Tripeptidil peptidasa 1 en pacientes con ceroidolipofuscinosis neuronal infantil tardía / Tripeptidyl peptidase 1 in patients with late infantile neuronal ceroid lipofuscinosis

Introducción: Las ceroidolipofuscinosis neuronales (CLN) representan un grupo de enfermedades lisosomales hereditarias de herencia autosómica recesiva, de presentación más frecuente durante la niñez, caracterizadas neuropatológicamente por acumulación de lipopigmentos autofluorescentes en los lisosomas de neuronas y otras células. Clínicamente se presentan con pérdida de las habilidades psicomotoras adquiridas, incoordinación motora, ataxia, pérdida de la visión, cambios de conducta, convulsiones de difícil tratamiento asociadas a mioclonías y una corta expectativa de vida. En la actualidad, se conocen 10 formas genéticamente distintas de esta enfermedad, entre ellas la forma infantil tardía donde las manifestaciones clínicas aparecen entre el segundo y cuarto año de vida. El gen responsable de la enfermedad es el TPP1 ubicado en 11p15 y codifica la enzima tripeptidil peptidasa 1. Pacientes y métodos: Se estandarizó la técnica para el diagnóstico enzimático de la ceroidolipofuscinosis neuronal infantil tardía a través de sangre seca en papel de filtro en 76 individuos sanos en edad preescolar y adulta de población venezolana. La actividad enzimática de la TPP1 fue determinada en 9 pacientes con diagnóstico clínico de ceroidolipofuscinosis infantil tardía 2 (CLN2). Resultados: Seis pacientes mostraron valores de actividad muy por debajo del rango establecido (0,11-0,45 nmol/mancha) para los controles sanos en edad preescolar, confirmando el diagnostico enzimático. Tres de los 14 padres estudiados presentaron valores en el rango de heterocigotos. Conclusiones: El diagnóstico enzimático de CLN2 a través de la determinación de la actividad enzimática de la enzima TPP1 mediante la técnica de sangre seca en papel de filtro permite un diagnóstico rápido, sencillo, económico y confiable(AU)

Introduction: Neuronal ceroid lipofuscinoses are a group of inherited autosomal recessive lysosomal diseases, most commonly found in infancy. These are neuropathologically characterised by accumulation of an autofluorescent lipopigment in neurons and other cells. This condition is clinically characterised by loss of motor and cognitive skills, lack of motor coordination, ataxia, progressive visual impairment, behavioural changes; seizures of difficult to manage seizures, particularly myoclonic, and premature death. Ten clinical forms have been described, one of which is late infantile where clinical signs begin between two and four years. The gene responsible for this disease is located at 11p15 locus, and the enzyme encoded by this gene is the tripeptidyl peptidase 1. Patients and methods: We standardised the technique for the enzymatic diagnosis of late infantile neuronal ceroid lipofuscinoses from dried blood on filter paper card in 76 healthy individuals adults and children in order to establish a normal range in the Venezuelan population. The tripeptidyl peptidase activity was also determined in 9 patients with a clinical diagnosis of late infantile neuronal ceroid lipofuscinoses. Results: Six of the samples showed activity lower than the lowest control value (0.11 to 0.45 nmol/spot) from healthy controls of infantile age, confirming the enzymatic diagnosis. Three of the 14 parent samples analysed showed values in the heterozygote ranges. Conclusions: The enzymatic diagnosis of late infantile neuronal ceroid lipofuscinoses from dried blood on filter paper card is a rapid, easier, less expensive and accurate molecular diagnosis tool(AU)

[Clonal chromosome abnormalities in malignant hematological diseases using fluorescence in situ hybridization]. / Anormalidades cromosómicas clonales en enfermedades hematológicas malignas mediante FISH.

Fluorescent in situ hybridization (FISH) is a rapid, sensitive and reliable method for the identification of complete chromosomes, or segments of them, during metaphase or nuclear interphase. The present study shows the results of the analysis of 32 bone marrow aspirates from patients with malignant hematological diseases (11 AML, 7 ALL, 12 CML and 2 CLL), referred to the Medical Genetics Unit of the Faculty of Medicine, Zulia University, Maracaibo, Venezuela between 1994 and 1996. All samples were studied by conventional and molecular techniques (FISH), using probes of total chromosomes, alpha-satellites and locus specific. In patients with AML and ALL and FISH technique detected clonal chromosomal abnormalities, that were not found by the conventional cytogenetic technique. Furthermore, the PML-alpha RARA complex was identified in the promyelocytic acute leukemias. The presence of the molecular complex ABL-BCR was also demonstrated in CML. The present study demonstrates the usefulness of the FISH technique in the detection of clonal chromosomal abnormalities, which are important when considering the clinical care of patients with these pathologies.

[Prenatal diagnosis. II. Importance of ultrasonographic markers in prenatal diagnosis of chromosome abnormalities]. / Diagnóstico Prenatal II: importancia de los marcadores ecográficos en el diagnóstico prenatal de cromosomopatías.

The Medical Genetic Unit of the University of Zulia (MGUUZ) has developed a Prenatal Diagnosis Program (PDP) since January-1993, in which Genetic Risk Factors are determined in couples who request prenatal genetic counseling. In this program, different prenatal diagnostic procedures are performed to detect congenital defects during intrauterine life. One of these procedures is the Fetal Sonogram (FS). FS is a non invasive technique which permits the prenatal diagnosis of many genetic dysmorphic syndromes. Through the search of abnormal specific characteristics in the fetus, chromosomopathies may be suspected. These findings are named "Echosonographic Markers of Chromosomal Abnormalities" (EMCA). During three years (January-1993 to December-1996), patients attended in the PDP included 321 pregnant women in which 312 FS were performed. Abnormal outcomes were 22 (17 with isolated congenital malformations and 5 with EMCA). Only one fetus with chromosome abnormality (46,XX21q-) could not be detected by FS. The goals of this paper are: 1) to report 5 patients with sonographic markers suggestive of chromosomal abnormalities and 2) to show the FS usefulness in prenatal diagnosis of chromosompathies. We conclude that, in the search of the EMCA the FS should be offered systematically to all pregnant women without recognizable genetic risk. They are the main group with optimal reproductive age and in consequence, with the possibility of having a relatively major number of conception outcomes with congenital defects, with or without chromosomic etiology. The majority of those defects can be detected by FS and could allow us to select the patients in which the use of an invasive prenatal diagnostic procedure could be justified.

[Diagnosis and management of patients with sex differentiation disorders: experience at the Unit of Medical Genetics of the University of Zulia, Maracaibo, Venezuela]. / Diagnóstico y manejo de pacientes con anormalidades de la diferenciación sexual: experiencia de la Unidad de Genética Médica de la Universidad del Zulia, Maracaibo, Venezuela.

Abnormalities of sexual differentiation (ASD) represent a group of entities, heterogeneous in their etiopathogenesis and clinical manifestations. In order to characterize and analyze the epidemiologic, clinical, endocrine and genetic aspects of patients with ASD consulting UGM-LUZ between 1971-1996, the families that had at least one of its members affected were evaluated. Strict diagnostic criteria to each entity were applied. Cytogenetic, hormonal, radiological, echographic and anatomopathological evaluations were done in each patient. From 391 families, 429 patient consulted with ASD. They represent 5.4% of the patient who consulted to UGM-LUZ in the same period. 214 (50%) patients with definitive diagnosis of ASD were identified to fill the established inclusion criteria. The distribution was the following: 139 with anomalies of the sexual chromosomes; 36 with congenital adrenal hyperplasia; 21 with complete androgen insensitivity syndrome; 14 with mixed gonadal dysgenesis; and 4 with true hermaphroditism. 183 (42.7%) patients with male pseudohermaphroditism and 17 (3.9%) with female pseudohermaphroditism were diagnosed as they did not fulfill the established diagnostic criteria. 15 (3.4%) patients presented ASD associated to a polymalformative syndrome. The ASD are very complex entities, they need the participation of an interdisciplinary team for their diagnosis and management process.

PIP: 429 patients in 391 families consulted the Medical Genetics Unit of the University of Zulia in Maracaibo, Venezuela, from 1971 through 1996 concerning disorders of sexual differentiation. Strict diagnostic criteria were established for each condition. Each patient underwent a cytogenetic study of the peripheral blood, hormonal determinations, ultrasound diagnosis, and anatomic studies. Patients consulting for disorders of sexual differentiation represented 5.4% of all patients in the study period. 214 patients (50%) received definitive diagnoses of disorders of sexual differentiation. 139 received diagnoses of sex chromosome abnormalities, 36 had congenital adrenal hyperplasia, 21 had complete androgen insensitivity syndrome, 14 had mixed gonadal dysgenesis, and 4 had true hermaphrodism. 183 patients (42.7%) had male pseudohermaphrodism and 17 had female pseudohermaphrodism, but did not satisfy the established diagnostic criteria. 15 (3.4%) had disorders of sexual differentiation associated with polymalformative profiles. The disorders represented a significant cause of morbidity in the Medical Genetics Unit. Because of the complexity of the problem, such cases require the services of an integrated multidisciplinary health team.

[Chronic myeloid leukemia. Karyotype changes]. / Leucemia mieloide crónica. Evolución en el cariotipo.

Chronic Myeloid Leukemia (CML) is a clonal disease of bone marrow, citogenetically characterized by the presence of the Philadelphia chromosome (Ph). Additional anomalies in the Ph cromosome have been found during the evolution of CML. This paper will show evidence of cytogenetic abnormalities during the evolution of CML in this region, and its correlation with clinical evolution. 55 samples of bone marrow, 81.3% (45/55) in chronic phase (CP), 12.7% (7/55) in an accelerated phase (AP), and 5.4% (3/55) in blastic phase (BP) were received. In 12/45 patients in CP the karyotype was repeated at least once a year during the evolution of their illness. 9/12 presented the Ph chromosome as a single anomaly at the moment of diagnosis; the other 3 presented a distinct anomaly. 4/9 presented additional abnormalities moving to the stages AP or BP between 4-8 months after initial discovery. 7/10 patients referred in AP or BP presented additional abnormalities in the Ph chromosome. It is evident that the chromosome study of each patient with CML must be carried out at least once a year in order to detect chromosomal abnormalities in addition to the Ph chromosome. Thus, a greater therapeutic control of the disease is possible.

[Leigh's encephalopathy (subacute necrotizing encephalopathy). Documentation of its evolution through neuroimaging]. / Encefalopatía de Leigh (encefalopatía necrotizante subaguda). Documentación de su evolución por neuroimagen.

A 30 months-old boy developed bilateral nistagmus, tremor, gait disturbance, hypotonia and disartria. The diagnose of Leigh encephalopathy was suggested on the basis of clinical, neuroimaging and laboratory findings. Computed tomography and magnetic resonance imaging (MRI) at an early stage revealed bilateral and symmetric lesions in the putamen, appearing as hyperintense signal on T2-weighted images. Twelve months later a relatively large hypertense area in the posterior brainstem was observed. At this stage, the patient exhibited marked deterioration, dystonic manifestations, rigidity and respiratory disturbances. He died 6 months later for respiratory arrest during bronconeumonic infection. We believe MRI is a valuable means to allow assessment of the evolution of the disease.

[Hereditary diseases and congenital malformations at the Unit of Medical Genetics of the University of Zulia. Years: 1983-1992]. / Enfermedades hereditarias y malformaciones congénitas en la Unidad de Genética Médica de la Universidad del Zulia. Años: 1983-1992.

The Medical Genetics Unit at Universidad del Zulia (UGM-LUZ) gives counsel to patients with partial and total genetic diseases. Counseling is available for patients of both sexes and all ages, from public and private health centers and several medical specialities. In the present study an analysis of 4617 clinical records from families referred for genetic counseling to the UGM-LUZ is given. The study spans from January 1983 to December 1992. Fifty four (1.2%) of these histories correspond to pre-nuptial counseling, 773 (16.7%) pre-conceptional, 316 (6.8%) pre-natal and 3474 (75.3%) for diagnosis. A computerized system was developed, based on relational data base manager, that permits access with interactive Dbase type applications. A total of 5433 diagnoses were made. The most frequent causes of genetic diseases were chromosomal abnormalities (12.32%), mainly Down and Turner syndromes. Mendelian diseases occupied 14.45% of all cases, with Marfan and Noonan syndrome, Osteogenesis imperfecta. Duchenne-Becker muscular dystrophy and Incontinentia Pigmenti as the most frequent syndromes. Diseases that involve multifactorial inheritance, such as neural tube defects, accounted for 7.36% of all diagnosis. Effects of teratogenic agents such as german measles, radiations and others were detected in 3.96% of all cases. In 8.5% of the patients a hereditary factor was suspected. No definitive diagnosis was reached in 32.45% of all cases and 20.96% of the patients were normal. The need for data from other medical genetic centers is stressed. In this way the regional and national genetic diseases on morbidity can be known.

[Application of the high resolution chromosomic technic in patients in high risk of cytogenetic anomalies]. / Aplicación de la técnica de Alta Resolución Cromosómica en pacientes con alto riesgo para anomalías citogenéticas.

Since the beginning of cytogenetics, there has been a constant improvement of chromosomal culture and banding techniques. In 1976, Yunis described a high chromosomal resolution technique (HRC), that permits the detection of subtle chromosomal abnormalities. The present work, reports the results obtained when HRC was applied to the study of chromosomal abnormalities in patients with high risk of such. The study comprised 434 specimens of venous blood and 182 bone marrow aspirates. The samples were classified according to the presuntive diagnoses. The highest frequency of chromosomal abnormalities, was found in blood samples from patients with physical deformities with or without mental retardation (22.22%), followed by mental retardation autism and/or fragile X chromosome (13.66%), and in couples with reproductive disorders (5.8%). In bone marrow, the most frequent abnormalities corresponded to patients with chronic myeloid leukemia (78.43%), acute lymphocytic leukemia (62.10%), acute myeloide leukemia (61.9%), myelodisplastic syndromes (43.7%) and chronic lymphocytic leukemia (14.2%). The present results stress the need to apply the HRC technique when the probability of minute chromosomal abnormalities is high.

[Hallervorden-Spatz syndrome in 2 Venezuelan patients]. / Síndrome de Hallervorden-Spatz en 2 pacientes venezolanos.

Hallervorden Spatz syndrome (HSS), described in 1.922, is a rare progressive disorder recessively inherited involving the basal ganglia. It is manifested clinically by mental deterioration, rigidity, choreoathetosis and spasticity evident during the first two decades of life. Increased concentration of iron in the globus pallidus and substantia nigra has been demonstrated convincingly. the objective of this paper is to describe two venezuelan children with this syndrome. Patient 1 is a 14-year-old boy with progressive impairment of language, mental deterioration and slowing of voluntary movements started at the age of 8 years. Patient 2 is a young girl first examined at 8 years of age because of psychomotor development delay, progressive impairment of gait, rigidity of the limbs, progressive dystonia and mental deterioration. Multiple test were performed, including metabolic studies, CT scan and magnetic resonance imaging in the brain. These two cases may lead us to think that besides the Huntington Disease, the HSS is also an entity to be taken into consideration in a young patient with movement disorder, mental deterioration and progressive course.