Cutaneous porphyria in a neonate with tyrosinaemia type 1.

UNLABELLED: A term infant born to consanguineous parents presented at birth with hypoglycaemia, thrombocytopenia, coagulopathy and hyperbilirubinaemia associated with polycythaemia due to delayed cord clamping. Despite phototherapy and correction of polycythaemia by partial exchange transfusion, coagulopathy, hypoglycaemia and conjugated hyperbilirubinaemia persisted, suggesting hepatic failure. Metabolic work-up led to the diagnosis of tyrosinaemia type 1 on day 4. Two--(2-nitro-4-trifluoromethylbenzoyl)--1,3 cyclohexanedione (NTBC) treatment, started on day 5, resulted in progressive clinical improvement and unambiguous biochemical response. Severe skin purpuric lesions occurred in areas exposed to phototherapy. These resolved slowly after its discontinuation. Urine analysis sampled just before and 6 days after starting NTBC treatment showed high levels of type 1 coproporphyrin isomers. Such findings do not seem directly related to tyrosinaemia type 1 where succinylacetone inhibits delta-aminolevulinic acid (delta-ALA) dehydratase and where the accumulation of delta-ALA results in neurotoxicity without photosensitivity. CONCLUSION: We describe a cutaneous form of porphyria in a neonate presenting with severe liver failure due to tyrosinaemia type 1. This porphyria is tentatively attributed to a secondary accumulation of coproporphyrins due to cholestasis, as reported in the bronze baby syndrome and recently described in neonates with purpuric phototherapy-induced eruption, rather than to a primary defect of porphyrin metabolism. The hypothesis of a direct effect of tyrosinaemia type 1 on porphyrin excretion is also discussed.

Temporal distortion products (kernel slices) evoked by maximum-length-sequences in auditory neuropathy: evidence for a cochlear pre-synaptic origin.

When special pseudo-random stimuli sequences (maximum length sequences: MLS) are combined with a deconvolution analysis technique, it is possible to derive new evoked potential components that are called kernels. The kernels give a measure of the temporal interactions that take place between the responses to successive stimuli. This may provide an objective neurophysiological test for the exploration of a dimension of hearing which has hitherto been limited to psychophysical methods. Until now, auditory short-latency kernels obtained by the MLS method have been related to the late portion of the brainstem auditory evoked potential (BAEP), suggesting that temporal interactions occur rather late in the auditory pathways. We report 4 children without any BAEP neural components, who all retained isolated cochlear microphonic potentials. Three of them produced click-evoked otoacoustic emissions and two of them demonstrated only moderately impaired audiometric thresholds. This combination of absent BAEP neural components with preserved otoacoustic emissions and cochlear microphonic potential corresponds to a peculiar pattern of auditory dysfunction recently coined "auditory neuropathy'. All 4 children exhibited well-defined kernels at latencies consistent with the microphonic potential. These data indicate that the cochlea itself can generate kernels at a presynaptic level. They open up the question of the identification of the physiological site(s) responsible for the generation of MLS-evoked kernels.

Auditory neuropathy: a report on three cases with early onsets and major neonatal illnesses.

We report 3 children without any brainstem auditory evoked potential (BAEP) neural component who all retained isolated cochlear microphonic potentials as well as click-evoked otoacoustic emissions. Two of them demonstrated only moderately impaired audiometric thresholds. These features correspond to a peculiar pattern of auditory dysfunction recently coined "auditory neuropathy'. In contrast with the published previous cases of auditory neuropathy presenting with an acquired hearing deficit as children or young adults, all 3 children had a history of major neonatal illness and the auditory neuropathy was already demonstrated in the first months of their lives.

Maternal diabetes and fetal malformations: a case associating cardiovascular, facial and skeletal malformations.

Maternal diabetes is known to be a condition associated with a high frequency of fetal malformations. However, pathogenic factors for these malformations and their possible classification into different entities are not yet well established. We present the case of an infant born to a diabetic mother and affected by several malformations. This report consolidates different hypotheses put forward in recent years.

Erythroblastopenia associated with methylmalonic aciduria. Case report and in vitro studies.

Various cytopenias, including neutropenia, thrombocytopenia and pancytopenia, have been reported in association with inborn errors of branched amino acid metabolism. We report here on a case of anemia associated with erythroblastopenia-that is less frequent in this context-in a neonate with methylmalonic aciduria. We used a semisolid erythroid culture system to investigate the effect on in vitro erythropoiesis of organic acids found in excess in this patient: methylmalonic (MMA) and propionic (PA) acids. First, the addition of 10% serum of the patient to a normal bone marrow progenitor culture suppressed the erythrocyte colony-forming unit growth in comparison to a pool of normal serum, while the addition of a 1:1 mixture of normal and patient serum resulted in an intermediate inhibition. MMA, when added to culture medium, resulted in a moderate inhibition of erythropoiesis only at a higher concentration than observed in our patient or reported in other cases. Conversely, PA showed an inhibitory effect at a concentration commonly observed in methylmalonic aciduria. The same effect was observed when the cells were in the presence of PA only for 72 h and then secondly plated in semisolid culture. Neither MMA nor PA showed any effect on the cell number and viability after a 3-, 4- or 7-day incubation except at the highest concentration tested.

Structural and functional importance of the C-terminal part of the pulmonary surfactant polypeptide SP-C.

A synthetic non-palmitoylated form of the pulmonary surfactant protein SP-C and three peptides of different lengths corresponding to its N-terminal and middle parts were reconstituted into dipalmitoylglycerophosphocholine/phosphatidylglycerol (7:3, by mass) lipid bilayers. The adsorption properties of each reconstituted system were determined by measurement of the surface pressure after injection of the samples underneath an air/water interface. Attenuated total reflection infrared spectroscopy provided information about the structure and orientation of peptides in lipid bilayers. The hydrophobic C-terminal helix is crucial for the rapid adsorption as shortening of the C-terminal part drastically restricted this activity. The C-terminal amino acid sequence can however be replaced with that of the second transmembrane helix of bacteriorhodopsin without significantly modifying the adsorption properties. The data suggest that the hydrophobic C-terminal part allows the anchorage of SP-C in the lipid bilayer in such a manner that the N-terminal domain adopts an optimal conformation and orientation for the rapid adsorption of phospholipids at the air/water interface, and/or that a membrane-spanning helix as such is needed for this activity.

Early MR detection of cortical and subcortical hypoxic-ischemic encephalopathy in full-term-infants.

Four observations illustrate the potential of MR imaging in the early depiction of multiple types of neuropathologic lesions which may coexist in the full-term newborn, upon severe hypoxic-ischemic encephalopathy (HIE). In particular, diffuse, postnatal involvement of cerebral cortex and subcortical white matter (WM) is demonstrated. Cortical hyperintensity on both proton-density- and T1-weighted images is probably related to cellular necrosis which is distributed diffusely or parasagittally. Hyperintense, frontal, subcortical WM edging on proton-density-weighted images results from the increase of water concentration, induced either by infarct or by edema. Diffuse WM areas of low intensity on T1-weighted images and of high intensity on T2-weighted images are presumably related to cytotoxic and/or vasogenic edema, proportional to the underlying damaged tissues. On follow-up MR examinations, several months later, the importance of cortical atrophy and of the myelination delay appeared related to the importance of the lesions detected during the postnatal period.

Idiopathic infantile arterial calcification: a surviving patient with renal artery stenosis.

Idiopathic infantile arterial calcification (IIAC) is a rare hereditary, fatal disease. Death occurs usually within the first 28 months of life. IIAC is characterized by calcifications along the internal elastic membrane and proliferation of the intimal layer of muscular arteries. Specific therapy consists of administration of diphosphonates, but its effectiveness has been a matter of controversy. We report a case treated with diphosphonates which has had an unusual outcome.

Secondary structure and orientation of the surfactant protein SP-B in a lipid environment. A Fourier transform infrared spectroscopy study.

Attenuated total reflection Fourier transform infrared spectroscopy was used to investigate the secondary structure of the surfactant protein SP-B. Nearly half of the polypeptide chain is folded in an alpha-helical conformation. No significant change of the secondary structure content was observed when the protein is associated to a lipid bilayer of dipalmitoylphosphatidylcholine (DPPC)/phosphatidylglycerol (PG) or of dipalmitoylphosphatidylglycerol (DPPG). The parameters related to the gamma w(CH2) vibration of the saturated acyl chains reveal no modification of the conformation or orientation of the lipids in the presence of SP-B. A model of orientation of the protein at the lipid/water interface is proposed. In this model, electrostatic interactions between charged residues of SP-B and polar headgroups of PG, and the presence of small hydrophobic alpha-helical peptide stretches slightly inside the bilayers, would maintain SP-B at the membrane surface.

Modifications of surfactant phospholipid pattern in premature infants treated with curosurf: clinical and dietary correlations.

Neonatal respiratory distress syndrome (RDS) is characterized by an immature surfactant phospholipid pattern. We aimed to study the evolution of surfactant phospholipids over a 6-day period, before and after surfactant replacement therapy with Curosurf, and to investigate possible interactions with exogenous phospholipids administered during total parenteral nutrition (TPN). Seventeen premature infants with RDS were randomly assigned to receive TPN with lipids or without (glucose group). Both groups showed a similar evolution of the surfactant phospholipids. At day 6, the surfactant composition had changed towards a mature human surfactant pattern except for phosphatidylglycerol which remained low (1%), compensated for by a high phosphatidylinositol and phosphatidylserine proportion (13.3%), Phospholipid subcomponents in plasma remained unchanged in both groups. Plasma total cholesterol (151 +/- 18 vs. 113 +/- 6 mg/dl, p less than 0.05) and cholesteryl esters (172 +/- 20 vs. 113 +/- 9 mg/dl, p less than 0.01) were higher in the glucose than in the lipid group. Total calorie intake was significantly higher in the lipid group (85 +/- 4 vs. 64 +/- 6 kcal/kg.day, p less than 0.01).

Structure and orientation of the surfactant-associated protein C in a lipid bilayer.

The secondary structure of native and depalmitoylated porcine surfactant-associated protein C (SP-C) was studied by attenuated total reflection Fourier-transform infrared spectroscopy. Both forms of porcine SP-C adopt mainly an alpha-helical conformation. These two forms of the protein were reconstituted in a lipid bilayer. The insertion of the protein in a membrane is associated with an increase of the alpha-helical content. Dichroic measurements show that, in both cases, the long axis of the alpha-helix is oriented parallel to the lipid acyl chains.

Carnitine deficiency with cardiomyopathy presenting as neonatal hydrops: successful response to carnitine therapy.

A small-for-date infant presented at birth with severe non-immune hydrops, cardiac failure, metabolic acidosis and hypoglycaemia. Ultrasonography disclosed a cardiomyopathy. Initial therapy consisting of artificial ventilation, inotropes and diuretics resulted in partial disappearance of oedema without significant improvement in cardiac function. Episodes of hypoglycaemia recurred despite continuous glucose infusions. Total serum carnitine from cord blood was 1.65 nmoles/ml and was undetectable on day 20. Oral DL-carnitine supplements resulted in normoglycaemia, dramatic improvement in cardiac function and restoration of serum carnitine levels to normal values. The infant was thereafter maintained on carnitine therapy. Follow-up over 1 year showed moderate growth retardation and normal developmental milestones. In order to account for such a severe neonatal presentation of carnitine deficiency, a combination of defective pre- and postnatal carnitine supply with an inborn error of carnitine handling is considered. The present case illustrates the need for evaluation of carnitine status in fetuses and neonates presenting with hydrops associated with cardiac failure.

Fatal ureaplasma infection in second twin born 60 days after delivery of the first in a patient with recurrent spontaneous abortion--a case report.

A delay of more than one month between the birth of twins is an unusual occurrence presenting the obstetrician and the neonatalogist with many questions regarding the management of the case. There is the risk of prematurity for the second twin as labor has already occurred in the pregnancy. There is also a risk of infection to both mother and fetus during the interval between the two deliveries, since the stump of the first twin's cord may precipitate ascending colonization from vagina and cervix. Germs frequently recovered from the vagina e.g. Ureaplasma urealyticum, are associated with prematurity. The latter has also been responsible for lethal interstitial pneumonia in the neonate. We present a case of a patient who though she delivered twice normally, had suffered 4 first trimester abortions and one late abortion, all spontaneous. Her eighth pregnancy was a twin pregnancy. She underwent a cerclage at 14 weeks, but went into labor at 17 weeks, when she delivered the first macerated twin. She was then treated with fenoterol and ampicillin; nevertheless she delivered twin the second at 26 weeks. This 750 g baby-girl presented with severe respiratory distress. Repeated chest X rays showed perihilar infiltrates which became nodular. All cultures were negative. At the end of the first week, when her condition was considered satisfactory, she deteriorated dramatically and died in respiratory failure and DIC. Tracheal aspirates were positive for Ureaplasma urealyticum.

[Periarteritis nodosa in children. Diagnostic difficulties in 2 cases]. / Périartérite noueuse chez l'enfant. Difficultés diagnostiques dans 2 cas.

Periarteritis nodosa is a rare multisystemic disease whose diagnosis is difficult: diagnostic approach by biopsies in various involved organs is of poor efficacy; abdominal selective angiography yields a precise diagnosis in 50 to 60 of the studied cases as far as the celiac, mesenteric and renal circulations are investigated selectively. Digitalized intravenous angiography (DIVA) carried out in two patients of 9 and 13 years of age allowed to demonstrate aneurysm formations in hepatic, renal and cerebral circulations. Its true efficacy in the diagnosis of periarteritis nodosa of children remains to be determined.