ABSTRACT
Resumen La enfermedad de sustancia blanca representa una enfermedad poco común en usuarios que se apersonan al Organismo de Investigación Judicial, por este motivo al valorar un caso es necesario investigar los antecedentes de la medicina legal para establecer mecanismos causales con hechos representados en la sociedad. Además, es necesario abordar la enfermedad de sustancia blanca desde su aparición, incidencia, aspectos clínicos, hallazgos ante una posible autopsia, explorar el desarrollo de fisiopatología como indagar acerca de las formas de diagnosticar la enfermedad y valorar las opciones terapéuticas. Estos conocimientos son base para establecer una relación médico legal y analizar si el caso de una niña de 9 años tiene correlación con una historia de trauma en cabeza que no evidencia cambios inflamatorios, aumento de volumen de tejidos blandos o duros, excoriaciones, equimosis, hematomas, cicatrices, gradas o callos óseos y con valoraciones médicas que indican tetraparesia flácida en ausencia de hallazgos patológicos al reporte de tomografía axial computarizada y resonancia magnética de columna cervicodorsal.
Abstract White matter disease represents a rare disease in users who go to the Organismo de Investigación Judicial (Judicial Investigation Agency) for this reason, when evaluating a case, it is necessary to investigate the antecedents of legal medicine to establish causal mechanisms with facts represented in society. In addition, it is necessary to address white matter disease from its appearance, incidence, clinical aspects, findings in a possible autopsy, explore the development of pathophysiology such as inquire about ways to diagnose the disease, and assess therapeutic options. This knowledge is the basis for establishing a legal medical relationship and analyzing whether the case of a 9-year-old girl has a correlation with a history of head trauma that does not show inflammatory changes, increased soft or hard tissue volume, excoriations, bruising, bruising. , scars, bleachers or calluses and with medical evaluations that indicate flaccid tetraparesis in the absence of pathological findings on the report of computed tomography and magnetic resonance imaging of the cervicodorsal spine.
Subject(s)
Humans , Female , Child, Preschool , Leukoencephalopathies , White Matter , Costa RicaABSTRACT
Vanishing white matter (VWM) disease is an autosomal recessive disorder that affects the central nervous system of a patient, and is caused by the development of pathogenic mutations in any of the EIF2B1-5 genes. Any dysfunction of the EIF2B1-5 gene encoded eIF2B causes stress-provoked episodic rapid neurological deterioration in the patient, followed by a chronic progressive disease course. We present the case of a patient with an infantile-onset VWM with the pre-described specific clinical course, subsequent neurological aggravation induced by each viral infection, and the noted consequent progression into a comatose state. Although the initial brain magnetic resonance imaging did not reveal specific pathognomonic signs of VWM to distinguish it from other types of demyelinating leukodystrophy, the next-generation sequencing studies identified heterozygous missense variants in EIF2B3, including a novel variant in exon 7 (C706G), as well as a 0.008% frequency reported variant in exon 2 (T89C). Hence, the characteristic of unbiased genomic sequencing can clinically affect patient care and decisionmaking, especially in terms of the consideration of genetic disorders such as leukoencephalopathy in pediatric patients.
Subject(s)
Humans , Brain , Central Nervous System , Coma , Eukaryotic Initiation Factor-2B , Exome , Exons , Leukoencephalopathies , Magnetic Resonance Imaging , Patient Care , White MatterABSTRACT
RESUMO Objetivo: Descrever uma criança diagnosticada com leucoencefalopatia com substância branca evanescente (LSBE), uma doença genética rara que possui padrão de herança autossômico recessivo. Descrição do caso: Criança do sexo masculino, com 5 meses de idade, que mostrava recusa da amamentação e sonolência, começou a apresentar quadro de desidratação, com boca seca, aumento da temperatura corporal e adipsia. Com o passar dos dias, os sintomas agravaram-se. O lactente apresentou-se muito sonolento e foi transferido para a unidade de tratamento intensivo (UTI), onde permaneceu por uma semana. Nesse período, foi identificada, na ressonância magnética de crânio, uma alteração de sinal com predomínio hiperatenuado T2, comprometendo particularmente a substância branca, de aspecto difuso e simétrico. O lactente apresentou crises convulsivas desde então. Aos 11 meses foi diagnosticado com tonsilite, demonstrando quadros recorrentes de picos febris e sonolência excessiva. Na evolução do quadro, o lactente entrou em estado comatoso progredindo a óbito. O diagnóstico de LSBE foi confirmado em exames realizados após o óbito, e tardiamente foi identificada uma doença genética decorrente de mutações em um dos cinco genes que são responsáveis pela codificação do complexo fator de iniciação da tradução de eucariontes 2B (eIF2B), envolvido com o controle da tradução de proteínas, sendo descrita como patogênica em indivíduos com LSBE. Comentários: A LSBE é uma doença cerebral hereditária com início na infância. A doença apresenta-se de maneira crônica e progressiva, com episódios adicionais de rápida deterioração, como evidenciado no presente relato de caso.
ABSTRACT Objective: To describe the case of a child diagnosed with leukoencephalopathy with vanishing white matter (LVWM), a rare genetic disease with autosomal recessive inheritance pattern. Case description: A 5-month-old male child started to refuse breast-feeding, showing somnolence and signs of dehydration,with dry mouth, increasing body temperature and adipsy. As days went by, the symptoms got worse. The infant was very sleepy and was transferred to the intensive care unit, where he stayed for one week. At this time, a signal alteration with hyper attenuated T2 predominance was identified in the magnetic resonance imaging, compromising the white matter, which had diffuse and symmetrical aspect. At this time, the infant started to present seizures. When the infant was 11 months old, he was diagnosed with tonsillitis and presented recurrent fever peaks and extreme sleepiness. After hospital admission, the infant progressed to a comatose state and died. The diagnosis of LVWM was confirmed in examinations performed after death. As a late diagnosis, a genetic disease was identified with a mutation in one of the five genes responsible for the codification of complex eukaryotic translation initiation factor 2B (eIF2B), involved with the control of the protein translation and which is described as pathogenic in individuals with LVWM. Comments: LVWM is a hereditary brain disease that occurs primarily in children. The disease is chronic and progressive, with additional episodes of rapid deterioration, as shown in the present case report.
Subject(s)
Humans , Male , Infant , Leukoencephalopathies/diagnosisABSTRACT
Resumen: Introducción: La leucoencefalopatía con sustancia blanca evanescente es una de las leucodistrofias más frecuentes. Generalmente inicia en la infancia y presenta un patrón de herencia autosómica recesiva. El 90% de los casos manifiesta mutaciones en uno de los genes que codifican para las cinco subunidades del factor de iniciación eucariótica 2 (EIF2B5). El diagnóstico se realiza por las manifestaciones clínicas, hallazgos en la resonancia magnética cerebral y estudios moleculares confirmatorios. Caso clínico: Paciente masculino de 13 meses con neurodesarrollo previo normal. Antecedente de internamiento por vómito, hipertermia, irritabilidad y rechazo a la vía oral de 15 días de evolución. Ante la exploración presentó perímetro cefálico y pares craneales normales. Se encontró hipotónico, con reflejos incrementados, sin datos meníngeos ni de cráneo hipertensivo. La tomografía de cráneo mostró hipodensidad generalizada de la sustancia blanca. Egresó sin recuperar deambulación. A los 15 días presentó somnolencia y crisis convulsivas focales después de traumatismo craneoencefálico. En la resonancia magnética se observó hipointensidad generalizada de sustancia blanca. Ante la sospecha de leucoencefalopatía con sustancia blanca evanescente, se solicitó la secuenciación del gen EIF2B5, que reportó mutación homocigota c.318A>T en el exón 2. El paciente requirió múltiples hospitalizaciones por hipertermia y descontrol de crisis convulsivas. Posteriormente mostró deterioro cognitivo, motor y pérdida de la agudeza visual. Falleció a los 6 años por neumonía severa. Conclusiones: Este caso contribuye a conocer el espectro de mutaciones que se presenta en pacientes mexicanos y permite ampliar el fenotipo asociado con esta mutación.
Abstract: Background: Vanishing white matter disease is one of the most frequent leukodystrophies in childhood with an autosomal recessive inheritance. A mutation in one of the genes encoding the five subunits of the eukaryotic initiation factor 2 (EIF2B5) is present in 90% of the cases. The diagnosis can be accomplished by the clinical and neuroradiological findings and molecular tests. Case report: We describe a thirteen-month-old male with previous normal neurodevelopment, who was hospitalized for vomiting, hyperthermia and irritability. On examination, cephalic perimeter and cranial pairs were normal. Hypotonia, increased muscle stretching reflexes, generalized white matter hypodensity on cranial tomography were found. Fifteen days after discharge, he suffered minor head trauma presenting drowsiness and focal seizures. Magnetic resonance showed generalized hypointensity of white matter. Vanishing white matter disease was suspected, and confirmed by sequencing of the EIF2B5 gene, revealing a homozygous c.318A> T mutation in exon 2. Subsequently, visual acuity was lost and cognitive and motor deterioration was evident. The patient died at six years of age due to severe pneumonia. Conclusions: This case contributes to the knowledge of the mutational spectrum present in Mexican patients and allows to extend the phenotype associated to this mutation.
Subject(s)
Child , Child, Preschool , Humans , Infant , Male , Eukaryotic Initiation Factor-2B/genetics , Leukoencephalopathies/diagnosis , Phenotype , Magnetic Resonance Imaging/methods , Tomography, X-Ray Computed/methods , Exons , Fatal Outcome , Leukoencephalopathies/physiopathology , Leukoencephalopathies/genetics , MutationABSTRACT
Objective To explore the clinical features and gene mutations of antenatal form leukoencephalopathy with vanishing white matter disease (VWM).Methods The clinical data and genetic test results in a patient with antenatal form of VWM were retrospectively analyzed.Results A three months old patient was admitted to our hospital with intermittent convulsions commenced from the first month after birth.The baby had low birth weight (1900g) and asphyxia at birth.Developmental retardation and cataracts in both eyes were found on physical examination,and the patient couldn't stare,gaze-following,be amused and raise his head.In addition,he showed hypermyotonia of both lower extremities.Diffused and symmetrical abnormal signals same as that of the cerebrospinal fluid in the cerebral white matter were observed by brain CT and MRI scanning,and the lesions were gradually enlarged.Moreover,a missense mutation (c.1016G＞A) and a frameshift mutation (c.1809delC) in EIF2B5 gene inherited from his parent were detected by DNA sequencing.Conclusions VWM is one of the most prevalently inherited childhood white matter disorders,but the case of antenatal form is very rare.The diagnosis should be based on clinical manifestations and EIF2B genetic analysis.To our knowledge,the frameshift mutation c.1809delC has never been reported to date.
ABSTRACT
Leukoencephalopathy with vanishing white matter(VWM) is one of the most prevalent inherited white matter disorders in childhood,and it′s the only known hereditary human disease due to the direct defects in protein synthesis process,with the gene defects in EIF2B1-5,encoding the five subunits of eukaryotic translation initiation factor(eIF2B ?,?,?,? and ?) respectively.eIF2B is essential for the protein translation initiation process,and its action is realized via eukaryotic translation initiation factor2(eIF2).Phosphorylation of eIF2? and eIF2B? is an important way to regulate eIF2B function,and thus play a key role in control of the protein translation level under physiological condition.Mutant eIF2B results in functional defects and decrease of the overall protein translation in cells,but in increase the translation of proteins with multiple upstream open reading frames,such as activating transcription factor 4(AFT4),which leads to the susceptibility to un-folded protein response under stress,and the following apoptosis.The exact pathogenic mechanisms of VWM are far from well understood.It′s suggested that level of AFT4 in cells with eIF2B mutations is higher than in wild type cells under physiological condition,which makes the mutant cells more susceptible to endoplasmic reticulum(ER) stress and unfolded protein response(UPR).Under stress,the defect eIF2B leads to a vicious cycle of UPR activation,which may underlie the neurological aggravation in VWM patients after minor stress,a specific cli-nical feature of VWM.Elucidating the pathogenesis of VWM will be helpful to further understand the protein translation process in eukaryotic cells,and provide a clue for possible therapeutic targets and treatment strategies in the future.Abstract:SUMM ARY Leukoencephalopathy with vanishing white matter(VWM) is one of the most prevalent in-herited white matter d isorders in childhood,and i′ts the only known hered itary human d isease due to the d irect defects in protein synthesis process,with the gene defects inEIF2B1-5,encod ing the five sub-units of eukaryotic translation initiation factor(eIF2B?,?,?,?and?) respectively.eIF2B is essential for the protein translation initiation process,and its action is realized via eukaryotic translation initiation factor2(eIF2).Phosphorylation of eIF2?and eIF2B?is an important way to regulate eIF2B function,and thus play a key role in control of the protein translation level under physiological cond ition.Mutant eIF2B results in functional defects and decrease of the overall protein translation in cells,but in increase the translation of proteins with multiple upstream open read ing frames,such as activating transcription factor 4(AFT4),which leads to the susceptibility to un-folded protein response under stress,and the following apoptosis.The exact pathogenic mechanisms ofVWM are far from well understood.I′ts sugges-ted that level ofAFT4 in cells with eIF2B mutations is higher than in wild type cells under physiological cond ition,which makes the mutant cellsmore susceptible to endoplasm ic reticulum(ER) stress and un-folded protein response(UPR).Under stress,the defect eIF2B leads to a vicious cycle ofUPR activa-tion,which may underlie the neurological aggravation in VWM patients afterm inor stress,a specific cli-nical feature ofVWM.E lucidating the pathogenesis ofVWM will be helpful to further understand the pro-tein translation process in eukaryotic cells,and provide a clue for possible therapeutic targets and treat-ment strategies in the future.