Subcutaneous vitamin B12 administration using a portable infusion pump in cobalamin-related remethylation disorders: a gentle and easy to use alternative to intramuscular injections

BACKGROUND Cobalamin (cbl)-related remethylation disorders are a heterogeneous group of inherited disorders comprising the remethylation of homocysteine to methionine and affecting multiple organ systems, most prominently the nervous system and the bone marrow. To date, the parenteral, generally intramuscular, lifelong administration of hydroxycobalamin (OHCbl) is the mainstay of therapy in these disorders. The dosage and frequency of OHCbl is titrated in each patient to the minimum effective dose in order to account for the painful injections. This may result in undertreatment, a possible risk factor for disease progression and disease-related complications. RESULTS We describe parenteral administration of OHCbl using a subcutaneous catheter together with a portable infusion pump in a home therapy setting in four pediatric patients with remethylation disorders, two patients with cblC, one patient with cblG, and one patient with cblE deficiency, in whom intramuscular injections were not or no longer feasible. The placement of the subcutaneous catheters and handling of the infusion pump were readily accomplished and well accepted by the patients and their families. No adverse events occurred. The use of a small, portable syringe driver pump allowed for a most flexible administration of OHCbl in everyday life. The concentrations of total homocysteine levels were determined at regular patient visits and remained within the therapeutic target range. This approach allowed for the continuation of OHCbl therapy or the adjustment of therapy required to improve metabolic control in our patients. CONCLUSIONS Subcutaneous infusion using a subcutaneous catheter system and a portable pump for OHCbl administration in combined and isolated remethylation disorders is safe, acceptable, and effective. It decreases disease burden in preventing frequent single injections and providing patient independence. Thus, it may promote long-term adherence to therapy in patients and parents

Kindler syndrome: extension of FERMT1 mutational spectrum and natural history

Mutations in the FERMT1 gene (also known as KIND1), encoding the focal adhesion protein kindlin-1, underlie the Kindler syndrome (KS), an autosomal recessive skin disorder with an intriguing progressive phenotype comprising skin blistering, photosensitivity, progressive poikiloderma with extensive skin atrophy, and propensity to skin cancer. Herein we review the clinical and genetic data of 62 patients, and delineate the natural history of the disorder, for example, age at onset of symptoms, or risk of malignancy. Although most mutations are predicted to lead to premature termination of translation, and to loss of kindlin-1 function, significant clinical variability is observed among patients. There is an association of FERMT1 missense and in-frame deletion mutations with milder disease phenotypes, and later onset of complications. Nevertheless, the clinical variability is not fully explained by genotype-phenotype correlations. Environmental factors and yet unidentified modifiers may play a role. Better understanding of the molecular pathogenesis of KS should enable the development of prevention strategies for disease complications.Contract grant sponsors: International Kindler Syndrome; The German Federal Ministry for Education and Research; The Excellence Initiative of the German federal and stage government and Freiburg Institute for Advanced Studies, School of Life Sciences (to L.B.T); The Italian Ministry of Heat

Tetra-amelia and lung hypo/aplasia syndrome: New case report and review

Tetra-amelia is a rare malformation that may be associated with other anomalies and is usually inherited in an autosomal recessive pattern. We describe a fetus, born to a nonconsanguineous couple, with tetra-amelia, bilateral cleft lip and palate and bilateral lung agenesis, without other anomalies. Karyotype was normal (46,XX) and premature centromere separation was excluded. No mutation was identified upon molecular analysis of WNT3, HS6ST1, and HS6ST3. We reviewed the literature and the differential diagnosis to clarify the clinical delineation of conditions associated with tetra-amelia. The present report describes the sixth family with this pattern of malformations and reinforces the evidence that the ldquotetra-amelia and lung hypo/aplasia syndromerdquo is a distinct autosomal recessive condition, with no identified gene thus far. © 2008 Wiley-Liss, Inc

Expanding the phenotypic spectrum of lupus erythematosus in Aicardi-Goutie`res syndrome

Objective. Aicardi-Goutie`res syndrome (AGS) isan early-onset encephalopathy resembling congenitalviral infection that is characterized by basal gangliacalcifications, loss of white matter, cerebrospinal fluid(CSF) lymphocytosis, and elevated interferon- levels inthe CSF. Studies have shown that AGS is an autosomalrecessivedisease linked to mutations in 5 genes, encodingthe 3 -repair DNA exonuclease 1 (TREX1), the 3subunits of ribonuclease H2 (RNASEH2A–C), and sterilealpha motif domain and HD domain–containingprotein 1 (SAMHD1). In this study we further characterizedthe phenotypic spectrum of this disease.Methods. Clinical and laboratory data were obtainedfrom 26 patients fulfilling the clinical diagnosticcriteria for AGS. Genomic DNA was screened for mutationsin all 5 AGS genes by direct sequencing, and serawere analyzed for autoantibodies.Results. In 20 patients with AGS, 20 mutations,12 of which were novel, were identified in all 5 AGSgenes. Clinical and laboratory investigations revealed ahigh prevalence of features (some not previously describedin patients with AGS) that are commonly seen inpatients with systemic lupus erythematosus (SLE), suchas thrombocytopenia, leukocytopenia, antinuclear antibodies,erythematous lesions, oral ulcers, and arthritis,which were observed in 12 (60%) of 20 patients withAGS. Moreover, the coexistence of AGS and SLE, wasfor the first time, demonstrated in 2 patients withmolecularly proven AGS.Conclusion. These findings expand the phenotypicspectrum of lupus erythematosus in AGS andprovide further insight into its disease mechanisms by showing that activation of the innate immune system asa result of inherited defects in nucleic acid metabolismcould lead to systemic autoimmunity

The HNF4A R76W mutation causes atypical dominant Fanconi syndrome in addition to a β cell phenotype

types: JOURNAL ARTICLEMutation specific effects in monogenic disorders are rare. We describe atypical Fanconi syndrome caused by a specific heterozygous mutation in HNF4A. Heterozygous HNF4A mutations cause a beta cell phenotype of neonatal hyperinsulinism with macrosomia and young onset diabetes. Autosomal dominant idiopathic Fanconi syndrome (a renal proximal tubulopathy) is described but no genetic cause has been defined.This article presents independent research supported by the National Institute for Health Research (NIHR) Exeter Clinical Research Facility. The research is funded by a Wellcome Trust Senior Investigator Award, (grant number 098395/Z/12/Z).Wellcome Trus