Severe infantile type of carnitine palmitoyltransferase II (CPT II) deficiency due to homozygous R503C mutation.

We report a patient with severe infantile carnitine palmitoyltransferase II (CPT II) deficiency who died at the age of 3 months. Genetic analysis of the CPT2 gene revealed that the patient was homozygous, and her parents were heterozygous, for a R503C missense mutation. Heterozygosity for R503C, without a second mutation, has previously been reported in symptomatic patients from two families, one with the mild adult myopathic form and one with malignant hyperthermia. In contrast, the R503C heterozygous parents of the patient were entirely asymptomatic, suggesting that additional genetic and/or environmental factors must have contributed to the occurrence of symptoms in previously reported carriers. Our findings indicate that the mutation R503C should be added to the handful of mutations associated with the severe phenotype when present in the homozygous state or combined with another severe mutation.

TAT gene mutation analysis in three Palestinian kindreds with oculocutaneous tyrosinaemia type II; characterization of a silent exonic transversion that causes complete missplicing by exon 11 skipping.

Deficiency of the hepatic cytosolic enzyme tyrosine aminotransferase (TAT) causes marked hypertyrosinaemia leading to painful palmoplantar hyperkeratoses, pseudodendritic keratitis and variable mental retardation (oculocutaneous tyrosinaemia type II or Richner-Hanhart syndrome). Parents may therefore seek prenatal diagnosis, but this is not possible by biochemical assays as tyrosine does not accumulate in amniotic fluid and TAT is not expressed in chorionic villi or amniocytes. Molecular analysis is therefore the only possible approach for prenatal diagnosis and carrier detection. To this end, we sought TAT gene mutations in 9 tyrosinaemia II patients from three consanguineous Palestinian kindreds. In two kindreds (7 patients), the only potential abnormality identified after sequencing all 12 exons and exon-intron boundaries was homozygosity for a silent, single-nucleotide transversion c.1224G > T (p.T408T) at the last base of exon 11. This was predicted to disrupt the 5' donor splice site of exon 11 and result in missplicing. However, as TAT is expressed exclusively in liver, patient mRNA could not be obtained for splicing analysis. A minigene approach was therefore used to assess the effect of c.1224G > T on exon 11 splicing. Transfection experiments with wild-type and c.1224G > T mutant minigene constructs demonstrated that c.1224G > T results in complete exon 11 skipping, illustrating the utility of this approach for confirming a putative splicing defect when cDNA is unavailable. Homozygosity for a c.1249C > T (R417X) exon 12 nonsense mutation (previously reported in a French patient) was identified in both patients from the third kindred, enabling successful prenatal diagnosis of an unaffected fetus using chorionic villous tissue.

D-2-hydroxyglutaric aciduria and glutaric aciduria type 1 in siblings: coincidence, or linked disorders?

Glutaric aciduria type 1 (GA1) and D-2-hydroxyglutaric aciduria ( D-2-HGA) are cerebral organic acidurias characterized by the excretion of 3-hydroxyglutaric and D-2-hydroxyglutaric acids, respectively. GA1 is caused by a deficiency of glutaryl-CoA dehydrogenase encoded by the GCDH gene; the biochemical and genetic basis of D-2-HGA is unknown. We diagnosed GA1 in the son of consanguineous Palestinian parents, and D-2-HGA in his sister and brother. All three siblings were neurologically and developmentally normal. A small but abnormal increase in excretion of D-2-hydroxyglutaric acid was also found in the sibling with GA1. These observations suggested a possible pathophysiological link between these two disorders. The sibling with GA1 was homozygous whilst his siblings with D-2-HGA were heterozygous for a 1283 C>T missense mutation (T416I) in exon 11 of the GCDH gene. However, sequence analysis of the GCDH gene in 8 additional unrelated patients with D-2-HGA and 3 with combined D/ L-2-HGA did not reveal any pathogenic mutations. The biochemical and genetic basis of D-2-HGA remains to be determined.

Identification of a common mutation (Gly194Cys) in both Arab Moslem and Ashkenazi Jewish patients with dihydrolipoamide dehydrogenase (E3) deficiency: possible beneficial effect of vitamin therapy.

Dihydrolipoamide dehydrogenase (E3) deficiency with a clinical phenotype and genotype (Gly194Cys homozygous) previously identified only in Ashkenazi Jewish patients, was diagnosed in two Palestinian Arab siblings and two unrelated Ashkenazi Jewish patients. While three of the four patients died in childhood without specific treatment, the surviving patient at age 18 years may have benefited from long-term daily supplementation with a cocktail of riboflavin, biotin, coenzyme Q and carnitine.

Phenotype and genotype variation in primary carnitine deficiency.

PURPOSE: Primary carnitine deficiency is an autosomal recessive disorder of fatty acid oxidation resulting from defective carnitine transport. This disease is caused by mutations in the carnitine transporter gene SLC22A5. The objective of this study was to extend mutational analysis to four additional families with this disorder and determine whether recurrent mutations could be found. METHODS: The SLC22A5 gene encoding the OCTN2 carnitine transporter was sequenced, and the missense mutations identified were expressed in Chinese hamster ovary (CHO) cells. RESULTS: DNA sequencing revealed four novel mutations (Y4X; dup 254-264, 133X; R19P; R399Q). Alleles introducing premature STOP codons reduced the levels of OCTN2 mRNA. Carnitine transport in CHO cells expressing the R19P and R399Q mutations was reduced to < 5% of normal. The 133X mutation was found in two unrelated European families. Two patients within the same family, both homozygous for the same mutation (R399Q) had completely different clinical presentation. CONCLUSIONS: Heterogeneous mutations in the SLC22A5 gene cause primary carnitine deficiency. Different presentations are observed even in children with identical mutations.

[Criteria of bistability of the cylindrical dendrite with the variable negative slope of the N-shaped current-voltage membrane characteristic]. / Uslovie bistabil'nosti tsilindricheskogo dendrita s peremennoi krutiznoi otritsatel'nogo naklona N-obraznoi vol't-ampernoi kharakteristiki membrany.

The criteria for hystheresis in the input current-voltage relation of a cylindrical dendrite, i.e. cable bistability, were studied earlier in case of the constant negative slope of the N-shaped membrane current-voltage characteristic. For a membrane with a variable negative slope of the current-voltage characteristic, only sufficient conditions of dendritic bistability were formulated: [equation: see text], where df/dV/h is the negative slope of the membrane current-voltage characteristic at zero current point, h; X is the electrotonic length of the dendrite. We propose to use as the necessary condition of bistability the above equation but with the maximal value of the negative slope df/dV/max instead of df/dV/h. Calculations illustrate that this necessary condition, with acceptable accuracy, can be used as the necessary and sufficient condition of the cable bistability when the N-shaped current-voltage characteristic of the membrane is arbitrary.

Electrotonic structure of motoneurons in the spinal cord of the turtle: inferences for the mechanisms of bistability.

Understanding how voltage-regulated channels and synaptic membrane conductances contribute to response properties of neurons requires reliable knowledge of the electrotonic structure of dendritic trees. A novel method based on weak DC field stimulation and the classical method based on current injection were used to obtain two independent estimates of the electrotonic structure of motoneurons in an in vitro preparation of the turtle spinal cord. DC field stimulation was also used to ensure that the passive membrane properties near the resting membrane potential were homogeneous. In two cells, the difference in electrotonic lengths estimated with the two methods in the same cell was 6 and 9%. The majority of dendritic branches terminated at a distance of 1 electrotonic unit from the recording site. The longest branches reached 2 lambda. In the third cell, the difference was 36%, demonstrating the need to use both methods, field stimulation and current injection, for reliable measurements of the electrotonical structure. Models of the reconstructed cells endowed with voltage-dependent conductances were used to explore generation mechanisms for the experimentally observed hysteresis in input current-voltage relation of bistable motoneurons. The results of modeling suggest that only some dendrites need to possess L-type calcium current to explain the hysteresis observed experimentally and that dendritic branches with different electrotonical lengths can be bistable. Independent bistable behavior in individual dendritic branches can make motoneurons complex processing units.

Prolidase deficiency among an Israeli population: prenatal diagnosis in a genetic disorder with uncertain prognosis.

Prolidase deficiency is an autosomal recessive disorder that is characterized by considerable inter- and intrafamilial variability in its clinical presentation, ranging from asymptomatic to severe and fatal illness. We report here, for the first time, prenatal diagnosis of prolidase deficiency in a family whose first child was severely affected since birth and died at an early age. However, unexpectedly, the parents decided to continue the second pregnancy, which produced a full-term, healthy-appearing baby. The diagnosis of severe prolidase deficiency was confirmed in the baby's leukocytes. At age 4 months the baby is asymptomatic. Since the clinical severity of the disorder cannot be predicted, genetic counselling remains problematic despite the feasibility of prenatal diagnosis.

Methylenetetrahydrofolate reductase deficiency: importance of early diagnosis.

Methylenetetrahydrofolate reductase deficiency is the most common inborn error of folate metabolism and should be suspected when homocystinuria is combined with hypomethioninemia. The main clinical findings are neurologic signs such as severe developmental delay, marked hypotonia, seizures, microcephaly, apnea, and coma. Most patients present in early life. The infantile form is severe, with rapid deterioration leading to death usually within 1 year. Treatment with betaine has been shown to be efficient in lowering homocysteine concentrations and returning methionine to normal, but the clinical response is variable. We report two brothers with methylenetetrahydrofolate reductase deficiency: the first was undiagnosed and died at 8 months of age from neurologic deterioration and apnea, while his brother, who was treated with betaine from the age of 4 months, is now 3 years old and has developmental delay.

Effects of the supine and prone position on diaphragm thickness in healthy term infants.

BACKGROUND: The physiological basis underlying the decline in the incidence of sudden infant death syndrome (SIDS) associated with changing the sleep position from prone to supine remains unknown. AIMS: To evaluate diaphragm thickness (t(di)) and shortening in healthy term infants in the prone and supine positions in order to determine whether changes in body position would affect diaphragm resting length and the degree of diaphragm shortening during inspiration. METHODS: In 16 healthy term infants, diaphragm thickness at the level of the zone of apposition on the right side was measured using ultrasonography. Heart rate (HR), breathing frequency (f), and transcutaneous oxyhaemoglobin saturation (SaO(2)) were recorded simultaneously during diaphragm imaging with the infants in the supine and prone positions during quiet sleep. RESULTS: At end expiratory (EEV) and at end inspiratory lung volumes (EIV), t(di) increased significantly in the prone position. The change in t(di) during tidal breathing was also greater when the infant was prone. SaO(2), HR, and f were not significantly different at EEV and at EIV in both positions. CONCLUSION: In healthy term infants, placed in the prone position, the diaphragm is significantly thicker and, therefore, shorter, both at EEV and EIV. Diaphragm shortening during tidal breathing is greater when the infant is prone. In the prone position, the decreased diaphragm resting length would impair diaphragm strength, and the additional diaphragm shortening during tidal breathing represents added work performed by the diaphragm. This may compromise an infant's capacity to respond to stressful situations when placed in the prone position and may contribute to the association of SIDS with prone position.

Familial mitochondrial intestinal pseudo-obstruction and neurogenic bladder.

Intestinal dysmotility and neurogenic bladder have been described as part of two autosomal-recessive mitochondrial disorders assumed to be due to a defect in communication between the nuclear and mitochondrial genomes: myoneurogastrointestinal encephalopathy (MNGIE) and diabetes insipidus, diabetes mellitus, optic atrophy, and deafness (Wolfram syndrome). Partial cytochrome c oxidase deficiency has been described in both. We describe three Ashkenazi Jewish siblings with progressive intestinal dysmotility, neurogenic bladder, and autonomic manifestations but no central nervous system involvement. Cytochrome c oxidase deficiency was demonstrated in peripheral and multiple intestinal muscle biopsies. Mitochondrial DNA analysis of an intestinal biopsy of patient 1 showed heteroplasmy consisting of a normal 16.5-kb band and an approximately 28-kb band, suggestive of a duplication. Mitochondrial DNA analysis of a muscle biopsy of patient 2 showed multiple deletions, mainly 10- and 11-kb bands. We suggest that this unique combination of intestinal pseudo-obstruction and neurogenic bladder could comprise a new autosomal-recessive mitochondrial disorder.

[The branching structure of the bistable dendrite]. / Vetviashchaiasia struktura bistabil'nogo dendrita.

A branching structure consisting of three bistable cylindrical branches was considered. Both stable and unstable solutions for the voltage distribution in such a structure, were obtained using the method developed in our laboratory. This made it possible to calculate the input current-voltage characteristic of the bistable branching structure, including unstable segments of this characteristic. Possible stable states of the structure when its proximal end is loaded by a resistance were determined. It is shown that the binary exclusive-OR could be accomplished by the elementary branching structure of a bistable dendrite. A model with overexcitation carried out by Ca-dependent K channels was developed. It is shown that the model parameters do not fall outside the physiological range of values.

Neurologic presentations of mitochondrial disorders.

This article describes the neurologic presentations of children with mitochondrial disorders. The charts of 42 children with highly suspect mitochondrial disorders were reviewed. Thirty-seven children were diagnosed as having definite mitochondrial disorders based on a suggestive clinical presentation and at least one accepted criteria, while in five patients the diagnosis remained probable. All patients had nervous system involvement, but it was the presenting symptom in 28 of 42. Eighteen children had normal intelligence and 24 had mental retardation or developmental delay at the onset of their disease. Twenty-five patients had either an acute regression or a progressive encephalopathy. The most frequent neurologic manifestations were abnormal tone, seizures, extrapyramidal movements, and autonomic dysfunction. The eyes were involved in 11 children. Nerve deafness was found in seven patients. Myopathy was found in only six patients. In conclusion, a complex neurologic picture, especially with other organ involvement, warrants a full mitochondrial evaluation.

Detection of inhomogeneities in membrane ohmic resistance in geometrically complex systems.

DC field-evoked transients in arbitrarily shaped neurons and syncytia were analyzed theoretically. In systems with homogeneous passive membrane properties, the transients develop much faster than the membrane discharges. Conductance of the proximal membrane could be larger due to the injury imposed by sharp electrode impalement. In this case, the transients have an overshoot and an undershoot when the field is switched on and off. The overshoot and undershoot decay with the time constant of the response to current injection. If the conductance of the distal membrane is larger, the fast transients develop only partially and have slow tails which decay according to the time constant of the response to current injection. We recorded DC field-evoked potentials in motoneurons in turtle spinal cord slices by sharp electrodes and in the whole-cell mode. All three theoretically predicted types of responses were observed. The sharp electrodes were found not to impose a shunt in 60% of recorded cells. Detection of various membrane inhomogeneities in 1D-syncytium is discussed. We also suggest that it is possible to detect the inhomogeneities in intercellular resistance of the syncytium and intracellular resistance of a neuron when the membrane passive properties are homogeneous.

[Adiabatic solution of the Ohmic cable equation. General theory, homogeneous cylindrical fiber]. / Adiabaticheskoe reshenie uravneniia omicheskogo kabelia. Obshchaia teoriia, odnorodnoe tsilindricheskoe volokno.

An adiabatic solution of the Ohmic cable equation is suggested, which reduces the non-stationary equation to a stationary form. The adiabatic length constant of the stationary equation is time-dependent. The adiabatic solutions for the boundary conditions that change in time linearly and exponentially were studied. In the latter case, the adiabatic length constant does not depend on time though it differs from the usual length constant. The cable input characteristics of exact and adiabatic solutions were compared in the cases of the voltage- and current-clamp, and electric field stimulation. The adiabatic and exact solutions are identical for the rising exponential stimuli. For the falling exponential stimuli, the adiabatic solution determines the exact asymptotic solution if the stimulus decays slower than the relaxation of initial conditions. It is propose to use linear and exponential ramp stimulation in electrotonic measurements.

[Adiabatic solution for the Ohmic cable equation. An homogeneous cell, prospects for electronic measurements]. / Adiabaticheskoe reshenie uravneniia omicheskogo kabelia. Odnorodnaia kletka, vozmozhnosti dlia élektronicheskikh izmerenii.

Exact and adiabatic electrotonic solutions [1] were calculated for reconstructed motoneurone and hippocampal interneurone in case of linear and exponential ramp stimulation by the fixed current, potential or homogenous electric field. For the rising exponential ramp the solutions are identical. In case of the decaying exponent the adiabatic solution becomes an asymptote for the exact one if the stimulus decays slower than relaxation of the initial conditions in the cell. If the stimulus decays faster, the asymptote is the current or potential axis, depending on the stimulation mode. For electrotonically short cell, the exact solution approaches the asymptote faster. The solution for the exponentially rising field does not depend on the dendritic tree configuration and depends only on the effective electrotonic length of the neurone. It could be useful to apply ramp stimulation, especially exponential ramp of the electric field, to estimate electrotonic parameters of cells.

Urinary organic acid screening in children with developmental language delay.

The prevalence of 3-methylglutaconic aciduria was evaluated among children with developmental language disorders. A urine specimen was obtained from 40 children referred for developmental language delay to the Tel-Aviv Child Development Center during 12/96-6/97 and from 50 age-matched controls. Urine organic acids were analysed by gas chromatography-mass spectrometry. Urinary 3-methylglutaconic acid was quantified. A mildly increased excretion of 3-methylglutaconic acid was found in 8 children with developmental language delay. The combined excretion of 3-methylglutaconic and 3-methylglutaric acid was increased in 9 patients. There were no differences in the excretion of other organic acids. The patients with elevated 3-methylglutaconic acid did not differ from the other patients with developmental language disorders in any of the parameters evaluated. Mildly elevated urinary levels of 3-methylglutaconic acid may be a marker of a still undefined metabolic disorder presenting with developmental language delay. A further study in large groups of children with different developmental disorders is mandatory.

Multiple presentation of mitochondrial disorders.

The aim of this study was to assess the heterogeneous clinical presentations of children with mitochondrial disorders evaluated at a metabolic neurogenetic clinic. The charts of 36 children with highly suspected mitochondrial disorders were reviewed. Thirty one children were diagnosed as having a mitochondrial disorder, based on a suggestive clinical presentation and at least one of the accepted laboratory criteria; however, in five children with no laboratory criteria the diagnosis remained probable. All of the patients had nervous system involvement. Twenty seven patients also had dysfunction of other systems: sensory organs in 15 patients, cardiovascular system in five, gastrointestinal system in 20, urinary system in four, haematopoietic system in four, and endocrine system in nine. The clinical presentation was compatible with an established syndrome in only 15 children. Severe lactic acidosis or ragged red muscle fibres were encountered in very few patients. These results suggest that mitochondrial disorders should be evaluated in children presenting with a complex neurological picture or multisystem involvement.