In the last two decades, the introduction of tandem mass spectrometry in clinical laboratories has enabled simultaneous testing of numerous acylcarnitines and amino acids from dried blood spots for ...detecting many aminoacidopathies, organic acidurias and fatty acid oxidation disorders. The expanded newborn screening was introduced in Slovenia in September 2018. Seventeen metabolic diseases have been added to the pre-existing screening panel for congenital hypothyroidism and phenylketonuria, and the newborn screening program was substantially reorganized and upgraded.
Tandem mass spectrometry was used for the screening of dried blood spot samples. Next-generation sequencing was introduced for confirmatory testing. Existing heterogeneous hospital information systems were connected to the same laboratory information system to allow barcode identification of samples, creating reports, and providing information necessary for interpreting the results.
In t he first y ear of t he expanded newborn screening a total of 15,064 samples w ere screened. Four patients were confirmed positive with additional testing.
An expanded newborn screening program was successfully implemented with the first patients diagnosed before severe clinical consequences.
Fetal and neonatal thyrotoxicosis occurs in up to 5% of pregnancies in mothers with Graves’ disease (GD). This condition is caused by stimulating antibodies against the thyrotropin receptor (TRAbs) ...that cross the placenta and may stimulate the fetal thyroid, typically in the second half of pregnancy. GD is often treated with radioiodine, resulting in hypothyroidism in most patients, but TRAbs can persist for several years. Even if a pregnant mother is hypothyroid after radioiodine therapy or surgery, her TRAbs can still, although rarely, induce fetal hyperthyroidism. In this review, we first present two cases of neonatal hyperthyroidism in mothers with GD who became hypothyroid after prior radioiodine therapy, identified through a 10-year analysis of the National Perinatal System in Slovenia. Based on these cases, we provide an overview of existing data on this rare clinical condition in neonates. We also discuss the underlying mechanisms and clinical outcomes based on currently available data. In conclusion, our review highlights the importance of careful monitoring during pregnancy in all women with GD, even in those well managed after radioiodine therapy or surgery.
Mukopolisaharidoze so skupina lizosomskih bolezni kopičenja. Njihova skupna značilnost je pomanjkanje delovanja encimov, ki razgrajujejo glikozaminoglikane, polisaharide, ki se povezujejo s ...proteoglikani in tvorijo zunajcelični matriks. Ker ni encimov, ki bi glikozaminoglikane razgrajevali, se ti kopičijo v lizosomih in povzročijo njihovo okvaro in zato se okvarijo drugi celični organeli, celice in končno organi. Klinična slika je široka, od nevro-kognitivnega upada, skeletno-mišičnih deformacij in tipičnih obraznih sprememb. Ključno je zgodnje prepoznavanje bolezni, čeprav s trenutno dostopnimi načini zdravljenja bolezni ne moremo ozdraviti, lahko pa le upočasnimo njen potek, kar je najbolj učinkovito v fazi bolezni še pred pojavom simptomov. Obetavni način zdravljenja je gensko zdravljenje, ki nakazuje možnost ozdravitve bolezni.Predstavljamo primer dečka, pri katerem je bil prepoznan zgodnji kognitivni upad in za bolezen tipične spremembe. Napoten je bil v terciarno ustanovo, kjer je bila diagnoza potrjena. Deček je bil julija 2018 zdravljen z eksperimentalnim genskim zdravljenjem v tujini (bolnišnica San Raffaele, Milano, Italija). V opisanem primeru gre po našem vedenju za prvo uspešno izpeljano gensko zdravljenje pri slovenskih bolnikih ter za enega prvih primerov genskega zdravljenja mukopolisaharidoze tipa I v svetovnem merilu. Gensko zdravljenje s tem postaja del nove klinične stvarnosti, kar predstavlja pomemben mejnik za naš prostor. Zaradi naprednih zdravljenj bi bilo v prihodnosti smiselno uvesti presejalno testiranje novorojenčkov za MPS tipa I, ki se pri nas ali v Evropi doslej še ne izvaja. Do tedaj pa ostaja najpomembnejši predpogoj za uspešno zdravljenje zgodnja klinična prepoznava bolezni in napotitev v terciarno zdravstveno ustanovo.
Phosphoribosylpyrophosphate synthetase 1 (PRSI) is an enzyme involved in nucleotide metabolism. Pathogenic variants in the PRPS1 are rare and PRS-I deficiency can manifest as three clinical ...syndromes: X-linked non-syndromic sensorineural deafness (DFN2), X-linked Charcot-Marie-Tooth neuropathy type 5 (CMTX5) and Arts syndrome. We present a Slovenian patient with PRS-I enzyme deficiency due to a novel pathogenic variant – c.424G > A (p.Val142Ile) in the PRPS1 gene, who presented with gross motor impairment, severe sensorineural deafness, balance issues, ataxia, and frequent respiratory infections. In addition, we report the findings of a systemic literature review of all described male cases of Arts syndrome and CMTX5 as well as intermediate phenotypes. As already proposed by other authors, our results confirm PRS-I deficiency should be viewed as a phenotypic continuum rather than three separate syndromes because there are multiple reports of patients with an intermediary clinical presentation.
Interstitial 3p21.31 deletions have been very rarely reported. We describe a 7-year-old boy with global developmental delay, specific facial characteristics, hydronephrosis, and hypothyreosis with a ...de novo deletion of 3p21.31, encompassing 29 OMIM genes. Despite the wide use of microarrays, no similar case has been reported in the literature so far. Five overlapping cases are deposited in the DECIPHER database, 2 of which have significant overlapping chromosomal aberrations. They both share some phenotypic characteristics with our case, e.g. developmental delay, intellectual disability and facial dysmorphism (arched eyebrows, hypertelorism, low-set ears, and a large nose tip). In addition, loss-of-function mutations in the SETD2 gene (OMIM 612778) of the deleted region have been described in 3 patients, presenting with some similar clinical features, namely overgrowth, intellectual disability, speech delay, hypotonia, autism, and epilepsy. Therefore, SETD2 may explain part of the phenotype in our case. We focused on 3 other genes in the deleted region, based on their known functions, namely CSPG5 (OMIM 606775), PTH1R (OMIM 168468) and SMARCC1 (OMIM 601732), and assessed their potentially important role in describing the patient's phenotype. Additional cases with haploinsufficiency of this region are needed to elucidate further genotype-phenotype correlations.
Spektroavtistične motnje (SAM) so kompleksne razvojne motnje, ki se kažejo predvsem kot kakovostno spremenjeno vedenje na področju socialnih interakcij, besedne in nebesedne komunikacije ter ...imaginacije. Pogostost SAM se v zadnjih letih izrazito povečuje. Vzroka še niso opredelili, najverjetnejši etiološki vzrok pa je interakcija med genetskimi dejavniki in okoljskimi vplivi. Med genetske vzroke za avtizem sodijo tudi prirojene presnovne bolezni (PPB), ki so dokazane pri 2−5 % otrok s SAM. Na PPB kot vzrok za spektroavtistično motnjo pomislimo predvsem ob anamnes-tičnem podatku o regresiji v razvoju in pridruženih dodatnih kliničnih znakih. Diagnostična potrditev zahteva individualno obravnavo in usmerjene presnovne in genetske preiskave. V prihodnosti bodo pri diagnosticiranju SAM v ospredju genetske analize, usmerjene predvsem v potrditev monogenskih vzrokov SAM, med katere uvrščamo tudi PPB. Cilj bo čimprejšnje diagnosticiranje, morda že prenatalno, zlasti če bo z razvojem zdravil dostopno vzročno gensko zdravljenje. V preglednem prispevku povzemamo priporočila za diagnosticiranje prirojenih presnovnih bolezni pri bolnikih s sindromskim avtizmom in s prikazom primera otroka z lizosomsko boleznijo kopičenja in SAM opozarjamo na pomen pravočasne in pravilno postavljene diagnoze.
Angiokeratomas are the cutaneous hallmark of Fabry disease. Although it is well established that enzyme replacement therapy (ERT) prevents or slows the progression of disease on target organs in the ...majority of patients, the long-term effect of ERT on angiokeratomas remains unknown. We present a patient diagnosed with Fabry disease at age 11, with rapid progression of new angiokeratomas in typical regions before beginning treatment with ERT. To date, our patient has been treated with ERT for 10 years. During the treatment period, new angiokeratomas have not arisen nor have existing ones enlarged during puberty, adolescence, and early adulthood. Furthermore, partial regression of the angiokeratomas has occurred in association with regression of left ventricular hypertrophy and anhidrosis. Overall, this case suggests that long-term ERT could stop the progression of angiokeratomas and induce their partial regression but does not produce complete resolution. Importantly, regression of angiokeratomas might be a marker of systemic target-organ efficacy of ERT.
Mukopolisaharidoze so lizosomske bolezni kopičenja, pri katerih se klinična slika razvija postopno. Bolezni napredujejo in prizadenejo številne organe. S trenutno dostopnimi možnostmi zdravljenja ...bolnikov ne moremo ozdraviti, a s prihodom genskega zdravljenja ob pravočasni postavitvi diagnoze in zgodnjem zdravljenju lahko upamo tudi na to možnost. V prispevku predstavljamo primera bolnikov s polisaharidozo. V prvem primeru opisujemo dečka, pri katerem je prisotnost bolezni pri starejšem bratu odprla možnost pra-vočasne postavitve diagnoze in vključitev v eksperimentalno gensko zdravljenje v tujini, ki se po do sedaj opravljenih preiskavah kaže kot učinkovita. V drugem primeru gre za dečka, pri katerem so po kliničnem sumu in ustreznem diagnosticiranju bolezen potrdili relativno zgodaj in s tem omogočili eksperimentalno gensko zdravljenje v tujini. V opisanih primerih gre torej za dva izmed prvih petih primerov uspešno izpeljanega genskega zdravljenja pri slovenskih bolnikih, ki za zdaj še poteka v okviru raziskovalnega protokola v tujini. Gensko zdravljenje torej postopno, a nezadržno postaja del klinične realnosti. Pogoj za uspešno zdravljenje mukopolisaharidoze z genskim zdravljenjem je, da bolezen čim prej prepoznamo, kar bo v prihodnosti verjetno uresničljivo z uvedbo programa presejanja novorojenčkov.
BACKGROUND Niemann-Pick disease (NPD) type A is an autosomal recessive lipid storage disorder caused by acid sphingomyelinase deficiency due to a mutation in the SMPD1 gene. Type A is the most severe ...phenotype of NPD, with early onset in infancy and unfavorable outcome in early childhood. CASE REPORT An 11-month-old boy with hepatosplenomegaly, elevated liver transaminases, and faltering growth was admitted to our hospital for further assessment of potential liver disease. He had severe generalized muscular hypotonia, muscular hypotrophy, reduced muscular strenght, joint laxity, weak deep tendon reflexes, and severe motor developmental delay. Leukodystrophy was seen on the brain MRI, and brainstem auditory evoked potentials were characteristic for auditory neuropathy. A chest X-ray showed signs of interstitial lung disease, which was not further evaluated due to absence of respiratory distress. Liver biopsy histopathologic findings were indicative for lipid storage disease. Genetic analysis showed that the patient is a compound heterozygote in the SMPD1 gene - (NM_000543.5): c.573delT p.(Ser192Alafs*65), which was inherited from the mother and c.1267C>T p.(His423Tyr) was inherited from the father. Both variants were previously individually reported in NPD type A and B. The clinical phenotype in our patient was characteristic of NPD type A, with an early onset and a rapidly progresive neurodegeneration. The patient was included in multidisciplinary follow-up, providing him symptomatic treatment and support. CONCLUSIONS We present a case of NPD type A caused by a rare compound heterozygote mutation in the SMPD1 gene. Most clinical findings and the disease course were typical for NPD type A, except for bilateral auditory neuropathy, which seems to be an uncommon finding in this phenotype and could be underestimated due to infrequent testing for auditory dysfunction.
Inborn errors of metabolism (IEM) are disorders with a block in the metabolic pathway caused by a genetic defect of a specific enzyme. Although each of these diseases is quite rare, as a group they ...account for a significant proportion of newborn and childhood morbidity and mortality. Early diagnosis is important to prevent complications or even death of the child. Selective screening is an important diagnostic tool for the diagnosis of IEM.
In Slovenia, symptomatic patients with suspected IEM are referred to the University Children's Hospital Ljubljana. Techniques used for selective screening are gas chromatography-mass spectrometry, ion exchange chromatography-post-column derivatization, liquid chromatography-tandem mass spectrometry and isoelectric focusing. Fluorimetric method is used for enzyme activity measurement.
There are 168 patients with amino and organic acidemias, 5 patients with disorders in fatty acids metabolism, 1 patient with a congenital disorder of glycosylation, 42 patients with Fabry disease (of which 37 are adult) and 20 patients with Gaucher disease (of which 18 are adult) in the Slovenian Register for Rare Diseases.
In Slovenia, management of patients with IEM is centralized at the University Children's Hospital, with the exception of adult patients with Fabry and Gaucher disease. The team work is well organized with close cooperation between the laboratory and pediatricians specialized in metabolic disorders. According to the known frequencies of IEM from the literature, we would expect more positive results than obtained. To evaluate these results, we are planning to perform a pilot study on expanded newborn screening.