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Molecular characterization of histidinemia: identification of four missense mutations in the histidase gene.

Histidinemia (MIM235800) is characterized by elevated histidine in body fluids and decreased urocanic acid in blood and skin and results from histidase (histidine ammonia lyase, EC 4.3.1.3) deficiency. It is the most frequent inborn metabolic error in Japan. Although the original description included mental retardation and speech impairment, neonatal screening programs have identified the majority of histidinemic patients with normal intelligence. Molecular characteristics of histidase in histidinemia have not been determined, and cytogenetically visible deletions of 12q22-24.1 in which histidase gene resides have not been identified in histidinemic patients. In order to investigate whether individuals with this disorder have small deletions, additions, or point mutations in the histidase gene, we screened genomic DNA isolated from 50 histidinemic individuals who were discovered by the neonatal screening program. The methods employed included polymerase chain reaction (PCR) amplification of exons 1-21 of the histidase gene, followed by mutation detection enhancement gel electrophoresis and sequencing of the PCR products displaying heteroduplex bands. Four missense mutations (R322P, P259L, R206T, and R208L), two exonic polymorphisms (T141T c.423A-->T and P259P c.777A-->G), and two intronic polymorphisms (IVS6-5T-->C and IVS9+25A-->G) were identified. The frequencies of each polymorphism estimated either by dot blot allele-specific oligonucleotide hybridization, restriction enzyme digestion, or direct sequencing of the PCR products amplified from 50 unrelated normal individuals were 0.28, 0.30, 0.40, and less than 0.01, respectively. Mutation analysis of one family demonstrated that the patient inherited R322P from the mother and P259L from the father. This report describes the first mutations occurring in the coding region of the histidase structural gene in patients with histidinemia.

Amino Acid Metabolism, Inborn Errors↗

Partial biotinidase deficiency: clinical and biochemical features.

Neonatal screening for profound biotinidase deficiency (less than 10% of the mean normal activity level) has identified a group of children with partial biotinidase deficiency (10% to 30% of mean normal activity). Because partial biotinidase deficiency may result in clinical consequences that may be prevented by treatment with biotin, we evaluated such individuals and their family members (1) to determine whether partial biotinidase deficiency is associated with symptoms and (2) to determine the inheritance pattern. We quantified serum biotinidase activity levels and obtained medical histories of probands, their parents and siblings, and additional family members. All children with partial deficiency were healthy at the time of diagnosis. One child, who was not initially treated with biotin, later developed hypotonia, hair loss, and skin rash, which resolved with biotin therapy. Four adults and three children with partial biotinidase deficiency were identified among family members of infants identified by neonatal screening. All these individuals were healthy, although one sibling had elevated urinary lactate excretion. A fifth adult with partial deficiency, found among clinically normal adult volunteers, later showed minor symptoms that resolved after biotin therapy. Like children with profound biotinidase deficiency, children with partial biotinidase deficiency are symptoms free at birth. However, the subsequent occurrence of symptoms of profound biotinidase deficiency in some persons with partial deficiency suggests that biotin therapy for this condition may be warranted.

Adult↗

The role of serum thyroglobulin concentration and thyroid ultrasound imaging in the detection of iodide transport defects in infants.

When discovered by neonatal screening, a thyroid dyshormonogenesis is usually not recognized as a goitre. Especially a total iodide transport defect can easily be misclassified as thyroid agenesis, since radionuclide imaging cannot visualize the thyroid. We present the only iodide transport defect ever discovered in the Netherlands, the 35th reported in the literature, and the first one found exclusively as a result of neonatal screening. We demonstrate that iodide transport defects, in common with organification and deiodinase defects, can be distinguished from thyroid dysgenesis by demonstrating a normal or enlarged thyroid ultrasound image, and especially by measuring very high serum thyroglobulin levels (above 1000 pmol/l). In the presented case, an iodide-123 saliva-to-serum ratio near unity completed the etiologic classification. Measurement of serum thyroglobulin levels, in combination with thyroid ultrasound imaging, will improve the early identification of hereditary types of congenital hypothyroidism, and especially iodide transport defects, in patients found by neonatal thyroid screening.

Biological Transport↗

Temporal associations among energy intake, plasma linoleic acid, and growth improvement in response to treatment initiation after diagnosis of cystic fibrosis.

OBJECTIVE: It is unclear why some patients with cystic fibrosis (CF) succeed ("responders") in recovering from malnutrition and growth faltering after treatment initiation whereas others fail to do so ("nonresponders"). We conducted a study to test the hypothesis that sustained high energy intake (increased EN) and normal plasma essential fatty acid status are critical determinants of treatment responsiveness within 2 years after diagnosis of CF. METHODS: A total of 71 CF children who had pancreatic insufficiency but not meconium ileus and were enrolled in the Wisconsin CF Neonatal Screening Project were studied. Responders were defined by having achieved adequate weight gain, as indicated by a recovery of weight z score (Wtz) comparable to Wtz at birth (WtzBR) within 2 years of diagnosis. Increased EN and sustained normal plasma linoleic acid level (increased pLA) were defined by achieving energy intake > or =120% of estimated requirement for > or =75% of the time and maintaining plasma LA > or =26% of total fatty acids for > or =75% of the time, respectively. RESULTS: Thirty-two (68%) screened patients and 13 (54%) patients whose CF was diagnosed conventionally recovered WtzBR within 2 years of diagnosis. Screened patients responded at significantly younger ages (mean/median: 6.3/4.3 months) than patients whose CF was diagnosed conventionally (mean/median: 15.8/11.8 months). Proportionately fewer screened patients (33%) achieved increased EN compared with patients whose CF was diagnosed conventionally (73%). However, more screened patients responded to increased EN and recovered WtzBR (91%) than patients whose CF was diagnosed conventionally (56%), although this difference was of borderline significance. Compared with having neither increased EN nor increased pLA, the likelihood of being a responder was greatest with combined increased EN and increased pLA, followed by increased EN only. The positive associations between increased EN and increased pLA to treatment responsiveness remained significant after adjustment for neonatal screening status, baseline height and weight status, and indices of pulmonary disease severity. CONCLUSION: Increased EN and increased pLA are critical in promoting adequate weight gain in children with newly diagnosed CF.

Birth Weight↗

Thyroid scintigraphy and perchlorate discharge test in the diagnosis of congenital hypothyroidism.

Quantitative thyroid scanning using low doses of technetium-99m sodium pertechnetate was performed on 147 infants (55 males and 92 females) with congenital hypothyroidism detected through the national neonatal screening programme. Thirty-two (21.8%) were athyrotic, while 62 (42.2%) had an ectopic thyroid and 53 (36%) had a eutopic gland with increased 99mTc uptake (mean 17%; range, 5%-38%). The perchlorate discharge test (PDT) was performed in nine of the infants with ectopic glands and 15 with eutopic glands; the findings were consistent with an organification defect in 22 cases (seven ectopic and 15 eutopic). Thyroid scintigraphy and PDT can add useful aetiological, genetic and prognostic information in the clinical evaluation of infants with congenital hypothyroidism detected by neonatal screening.

Choristoma↗

Sustained attention problems in children with early treated congenital hypothyroidism.

Sustained attention was studied in 48 children with early treated congenital hypothyroidism and 35 healthy controls, using a computer-paced and a self-paced continuous performance task. The performance of the patients, particularly those in the low T4 group (38 patients with T4 levels < 50 nmol/l at neonatal screening), declined in the final stage of the computer-paced task, suggesting a problem in remaining attentive over time. The performance of all children declined in the first and improved in the final stage of the self-paced task. This pattern was most pronounced in the low T4 group, reflecting greater variability in their task performance over time, again indicating a problem in sustaining attention. No correlation was found between onset of treatment and sustained attention. The small size of the intermediate T4 group (10 patients with T4 levels > or = 50 nmol/l at neonatal screening) made the results more difficult to interpret and may have concealed a problem with sustained attention in this group.

Attention↗

[Ultrasonic screening of neonates].

Till june of 1990 all newborns borned in the authors' hospital were examined with ultrasound before discharge. 7582 newborns were screened during 5 years. 120 urinary abnormalities were found (1.58%). Eleven of 26 hydronephrosis were operated and one of the two multicystic kidneys. 6 unilateral agenesis of kidney, 12 unilateral hypoplasies and 30 duplex kidneys were found. 2 of the laters had hydronephrosis, too. The form of position of 37 kidneys were abnormal. 463 newborns had pyelectasy (6.1%). All were recovered spontaneously but one of them had a gross vesico-ureteric reflux. 31 cerebral malformations were found, one of them was a progressive hydrocephalus. Two of the three babies with cerebral arterio-venous malformation died because of circulatory insufficiency. There were 38 abdominal malformations: 3 hepatic and 7 splenic cysts, 3 bile stones and one neuroblastoma were the most important. 86 delivery injuries were found: 60 adrenal apoplexies, 2 hepatic ruptures and 24 intracranial hemorrhages. All healed. The ultrasound screening in the 19-20th weeks of pregnancy showed only 24% of serious renal and cerebral malformations. The authors think important to screen newborns with ultrasound.

Congenital Abnormalities↗

[Thyroglobulin gene abnormalities].

Congenital hypothyroidism is caused either by abnormal development of thyroid glands or by inborn errors of thyroid hormone synthesis. Thyroglobulin mutations which caused overt Cretins with physical and mental development impairment were once believed rare. However, since the discovery of mild hypothyroidism due to thyroglobulin mutations, 54 cases from 43 families were identified in Japan. The patients presented either transient elevation of serum TSH during infancy or growing giant goiters from childhood. Among 15 patients who were born after initiation of neonatal screening in 1979, 13 patients were identified by high serum TSH. In contrast, the major manifestation in patients born before 1979 is persistent growth of goiters with euthyroidism or subclinical hypothyroidism. Among 25 mutations, Cys1264Arg and Cys1077Arg are hot spots. The Cys1264Arg patients were found all over Japan, but the Cys1077Arg patients were confined to a small village of a southern island in Japan. The occurrence of the thyroglobulin mutations in the general population is 1/67,000. The pathogenesis of abnormal thyroglobulin is defective intracellular transport. The histological findings include empty colloid in the follicles and distended ER filling the entire cytoplasm of the thyrocytes. An in vitro expression study showed that abnormal thyroglobulin was not secreted from cultured cells. Because of persistent growth of the thyroid, 25 patients underwent surgical treatment. Among them, 11 patients suffered from thyroid cancers, most of which were of the papillary type. We found two BRAF activating mutations Val599Glu and Cys600Gln in five patients tested. In conclusion, we found many patients with thyroglobulin mutations in Japan. They were found by high serum TSH at neonatal screening or persistent growth of goiters in adults. Surgical treatments were inevitable, and 40% of the removed thyroids contained thyroid cancers, some of which were caused by activating mutations of the BRAF gene.

Adult↗

Congenital adrenal hyperplasia in Sweden 1969-1986. Prevalence, symptoms and age at diagnosis.

A retrospective study of all Swedish patients with congenital adrenal hyperplasia (CAH) born 1969-1986, was conducted to elucidate possible benefits of neonatal screening for CAH. Information was obtained about 150 patients (67 male, 83 female). One hundred and forty-three cases were regarded as classical and seven as non-classical (symptoms after 5 years of age or cryptic). All but two (one girl with 11-hydroxylase deficiency and one boy with beta-hydroxysteroid-dehydrogenase deficiency) had 21-hydroxylase deficiency. The prevalence was 1:11,500. Ninety-three patients (48 male, 45 female) displayed salt loss, all before the age of 3 months. Two boys had died and many children had been critically ill during the first weeks of life. The median age at diagnosis for boys in this group was 21 days. Gender assignment was a major problem in 38 of 57 girls with ambiguous genitalia noticed during the first day. Fifteen of these girls were considered to be male for their first 40 days (median), before the CAH diagnosis was established. Patients in whom the first symptom was manifested after the age of one year often showed growth acceleration, which frequently was overlooked. Median diagnostic delay in this group was 17 months. Possible benefits of neonatal screening are: avoidance of a serious salt-loss crisis; earlier diagnosis and correct gender assignment in virilized girls; decreased virilization, growth acceleration and premature pubarche in prepubertal children; and reduced negative consequences for psycho-social development and final height.

Adrenal Hyperplasia, Congenital↗

Spectrophotometric microassay for delta-aminolevulinate dehydratase in dried-blood spots as confirmation for hereditary tyrosinemia type I.

BACKGROUND: Hereditary tyrosinemia type I (HT) fulfills the criteria for inclusion in neonatal screening programs, but measurement of tyrosine lacks clinical specificity and quantitative assay of succinylacetone is laborious. We developed a semiquantitative assay based on inhibition of delta-aminolevulinate dehydratase (ALA-D) by succinylacetone. METHODS: Preincubation of 3-mm discs from dried-blood spots and reaction of the enzyme with delta-aminolevulinic acid as substrate were performed in microtiter plates. After separation of the supernatant and 10 min of color reaction with modified Ehrlich reagent, the formation of porphobilinogen was measured at 550 nm in a plate reader. RESULTS: The detection limit for succinylacetone was 0.3 micromol/L; imprecision (CV) was <5.5% within-run and 10-16% between-run. Storage of blood spots at ambient temperature for several days led to a significant decrease of ALA-D activity. Enzyme activity was lost in filter cards at 45 degrees C, but remained stable at 2-37 degrees C. Enzyme activity was decreased in EDTA blood. The absorbance at 550 nm was 0.221 (+/- 0.073) in healthy neonates and 0.043-0.100 in 11 patients with HT. All neonates with increased tyrosine (above the 99.5th centile) in neonatal screening (97 of 47 000) had normal results by the new assay. CONCLUSIONS: The spectrophotometric microassay for ALA-D is a simple and sensitive test for HT. This represents a basis for further examination of its general reliability as a confirmatory test if tyrosine is found to be increased.

Blood Specimen Collection↗

Natural history, outcome, and treatment efficacy in children and adults with glutaryl-CoA dehydrogenase deficiency.

Glutaryl-CoA dehydrogenase (GCDH) deficiency is a rare inborn disorder of L-lysine, L-hydroxylysine, and L-tryptophan metabolism complicated by striatal damage during acute encephalopathic crises. Three decades after its description, the natural history and how to treat this disorder are still incompletely understood. To study which variables influenced the outcome, we conducted an international cross-sectional study in 35 metabolic centers. Our main outcome measures were onset and neurologic sequelae of acute encephalopathic crises. A total of 279 patients (160 male, 119 female) were included who were diagnosed clinically after clinical presentation (n = 218) or presymptomatically by neonatal screening (n = 23), high-risk screening (n = 24), or macrocephaly (n = 14). Most symptomatic patients (n = 185) had encephalopathic crises, characteristically resulting in bilateral striatal damage and dystonia, secondary complications, and reduced life expectancy. First crises usually occurred during infancy (95% by age 2 y); the oldest age at which a repeat crisis was reported was 70 mo. In a few patients, neurologic disease developed without a reported crisis. Differences in the diagnostic criteria and therapeutic protocols for patients with GCDH deficiency resulted in a huge variability in the outcome worldwide. Recursive partitioning demonstrated that timely diagnosis in neurologically asymptomatic patients followed by treatment with L-carnitine and a lysine-restricted diet was the best predictor of good outcome, whereas treatment efficacy was low in patients diagnosed after the onset of neurologic disease. Notably, the biochemical phenotype did not predict the clinical phenotype. Our study proves GCDH deficiency to be a treatable disorder and a good candidate for neonatal screening.

Adult↗

Simultaneous measurement of 25 inflammatory markers and neurotrophins in neonatal dried blood spots by immunoassay with xMAP technology.

BACKGROUND: Inflammatory reactions and other events in early life may be part of the etiology of late-onset diseases, including cerebral palsy, autism, and type 1 diabetes. Most neonatal screening programs for congenital disorders are based on analysis of dried blood spot samples (DBSS), and stored residual DBSS constitute a valuable resource for research into the etiology of these diseases. The small amount of blood available, however, limits the number of analytes that can be determined by traditional immunoassay methodologies. METHODS: We used new multiplexed sandwich immunoassays based on flowmetric Luminex xMAP technology to measure inflammatory markers and neutrophins in DBSS. RESULTS: The high-capacity 25-plex multianalyte method measured 23 inflammatory and trophic cytokines, triggering receptor expressed on myeloid cells-1 (TREM-1), and C-reactive protein in two 3.2-mm punches from DBSS. It also measured 26 cytokines and TREM-1 in serum. Standards Recovery in the 25-plex method were 90%-161% (mean, 105%). The low end of the working range for all 25 analytes covered concentrations found in DBSS from healthy newborns. Mean recovery of exogenous analytes added at physiologic concentrations in DBSS models was 174%, mean intra- and interassay CVs were 6.2% and 16%, respectively, and the mean correlation between added and measured analytes was r2 = 0.91. In DBSS routinely collected on days 5-7 from 8 newborns with documented inflammatory reactions at birth, the method detected significantly changed concentrations of inflammatory cytokines. Measurements on DBSS stored at -24 degrees C for >20 years showed that most cytokines are detectable in equal concentrations over time. CONCLUSIONS: The method can reliably measure 25 inflammatory markers and growth factors in DBSS. It has a large potential for high-capacity analysis of DBSS in epidemiologic case-control studies and, with further refinements, in neonatal screening.

Adult↗

Effect of screening for cystic fibrosis on the influence of genetic counseling.

We studied the influence of genetic counseling for cystic fibrosis on family planning, using neonatal screening, family size at time of diagnosis, and maternal age as possible determinants for reproductive behaviour. The expected number of children born to mothers of equal age and parity in the same period was approximated on the basis of population statistics. These numbers were compared to the numbers of children born in the study group after a CF diagnosis and information on the 25% recurrence risk were given. A 50.8% reduction in childbirth was found in the study group, although 77% of families had decided against further high-risk pregnancies. No statistically significant influence of neonatal screening could be demonstrated, but this may be due to the small number of families involved.

Adult↗

Neonatal examination and screening--survey of GP practice and opinion.

OBJECTIVE: To describe, within the Grampian region of Scotland, the current practice of routine neonatal screening by general practitioners and their opinions of it. DESIGN: Postal questionnaire survey. SETTING: Grampian region, Scotland. SUBJECTS: All general practitioners in Grampian (n = 339). RESULTS: 295 (88%) general practitioners (GPs) responded. 164/285 (58%) thought that two routine neonatal examinations were necessary; however only 29% actually carried out two examinations. Those who had previously held a paediatric job were more likely to advocate two examinations (65% versus 41%). 'City' GPs more often thought that hospital paediatric staff, rather than GPs, should carry out routine neonatal examinations (22% versus 7% 'peripheral' GPs). CONCLUSIONS: Actual practice and experience appear to influence GP opinions about routine neonatal screening. If a randomised trial comparing one versus two routine neonatal examinations, currently in progress in the region, demonstrates that one examination is sufficient, resources will be required to reverse the opinions of the majority who feel that two examinations are necessary.

Family Practice↗

[Neonatal mass-screening for congenital adrenal hyperplasia due to 21-hydroxylase deficiency. II. A pilot neonatal mass-screening study in the west of Shizuoka Prefecture, Japan].

Using a simplified radioimmunoassay method for "Disc-17 alpha-hydroxyprogesterone (Disc-17-OHP)", a pilot neonatal mass-screening study for 21-hydroxylase deficiency was performed in the West of Shizuoka Prefecture for a period of 19 months. During this period, 20,975 neonates were studied, and the mean value and S.D. of "Disc-17-OHP" values were 21.1 and 9.65 pg/disc, respectively. We tentatively decided the 99th-percentile value as a recalling point, and 219 neonates (1.04%) were the candidates for recall by this criteria. One hundred thirty-six neonates out of these 219 candidates who responded to recall were evaluated by physical examination, family history and measurements of plasma electrolytes, 17-OHP and 21-deoxycortisol values as well as concentrations of pregnanetriol and pregnanetriolone in spot urine specimens. As a result, 2 infants were proved to have the salt-losing type of 21-hydroxylase deficiency (21-OHD). Approximately one half of the candidates were premature or low birth-weight infants, and at least 80% had a history of some kind of problem at delivery or in the early neonatal period. Despite the problems remaining to be solved, the present study demonstrates the feasibility and importance of neonatal mass-screening programs for 21-OHD, and suggests that the incidence of 21-OHD is probably greater than previously expected.

17-alpha-Hydroxyprogesterone↗

The incidence of phenylketonuria in Thailand.

Phenylketonuria (PKU) is a congenital defect involving failure to metabolize phenylalanine to tyrosine because of the absence of phenylalanine hydroxylase. Untreated PKU causes severe mental retardation, musty odor, hyperactivity, seizures, eczema and hypopigmentation. Without therapy, the child may develop with an IQ of less than 20. Restricting dietary phenylalanine before the onset of brain damage is necessary, to maintain the phenylalanine concentration at 3-8 mg/dl. Thirteen thousand three hundred and ninety-seven mentally retarded outpatients, aged 4 months to 24 years, from the year 1963 to 1987 were studied for PKU. Seven patients had positive PKU test by ferric chloride test and Phenistix, six PKU confirmed by paper chromatography. Two PKU by fluorometry and one PKU by amino acid analyzer. The incidence is 1:1,900 mentally retarded patients or 1:1,200,000 population. So, the incidence seems to be lower than in other countries which have neonatal screening for PKU. Because early diagnosis is essential in order to avoid the severe effects of PKU, neonatal screening has become widespread in the U.S., Australia, Great Britain, and other European Countries. The incidence of 1 PKU out of 1:1,200,000 Thai population seems to be not important enough for initiation of a PKU screening program in Thai newborns.

Adolescent↗

Future directions.

With the continued explosion of genetic technology, the number of disorders amenable to screening is expanding geometrically. Historically, most genetic screening has been in the newborn period. Much more can be done for the fetus if genetic screening and diagnosis are accomplished early in the pregnancy rather than after birth. The principal requirements to make neonatal screening disorders possible in the first trimester center around those tests that can be one on a molecular basis, and the development of fetal cell isolation from the maternal circulation. Over the course of the next decade, it is likely that many of the tests currently performed in the newborn period will be accomplished in the early or mid-gestational period.

Forecasting↗