Prenatal Diagnosis in High Risk Pregnancies for Zellweger Syndrome

Zellweger syndrome is a lethal disorder. At present, no effective therapies are known for the patients of Zellweger syndrome. Recently a typical case of Zellweger syndrome in Japan was observed. In spite of intensive care, the patient died at the age of 3 months. Following this, the parents requested prenatal diagnosis for their following two pregnancies.
We investigated levels of very long chain fatty acids (VLCFA), levels of bile acids in amniotic fluid and immunoblotting of peroxisomal β-oxidation enzymes in cultured amniocytes. We report that immunoblotting using cultured amniocytes is an effective method for prenatal diagnosis of Zellweger syndrome. Furthermore, if we use immunoblotting for prenatal diagnosis, we can discriminate pseudoZellweger syndrome from pseudoneonatal adrenoleucodystrophy.
Following prenatal diagnosis, two healthy babies were delivered. After birth, no abnormal levels of VLCFA in either serum or red blood cell membranes were confirmed. In this paper, we report that we can diagnose a healthy fetus in a high risk pregnancy for Zellweger syndrome.     

A milder variant of Zellweger syndrome

A 4.5-year-old male patient is described with chorioretinopathy, minor facial anomalies, delayed closure of the fontanel, mental retardation, moderate hypotonia, epilepsy and hepatic fibrosis. Postural control, intentional vocalising and manual dexterity were superior to the performance of patients with classical Zellweger syndrome (ZS). Morphologically distinct peroxisomes were absent in the liver. In blood elevated pipecolic acid levels and abnormal levels of bile acid intermediates were found. The plasmalogen content of erythrocytes was normal. In fibroblasts we found an accumulation of very long chain fatty acids, decreased activity of acyl CoA: dihydroxyacetone phosphate acyltransferase, and impaired de novo biosynthesis of plasmalogens.On the basis of these clinical, ultrastructural and biochemical characteristics we assume that this patient represents a milder variant of the classical cerebro-hepato-renal syndrome of Zellweger.Abbreviations ZS Zellweger syndrome - THCA trihydroxycoprostanoic acid - VLCFA very long chain fatty acids - DHAP-AT acyl CoA: dihydroxyacetone phosphate acyltransferase - NALD neonatal adrenoleukodystrophy     

Deficiency of plasmalogens in the cerebro-hepato-renal (Zellweger) syndrome

We have analyzed the phospholipid composition of various organs of patients with the cerebro-hepato-renal (Zellweger) syndrome. The phospholipid composition of tissues from controls and patients was very similar except for their plasmalogen contents. In controls about 50% of the phosphatidylethanolamine fraction of brain, heart, kidney and skeletal muscle and about 10% of that fraction in control liver tissue was found to consist of plasmalogen. In control heart muscle, but not in other control tissues about 25% of the phosphatidylcholine fraction consist of plasmalogens. In contrast, plasmalogens were nearly absent in the corresponding tissues of Zellweger patients.The amount of phosphatidylethanolamine plasmalogens in both erythrocytes and fibroblasts of Zellweger patients is lowered significantly compared to control erythrocytes and control fibroblasts respectively, although this reduction is not as dramatic as in brain, heart, kidney, skeletal muscle and liver of patients. Phosphatidylcholine-plasmalogens are only present in low amounts in both controls, heterozygotes and patients.In recent years considerable evidence has accumulated to show that peroxisomes are involved in cellular lipid metabolism. Notably, the key enzymes of ether lipid (plasmalogen) biosynthesis in rodents were recently found to be located in peroxisomes. Since electronmicroscopic studies have shown that peroxisomes are absent in liver and kidney of patients with the cerebro-hepato-renal syndrome, our results suggest that an inability to integrate these key enzymes in a functional peroxisome leads to a severe disturbance in plasmalogen biosynthesis.We propose that the multiple clinical and biochemical defects in Zellweger patients are secondary to a deficiency in peroxisomal function.     

Bile Acid Abnormalities and the Diagnosis of Cerebro-Hepato-Renal Syndrome (Zellweger Syndrome)

ABSTRACT. The Zellweger or cerebro-hepato-renal syndrome (CHRS) is a congenital disorder characterized by cerebral dysfunction, craniofacial dysmorphic features, transient cholestasis and renal cysts. Patients fail to thrive, and usually die in their first year of life. In some cases, a definite diagnosis on purely clinical signs might not be possible. Several biochemical abnormalities have been observed in these patients and some of them have been tested as diagnostic markers. The aim of this study is to evaluate bile acid metabolites as biochemical markers of the CHRS. From a study of 20 CHRS patients, we conclude that screening for the presence of coprostanic acids and the C-29 dicarboxylic bile acid in serum or urine is a reliable method for detection of CHRS and confirmation of the diagnosis.     

Disturbed adrenocortical function in cerebro-hepato-renal syndrome of Zellweger

An ACTH stimulation test was performed in six patients suffering from the cerebro-hepato-renal syndrome of Zellweger. In contrast to controls, no rise in cortisol was observed. None of these patients showed clinical symptoms of adrenal insufficiency. The sudden death, which occurs in this syndrome, can probably be explained by an impaired stress reaction. In stress situations, such as respiratory infection, corticosteroids should be administered to these patients.A striking resemblance exists between the Zwellweger syndrome and the neonatal form of adrenoleukodystrophy.Abbreviations CHR-S cerebro-hepato-renal syndrome - ALD adrenoleukodystrophy     

Disturbances in bile acid metabolism of infants with the Zellweger (cerebro-hepato-renal) syndrome

The bile acid pattern in bile and serum from two infants with the cerebro-hepato-renal syndrome of Zellweger was severely disturbed. An increased concentration particularly of trihydroxycoprostanic acid and also of dihydroxycoprostanic acid could be demonstrated. A generalized mitochondrial defect could explain these increased concentrations. This hypothesis is supported by the abnormal structure of the mitochondria in the liver biopsy of one of our patients. It is possible that the abnormal bile acids contribute to the liver damage of infants with Zellweger syndrome.     

Neu-Laxova Syndrome: Report of Two Cases

Two cases of Neu-Laxova syndrome are reported. The pathological features are described. There is marked swelling of the palms and soles, which is due to massive fat and myxomatous connective tissue proliferation in addition to edema. Lissencephaly with hypoplasia of cortical descending fibers is observed, along with cerebellar hypoplasia. The occurrence of 2 micro cephalic male and female infants dying shortly after birth in the same sibship with 1 normal baby in between confirms similar findings by others and supports an autosomal-recessive inheritance. The relevance of pathological examination in further delineation of the phenotypic appearance is discussed.     

Prenatal diagnosis of Zellweger syndrome and related disorders: Impaired degradation of phytanic acid

Normal amniocytes and chorionic villous cells in culture are able to produce¹⁴CO₂ from exogenous [1-¹⁴C] phytanic acid. In contrast, cells from four fetuses at risk for the cerebro-hepato-renal (Zellweger) syndrome and related disorders showed a greatly reduced activity, indicating a block in oxidation of the fatty acid. Our data confirm that phytanic acid oxidase activity measurement can be used for the prenatal assessment of this group of disorders.     

A prenatal test for the cerebro-hepato-renal (Zellweger) syndrome by demonstration of the absence of catalase-containing particles (peroxisomes) in cultured amniotic fluid cells

In this paper we show that whereas acyl-CoA: dihydroxyacetone phosphate acyltransferase, a membranebound peroxisomal enzyme, is deficient in homogenates of cultured amniotic fluid cells of fetuses with Zellweger syndrome, catalase a soluble peroxisomal matrix enzyme is present in normal amounts. Digitonin titration experiments revealed a striking difference in the percentage of particle-bound catalase in control and Zellweger aminocytes: in Zellweger amniocytes all catalase activity was found to be present in the soluble cytoplasm, (<5% particlebound), whereas in control amniocytes catalase was found to be predominantly particle-bound (62%±8%, n=5).Measurement of the percentage of particle-bound catalase by means of digitonin titrations thus provides a simple prenatal test for Zellweger syndrome via the direct demonstration of the presence or absence of catalase-containing particles (peroxisomes).     

First Japanese case of Zellweger syndrome with a mutation in PEX14

Zellweger syndrome, one of the peroxisome biogenesis disorders, is an autosomal recessive disease caused by mutations in PEX genes. It is characterized by severe hypotonia, failure to thrive, psychomotor retardation, liver dysfunction, and sensorineural hearing impairment. Most of the patients with this disease die before the age of 1 year. PEX14 is the 13th PEX gene responsible for peroxisome biogenesis disorders. Thus far, only two patients with PEX14 deficiency have been reported. Here, we report the first case of a Japanese patient with a PEX14 mutation who showed severe hypotonia, psychomotor retardation, demyelination, and developed rickets at the age of 5 months. An increased excretion of 3,6‐epoxydicarboxylic acids leads to the diagnosis of Zellweger syndrome and a mutation analysis of PEX14 revealed a homozygous mutation of c.538C>T (p.Q180X). The patient survived for a prolonged period of time but died of liver failure at the age of 46 months.     

Two Unusual Cases of Congenital Rubella Syndrome Associated with Acute Myelocytic Leukemia or chilaiditi's Syndrome

In the Ryukyu Islands of Japan, an extensive epidemic of rubella occurred from the end of 1964 until the beginning of 1965. Approximately 400 children with congenital rubella syndrome were born in 1965 [1]. Two boys with unusual associated problems are reported in this paper. One case was complicated with leukemia and the other with Chilaiditi's syndrome.     

Effect of dietary Lorenzo's oil and docosahexaenoic acid treatment for Zellweger syndrome

We investigated the possible therapeutic effect of decreasing plasma levels of very-long-chain fatty acids (C26:0) with a synthetic oil containing trioleate and trielucate (Lorenzo's oil) as well as increasing docosahexaenoic acid (DHA) in red blood cells (RBC) with DHA ethyl ester in four patients with Zellweger syndrome. We investigated serial changes of plasma C26:0 levels and DHA levels in RBC membranes by gas-liquid chromatography/mass spectrometry (GC/MS). After death, the fatty acid composition of each patient's cerebrum and liver was studied. Dietary administration of Lorenzo's oil diminished plasma C26:0 levels. Earlier administration of Lorenzo's oil was more effective and the response did not depend on the duration of administration. DHA was incorporated into RBC membrane lipids when administrated orally, and its level increased for several months. The final DHA level was correlated with the duration of administration and was not related to the timing of initiation of treatment. DHA levels in the brains and livers of treated patients were higher than in untreated patients. Early initiation of Lorenzo's oil and the long-term administration of DHA may be useful for patients with Zellweger syndrome.     

Heterogeneity of the Erythropoietic Defect in Two Cases of Aase-Smith Syndrome

Here we report two children with Aase-Smith syndrome (triphalangeal thumbs and congenital red cell plasia). In vitro growth of erythroid colonies WLIS normal in the first patient and totally absent in the other. In both patients, treatment with glucocorticoidr induced remission of anemia. Our results suggest that the different growth patterns of erythroid colonies observed in the two patients could reflect the defect of erythroid differentiation occurring at discrete maturational levels.     

Inborn Errors of Peroxisome Biogenesis and Brain Malformation: Clinical and Biochemical Studies*

Zellweger's cerebro-hepato-renal syndrome is characterized by the absence of peroxisomes, severe neurologic manifestations, and neuropathological findings such as polymicrogyria and neuronal heterotopia which are based on disturbances of neuronal migration. We investigated the pathogenesis of peroxisome-deficient disorders in attempts to clarify the molecular basis of these brain dysgenesis. Complementation analysis revealed that at least 9 genes contribute to the formation of peroxisomes. One of these gene products, peroxisome assembly factor-1 (PAF-1), was isolated, using a functional cloning method and a mutant Chinese hamster ovary cell line with defective peroxisomes. PAF-1 restored the peroxisomes and biochemical abnormalities in fibroblasts from patients with Zellweger syndrome and who belonged to complementation group F. Defects in PAF-1 would result in dysfunction of peroxisomal membrane or in the transport machinery of peroxisomal proteins, and metabolic disturbances such as accumulation of very long chain fatty acids and defects in plasmalogen may occur.     

Clinical recognition of patients affected by a peroxisomal disorder: A retrospective study in 40 patients

Peroxisomal disorders are genetic diseases in which an impairment in one or more peroxisomal function(s) causes clinical and multiple biochemical abnormalities. Early recognition of the major peroxisomal disorders in which functional peroxisomes are virtually absent, leading to a generalised impairment of peroxisomal functions, is of utmost importance, as this will enable the prenatal diagnosis of these severe diseases in future pregnancies. Unfortunately, clinical recognition of these disorders can be difficult because of the aspecific and varying phenotypic presentation. We analysed the clinical characteristics in 40 patients suspected of having a peroxisomal disorder to identify specific clinical criteria for diagnosis. From this study we conclude that the combined presence of at least three major clinical characteristics (present in >75% of the affected patients, including psychomotor retardation, hypotonia, impaired hearing, low/broad nasal bridge, abnormal ERG, hepatomegaly) and one or more minor characteristics (present in 50%–75% of the patients, like large fontanelles, shallow orbital ridges, epicanthus, anteverted nostrils, retinitis pigmentosa) warrants biochemical investigation of peroxisomal functions. Further prospective investigations will have to be done to evaluate these criteria.     

Larsen综合征的诊断与治疗

目的：提高对Ｌａｒｓｅｎ综合征的诊断及治疗水平。方法：５例患儿，男２例，女３例，年龄２～８岁。主要临床表现：５例均有颜面扁平、眼距增宽、鼻梁塌陷，伴有多关节脱位，主要累及双髋、双膝、双肘和双髌骨。１例２岁双髋关节脱位行软组织松解，手法复位；２例４岁双髋关节脱位行切开复位，Ｓａｌｔｅｒ骨盆截骨和股骨旋转截骨；２例膝关节、３例髌骨脱位行外侧软组织松解，内侧关节囊紧缩，股内侧肌止点移向髌骨前外侧，外侧１／２髌韧带止点内移。结果：术后随访时间１～３年，关节复位，功能良好。结论：Ｌａｒｓｅｎ综合征有典型的临床特征，可早期诊断。对关节脱位给予正确治疗，可获得良好的复位和功能。     

Miller-Fisher综合征2例

例1,女,14岁,因四肢肌无力,呼吸困难十余日入院。患儿0.5个月前出现四肢渐进性肌无力,近3 d出现呼吸困难,声音低微,吞咽困难,痰多。查体:双下肢肌力0级,双上肢肌力1级,呼吸浅表,声音低微,吞咽困难,痰多,双眼球内聚,外展神经麻痹。血WBC 18.8×109/L,N 0.7。肌电图示神经传导速度减弱,潜伏期延长;血:CK 354 IU/L;脑脊液蛋白 ,细胞数正常,糖、氯化物正常。诊断为第4型Miller     

Neonatal Marfan Syndrome: Report of Two Cases

Background

Neonatal Marfan syndrome is a rare and severe phenotype of this disease. A poor prognosis is anticipated due to the high probability of congestive heart failure, and mitral and tricuspid regurgitations with suboptimal response to medical therapy and difficulties in surgical management at an early age.

Case Presentation

We present two consecutive patients with this disease who are the first reported cases from Iran to the best of our knowledge. Unfortunately both of them died shortly after diagnosis.

Conclusion

Neonatal Marfan syndrome is reported from Iran and has a poor prognosis like the patients reported from elsewhere.     

Cystic Lung Disease in Down's Syndrome: A Report of two Cases

Previously unreported lung disease found at autopsy in 2 young infants with Down's syndrome and congenital heart disease (complete atrioventricular canal malformation with left-to-right shunt) is described. The perinatal and neonatal period was unremarkable, and there was no history of mechanical ventilation or administration of high concentrations of oxygen for extended periods. In 1 of the cases respiratory symptoms and hyperinflation with focal cystic changes in the lung fields on chest X-ray were noted at 5-7 months of age. Pathologically there was cystic dilatation of alveoli with focal cuboidal metaplasia of alveolar epithelium and mild to moderate focal alveolar septal fibrosis. Wilson-Mikity syndrome, congenital pulmonary lymphangiectasia, bronchopulmonary dysplasia, and idiopathic interstitial fibrosis of lungs were ruled out on clinical and/or pathologic grounds. Factors such as compression of bronchi by enlarged pulmonary arteries or cardiac chambers, peribronchiolar accumulation of fluid, pulmonary hypoplasia occurring in Down's syndrome, and episodes of pulmonary arterial hypoperfusion associated with severe congenital heart disease may be related to the pathogenesis of the lesion.