Anna Maria Nurchi

Molecular characterization of Wilson disease in the Sardinian population—Evidence of a founder effect

Wilson disease (WD) in the Sardinian population has an approximate incidence of 1:7,000 live births. Mutation analysis of the WD gene in this population reported in our previous articles led us to the characterization of two common mutations and a group of 13 rare mutations accounting for the molecular defect of 8.5, 7.9, and 15.1% of the WD chromosomes. However, molecular analysis of the WD chromosomes containing the most common haplotype, which accounts for 60.5% of the WD chromosomes, failed to define the disease‐causing mutation. In this study, we characterized the promoter and the 5′ UTR of the WD gene sequence and carried out a mutation analysis in this DNA region from patients with the most common haplotype. The promoter is contained in a GC‐rich island and shows a TATA and a CAAT consensus sequence as well as potential binding sites for transcription factors and metal response elements. In all the analyzed 92 chromosomes with this haplotype, we detected a single mutation consisting of a 15‐nt deletion from position –441 to position –427 relative to the translation start site. Expression assays demonstrated a 75% reduction in the transcriptional activity of the mutated sequence compared to the normal control. By adding this mutation to those that have been already characterized, we have now defined the molecular defect in 92% of the WD chromosomes in Sardinians. The high frequency, the expected prevention by preclinical diagnosis and early treatment of the devastating effect of WD on the nervous system and liver tissue, and the feasibility to detect most of molecular defects by DNA analysis indicate that WD in the Sardinian population should be added to the list of diseases currently detected by newborn screening. Hum Mutat 14:294–303, 1999.

Value of histochemical stains for copper in the diagnosis of Wilson's disease

Aims: The histochemical demonstration of hepatic copper is important in the diagnosis of Wilsons disease (WD). Conflicting results have been published with regard to the ability of different histochemical methods to demonstrate copper storage in the liver. Therefore, we evaluated the diagnostic value of three available histochemical methods in a large series of patients affected by WD.

Epidemiology and prevention of rotavirus infection: an underestimated issue?

Rotaviruses (RVs) were found to cause human disease in 1973. They are the leading cause of severe gastroenteritis in infants and young children of <5 years of age worldwide and they are the cause of approximately half a million deaths each year. The impact of the disease on families and society (increased health care costs, lost productivity) is extremely significant and the incidence of gastroenteritis (RVGE) is similar both in industrialized and in developing countries. Virtually, all the children will be Infected by RVs before the ages of 3–5 years with the highest incidence rate registered between 6–24 months of age while the greatest risk for developing severe disease by RV occurs under 12 months of age. Clinically, the infection can vary from asymptomatic and sub clinic forms, which are more common in older children and adults, to acute gastroenteritis with fever, vomiting and self-limiting watery diarrhea which persist for 3 to 8 days. Severe forms with profuse diarrhea accompanied by vomiting and fever with risk of dehydration not adequately and rapidly correct can be fatal, mainly in developing countries. Hygienic-sanitary measures are unable to limit the diffusion of this infection and vaccination at present seems the only effective system to reduce the burden of the disease, human and economic costs related to RVGE. Since the 1980s research has focused on the development of RV vaccines. Vaccines against RV are efficacious, and underwent extensive safety trials (involving more than 130,000); no association with intussusception was detected and in four years since they were licensed a substantial reduction in the rates of RVs hospitalization and deaths for RVs infection have been observed both in developed and less-developed countries. It has been also described in different studies that herd immunity can be induced by RV vaccines (as an indirect effect) by reducing the risk of unvaccinated persons to be infected. Thus, introduction of the vaccine into countries immunization programs is likely to have a greater effect than that predicted on the basis of the efficacy trials. The worldwide epidemiological impact of RV infection pointed the development of safe and effective vaccines against RVs as a public health priority. The great economical burden on health care systems and families suggests the importance of monitoring circulating strains, establishment of systems for surveillance and implementation of universal newborns vaccinaton.

Mutation analysis of the ATP7B gene in a new group of Wilson's disease patients: Contribution to diagnosis.

Wilsons disease (WD), an autosomal recessive disorder of copper transport with a broad range of genotypic and phenotypic characteristics, results from mutations in the ATP7B gene. Herein we report the results of mutation analysis of the ATP7B gene in a group of 118 Wilson disease families (236 chromosomes) prevalently of Italian origin. Using DNA sequencing we identified 83 disease-causing mutations. Eleven were novel, while twenty one already described mutations were identified in new populations in this study. In particular, mutation analysis of 13 families of Romanian origin showed a high prevalence of the p.H1069Q mutation (50%). Detection of new mutations in the ATP7B gene in new populations increases our capability of molecular analysis that is essential for early diagnosis and treatment of WD.

Second-generation antipsychotic and diabetes mellitus in children and adolescents

Second generation antipsychotics (SGA) are used in children for the treatment of various psychiatric diseases, including pervasive developmental disorders. These drugs can cause metabolic effects as hyperglycemia and diabetes. A 16-year-old young-boy, diagnosed with autism, developed diabetes mellitus type 1 whilst he was on treatment with olanzapine (started 4 months before), clomipramine, valproic acid and lithium. The hypothesis of druginduced diabetes imposed olanzapine interruption and clozapine initiation. Insulin therapy was practiced, with progressive dosage reduction, until complete cessation of treatment after 13 months. Blood sugar and HbA1c levels remained stable for about a year and then increased again, requiring the introduction of metformin that improved glycemia. In children and adolescents assuming SGA serum glucose and lipid profile should always be assessed before therapy and then frequently monitored. Drug selection must consider family history and the individual risk. Molecule final choice remains equilibrium between efficacy and safety.

Atypical pleomorphic adenoma with chronic sialoadenitis of the submandibular gland: a case report in a child

A 12-year-old girl presented with an oval swelling in the left submandibular region. The tumor had gradually increased in size, during the last 9 months. Preoperative ultrasonography evidenced an hypoechoic oval mass, 14 x 12 mm in size. Submandibulectomy was performed. At macroscopy, the tumor was surrounded by a fibrous capsule, and appeared tan-white in color. At histology, an admixture of epithelial and mesenchymal cell components characterized the tumor. Epithelial cells showed large polymorphous atypical nuclei, with irregular nuclear membranes. The mesenchymal cells were embedded in a myxoid matrix, with focal areas of chondroid differentiation. The tumor showed pushing margins, focally extending into the fibrous capsule. Occasionally, some scattered foci of capsular pseudo-infiltration were detected. The proliferative index of tumor cells, detected by Ki67 immunostaining, reached levels around 10% in some tumor areas characterized by the highest frequency of atypical tumor cells. On these bases, a diagnosis of atypical pleomorphic adenoma was performed. A lymphocytic infiltrate, sometimes organized in lymphoid nodules, was observed in the surrounding submandibular gland. After 1 year of follow-up, the patient is in good health, in the absence of any recurrence. The case here reported confirms that tumors of the salivary gland occurring in children are characterized by a higher aggressive potential, here represented by the atypical tumor cells associated with the high proliferative index and with the pressure on the tumor capsule, and deserve the complete resection of the affected salivary gland, in order to prevent their potential malignant transformation. The association of the salivary gland tumor presenting in our patient with lymphocytic nodular sialoadenitis confirms previous reports of this peculiar association, and reinforces the hypothesis that the two conditions might share a common etiology.

Polyarteritis nodosa in a 21-month-old child: answer

Childhood polyarteritis nodosa (PAN) is a necrotizing vasculitis, affecting small and medium size blood vessels. This condition was first described by Kussmaul and Maier in 1866. Although comparatively rare in childhood, it is the most common form of systemic vasculitis in children. PAN includes two different subtypes, the classical systemic form presenting with a wide range of clinical manifestations including dermatologic, musculoskeletal, nervous, renal, and gastrointestinal systems and the more frequent cutaneous form (CPAN) that involves only the skin. The main clinical features of PAN are malaise, fever, weight loss, skin rash, myalgia, abdominal pain and arthropathy. Systemic involvement is variable, but the skin, the musculoskeletal system, the kidneys and the gastrointestinal tract are most prominently affected, with cardiac, neurological and respiratory manifestations occurring less frequently. However, clinical manifestations can be very confusing, with absence of conclusive diagnostic evidence in the early phase and sometimes in the late phase of the illness. The etiology of PAN remains unclear, but there are data to support roles for hepatitis B and reports of a higher frequency of exposure to parvovirus B19 and cytomegalovirus in PAN patients compared with control populations. However, in childhood, associations between PAN and these infections or other conditions are rare. Evidence has emerged suggesting that bacterial superantigens may play a role in some cases. Here we report the clinico-pathological findings of a 21-month-old child affected with PAN, with particular emphasis on the severity of renal pathological lesions.

Severe renal damage in a 21-month-old child: question

A male child aged 21 months was admitted fifteen days after abdominal pain and vomits. At clinical examination, he had a pale skin, erythematous eruptions on the arms and abdomen, edema of the eyelids and feet, whitish patches on the oral mucosa of the cheek, hypertrophic tonsils and latero cervical lymphadenopathy. Laboratory tests were within the normal range. The patient was not febrile. A few days later, the child’s general condition worsened and fever appeared. Seven days after admission, the child showed a skin rash on the face. He received several drugs, including aspirin and antibiotics. The patient general condition continued to worsen (body weight decreased, blood pressure and fever increased) until death. 1. Which is your macroscopic diagnosis? 2. Which is your histological diagnosis?

DILI (drug induced liver injury) in a 9-month-old infant: a rare case of phenobarbital-induced hepatotoxicity

Phenobarbital is one of the most commonly prescribed antiepileptic drugs in childhood, but it can rarely cause serious adverse effects, such as hepatotoxicity that includes a broad clinical spectrum (from isolate hypertransaminasemia to acute liver failure). We describe a case of DILI in a 9-month-old infant caused by chronic therapy with phenobarbital.