastropexy and fundoplication was not done due to gastric ischemia. Early diagnosis and surgical management can save the patient from fatal complications of gastric perforation due to gastric ischemia.

Open safety pin ingestion presenting as incarcerated umbilical hernia.

Foreign body ingestion is common in children. Sharp foreign bodies are potentially harmful and can result various complications. An 8-month-old infant presented with incarcerated umbilical hernia. With a suspicion of strangulation, operation was performed that revealed a loop of ileum being stuck in the umbilical defect. The loop of ileum was freed from the umbilicus which demonstrated open ends of safety pin piercing out of bowel lumen. The enterotomy followed by removal of safety pin was performed.

Volvulus of small bowel in a case of simple meconium ileus.

Meconium ileus is one of important causes of neonatal intestinal obstruction. Many patients respond well to nonsurgical management with enemas, however, few patients may develop complications in the postnatal period thus requiring urgent operation. A 2 day old newborn presented with clinical features of intestinal obstruction. There was a suspicion of meconium ileus. Contrast x-ray with gastrografin enema was suggestive of unused colon with beaded appearance. Patient had to be surgery as repeated enemas did not improve the condition and progressive abdominal distension occurred. At exploration twist of the dilated, meconium filled loop of small bowel found. De-twisting of the volvulus done and Bishop Koop ileostomy fashioned. Patient made an uneventful recovery. Stoma was closed six months later.