Novel OCTN2 mutations: No genotype–phenotype correlations: Early carnitine therapy prevents cardiomyopathy

Primary systemic carnitine deficiency or carnitine uptake defect (OMIM 212140) is a potentially lethal, autosomal recessive disorder characterized by progressive infantile‐onset cardiomyopathy, weakness, and recurrent hypoglycemic hypoketotic encephalopathy, which is highly responsive to L ‐carnitine therapy. Molecular analysis of the SLC22A5 (OCTN2) gene, encoding the high‐affinity carnitine transporter, was done in 11 affected individuals by direct nucleotide sequencing of polymerase chain reaction products from all 10 exons. Carnitine uptake (at Km of 5 μM) in cultured skin fibroblasts ranged from 1% to 20% of normal controls. Eleven mutations (delF23, N32S, and one 11‐bp duplication in exon 1; R169W in exon 3; a donor splice mutation [IVS3+1 G > A] in intron 3; frameshift mutations in exons 5 and 6; Y401X in exon 7; T440M, T468R and S470F in exon 8) are described. There was no correlation between residual uptake and severity of clinical presentation, suggesting that the wide phenotypic variability is likely related to exogenous stressors exacerbating carnitine deficiency. Most importantly, strict compliance with carnitine from birth appears to prevent the phenotype. © 2002 Wiley‐Liss, Inc.     

Oesophageal rupture in a patient with postoperative nausea and vomiting

Rupture of the oesophagus (Boerhaave's syndrome) is a rare complication of forceful or suppressed vomiting. Postoperative nausea and vomiting is common but does not usually lead to life-threatening complications. A case of oesophageal rupture in a man who experienced postoperative nausea and vomiting after an uncomplicated procedure is described in this report. Delayed diagnosis mandated conservative treatment. The clinical presentation, diagnosis and management of oesophageal rupture is discussed.     

Sensitivity and specificity of free and total glutaric acid and 3-hydroxyglutaric acid measurements by stable-isotope dilution assays for the diagnosis of glutaric aciduria type I

Glutaric aciduria type I (GA I) is a recessive disorder caused by a deficiency of glutaryl-CoA dehydrogenase (GCDH). The biochemical hallmark of the disease is the accumulation of glutaric acid and, to a lesser degree, of 3-hydroxyglutaric acid and glutaconic acid in body fluids and tissues. A substantial number of patients show only slightly, intermittently elevated or even normal urinary excretion of glutaric acid, which makes early diagnosis and treatment to prevent the severe neurological sequelae difficult. Furthermore, elevated urinary excretion of glutaric acid can also be found in a number of other disease states, mostly related to mitochondrial dysfunction. Stable-isotope dilution assays were designed for both glutaric acid and 3-hydroxyglutaric acid and their diagnostic sensitivity and specificity were evaluated. Control ranges of glutaric acid in urine were 1.1–9.7mmol/mol creatinine before and 4.1–32 after hydrolysis. The respective values of 3-hydroxyglutaric acid were 1.4–8.0 and 2.6–11.7mmol/mol creatinine. For other body fluids, control ranges in mol/L were: for glutaric acid 0.55–2.9 (plasma), 0.18–0.63 (cerebrospinal fluid) and 0.19–0.7 (amniotic fluid); and for 3-hydroxyglutaric acid, 0.2–1.36 (plasma), <0.2 (cerebrospinal fluid) and 0.22–0.41 (amniotic fluid). Twenty-five patients with GCDH deficiency were studied. Low excretors (12 patients) were defined by a urinary glutaric acid below 100mmol/mol creatinine down into the normal range, while high excretors (13 patients) had glutaric acid excretions well above this value. With and without hydrolysis there was an overlap of glutaric acid values between patients and controls. Diagnostic sensitivity and specificity of 100% could only be achieved by the quantitative determination of 3-hydroxyglutaric acid with the newly developed stable-isotope dilution assay, allowing an accurate diagnosis of all patients, regardless of the amount of glutaric acid excreted in urine.     

From the Cover: Dengue virus envelope protein domain I/II hinge determines long-lived serotype-specific dengue immunity

The four dengue virus (DENV) serotypes, DENV-1, -2, -3, and -4, are endemic throughout tropical and subtropical regions of the world, with an estimated 390 million acute infections annually. Infection confers long-term protective immunity against the infecting serotype, but secondary infection with a different serotype carries a greater risk of potentially fatal severe dengue disease, including dengue hemorrhagic fever and dengue shock syndrome. The single most effective measure to control this threat to global health is a tetravalent DENV vaccine. To date, attempts to develop a protective vaccine have progressed slowly, partly because the targets of type-specific human neutralizing antibodies (NAbs), which are critical for long-term protection, remain poorly defined, impeding our understanding of natural immunity and hindering effective vaccine development. Here, we show that the envelope glycoprotein domain I/II hinge of DENV-3 and DENV-4 is the primary target of the long-term type-specific NAb response in humans. Transplantation of a DENV-4 hinge into a recombinant DENV-3 virus showed that the hinge determines the serotype-specific neutralizing potency of primary human and nonhuman primate DENV immune sera and that the hinge region both induces NAbs and is targeted by protective NAbs in rhesus macaques. These results suggest that the success of live dengue vaccines may depend on their ability to stimulate NAbs that target the envelope glycoprotein domain I/II hinge region. More broadly, this study shows that complex conformational antibody epitopes can be transplanted between live viruses, opening up similar possibilities for improving the breadth and specificity of vaccines for influenza, HIV, hepatitis C virus, and other clinically important viral pathogens.The four dengue virus serotypes (DENV-1, -2, -3, and -4), transmitted by Aedes spp. mosquitoes, are endemic throughout tropical and subtropical regions of the world, with an estimated 390 million new infections annually (1). Primary infection with one serotype confers long-term immunity against that serotype, but repeat infection with a different serotype has an increased risk of potentially fatal severe dengue disease (2), including dengue hemorrhagic fever and dengue shock syndrome. This risk has been attributed, at least in part, to the ability of some cross-reactive antibodies to enhance infection of Fc-receptor bearing cells. The consensus is that, to be safe and effective, any dengue vaccine must simultaneously induce neutralizing antibodies (NAbs) to all four serotypes. However, DENV vaccine development has progressed slowly, highlighted by the disappointing results of the live-attenuated Sanofi Pasteur tetravalent DENV vaccine trial in Thailand (3). Progress is hindered, in part, because the epitopes targeted by the type-specific human NAbs critical for long-term protection (4, 5) remain poorly defined, limiting our understanding of natural DENV immunity and slowing effective vaccine development.The DENV envelope glycoprotein (E) (Fig. 1A) is the major surface-exposed DENV antigen and the principle target of NAbs. The E structure consists of three distinct domains: I, II, and III (EDI, EDII, and EDIII) (6, 7); EDIII is a continuous peptide extending from domain I and forming an Ig-like fold, whereas EDI and EDII are discontinuous and connect by four peptide linkers that form the EDI/EDII hinge. We and others have recently described potent human DENV NAbs that bind to epitopes around the EDI/EDII hinge (8, 9). To more fully explore the significance of this antigenic region, we used reverse genetics and synthetic biology to transplant the EDI/EDII antigenic region from DENV-4 into a DENV-3 background and showed by both gain- and loss-of-function assays that the EDI/EDII hinge region is the primary target of the long-lived DENV serotype-specific NAb response.Open in a separate windowFig. 1.(A) Cartoon representation of the DENV-3 E dimer with EDI (red), EDII (yellow), and EDIII (blue). The EDI/EDII hinge region is circled. Location of the critical residues associated with escape mutations and mutagenesis-mapped 5J7 residues are shown. Residues critical for 5J7 binding identified by shotgun mutagenesis loss of binding of E glycoprotein expressed in HEK-293T cells are shown in magenta. Mutations associated with both viral escape from 5J7 and loss of binding in HEK-293T cells (L53 and K128) are shown in orange, and the single residue identified by escape mutation alone (Q269K270_insK) is shown in cyan. All critical residues were individually identified but are shown on a single E dimer for simplicity. (B) Cartoon representation of the DENV E dimer with the locations of variable EDI/EDII hinge residues transplanted between rDENV-3 and rDENV-4 to make rDENV-3/4 shown in green. (C) Primary sequence alignment and secondary structure of rDENV-3 E, rDENV-3/4 E, and rDENV-4 E. Secondary structure is indicated above the primary sequence and color-coded to the corresponding domains on the tertiary structure (A and B). Arrows indicate β-sheets, cylinders indicate helices, and lines indicate spanning loops and strands. Binding, escape, and hinge residues shown in A and B are indicated by corresponding colors in the rDENV-3 sequence. Amino acid residues transplanted between rDENV-3/4 and rDENV-4 are indicated in green for both sequences.     

Identification of human neutralizing antibodies that bind to complex epitopes on dengue virions

Dengue is a mosquito-borne flavivirus that is spreading at an unprecedented rate and has developed into a major health and economic burden in over 50 countries. Even though infected individuals develop potent and long-lasting serotype-specific neutralizing antibodies (Abs), the epitopes engaged by human neutralizing Abs have not been identified. Here, we demonstrate that the dengue virus (DENV)-specific serum Ab response in humans consists of a large fraction of cross-reactive, poorly neutralizing Abs and a small fraction of serotype-specific, potently inhibitory Abs. Although many mouse-generated, strongly neutralizing monoclonal antibodies (mAbs) recognize epitopes that are present on recombinant DENV envelope (E) proteins, unexpectedly, the majority of neutralizing Abs in human immune sera bound to intact virions but not to the ectodomain of purified soluble E proteins. These conclusions with polyclonal Abs were confirmed with newly generated human mAbs derived from DENV-immune individuals. Two of three strongly neutralizing human mAbs bound to E protein epitopes that were preserved on the virion but not on recombinant E (rE) protein. We propose that humans produce Abs that neutralize DENV infection by binding a complex, quaternary structure epitope that is expressed only when E proteins are assembled on a virus particle. Mapping studies indicate that this epitope has a footprint that spans adjacent E protein dimers and includes residues at the hinge between domains I and II of E protein. These results have significant implications for the DENV Ab and vaccine field.     

Influence of Nutrition and Lifestyle on Bone Mineral Density in Children From Adoptive and Biological Families

Background

The precise contributions of hereditary and environmental factors to bone density are not known. We compared lifestyle predictors of bone density among adopted and biological children.

Methods

The study comprised 18 adopted children (mean [SD] age, 14.0 [4.1] years) with their non-biological parents and 17 children with their biological parents. Bone mineral density (BMD; g/cm²) was measured at the lumbar spine, total femur, and distal radius. Nutritional intake was assessed by food frequency questionnaire. Information on smoking and physical activity was obtained by questionnaire.

Results

Intakes of all nutrients, corrected for energy intake, and all lifestyle characteristics except sleep duration were similar in biological children and their parents. As compared with their parents, adopted children had significantly different energy, protein, and calcium intakes and physical activity levels. In a regression model, BMD z scores of adopted children and their parents were significantly inversely associated at the spine and total femur, whereas BMD z scores of biological children and their parents were significantly positively associated at all measurement sites. The greatest proportion of total variance in BMD was accounted for by calcium intake among adopted children and by parental BMD among biological children.

Conclusions

For some lifestyle characteristics and nutrient intakes, the differences between parents and children were more obvious among adoptive families than among biological families. The most important lifestyle predictor of bone density was calcium intake.Key words: bone mineral density, adopted children, lifestyle, heredity, nutrition     

Nutrition and lifestyle in relation to bone health and body weight in Croatian postmenopausal women

The objective was to investigate the association of nutrients and lifestyle modifiers with bone mineral density (BMD) and weight and/or body mass index (BMI) in 120 healthy Croatian postmenopausal women. The hip and spine BMD was assessed by Lunar Prodigy (GE Medical Systems). Nutrient assessment from 3-day records was analyzed using the US Department of Agriculture Food Composition Tables and the Croatian National Institute of Public Health database. Subjects were asked to record the consumption of alcohol, coffee, tea and mineral waters, the amount of salt added to foods and smoking habits, as well as involvement in recreational activities, walking and heavy housework. Spot urine samples were analyzed for calcium, magnesium, sodium, potassium and zinc and were normalized by creatinine. Alcohol showed statistically significant positive association with femur and spine BMD and its consumption was higher in subjects without osteoporosis. Urinary sodium/creatinine was significantly positively associated with femoral neck and trochanter BMD, while urinary calcium/creatinine was significantly negatively associated with trochanter, total femur and spine BMD. Consumption of mineral waters was inversely associated with weight/BMI and so were dietary fiber and magnesium. In conclusion, moderate alcohol consumption and urinary sodium were positively associated while urinary calcium was negatively associated with either hip and/or spine BMD. Mineral waters, higher fiber and magnesium intake were beneficial for weight/BMI in this population of apparently healthy Croatian women.     

<Emphasis Type="Italic">OPA3</Emphasis> mutation screening in patients with unexplained 3-methylglutaconic aciduria

Summary We have screened 13 patients with neurological abnormalities and 3-methylglutaconic aciduria (3MGA) for mutations in the OPA3 gene, which are known to be the cause of Costeff syndrome (optic atrophy, chorea and spasticity; type III 3MGA). We aimed to explore whether mutations in the OPA3 gene are present in patients with 3MGA but without classic Costeff syndrome. OPA3 mutations (IVS1−1G>C) were identified in 2 patients with the classic phenotype of type III 3MGA, but not in the other 11 patients with differing non-Costeff phenotypes associated with developmental delay and neurological signs and symptoms as described. We identified a previously described sequence variation in the OPA3 gene (c.231T>C) in 12/13 patients. The alteration was homozygous in 8/12 and heterozygous in 4/12. This alteration was also found in 60 of 98 normal control alleles. In a single patient, a novel sequence variation in the 5′ UTR was identified, (c.−38A>G). Our studies suggest that the c.231T>C sequence variation is of no clinical significance, whereas the significance of the 5′ UTR sequence variation remains open to speculation. Our study of the OPA3 gene in patients with 3MGA without Costeff syndrome suggests that mutations in OPA3 are not a common cause of 3MGA in the absence of signs of Costeff syndrome.     

Genotype–phenotype correlation in 44 Czech,Slovak, Croatian and Serbian patients with mucopolysaccharidosis type II

Mucopolysaccharidosis type II (Hunter syndrome, MPS II, OMIM 309900) is an X‐linked lysosomal storage disorder caused by deficiency of iduronate‐2‐sulfatase (IDS). We analyzed clinical and laboratory data from 44 Slavic patients with this disease. In total, 21 Czech, 7 Slovak, 9 Croatian and 7 Serbian patients (43 M/1 F) were included in the study (median age 11.0 years, range 1.2–43 years). Birth prevalence ranged from 1:69,223 (Serbia) to 1:192,626 (Czech Rep.). In the majority of patients (71%), the disease manifested in infancy. Cognitive functions were normal in 10 patients. Four, six and 24 patients had mild, moderate, and severe developmental delay, respectively, typically subsequent to developmental regression (59%). Residual enzyme activity showed no predictive value, and estimation of glycosaminoglycans (GAGs) had only limited importance for prognosis. Mutation analysis performed in 36 families led to the identification of 12 novel mutations, eight of which were small deletions/insertions. Large deletions/rearrangements and all but one small deletion/insertion led to a severe phenotype. This genotype–phenotype correlation was also identified in six cases with recurrent missense mutations. Based on patient genotype, the severity of the disease may be predicted with high probability in approximately half of MPS II patients.