Clinical and Genetic Features in Patients with Cystic Fibrosis in Southwestern Iran

Objective

Cystic fibrosis (CF) is a common autosomal recessive genetic disease caused by a mutation in the CF transmembrane conductance regulatory (CFTR) gene. This study attempted to identify the most common CFTR mutations and any correlations between certain mutations and the clinical presentation of the disease in CF patients in southwestern Iran.

Methods

Twenty nine common CFTR gene mutations were examined in 45 CF patients.

Findings

Chronic cough, intestinal obstruction, dehydration, heat exhaustion and steatorrhea were the most common early clinical symptoms among our patients. The most common mutation was ΔF508, with an allele frequency of 21%. The homozygous ΔF508 mutation was observed in eight patients (18%), and three patients (7%) were ΔF508 carriers. The 2183AA > G mutation was observed in four patients, one of whom was also a ΔF508 carrier. The R1162X mutation was detected in two patients. The G542X, R334W and N1303K mutations were detected each in one patient, the first of whom was also a ΔF508 carrier.

Conclusion

Out of 45 patients, 27 (60%) had none of the CFTR gene mutations we tested for. The most frequent mutations in southwestern Iranian patients with CF should be identified by sequencing the entire CFTR gene in order to optimize the design of a diagnostic kit for common regional mutations.     

Detecting Common CFTR Mutations by Reverse Dot Blot Hybridization Method in Cystic Fibrosis First Report from Northern Iran

Objective

Cystic fibrosis and its distribution vary widely in different countries and/or ethnic groups. Common cystic fibrosis transmembrane conductance regulator (CFTR) mutations were reported from Iran, but the northern population was not or underrepresented in those studies. The aim of this study was to determine the frequency of common CFTR mutations in children from northern Iran.

Methods

Thirty unrelated Iranian cystic fibrosis patients aged less than 11 years and living in Mazandaran province (in Iran) were screened for 5 common CFTR gene mutations. deltaF508, N1303K, G542X, R347H and W1282X using Reverse Dot Blot method.

Findings

Only one mutation, DeltaF508, was found in 7 patients accounting for 21.7% (13/60) of alleles.

Conclusion

These findings can be used for planning future screening and appropriate genetic counseling programs in Iranian CF families.     

Frequency of Genotype With ΔF508 Mutation in CFTR Gene Among Iranian Cystic Fibrosis Patients With Pancreatic Insufficiency

Background:

Cystic fibrosis (CF) is the most prevalent lethal autosomal recessive disease with a broad spectrum of phenotypes. Mutation of ΔF508 in the CFTR gene is the most important and lethal mutation in CF, which contains 70% of all predisposing mutations for CF worldwide.

Objectives:

Determining frequency of genotypes with ΔF508 mutation in CFTR gene, and evaluation of correlation between genotype and phenotype of Iranian patients with CF.

Patients and Methods:

Thirty six patients were included in this cross sectional study. ΔF508 mutations in both alleles of the CFTR gene were checked.

Results:

Among 36 pediatric patients, ΔF508 mutation was detected in 9 (25%) patients; 2 patients were heterozygous, and 7 patients homozygous for this mutation. From overall 72 tracked alleles, 11 (15.2%) were found to have ΔF508 mutations. Differences in prevalence of dyspnea and bronchiectasis were significant in homozygote group, compared with non-mutated group for ΔF508.

Conclusions:

It seems that more ΔF508 mutated alleles lead to more severe symptoms of CF.     

Effects of Probiotics on Quality of Life in Children with Cystic Fibrosis; A Randomized Controlled Trial

Objective

Patients with cystic fibrosis (CF) usually have abnormal intestinal microbiota and dysregulated immune mediators due to massive exposure to antibiotics. Probiotics as immunomodulatory and anti-inflammatory substances are considered to improve both clinical and biochemical intestinal and pulmonary function in CF patients. We decided to investigate the effects of probiotics on quality of life and pulmonary exacerbations in children with cystic fibrosis.

Methods

In a prospective, randomized, controlled clinical trial, 37 CF patients (2-12 years old) were randomly divided into two groups. 20 patients of probiotic group took probiotics (2×10⁹CFU/d) for one month while 17 patients of control group took placebo capsules. Quality of life was determined using PedsQL™4.0 questionnaire at the beginning, then three and six months after completing the treatment period. Rate of pulmonary exacerbation in probiotic group patients was also evaluated during three months after intervention and compared to the same three months of the previous year. Results were analyzed using SPSS (11.5). P<0.05 was considered statistically significant.

Findings

Significant improvement was observed in the mean total score of parent reported quality of life among probiotic group patients in comparison with placebo group at 3^rd month (P=0.01), but this was not significant at 6^th month of probiotic treatment. Rate of pulmonary exacerbation was significantly reduced among probiotic group (P<0.01).

Conclusion

Probiotics are considered as useful nutritional supplements on reducing number of pulmonary exacerbations and improving quality of life in patients with cystic fibrosis. Effects of probiotics seem to be temporary and probably continuous ingestion might have more stable improving effects on quality of life.     

Comparison of Classic Sweat Test and Crystallization Test in Diagnosis of Cystic Fibrosis

Objective

Sweat chloride measurement is considered a standard diagnostic tool for cystic fibrosis (CF). This study was performed to compare sweat chloride values obtained by quantitative pilocarpine iontophoresis (classic test) with sweat crystallization detected by direct observation of a drop of perspiration under light microscopy in patients with and without CF.

Methods

The tests using both techniques were performed simultaneously in patients with and without CF. Cutoff values of ≥60 mmol/L of chloride concentration for the classic sweat test was considered for diagnosis of CF. In crystallization method, observation of typical dendritic forms of salt crystals under light microscopy was interpreted positive.

Findings

Sixty patients suspected to CF (31 males and 29 females) with age range of 9 months to 2 years underwent the sweat test using both techniques. Median sweat chloride values was 26.13+10.85 in group with negative and 72.76+12.78 mmol/L in group with positive sweat test, respectively. All the patients who had positive sweat test in classic method showed typical dendritic forms of salt crystal in sweat crystallization test, which provided the test with 100% sensitivity (95%CI: 93.1–100). Only one of the 31 subjects with negative results for classic sweat test had positive result for crystallization sweat test, which provided the test with 96.7% specificity (95%CI: 92.9–100). Time spent to perform the crystallization test was significantly shorter than the classic method whereas its cost was also lower than the second method.

Conclusion

There was a good correspondence between two studied methods of sweat test. These results suggested the sweat crystallization test as an alternative test for detecting CF disease with high sensitivity and specificity.     

Ceftriaxone–Associated Nephrolithiasis in Children

Objective

Ceftriaxone is a third-generation cephalosporin which is widely used for treatment of infection in children accompanied by complications like urinary tract lithiasis and gallbladder psudolithiasis or sludge. The aim of this study was to investigate the incidence and predisposing factors that contribute to these complications in children.

Methods

This quasi-experimental and before- and after-study was conducted in 96 children who were hospitalized for treatment of different bacterial infections and received 50-100 mg/kg/day ceftriaxone divided into two equal doses intravenously under conditions of adequate hydration. Sonographic examinations of urinary tract and gallbladder were carried out before and after treatment for that purpose. Patients with positive sonographic findings after treatment were followed with serial sonographic examinations.

Findings

Post-treatment sonography demonstrated nephrolithiasis in 6 (6.3%) and gallbladder stone in one (1%), all were asymptomatic. Comparison of the groups with and without nephrolithiasis demonstrated no significant differences with respect to age, body weight, diagnosis, season of hospitalization, dosage of drug and the duration of treatment. Nephrolithiasis had a significant relation with male gender (P=0.02).

Conclusion

Our results showed that pediatric patients may develop small sized, asymptomatic renal stones during a 2-6 day course of normal or moderate dose of ceftriaxone therapy. Close monitoring of ceftriaxone treated patients especially on high dose long term therapy for nephrolithiasis and gallbladder psudolithiasis or sludge is recommended.     

Zinc and Copper Status in Children with Beta-Thalassemia Major

Objective

There are some reports in which a condition of zinc deficiency and its associated outcomes with a change in concentration of serum copper among the thalassemic patients has been highlighted. The aim of this prospective study was to determine the serum zinc and copper levels in children with beta-thalassemia major.

Methods

In this cross sectional study all children under 12 years affected by beta thalassemia major (40 patients) were evaluated for serum zinc and copper levels in Qazvin thalassemia center (Qazvin, Iran) in 2007. Serum measurements for zinc and copper were performed by atomic absorption spectrophotometer.

Findings

The mean concentrations of serum zinc and copper levels were 67.35±20.38 and 152.42±24.17 µg/dl respectively. Twenty-six (65%) of thalassemic patients had zinc concentration under 70 µg/dl (hypozincemia). None of the thalassemic children had copper deficiency. No significant correlation between serum zinc level with age, weight, height, body mass index, duration of blood transfusion, desferrioxamine dose and ferritin level was observed in thalassemic patients (P=0.3).

Conclusion

This study revealed that hypozincemia is common in thalassemic patients, but in contrast, there is no copper deficiency. Further evaluation in this regard is recommended.     

Dental Problems in Hypophosphatemic Rickets,a Cross Sectional Study

Objective

Hypophosphatemic rickets is an uncommon metabolic bone disorder which affects all ages and both sexes. It is characterized by low concentration of serum phosphate levels, impairment of mineralization of bone matrix and teeth with variable etiology. Dental problems in this disorder have not been described well in previous studies.

Methods

All hypophosphatemic rickets patients who came to a referral clinic during 2008-2010 enrolled in this study. All patients had low phosphorous and high ALP, normal PTH and 25-hydroxy-vitamin D and normal or low level of serum calcium. After diagnosis all patients were examined by a dentist for enamel hypoplasia, taurodontism, dental abscess, gingivitis, dental caries, and dentition delay.

Findings

Nineteen patients were enrolled in this study. The average age of the patients was 10 (±4.23) years (range 3-17). Seventy-nine percent of patients had regular follow-up after diagnosis of background disease. Dental caries and delay in the dentition were most prevalent (each one 47.7%) followed by enamel hypoplasia in 42.1% of the patients. Other problems were taurodontism in 15.8% patients, dental abscess and gingivitis in 10.9%.

Conclusion

Hypophosphatemic rickets is a disease with different clinical features; one of them is dental problem, dental caries is the most common problem.     

Effect of Anti-Epileptic Drugs on Serum Level of IgG Subclasses

Objective

There are some controversial studies on effects of anti-epileptic drugs (AEDs) on serum IgG subclasses; however, the role of these medications is still unclear. The aim of this study was evaluation the effects of anti-epileptic drugs on serum concentration of IgG and its subclasses

Methods

Serum IgG and IgG subclasses of 61 newly diagnosed epileptic patients were measured at the beginning of monotherapy with carbamazepine, sodium valproate, and phenobarbital, and 6 months later. Measurement of IgG and its subclasses was performed using nephlometry and ELISA techniques, respectively.

Findings

Reduction of at least one IgG subclass was found in 6 patients 6 months after treatment with AEDs. Among 27 patients receiving carbamazepine, decrease in at least one serum IgG subclass level was found in 5 patients. Among 20 patients using sodium valproate, only one patient showed decrease in IgG2 subclass. None of the 14 patients using phenobarbital revealed significant decrease in IgG subclasses. No infection was seen in the patients with reduction of subclasses.

Conclusion

Although in our study, children with selective IgG subclass deficiency were asymptomatic, assessment of serum immunoglobulin levels could be recommended at starting the administration of AEDs and in serial intervals afterward in epileptic patients.     

Serum Immunoglobulin Levels in Splenectomized and Non- Splenectomized Patients with Major Beta-Thalassemia

Objective

Thalassemia is a common disease in many countries, in which several complications such as infections can occur. Although aberration in the function of the immune system could be a reason for such complication, a little is known about the status of humoral immune system in major beta thalassemia. In this study we measured serum immunoglobulins level in a group of patients with major beta thalassemia.

Methods

Ninety nine patients with major beta thalassemia were enrolled in this study divided into two groups of splenctomized and not splenctomized patients. Serum IgG, IgM and IgA levels of these patients were measured and analyzed.

Findings

Serum mean levels of IgG and IgM in patients of all ages in both groups were normal. The mean serum IgA level in the group of not splenectomized patients aged less than five years as well as in the splenectomized patients aged more than twenty years was increased. However, it was normal in other age groups.

Conclusion

Although this study could not show any defect in the humoral immune system, evaluation of immunoglobulins could be useful to understand the relmarkable high rate of infection in the patients with major beta thalassemia.     

Determination of Hepatitis C Genotypes and the Viral Titer Distribution in Children and Adolescents with Major Thalassemia

Objective

Hepatitis C virus (HCV) is an etiological agent responsible for occurrence of post-transfusion hepatitis in thalassemic patients. This study identified hepatitis C genotypes in pediatric and adolescent thalassemic patients and their correlation with age, blood transfusion, HCV RNA viral titer and liver function.

Methods

This study considers cross-sectional data from the Center for Thalassemia in Zahedan (Iran) carried out between August 2005 and September 2007. Twenty multitransfused patients suffering from β-thalassemia major and chronic HCV infection (13 males, 7 females) were included in the study. Patients were considered eligible for the study if they were seropositive for HCV RNA polymerase chain reaction (PCR) before initiation of evaluation. Blood sample was taken for HCV genotype and viral titer as well as biochemical markers. Type specific primer and real-time RT-PCR HCV were used for determination of viral genotype and HCV-RNA titer.

Findings

There was a significant positive correlation between serum HCV RNA titer and genotypes (P<0001). Serum HCV RNA levels were found higher in genotype 3a than in others. The most prevalent genotype in thalassemic patients was genotype 3a (40%) followed by 1b (25%), unclassified (20%) and la (15%). There was no meaningful relationship between genotype, Alanine aminotranferease, ferritin and alkaline phosphatase. Age, serum HCV RNA titer and number of transfusions were the only significant factors associated with genotypes (P<015, P<0.0001 and P<0.001 respectively).

Conclusion

This study showed that HCV genotype and viral titer are related to the number of blood transfusions received by thalassemic patients. Screening donated blood in blood banks would prevent the occurrence of hepatitis C in this high-risk group.     

Association of TNF-α Gene Variants With Clinical Manifestation of Cystic Fibrosis Patients of Iranian Azeri Turkish Ethnicity

Background:

Cystic fibrosis (CF), a life-limiting autosomal recessive disorder, is considered a monogenic disease that is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. According to several studies, mutation analysis of the cystic fibrosis transmembrane conductance regulator (CFTR) gene alone is insufficient to predict the phenotypic manifestations observed in cystic fibrosis (CF) patients. In addition, some patients with a milder CF phenotype do not carry any pathogenic mutation. Tumor Necrosis Factor-alpha (TNF-α) contributes to the pathophysiology of CF by causing cachexia. There is a reverse association between TNF-α concentration in patient''s sputum and their pulmonary function.

Objectives:

To assess the effect of non-CFTR genes on the clinical phenotype of CF, two polymorphic sites (-1031T/C and -308G/A) of the TNF-α gene, as a modifier, were studied.

Patients and Methods:

Focusing on the lung and gastrointestinal involvement as well as the poor growth, we first investigated the role of TNF-α gene in the clinical manifestation of CF. Furthermore, based on the hypothesis that the cumulative effect of specific alleles of multiple CF modifier genes, such as TNF-α, may create the final phenotype, we also investigated the potential role of TNF-α in non-classic CF patients without a known pathogenic mutation. In all, 80 CF patients and 157 healthy control subjects of Azeri Turkish ethnicity were studied by the PCR–RFLP method. The chi-square test with Yates'' correction and Fisher''s exact test were used for statistical analysis.

Results:

The allele and genotype distribution of the investigated polymorphisms, and their associated haplotypes were similar in all groups.

Conclusions:

There was no evidence that supported the association of TNF-α gene polymorphisms with non-classic CF disease or the clinical presentation of classic CF.     

Markedly elevated neonatal immunoreactive trypsinogen levels in the absence of cystic fibrosis gene mutations is not an indication for further testing

Aims

To investigate the immunoreactive trypsinogen (IRT) values above the usual 99th centile laboratory cut‐off and determine the value of offering further testing to those infants with a markedly elevated IRT but no cystic fibrosis transmembrane regulator (CFTR) gene mutation identified by the screening programme.

Methods

All babies born in Victoria, Australia, between 1991 and 2003, were screened by IRT followed by CF gene mutation analysis.

Results

Of the 806 520 babies born, 9268 with the highest IRT levels had CFTR mutation analysis. There were 123 ΔF508 homozygotes and 703 heterozygotes (86 with CF, 617 carriers). A total of 8442 babies had no CFTR gene mutation, of whom 18 (0.21%) had CF. The total number of CF babies with IRT greater than the laboratory cut‐off was 227 (2.4%). The IRT results of the CF patients were distributed normally, with the majority above the laboratory cut‐off of newborn IRT results. There was no evidence of an excess of babies with CF in the very highest levels of IRT above the 99th centile.

Conclusions

Only a small proportion of babies with a neonatal IRT >99th centile have CF. Additional CF testing for infants with an elevated IRT but no CFTR gene mutation has an extremely low yield, no matter how high the IRT result.     

Correlation between QRS Duration,Pulmonary Insufficiency and Right Ventricle Performance in Totally Corrected Tetralogy of Fallot

Objective

Despite progresses in surgical correction of Tetralogy of Fallot, pulmonary insufficiency and progressive dysfunction of the right ventricle impress its long-term prognosis. In this study we examined the correlations between QRS duration, pulmonary insufficiency and right ventricular performance index.

Methods

We enrolled 57 repaired Tetralogy of Fallot patients. QRS duration on electrocardiogram, pulmonary regurgitation index (regurgitation time to diastolic time ratio), and right ventricular myocardial performance index were measured.

Findings

There was a strong inverse correlation between QRS duration and pulmonary regurgitation index. However, significant correlation did not exist between QRS duration and right ventricular myocardial performance index. QRS duration ≥160 ms predicted severe pulmonary regurgitation with 100% sensitivity and 87% specificity.

Conclusion

Increased QRS duration can predict severity of pulmonary regurgitation.     

Attempt to Suicide in Young Ages with Epilepsy

Objective

The suicidal rate among epileptic patients is up to 5 times more than general population and depression is the most common mood disturbance among them while usually under noticed. This study was performed to determine possible symptoms of psychiatric disorders for suicidal behavior in pediatric patients with epilepsy that had attempted suicide.

Methods

Among medical records of 1169 patients under 17 years of age being admitted to the exclusive university hospital for poisoning in Tehran since April 2006 to Feb 2008 due to attempt to suicide, 31 cases (13 male and 18 female) with mean age 15.8±1.3 years had concomitant epilepsy. Mental status and epilepsy data sheet of these patients were analyzed.

Findings

The psychological evaluation of these 31 cases revealed long lasting symptoms of psychological disorder in 21 (91.4%) cases before their attempt to suicide while only 5(16%) cases had been noticed for psychiatric care and merely 3 of them had been under treatment.

Conclusion

Despite strong correlation between affective disorders and epilepsy it is unfortunately under-diagnosed or undertreated. Since overdose of antiepileptic drugs used for treatment of epilepsy may be lethal, dismissing suicidal behavior can be life threatening.     

Hypercalciuria and nephrocalcinosis in cystic fibrosis patients

The objective of this study was to determine the frequency of nephrocalcinosis and hypercalciuria in cystic fibrosis (CF) patients, and to search possible causes of this phenomenon. Forty-three CF children (24 boys, 19 girls; mean age 64.9 months, range 5 months-18 years) were included in this study. Plasma sodium, potassium, chloride, BUN, creatinine, calcium, phosphorus, magnesium, alkaline phosphatase; spot urine sodium, potassium, chloride, creatinine, calcium, magnesium; and serum 25-hydroxyvitamin-D levels were measured in all patients. Urine samples were examined for microscopic hematuria. Fractional sodium, potassium, chloride excretion and estimated glomerular filtration rate (GFR) were calculated. All patients underwent renal ultrasonography. Hypercalciuria, nephrocalcinosis and microscopic hematuria were detected in 15 patients (34.2%), 10 patients (23.2%) and two patients (5%), respectively. There was no significant but borderline correlation between 25-hydroxyvitamin-D levels and hypercalciuria (r: 0.308, p:0.05). There were no correlations between Shwachman clinical scoring system results and hypercalciuria (r: 0.221, p: 0.148) and age and hypercalciuria (r: -0.229, p: 0.135). Patients with chronic Pseudomonas colonization showed no hypercalciuria or nephrocalcinosis. There was no difference for plasma biochemical results, renal function tests, hypercalciuria and nephrocalcinosis between CF patients who had or had not experienced pseudo Bartter's syndrome (PBS) before. There was no relation between detected CF mutations of the patients and hypercalciuria and nephrocalcinosis. These results suggested that it is a primary abnormality of calcium metabolism in the kidney.     

Assessment of Thyroid Function in Children Aged 1-13 Years with Beta-Thalassemia Major

Objective

Hypothyroidism usually appears in the second decade of life and is thought to be associated with iron overload in patients with thalassemia major. This study aimed to evaluate thyroid dysfunctions in patients with beta-thalassemia major and to see if they appear in the earlier period of life.

Methods

Thyroid function and iron load status were evaluated in 90 children with a mean age of 7.17±3.78 years with beta-thalassemia major by measuring serum free thyroxin (FT4), serum free triiodothyronine (FT3), total thyroxin (T3), serum total triiodothyronine (T4), thyroid-stimulating hormone (TSH) and ferritin levels from serum of patients admitted to the Pediatric Department, Faculty of Medicine University of Dicle between March 2005 and July 2009. A control group formed from an age-sex matched healthy children with a mean age of 6.98±3.66 years was also included. A standard thyrotropin releasing hormone test was applied to 3 patients who had high TSH levels and were classified as subclinical primer hypothyroidism. The study was designed according to the Declaration of Helsinki and informed consent was obtained from the parents of all participants.

Findings

All thyroid parameters in patients were in the normal ranges compared with the controls except three of them which had high TSH levels. Serum ferritin level (2703±1649 ng/mL) in patients was significantly higher than in controls (81.5±15.5 ng/mL).

Conclusion

The work implies that hypothyroidism could be even seen in the first decade of life in patients with beta-thalassemia major in spite of improved hematological cares.     

Transcatheter Atrial Septal Defect Closure under Transthorasic Echocardiography in Children

Objective

Atrial septal defect (ASD) device closure is routinely done under the guide of transesophageal or intracardiac echocardiography which are expensive techniques and not easily affordable in developing countries.

Methods

Using metallic devices, we attempted 32 ASD device closures under transthoracic echocardiography.

Findings

Of those, 30 procedures were successful (94 %). In two patients with relatively large ASD we encountered difficulty in positioning the device. These patients were referred for surgical closure.

Conclusion

ASD device closure can be carried out successfully in most patients under transthoracic echocardiography in situations where transesophageal or intravenous echocardiographies are not available or affordable.