Mucopolysaccharidoses

A group of 7 progressive, multi-system disorders with at least 11 different lysosomal enzyme deficiencies.http://www.specialistforum.co.zaam2016Paediatrics and Child Healt

Medullary neuroschistosomiasis in a pediatric patient : a case report

A pediatric patient with neurological deficit was examined using magnetic resonance imaging (MRI]. The images revealed abnormal signal intensity and enhancement of the spinal cord, indicating myelopathy. Identifying the cause of the myelopathy required a differential diagnosis. Images from MRI included a pre-contrast T1 weighted sagittal sequence, which revealed expansion of the distal lumbar spinal cord and conus medullaris from T10-L1. The T2 weighted sagittal sequence revealed patchy areas of hyperintense signal. We did not notice any chronic hemorrhagic products or cysts. Within the field of view, we saw multifocal areas of bladder wall thickening. Sagittal and axial T1 weighted post gadolinium images demonstrated mixed linear and nodular patchy enhancement of the conus medullaris predominantly anteriorly and along the anterior surface of the meninges. On the 18 day of hospitalization, a spinal biopsy revealed the presence of granuloma with non-viable bilharzia ova, and schistosomiasis of the spinal cord was diagnosed. Although uncommon, when it does occur, schistosomiasis has significant implications. Using MRI, the medical team noticed abnormal features that called for a biopsy, and were thus able to differentiate between medullary schistosomiasis and other infective/inflammatory conditions. A prompt diagnosis is vital for initiating early treatment, and avoiding complications and invasive surgery.http://www.elsevier.com/locate/radcrdm2022Radiolog

Cerebral palsy and criteria implicating intrapartum hypoxia in neonatal encephalopathy – an obstetric perspective for the South African setting

The science surrounding cerebral palsy (CP) indicates that it is a complex medical condition with multiple contributing variables and factors, and causal pathways are often extremely difficult to delineate. The pathophysiological processes are often juxtaposed on antenatal factors, genetics, toxins, fetal priming, failure of neuroscientific autoregulatory mechanisms, abnormal biochemistry and abnormal metabolic pathways. Placing this primed compromised compensated brain through the stresses of an intrapartum process could be the final straw in the pathway to brain injury and later CP. It is therefore simplistic to base causation of CP on only an intrapartum perspective with radiological ‘confirmation’, as is often the practice in medico-legal cases in South African courts. The present modalities (magnetic resonance imaging (MRI) and cardiotocography (CTG)), when available, that retrospectively attempt to determine causation in courts are inadequate when used in isolation. Unless a holistic scientific review of the case including all contributing clinical factors (antepartum, intrapartum and neonatal), fetal heart rate monitoring, neonatal MRI if possible (and preferred) or late MRI, and histology (placental histology if performed) is taken into account, success for the plaintiff or defendant currently in a court of law will depend on eloquent legal argument rather than true scientific causality. The 10 criteria set out in this article to implicate intrapartum hypoxia in hypoxic-ischaemic encephalopathy/neonatal encephalopathy serve as a guideline in the medico-legal setting.http://www.samj.org.zadm2022Obstetrics and Gynaecolog

Cerebral palsy and its medicolegal implications in low-resource settings – the need to establish causality and revise criteria to implicate intrapartum hypoxia : a narrative review

The objective of this study was to establish scientific causality and to devise criteria to implicate intrapartum hypoxia in cerebral palsy (CP) in low-resource settings, where there is potential for an increase in damaging medicolegal claims against obstetric caregivers, as is currently the situation in South Africa. For the purposes of this narrative review, an extensive literature search was performed, including any research articles, randomised controlled trials, observational studies, case reports or expert or consensus statements pertaining to CP in low-resource settings, medicolegal implications, causality, and criteria implicating intrapartum hypoxia. In terms of causation, there are differences between high-income countries (HICs) and low-resource settings. While intrapartum hypoxia accounts for 10 - 14% of CP in HICs, the figure is higher in low-resource settings (20 - 46%), indicating a need for improved intrapartum care. Criteria implicating intrapartum hypoxia presented for HICs may not apply to low-resource settings, as cord blood pH testing, neonatal brain magnetic resonance imaging (MRI) and placental histology are frequently not available, compounded by incomplete clinical notes and missing cardiotocography tracings. Revised criteria in an algorithm for low-resource settings to implicate intrapartum hypoxia in neonatal encephalopathy (NE)/ CP are presented. The algorithm relies first on specialist neurological assessment of the child, determination of the occurrence of neonatal encephalopathy (by documented or verbal accounts) and findings on childhood MRI, and second on evidence of antepartum and intrapartum contributors to the apparent hypoxia-related CP. The review explores differences between low-resource settings and HICs in trying to establish causation in NE/CP and presents a revised scientific approach to causality in the context of low-resource settings for reaching appropriate legal judgments.https://samajournals.co.za/index.php/samj/indexam2024Obstetrics and GynaecologyPaediatrics and Child HealthSDG-03:Good heatlh and well-bein

Causation of term perinatal hypoxic-ischaemic basal ganglia and thalamus injury in the context of cerebral palsy litigation : position statement

Basal ganglia and thalamus (BGT) hypoxic-ischaemic brain injury is currently the most contentious issue in cerebral palsy (CP) litigation in South Africa (SA), and merits a consensus response based on the current available international literature. BGT pattern injury is strongly associated with a preceding perinatal sentinel event (PSE), which has a sudden onset and is typically unforeseen and unpreventable. Antepartum pathologies may result in fetal priming, leading to vulnerability to BGT injury by relatively mild hypoxic insults. BGT injury may uncommonly follow a gradual-onset fetal heart rate deterioration pattern, of duration ≥1 hour. To prevent BGT injury in a clinical setting, the interval from onset of PSE to delivery must be short, as little as 10 - 20 minutes. This is difficult to achieve in any circumstances in SA. Each case needs holistic, multidisciplinary, unbiased review of all available antepartum, intrapartum and postpartum and childhood information, aiming at fair resolution without waste of time and resources.http://www.samj.org.zaam2024Obstetrics and GynaecologySDG-03:Good heatlh and well-bein

Untargeted urine metabolomics reveals a biosignature for muscle respiratory chain deficiencies

Mitochondrial diseases are a heterogeneous group of disorders characterised by impaired mitochondrial oxidative phosphorylation system. Most often for mitochondrial disease, where no metabolic diagnostic biomarkers exist, a deficiency is diagnosed after analysing the respiratory chain enzymes (complexes I-IV) in affected tissues or by identifying one of an ever expanding number of DNA mutations. This presents a great challenge to identify cases to undergo the invasive diagnostic procedures required. An untargeted liquid chromatography mass spectrometry metabolomics approach was used to search for a metabolic biosignature that can distinguish respiratory chain deficient (RCD) patients from clinical controls (CC). A cohort of 37 ethnically diverse cases was used. Sample preparation, liquid chromatography time-of-flight mass spectrometry methods and data processing methods were standardised. Furthermore the developed methodology used reverse phase chromatography in conjunction with positive electrospray ionisation and hydrophilic interaction chromatography with negative electrospray ionisation. Urine samples of 37 patients representing two different experimental groups were analysed. The two experimental groups comprised of patients with confirmed RCDs and CC. After a variety of data mining steps and statistical analyses a list of 12 features were compiled with the ability to distinguish between patients with RCDs and CC. Although the features of the biosignature needs to be identified and the biosignature validated, this study demonstrates the value of untargeted metabolomics to identify a metabolic biosignature to possibly be applied in the selection criteria for RCDs.North-West University, Potchefstroom Campushttp://link.springer.com/journal/113062016-02-28hb201

A case for genomic medicine in South African paediatric patients with neuromuscular disease

DATA AVAILABILITY STATEMENT : The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author/s.Paediatric neuromuscular diseases are under-recognised and under-diagnosed in Africa, especially those of genetic origin. This may be attributable to various factors, inclusive of socioeconomic barriers, high burden of communicable and non-communicable diseases, resource constraints, lack of expertise in specialised fields and paucity of genetic testing facilities and biobanks in the African population, making access to and interpretation of results more challenging. As new treatments become available that are effective for specific sub-phenotypes, it is even more important to confirm a genetic diagnosis for affected children to be eligible for drug trials and potential treatments. This perspective article aims to create awareness of the major neuromuscular diseases clinically diagnosed in the South African paediatric populations, as well as the current challenges and possible solutions. With this in mind, we introduce a multi-centred research platform (ICGNMD), which aims to address the limited knowledge on NMD aetiology and to improve genetic diagnostic capacities in South African and other African populations.The National Health Laboratory Services (NHLS) of South Africa; the South African Medical Research Council (SAMRC), The genetics of Neuromuscular Diseases in South African patient populations: the ICGNMD study as well as the National Research Foundation (NRF) of South Africa.https://www.frontiersin.org/journals/pediatricsam2023Paediatrics and Child Healt

Metabolomics of urinary organic acids in respiratory chain deficiencies in children

Metabolomic analysis of the urinary organic acids from 39 selected children with defined respiratory chain deficiencies (RCDs) was performed using untargeted gas chromatography–mass spectrometry, revealing the presence of 255 endogenous and 46 exogenous substances. Variable reduction identified 92 variables from the endogenous substances, which could be analysed by univariate and multivariate statistical methods. Using these methods, no characteristic organic acid biomarker profile could be defined of practical value for diagnostic purposes for complex I (CI), complex III (CIII) and multiple complex (CM) deficiencies. The statistical procedures used did, however, disclose 24 metabolites that were practical highly (d > 0.75) and statistically (p < 0.05) significant for the combined and clinically closely related group of RCDs. Several of these metabolites occur in single enzyme inherited metabolic diseases, but most were not previously reported to be linked to the metabolic perturbations that are due to RCDs. Ultimately, we constructed a global metabolic profile of carbohydrate, amino acid and fatty acid catabolism, illuminating the diverse and complex biochemical consequences of these disorders. This metabolomics investigation disclosed a metabolite profile that has the potential to define an extended and characteristic biosignature for RCDs and the development of a non-invasive screening procedure for these disorders.This study formed part of BioPAD Project BPP007.The South African Department of Science and Technology and North-West University.http://link.springer.com/journal/11306hb2017Paediatrics and Child Healt

Characterization of mtDNA variation in a cohort of South African paediatric patients with mitochondrial disease

Mitochondrial disease can be attributed to both mitochondrial and nuclear gene mutations. It has a heterogeneous clinical and biochemical profile, which is compounded by diversity of the genetic background. Disease-based epidemiological information has expanded significantly in recent decades, but little information is known that clarifies the aetiology in African patients. The aim of this study was to investigate mitochondrial DNA variation and pathogenic mutations in muscle of diagnosed paediatric patients from South Africa. A cohort of 71 South African paediatric patients was included and a high-throughput nucleotide sequencing approach was used to sequence full-length muscle mtDNA. The average coverage of the mtDNA genome was 81 ± 26 per position. After assigning haplogroups, it was determined that although the nature of non-haplogroup defining variants was similar in African and non-African haplogroup patients, the number of substitutions were significantly higher in African patients. We describe previously reported disease-associated and novel variants in this cohort. We observed a general lack of commonly reported syndrome-associated mutations, which supports clinical observations and confirms general observations in African patients when using single mutation screening strategies based on (predominantly non-African) mtDNA disease-based information. It is finally concluded that this first extensive report on muscle mtDNA sequences in African paediatric patients highlights the need for a full length mtDNA sequencing strategy, which applies to all populations where specific mutations is not present. This, in addition to nuclear DNA gene mutation and pathogenicity evaluations, will be required to better unravel the aetiology of these disorders in African patients.http://www.nature.com/ejhg/index.htm