Roberto Finocchiaro

Abnormal intestinal permeability in children with autism

We determined the occurrence of gut mucosal damage using the intestinal permeability test in 21 autistic children who had no clinical and laboratory findings consistent with known intestinal disorders. An altered intestinal permeability was found in 9 of the 21 (43%) autistic patients, but in none of the 40 controls. Compared to the controls, these nine patients showed a similar mean mannitol recovery, but a significantly higher mean lactulose recovery (1.64%± 1.43 vs 0.38%±0.14; P < 0.001). We speculate that an altered intestinal permeability could represent a possible mechanism for the increased passage through the gut mucosa of peptides derived from foods with subsequent behavioural abnormalities.

Low serum tryptophan to large neutral amino acids ratio in idiopathic infantile autism.

The serum tryptophan to large neutral amino acids ratio (Try/LNAA) is considered a reliable marker of tryptophan availability for brain serotonin synthesis. A dysfunction of brain serotonergic activity has been postulated to exist in autistic disorder and supported by recent studies. On this basis, we determined the serum amino acids levels in 40 children with idiopathic infantile autism as well as in 46 control children. A significantly lower serum Try/LNAA ratio was observed in the autistic subjects compared to the normal controls. In 14 autistic children (35%) this ratio was 2 SD below the mean value obtained in the control group. These results suggest that a low brain tryptophan availability due to a low serum Try/LNAA ratio could be one of the possible mechanisms involved in the alteration of serotonergic function in autism.

Usefulness of cyanide-nitroprusside test in detecting incomplete recessive heterozygotes for cystinuria: a standardized dilution procedure

Abstract We present the results of a cyanide-nitroprusside test (CNT) after a standardized dilution procedure of urine samples and report the efficiency of this method in detecting heterozygotes for cystinuria when applied on an open pediatric population. In the preliminary study we assayed by quantitative determination of amino acids 162 urine samples from a hospital population identifying 24 type III heterozygotes and 2 type II heterozygotes for cystinuria. The classic CNT gave 38 false positive results and 5 false negative results showing a sensitivity and specificity of 0.808 and 0.721, respectively. When progressively diluted, all samples of heterozygotes remained CNT positive up to a creatinine concentration of 90 mg/dl. At this level of dilution 31 out of 38 false positive turned to negative, thus obtaining a specificity of 0.922 without a lowering of the sensitivity in detecting heterozygotes. The standardized dilution at 90 mg/dl of creatinine concentration was applied to 74.7% of a population of 1024 schoolchildren. In this way 163 out of 210 positive results were eliminated and thus the specificity of CNT rose from 0.789 to 0.953. On the basis of these results, the method proposed can be regarded as reliable and useful for a␣screening program in detecting heterozygotes for cystinuria.

Determination of urinary orotic acid and uracil by capillary zone electrophoresis.

We describe a simple method for measuring orotic acid and uracil concentration in urine by capillary zone electrophoresis in 20 mM Na-borate buffer, pH 9.2. The method was applied for studying a patient with HHH (hyperomithinemia, hyperammonemia and homocitrullinuria) syndrome. A high value of uracil excretion was found during periods of relatively low orotic acid excretion and normal ammonemia. The orotic acid level in urine was increased by increasing protein intake.

Effect of D-Ribose Administration to a Patient with Inherited Deficit of Adenylosuccinase

Adenylosuccinase (EC 4.3.2.2; ASase) deficiency is a newly discovered inborn error of metabolism that involves the purine de novo pathway and results in the accumulation of dephosphorylated substrate derivatives of the defective enzyme, namely succinylaminoimidazole carboxamide (SAICA) riboside and succinyladenosine (S-Ado).1–3 Although substantial progress has been made regarding our knowledge of the inherited disease, including its characterisation at gene level,4–5 much work remains to be done, particularly with respect to the mechanisms whereby the defect exerts its deleterious effects on brain function.

Neutrophil Glutamine Deficiency in Relation to Genotype in Children with Cystic Fibrosis

Pulmonary disease in cystic fibrosis (CF) is characterized by a chronic neutrophil-dominated inflammation of lung tissue. Inasmuch as some amino acids (AA) play a pivotal role in various aspects of neutrophil metabolism, the aim of this study was to investigate a possible alteration of neutrophil AA metabolism and to evaluate its relation (if any) with the genotype. We performed plasma and neutrophil AA analysis in 26 CF patients with known genotype, 10 patients with non-CF bronchiectasis, and 20 normal subjects. The CF group showed a significant decrease of free intracellular neutrophil glutamine (Gln) content compared with controls and the non-CF bronchiectasis group. In the latter group, levels of neutrophil Gln were significantly lower compared with the controls. Amino acid plasma concentration in non-CF bronchiectasis showed a decrease of Gln and taurine compared with controls. Neutrophil Gln content showed values significantly lower in CF patients with severe mutations (class I, II, and III mutations) compared with mild mutations (class IV and V mutations). Results of our study add further evidence for intrinsic neutrophil alterations that could play an important role in the pathogenesis of chronic pulmonary disease in CF patients.

Taurine deficiency in thalassemia major-induced osteoporosis treated with neridronate

The aetiology of thalassemia major-induced osteoporosis is multifactorial. Up to now, bisphosphonates seem to be a promising therapy. Taurine is found in a high concentration in bone cells enhancing bone tissue formation and inhibiting bone loss. Recently we found a decrease taurine plasma level in children affected by osteogenesis imperfecta during neridronate (amino-bisphosphonate) therapy suggesting a possible interaction between pharmacological effect of this drug and taurine availability. On the basis of these results, we performed plasma and urine amino acid (AA) analysis in thalassemia major-induced osteoporosis before and after 12 months of neridronate treatment. Twelve patients, five males and seven females, aged from 20 to 29 years following a hypertransfusion treatment protocol were enrolled in the study. Patients were treated with neridronate infusion every one month (30 mg in 100ml of saline). Plasma and urine specimens for AA analysis, bone mineral density, bone mineral content and vertebral project area were examined at baseline (T0) and after 12 months of treatment (T12). A significant decrease was observed for plasma level and urinary excretion of taurine (T0 vs. T12=p<0.01) whereas bone mineral content and vertebral projection area showed a statistical significant increase (T0 vs. T12=p<0.05). These results and other experimental researches warrant further studies examining the long-term effect of taurine supplementation in association with neridronate treatment.

High levels of serum prostaglandin E2 in children with osteogenesis imperfecta are reduced by neridronate treatment.

Prostaglandin E2 (PGE2) is an activator of bone remodeling, and increase levels of PGE2 are found in several disorders characterized by chronic inflammation. Bisphosphonates are used in the treatment of osteogenesis imperfecta (OI), an inherited disorder characterized by bone fragility and low bone mass. We evaluated the serum PGE2 (ng/mL) level in 16 children affected by OI (11 with mild and 5 with severe forms) at basal time and during treatment with neridronate. The levels of PGE2 in mild and severe forms were increased at basal time compared with controls (13.14 ± 4.2 versus 0.72 ± 0.05, p < 0.01; 15.1 ± 1.5 versus 0.72 ± 0.05, p < 0.01, respectively) and showed a significant decrease after the second (T1) cycle of treatment (mild: 4.97 ± 5.0 versus 13.14 ± 4.2, p < 0.01; severe: 5.32 ± 4.5 versus 15.1 ± 1.5, p < 0.01) with a further significant decrease after the fourth (T2) cycle. The high basal PGE2 levels in OI, a noninflammatory disorder, could be explained by stress-induced release mediated by inducible cyclooxygenase-2-catalyzed pathway. The reduction obtained by treatment with bisphosphonates could be attributed to a direct pharmacological effect since these drugs has been reported to modulate the release of proinflammatory mediators.

Tyrosinemia type I: long-term outcome in a patient treated with doses of NTBC lower than recommended

Sir, The paper by El-Karasky et al. “NTBC therapy for tyrosinemia type 1: how much is enough?” raises the question if doses of nitisinone (NTBC) lower than recommended could be effective in the treatment of tyrosinemia type 1 [1]. The authors report that the duration of follow-up, which does not exceed 27 months, represents a limitation of their study. We follow a 15-year-old male patient with tyrosinemia type 1 diagnosed at 6 months of age and promptly enrolled in an NTBC trial [2]. He started treatment with the recommended average dose of 1 mg/kg/day divided in two doses. After 2 months of treatment, plasma and urinary succinylacetone were undetectable. An improvement in hepatic function was noted within 18 months and serum alpha-fetoprotein progressively decreased and normalized after 24 months. Before starting NTBC therapy, the hepatic ultrasonography showed multiple cirrhotic nodules that disappeared after 48 months of treatment. Our patient thrived well but corneal opacities occurred, when tyrosine levels exceeded 700 μmol/l because of dietary noncompliance. After 114 months of treatment, based on clinical and biochemical follow-up, we progressively reduced the NTBC dose to the actual dose of 0.55 mg/kg/day. The NTBC serum concentration always remained above the recommended level of 30 μmol/l and urinary succinylacetone remained undetectable. Until now, the patient is in good condition with normal growth and absence of biochemical and ultrasound evidence of liver injury. Our case suggests that doses of NTBC, lower than recommended, could be effective in the long-term outcome.

Increased nitric oxide release by neutrophils of a patient with tyrosinemia type III

Tyrosinemia type III (OMIM 276710) is an autosomal recessive disorder caused by the deficiency of 4-hydroxyphenylpyruvate dioxygenase (4-HPD). Few cases have been described with mental retardation or neurological symptoms. Recently it has been demonstrated that 4-HPD participates to nitric oxide (NO) intracellular sequestration in Pseudomonas aeruginosa. 4-HPD is an ubiquitous enzyme with a prominent expression in neutrophils and neurons. In the nervous system NO has been perceived to be a potential neuromodulator although prolonged excessive generation is detrimental. We analyzed NO release by neutrophils of a patient with tyrosinemia type III in order to evaluate a possible influence of 4-HPD deficiency on this process. Our patient, previously described, is a 30-year-old women with persistent tyrosinemia (450-680 micromol/l) and deficient activity of 4-HPD. At 17 months of age she experienced an acute ataxia and drowsiness lasting for 10 days, but further clinical course showed persistent tyrosinemia with normal growth and psychomotor development. Neutrophils isolated from our patient exhibited a NO release greatly higher in respect to the controls (mean+/-SEM 23.2+/-1.8 micromol/10(6) cells vs 3.5+/-0.5 micromol/10(6) cells). Clinical findings of tyrosinemia type III include neurological symptoms and mental retardation but no consistent phenotype has emerged. Therefore the pathogenesis of neurological involvement is yet not well understood. Our results suggest that an excessive neutrophils of NO release could reflect the lack of scavenging action of 4-HPD. Considering the prominent expression of this enzyme in neurons, we hypothesize that excessive NO release could participate in neuronal damage explaining the neurological involvement described in patients with tyrosinemia type III.