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本研究の目的は，子どもの肥満治療に対する母親のモチベーション（動機）の推移や動機に影響を与える要因を明らかにすることであった。複線経路・等至性モデル（Trajectory Equifinality Model：TEM）により動機の推移と影響要因を図式化し，母親への支援を中心に治療者及び支援者の介入を検討した。その結果，母親の動機は，子どもからの反発，家族・親族の肥満治療に対する理解の有無，仕事の負担など様々な影響を受け推移していた。支援について，1）生活習慣の改善は，子どもの意思，家族構成，母親の仕事状況などを考慮し，母子共に継続可能な目標をスモールステップで設定すること，2）家族や親族，学校など，母子の周囲の関係に働きかけて肥満治療の協力者を増やすこと，3）肥満に対処する中で，母子が抱える心労に対するケアを行うこと，などが考えられた。また，これらの支援は多職種が連携して行うことが求められる。The purpose of this study was to elucidate the changes and factors that affect mothers’ motivation for treating obesity in their children. Changes in motivation and the influencing factors were schematized using a Trajectory Equifinality Model (TEM), and interventions by therapists and supporters were examined, focusing on the support for mothers. The results show that the motives of mothers were influenced by various factors, such as opposition from children, understanding of obesity treatment among family members and relatives, and the burden of work. Regarding support, the suggestions included 1) to improve lifestyle habits, set goals that can be sustained by both mother and child in small steps, considering the child’s will, family structure, mother’s work situation, etc. 2) to increase the number of people who support the obesity treatment by working with the relationships around the mother and child, such as families, relatives, schools etc., and 3) to provide care for the mental burden of the mother and child while dealing with obesity. Besides, a multidisciplinary collaboration is required to provide such support.

Serum growth differentiation factor 15 (GDF15) is a useful biomarker of mitochondrial diseases; its utility in newborns remains unknown. To investigate the temporal change in GDF15 within the first week of life, and to identify its potential control variables, blood samples were obtained from 18 newborns. The GDF15 levels declined to approximately 35% of the cord blood levels within the first week of life and were negatively correlated with postnatal age and Z-score of birth weight but were positively correlated with N-terminal pro-brain natriuretic peptide and lactate levels. GDF15 levels may reflect the progress of postnatal transition to aerobic metabolism.

Neonatal arterial ischemic stroke (NAIS) presents as seizures, including convulsions, subtle seizures, and apnea, and most patients experience neurological sequelae. Diagnosis is often delayed owing to low test sensitivity. The present study aimed to identify the early clinical diagnostic factors for NAIS in neonates with seizures.The present study included 54 patients born at ≥36 weeks of gestation during the last 15 years who presented to the neonatal intensive care unit with neonatal seizures and underwent brain magnetic resonance imaging (MRI), 6 of whom were diagnosed with NAIS. Maternal background, clinical characteristics, and transcranial pulsed Doppler sonography results were retrospectively reviewed.Of the 24 patients who presented with convulsions or subtle seizures, 3 (13%) were diagnosed with NAIS and 3 of 30 patients (10%) presented with apnea. Maternal premature ventricular contraction complications were higher in the NAIS group than in the non-NAIS group (p = 0.01). NAIS group showed lower mean middle cerebral artery (MCA) resistance index (RI) was lower the non-NAIS group (p = 0.009), while the left-right RI difference (p = 0.019), mean MCA blood velocity (MnV; p = 0.04), and left-right MnV difference (p 0.001) in cerebral blood flow velocities (CBFVs) were higher in the NAIS group.Our results revealed that maternal arrhythmia may be a diagnostic factor for NAIS in neonates with seizures. Early brain MRI is essential in neonates with seizures and findings of low MCA-RI, high MCA-MnV, or high left-right difference in CBFVs to distinguish between NAIS and non-NAIS.

Background: Pediatricians in Japan usually measure child body weight during medical examinations. However, they rarely measure height. There are no reports addressing the efficiency of height measurement at night or on holidays. Our study asked whether height measurements and obesity index calculations during all pediatric visits were efficient. Methods: We analyzed data collected on patients between the ages of 3 and 10 years who visited a pediatrics department over a 1-month period. We divided the patients into four groups based on when they visited the department: 1) weekday daytime, 2) weekday Semi-night, 3) weekday Mid-night, 4) holiday. The height and the body weight of all patients were measured. This analysis included 1101 patients. The numbers of patients visiting the hospital were 727, 176, 34, and 164 for Day-time, Semi-night, Mid-night, and Holiday visits, respectively. Resalts: There were no significant differences in ages of children visiting at different times (p=0.211). However, there were significant differences in height among children visiting at different times (p=0.018), with the Mid-night group being the highest. There were no significant differences in the incidence of obesity among patients visiting at different times (p=0.44); however, significant variations were found for BMI %tile among the patients (p=0.03), being significantly lower for the Mid-night group than the others. Conclusions: We conclude that height measurement to detect short stature (SS) and calculating BMI to detect obesity is inefficient for children who visit hospital during emergency times.

Background Growth differentiation factor 15 (GDF 15) is a member of the transforming growth factor-beta superfamily and is considered to be a useful biomarker for severity of heart failure (HF) in repaired congenital heart disease (CHD). The aim of this study was to determine the clinical implication of GDF 15 in children with unrepaired CHD. Methods Subjects included 69 patients (≤14 years old) who had unrepaired CHD with left to right shunt and underwent cardiac catheterization. Demographic and hemodynamic data, including oxygen demand–supply relationship, were collected from medical records. Severity of HF was evaluated using modified Ross score. Serum GDF 15 levels were determined using enzyme-linked immunosorbent assay and correlated with patients’ demographics, hemodynamic data, and blood chemistry data. Results Subjects had median age of 71 (range 1–173) months and simple acyanotic CHDs with mean pulmonary to systemic flow ratio of 2.0 (1.0–5.6), median N-terminal pro type Brain natriuretic peptide (NT-pro-BNP) of 162.8 (17.1–8789) pg/mL, and median GDF 15 of 242.1 (13.6–1116.7) pg/mL. GDF 15 significantly positively correlated with the modified Ross score, mean pulmonary artery pressure, oxygen extraction rate (OER), and Ln NT-pro-BNP, but negatively correlated with age, oxygen delivery and its components, and estimated glomerular filtration rate (eGFR). Multiple linear regression analysis revealed significant correlation of GDF 15 levels with the modified Ross score, OER, and eGFR. Conclusions GDF 15 mainly reflects oxygen demand–supply relationship and can be used as a diagnostic marker of HF in unrepaired CHD with left to right shunt for a wide range of age and diagnoses.

Congenital adrenal hyperplasia is a category of disorders characterized by impaired adrenocortical steroidogenesis. The most frequent disorder of congenital adrenal hyperplasia is 21-hydroxylase deficiency, which is caused by pathogenic variants of

Background: Pediatricians in Japan usually measure child body weight during medical examinations. However, they rarely measure child height. Furthermore, during examinations at night or on holidays they may not measure child height at all. There are no reports addressing the efficiency of pediatric height measurement during medical examinations, especially those taking place at night or on holidays. Our study asked whether height measurements and obesity index calculations during all pediatric visits were efficient. Methods: We analyzed data collected on patients between the ages of 3 and 10 years who visited a pediatrics department over a 1-month period. We divided the patients into four groups based on when they visited the department: 1) weekday-day, 2) weekday-early night, 3) weekday-late night, 4) holiday-day. The height and the body weight of all patients were measured. This analysis included 1101 patients. The numbers of patients visiting the hospital were 727, 176, 34, and 164 for daytime, early night, late night, and holiday visits, respectively. Resalts: There were no significant differences in ages of children visiting at different times (p=0.57). However, there were significant differences in height variation among children visiting at different times (p=0.008), with the late-night group being the most variable. There were no significant differences in the incidence of obesity (depend on body mass index (BMI)) among patients visiting at different times (p=0.44); however, significant variations were found for BMI among the patients, (p=0.03), being significantly lower for the late night group than the others. Conclusions: We conclude that using height measurement to detect short stature (SS) and calculating BMI to detect obesity is inefficient for children who visit hospital during emergency times.

Recently, high concentrations of caffeine present in energy drinks and over-the-counter (OTC) drugs have become a concern worldwide. Several deaths due to caffeine intoxication have been reported, necessitating caution. Typically, supportive care is used to treat caffeine intoxication. However, in severe cases of caffeine intoxication, hemodialysis may be used. For adults, a lethal blood caffeine concentration is at least 80 µg/mL, whereas lethal blood caffeine concentration is unknown for children. In the present case, a 15-year-old girl took a large dose of an OTC antipyretic analgesic to commit suicide, resulting in caffeine intoxication. In this case, even though blood caffeine concentration was higher than the adult lethal dose, the patient recovered through a simple treatment with intravenous infusion of extracellular fluid.

Immunoglobulin G4 (IgG4)-related disorders are characterized by tissue hypertrophy due to IgG4-positive cell infiltration and increased serum IgG4 levels. IgG4-related hypophysitis (IgG4-RH) is characterized by pituitary hypertrophy, IgG4-positive cell infiltration, central diabetes insipidus, and increased serum IgG4 levels. IgG4-RH is diagnosed through diagnostic criteria. A few cases of IgG4-RH in children have been reported. We report a case of CDI with increased serum IgG4 levels that failed to meet the diagnostic criteria of IgG4-RH. The patient developed polyuria and polydipsia at age 11 and was diagnosed as having idiopathic CDI at age 12. The patient was not treated with steroids and is well controlled with antidiuretic hormones. It has been reported that pediatric IgG4-RH differs from that of adults in several respects. We believe that the pediatric IgG4-RH may not fit the diagnostic criteria of adults. There may be also other cases of increased serum IgG4 levels in pediatric patients with idiopathic CDI. We do not know if they are subtypes of IgG4-RH or if serum IgG4 levels are by chance raised in CDI, however, we report them here because IgG4-RH in children may be different from that in adults.

As sodium level in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) is usually low, normal, or slightly elevated, severe hypernatremia with DKA and/or HHS is rare. Case 1 was a 14-year-old boy, presenting with typical laboratory test values and symptoms consistent with DKA and HHS. His corrected sodium level, 172 mEq/L, might have occurred as a result of consuming 6 L/day of highly carbonated, carbohydrate- and sodium-rich drinks during the week preceding the diagnosis. This patient developed right lung artery thrombosis, which did not require treatment. Case 2 was a 10-year-old girl, presenting with typical laboratory test values and symptoms of DKA and HHS. Her corrected sodium level, 175 mEq/L, might have occurred as a result of large electrolyte-free water loss associated with osmotic diuresis. These two cases of patients presenting with DKA-HHS and severe hypernatremia are the first to be reported in Japan.

Temple syndrome (TS14), caused by abnormal gene expression of the imprinted genes at 14q32.2, is associated with nonspecific symptoms such as prenatal and postnatal growth failure, feeding difficulty, hypotonia, precocious puberty, obesity, and diabetes mellitus (DM).1, 2 Genetic causes of TS14 are paternal deletions and an epimutation affecting the 14q32.2 imprinted region, and maternal uniparental disomy of chromosome 14, which lead to hypomethylation of the intergenic differentially methylated region (IG‐DMR) and/or MEG3‐DMR.1 Nonspecific TS14 clinical features such as prenatal and postnatal growth failure, feeding difficulty, and hypotonia overlap with those of Prader‐Willi syndrome (PWS) and Silver‐Russell syndrome.1 Furthermore, some TS14 patients may not receive a diagnosis of TS14 due to nonspecific clinical features and almost normal intellectual development. Because all previously reported TS14 cases were detected in childhood or ascertained by familial studies of children with Kagami‐Ogata syndrome, which is an imprinting disorder as a mirror image of TS14,1, 2 long‐term prognosis of TS14 including the development of social behavior, language and learning ability, and communication skills remains to be clarified. Here, we report the clinical course of a male patient with clinical autism spectrum disorder (ASD) that received a diagnosis of TS14. This case study was approved by the Institutional Review Board Committee of Kurume University. Informed consent was obtained from the patient and the patient's parents.

Background 21-hydroxylase deficiency (21-OHD) is caused due to CYP21A2 gene variant. In males, the excess androgens produce varying degrees of penile enlargement and small testes. CHARGE syndrome (CS) has a broad spectrum of symptoms. In males, genital features such as micropenis and cryptorchidism are found in 48% of CS. There are no reports of patients with combined 21-OHD and CS; therefore, it is unknown whether the external genitalia shows penile enlargement or micropenis with/without cryptorchidism. Case A boy, born at 37 weeks and 5 days of gestational age with no consanguineous marriage, was admitted to our hospital due to congenital cleft lip, cleft palate, micropenis, cryptorchidism, and a ventricular septal defect. He had severe hyponatremia and hyperkalemia on day 10. He was diagnosed to have 21-OHD and CS. His external genitalia demonstrated both cryptorchidism and micropenis, but not penile enlargement. Methods DNA was extracted from peripheral leukocytes using standard procedures. Sanger sequence was performed in CYP21A2. Exome sequence was performed, and then, Sanger sequence was performed around variant in CHD7. Results Genetic screening for CYP21A2 gene was performed and compound heterozygous variants of c.293-13A/C>G (IVS2-13A/C>G) and c.518T>A (p.I172N) were detected in chromosome 6p21.3. His mother had been heterozygous variant of c.293-13A/C>G, and his father had been heterozygous variant of c.518T>A. Simultaneously, a de novo splicing acceptor alteration in c.7165-4 A>G, in chromodomain helicase DNA binding protein-7 (CHD7), located in chromosome 8q12 was detected, and the patient was diagnosed with 21-OHD and CS. Conclusion Although these two disorders exhibit different modes of inheritance and their co-morbidity is extremely rare, we encountered one male patient who suffered from both 21-OHD and CS.

GDF-15, a member of the transforming growth factor beta superfamily, regulates inflammatory and apoptotic pathways in various diseases, such as heart failure, kidney dysfunction, and cancer. We aimed to clarify potentially confounding variables affecting GDF-15 and demonstrate its utility as a mitochondrial biomarker using serum samples from 15 patients with mitochondrial diseases (MD), 15 patients with limbic encephalitis (LE), 10 patients with multiple sclerosis/neuromyelitis optica spectrum disorders (MS/NMOSD), and 19 patients with amyotrophic lateral sclerosis (ALS). GDF-15 and FGF-21 were significantly elevated in MD. GDF-15 and FGF-21 showed a good correlation in MD but not in LE, MS, and ALS. GDF-15 was potentially influenced by age in LE, MS/NMOSD, and ALS but not in MD. FGF-21 was not correlated with age in MS/NMOSD, ALS, LE, and MD. GDF-15 was not correlated with clinical features in LE or BMI or body weight in ALS. GDF-15 positively correlated with the Expanded Disability Status Scale (EDSS) in MS/NMOSD, while EDSS showed no correlation with age. In conclusion, the results revealed that GDF-15 may be influenced by EDSS in MS/NMOPSD and by age in LE, MS/NMOSD, and ALS but not in MD. Mitochondrial damage in MS/NMOSD is a potentially confounding variable affecting GDF-15.

We sequenced MKRN3, the major causative gene of central precocious puberty in Western countries, in 24 Japanese or Chinese patients and examined the DNA methylation and copy-number statuses of this gene in 19 patients. We identified no (epi)genetic defects except for one previously reported mutation. These results, together with reports from Korea, indicate that MKRN3 defects are rare in Asian populations. The ethnic differences likely reflect Western country-specific founder mutations and the rarity of de novo mutations.

NR0B1 is the causative gene for X-linked adrenal hypoplasia congenita, characterized by adrenal insufficiency, hypogonadotropic hypogonadism, and infertility. We identified an NR0B1 frameshift mutation in a boy with precocious puberty who had no signs of adrenal insufficiency. Blood examination revealed elevated testosterone levels and gonadotropin hyperresponses to gonadotropin releasing hormone (GnRH) stimulation, together with normal adrenal hormone levels. GnRH analog treatment partially ameliorated his clinical features. Molecular analysis identified a p.Glu3fsAla*16 in NR0B1. These results expand the clinical manifestations of NR0B1 mutations to include central precocious puberty without adrenal insufficiency. NR0B1 mutations likely underlie androgen overproduction via GnRH-dependent and -independent mechanisms.

Objective The diagnosis of mitochondrial disorders (MDs) is occasionally difficult because patients often present with solitary, or a combination of, symptoms caused by each organ insufficiency, which may be the result of respiratory chain enzyme deficiency. Growth differentiation factor 15 (GDF-15) has been reported to be elevated in serum of patients with MDs. In this study, we investigated whether GDF-15 is a more useful biomarker for MDs than several conventional biomarkers. Methods We measured the serum levels of GDF-15 and fibroblast growth factor 21 (FGF-21), as well as other biomarkers, in 48 MD patients and in 146 healthy controls in Japan. GDF-15 and FGF-21 concentrations were measured by enzyme-linked immunosorbant assay and compared with lactate, pyruvate, creatine kinase, and the lactate-to-pyruvate ratio. We calculated sensitivity and specificity and also evaluated the correlation based on two rating scales, including the Newcastle Mitochondrial Disease Rating Scale (NMDAS). Results Mean GDF-15 concentration was 6-fold higher in MD patients compared to healthy controls (2,711 ± 2,459 pg/ml vs 462.5 ± 141.0 pg/mL; p < 0.001). Using a receiver operating characteristic curve, the area under the curve was significantly higher for GDF-15 than FGF-21 and other conventional biomarkers. Our date suggest that GDF-15 is the most useful biomarker for MDs of the biomarkers examined, and it is associated with MD severity. Interpretation Our results suggest that measurement of GDF-15 is the most useful first-line test to indicate the patients who have the mitochondrial respiratory chain deficiency. Ann Neurol 2015;78:Ann Neurol 2015;78:679–696

Background: TRPM6 gene mutation has been reported to cause hypomagnesemia with secondary hypocalcemia (HSH). However, the genotype–phenotype correlation for TRPM6 gene mutations has not been clarified. Objective: To elucidate the factors underlying the severe neurological complications in HSH and evaluate the potential association between the location of TRPM6 gene mutations and clinical data of HSH. Methods: A Japanese patient diagnosed with HSH at 10 weeks of age exhibited neurological damage and failed to thrive. Magnesium supplements were therefore started at 12 weeks of age. Mutational analysis of the TRPM6 gene was performed using a direct sequencing method to determine the position and type of mutation. Using the data of 29 HSH patients reported in the literature, linear regression analysis was also performed to examine the association between TRPM6 gene mutation location and HSH onset age, initial serum magnesium and calcium concentrations, and dose of oral magnesium. Results: A novel stop-codon homozygous mutation [c.4190 G > A] W1397X was identified in exon 26 of the patient’s TRPM6 gene. No statistical correlation was found between the location of mutations in the TRPM6 gene and the clinical data for 4 clinical indicators of HSH. Conclusions: We identified the first Japanese HSH patient with a novel nonsense mutation in the TRPM6 gene. Regression analysis of mutation locations in the protein-coding region of TRPM6 and the reported clinical data for 4 clinical indicators of HSH in 30 HSH patients did not detect a genotype–phenotype correlation. 2014 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.

Pyruvate therapy is a promising approach for the treatment of mitochondrial diseases. To identify novel biomarkers for diagnosis and to evaluate therapeutic efficacy, we performed microarray analysis of 2SD cybrid cells harboring a MELAS-causing mutation and control cells treated with either lactate or pyruvate. We found that expression and secretion of growth differentiation factor 15 (GDF15) were increased in 2SD cells treated with lactate and that serum GDF15 levels were significantly higher in patients with mitochondrial diseases than in those with other diseases, suggesting that GDF15 could be a useful marker for diagnosis and evaluating the therapeutic efficacy of pyruvate.

Dear Sirs, Though neurological signs in mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) resemble features of ischemic stroke. According to the limited analyses, recurrent strokes are associated with vasogenic edema by diffusion weighted image (DWI) on magnetic resonance image (MRI) [1, 2]. Endothelial dysfunction has been found in MELAS [3], and l-arginine, a potent donor of nitric oxide at physiological condition, has been used as a therapeutic purpose [4]. In this study, we evaluate the therapeutic effects of l-arginine infusion at super-acute phase of stroke-like episodes (SLE) on the clinical and the serial neuroimaging analysis in two MELAS patients. Patient 1 is a 7-year-old girl who was diagnosed as MELAS based on a finding of symptoms and 79 % mutation of an A3243G in the mitochondrial DNA in urine. She has a history of SLE at the age of 5.5 years-old. She complained of the sudden headache, vomit, hemi-convulsion and hemianopia in the left side. After getting the written informed consent (Kurume University IRB#9715), we infused 0.5 g/kg/dose of l-arginine within 60 min after the onset and took the brain MRI at 18 h from the onset. All of clinical symptoms disappeared within 30 min after l-arginine infusion without using anti-convulsants. The series of MRIs were performed till 6 month from the onset of stroke-like episodes. MRI obtained at 18 h after the onset showed high intensity signal in T2WI, and DWI and low in ADC in right and left hemisphere of cerebrum and right occipital region. However those abnormal findings completely normalized on MRIs at 7 days and 1 month later. Patient 2 is a 32-year-old girl who fulfilled the diagnostic criteria of MELAS and has a 45 % mutation of A3243G in urine. She has history of two SLE and was then followed as MELAS. She complained of the sudden onset of left-hemi-convulsion, severe headache, and vomit. After getting informed consent, she was infused with 0.5 g/kg/dose of l-arginine at 60 min after the onset, and then the series of brain MRI were taken. Hemi-convulsion was getting worse to generalized convulsion, however the seizures and vomit disappeared within 120 min after l-arginine infusion followed by using anti-convulsants. MRI obtained at 2 and 9 h after the onset showed high intensity on T2WI and DWI and low ADC in right parietal lobe. However those abnormal findings completely normalized in MRI at 1 week and 1 month later as shown in Fig. 1. Fig. 1 Serial brain MRI images in two MELAS patients. A A serial brain MRI was taken at 18 h (a–c), 7 days (d–f), and at 1 month (h–J) after the onset of SLE in patient 1. DWI showed high intensity signal in bilateral ... Abnormal MRI region in superficial layers of cortex showed low ADC with high intensity on DWI suggested cytotoxic edema. Meanwhile, adjacent subcortical white matter that showed high ADC and high intensity on DWI suggested vasogenic edema. The follow up MRIs in two MELAS patients showed no abnormal signal or atrophic change in 7 days and in 1 month after the onset of SLE. Since MRI abnormality seen in MELAS usually lasting several months after the SLE [5], l-arginine infusion at hyperacute phase may prevents the prolonged change of MRI in our two patients. Though MRI abnormalities seen in our patients cannot be ruled out completely by the results of neuronal hyper-excitability, current episodes are the typical and the same as their previous SLE evident by prolonged changes in MRI. We speculate that l-arginine may protect neuron in cortex from permanent cell death, by improving either regional microcirculation of cerebral blood flow [3, 4], permeability of BBB, or interaction by astrocyte–neuron coupling which controls the cerebral circulation [2, 6]. Our data indicated that l-arginine infusion during the hyperacute phase of SLE in MELAS may significantly improve the symptoms, and also completely protect the progression of neuroimaging change from transient to permanent brain atrophy.

SummaryObjective Hypophosphatasia (HPP) is a rare skeletal disease characterized by hypomineralization and low alkaline phosphatase activity. Asfotase alfa (AA) has been recently developed to treat HPP complications. This study evaluated its safety and efficacy in Japan. Design Open-label, multicentre, prospective trial. Patients were enrolled in 11 hospitals from June 2014 to July 2015. Patients Thirteen patients (9 females, 4 males) ages 0 days to 34 years at baseline were enrolled and treated with AA (2 mg/kg three times weekly subcutaneously in all but one patient). All had ALPL gene mutations. HPP forms were perinatal (n=6), infantile (n=5), childhood (n=1) and adult (n=1). Measurements Safety determined from adverse events (AEs) and laboratory data was the primary outcome measure. Efficacy was assessed as a secondary outcome measure from overall survival, respiratory status, rickets severity and gross motor development. Results Injection site reactions were the most frequent AEs. Serious AEs possibly related to treatment were convulsion and hypocalcaemia observed in a patient with the perinatal form. In addition, hypercalcaemia and/or hyperphosphatemia was observed in three patients with the infantile form and a low-calcium and/or low-phosphate formula was given to these patients. With respect to efficacy, all patients survived and the radiographic findings, developmental milestones and respiratory function improved. Conclusion Asfotase alfa therapy improved skeletal, respiratory and physical symptoms with a few serious AEs in patients with HPP. Our results add support to the safety and efficacy of AA therapy for HPP patients.

NR0B1 is the causative gene for X-linked adrenal hypoplasia congenita, characterized by adrenal insufficiency, hypogonadotropic hypogonadism, and infertility. We identified an NR0B1 frameshift mutation in a boy with precocious puberty who had no signs of adrenal insufficiency. Blood examination revealed elevated testosterone levels and gonadotropin hyperresponses to gonadotropin releasing hormone (GnRH) stimulation, together with normal adrenal hormone levels. GnRH analog treatment partially ameliorated his clinical features. Molecular analysis identified a p.Glu3fsAla*16 in NR0B1. These results expand the clinical manifestations of NR0B1 mutations to include central precocious puberty without adrenal insufficiency. NR0B1 mutations likely underlie androgen overproduction via GnRH-dependent and -independent mechanisms.

SummarySomatic stem cell (SSC) dysfunction is typical for different progeroid phenotypes in mice with genomic DNA repair defects. MtDNA mutagenesis in mice with defective Polg exonuclease activity also leads to progeroid symptoms, by an unknown mechanism. We found that Polg-Mutator mice had neural (NSC) and hematopoietic progenitor (HPC) dysfunction already from embryogenesis. NSC self-renewal was decreased in vitro, and quiescent NSC amounts were reduced in vivo. HPCs showed abnormal lineage differentiation leading to anemia and lymphopenia. N-acetyl-L-cysteine treatment rescued both NSC and HPC abnormalities, suggesting that subtle ROS/redox changes, induced by mtDNA mutagenesis, modulate SSC function. Our results show that mtDNA mutagenesis affected SSC function early but manifested as respiratory chain deficiency in nondividing tissues in old age. Deletor mice, having mtDNA deletions in postmitotic cells and no progeria, had normal SSCs. We propose that SSC compartment is sensitive to mtDNA mutagenesis, and that mitochondrial dysfunction in SSCs can underlie progeroid manifestations.

Rationale: Nonalcoholic fatty liver disease (NAFLD), among the commonest chronic liver disorders in children and adolescents, is considered a reflection of the current obesity epidemic in children and adults. This liver disease has been linked with various metabolic disorders, but not with prolactinoma (PRLoma). Patient concerns: A 13-year-old Japanese girl manifested obesity, serum transaminase and γ-glutamyltransferase elevations, and amenorrhea. Abdominal ultrasonography showed fatty liver. Her serum prolactin concentration was elevated, and cranial magnetic resonance imaging showed a pituitary mass consistent with macroadenoma. Diagnoses: NAFLD and PRLoma. Interventions and outcomes: After the patient's NAFLD failed to respond to diet and exercise, cabergoline treatment of the PRLoma decreased body weight, serum transaminase and γ-glutamyltransferase elevations, and ultrasonographic fatty liver grade as the tumor became smaller. Lessons: Physicians should consider the possibility of PRLoma when diet and exercise fail to improve fatty liver disease in a patient with endocrine symptoms such as amenorrhea.

CHARGE syndrome is a rare autosomal dominant disease that is typically caused by heterozygous CHD7 mutations. A de novo variant in a CHD7 splicing acceptor site (NM_017780.3:c.7165-4A>G) was identified in a Japanese boy with CHARGE syndrome. This variant has been considered to be an "unclassified variant" due to its position outside the consensus splicing sites. In this study, abnormal splicing derived from this known variant was confirmed by cDNA sequencing.

Objective: Specific aim of this study is to elucidate the direct effects of l -arginine on the synaptosomal neurotransmission related to the mitochondrial respiratory function. Methods: Using isolated endbrains from wild-type mice (ICR), crude synaptosome was analyzed for their concentration of γ-aminobutyric acid (GABA) and glutamate (Glu) with/without addition of l -arginine. We analyzed the contents of releasing amino acids evoked by high potassium condition and uptake of them in three separated fractions (cytosol, vesicles, and intact mitochondria). The oxygen consumption was also measured by oxygen electrode. Results: The entire uptakes of GABA and Glu were inhibited by rotenone (about 30 nmol/mg protein) with dose-dependent manner and showed a plateau at about 70% of total uptake. l -arginine inhibited the uptake of Glu logarithmically, however it showed no change in uptake of GABA. The contents of GABA and Glu in synaptosome were decreased in the presence of l -arginine. l -arginine enhanced the respiration of state II by succinate on synaptosomal respiration, although the respiration of synaptosomal mitochondrial fraction and the respiratory chains enzyme activities were almost unaffected by l -arginine. In the presence of rotenone, l -arginine decreased the uptake of Glu without changing the uptake of GABA, increased the releasing of GABA, and may modulate the excitability of neuronal state on the cytosol, cytomembrane, and/or organelles except for mitochondria. Conclusions: l -arginine may modulate excitation by neurotransmitters at nerve endings, in relation to potentiated respiratory metabolism of succinate in synaptosomes. Such effects might contribute to alleviation of stroke-like symptoms in MELAS.

The abnormalities of intracranial hemodynamics associated with strokelike episodes in MELAS are variable depend on the time phase from the onset of strokelike episodes and on the progression of the dementia state. To clarify the regional cerebral blood flows (rCBF) in the natural course of MELAS is very important to understand the pathogenic mechanism of this disorder, either cytopathy, angiopathy or both. We analyzed the serial studies of brain statistical parametric mapping (SPM) 99 single photon emission computed tomography (SPECT) in 5 MELAS patients in maximum 10 years interval, who fulfilled the clinical, pathological and genetic criteria of MELAS, and have an A3243G mutation in the mitochondrial tRNA(Leu(UUR)) gene. SPM is a proven and effective method for the voxel-by-voxel analysis of functional images which show the advantage in its promise of fully automated neurophysiological imaging analysis throughout the whole brain using various statistical analyses. SPECT acquisition was initiated and was reconstructed by iterative algorithm and were processed and analyzed with SPM 99 for Windows software. Statistics were displayed as Z scores (threshold: P < 0.01). The inappropriate intracranial hemodynamics was found not only at the acute but at the interictal phase, and was getting worse as the disease progress. Hypoperfusion in the posterior cingulate cortex was always observed (corrected P < 0.01) in MELAS patients, which is the typical finding reported in Alzheimer's disease. The inappropriate intracranial hemodynamics is a common feature and may be related with mitochondrial angiopathy in the natural course of MELAS.

We investigated the endothelial function in MELAS patients and also evaluated the therapeutic effects of L-arginine. Concentrations of L-arginine during the acute phase of MELAS were significantly lower than in control subjects. L-arginine infusions significantly improved all symptoms suggesting stroke within 30 min, and oral administration significantly decreased frequency and severity of stroke-like episodes. Flow-mediated dilation (FMD) in patients showed a significant decrease than those in the controls. Two years of oral supplementation of L-arginine significantly improved endothelial function to the control levels and was harmonized with the normalized plasma levels of L-arginine in patients. L-arginine therapy showed promise in treating stroke-like episodes in MELAS.

The authors evaluated endothelial function in patients with MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke) by flow-mediated vasodilation (FMD) and found a significant decrease vs controls. Two years of supplementation with oral l-arginine, a nitric oxide precursor, significantly improved endothelial function to control levels and was harmonized with the normalized plasma levels of l-arginine in patients. l-Arginine therapy improved endothelial dysfunction and showed promise in treating strokelike episodes in MELAS.

Lactic acidosis has been associated with a variety of clinical conditions and can be due to mutation in nuclear or mitochondrial genes. We performed mutations screening of all mitochondrial tRNA genes in 44 patients who referred as hyperlactic acidosis. Patients showed heterogeneous phenotypes including Leigh disease in four, MELAS in six, unclassified mitochondrial myopathy in 10, cardiomyopathy in five, MERRF in one, pure lactic acidosis in six, and others in 12 including facio-scaplo-femoral muscular dystrophy (FSFD), familial cerebellar ataxia, recurrent Reye syndrome, cerebral palsy with mental retardation. We measured enzymatic activities of pyruvate dehydrogenase complex, and respiratory chain enzymes. All mitochondrial tRNA genes and known mutation of ATPase 6 were studied by single strand conformation polymorphism (SSCP), automated DNA sequence and PCR-RFLP methods. We have found one patient with PDHC deficiency and six patients with Complex I+IV deficiency, though the most of the patients showed subnormal to deficient state of respiratory chain enzyme activities. We have identified one of the nucleotide changes in 29 patients. Single nucleotide changes in mitochondrial tRNA genes are found in 27 patients and one in ATPase 6 gene in two patients. One of four pathogenic point mutations (A3243G, C3303T, A8348G, and T8993G) was identified in 12 patients who showed the phenotype of Leigh syndrome, MELAS, cardimyopathy and cerebral palsy with epilepsy. Seventeen patients have one of the normal polymorphisms in the mitochondrial tRNA gene reported before. SSCP and PCR-RFLP could detect the heteroplasmic condition when the percentage of mutant up to 5, however, it cannot be observed by direct sequencing method. It is important to screen the mtDNA mutation not only by direct sequence but also by PCR-RFLP and the other sensitive methods to detect the heroplasmy when lactic acidosis has been documented in the patients who are not fulfilled the criteria of mitochondrial disorders.

Accumulation of RNA 19 has been associated with mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes. We analyzed total RNA in muscle specimens from six patients who had one of three pathogenetic point mutations in the mitochondrial tRNA(Leu(UUR)) gene, including A3243G, T3271C, and T3303C. Mitochondrial processing intermediates were identified and quantitated by Northern blotting. The percentage of DNA with the mutation also was determined in each patient. The intermediate (RNA 19) was significantly increased in all patients. The proportion of mutation-carrying RNA in processing intermediates was always higher than in the DNA fraction, suggesting that these mutations may have dominant-negative effects on mitochondrial RNA processing events at the tRNA(Leu(UUR)) gene boundary.

Mitochondrial dysfunction elicits various stress responses in different model systems, but how these responses relate to each other and contribute to mitochondrial disease has remained unclear. Mitochondrial myopathy (MM) is the most common manifestation of adult-onset mitochondrial disease and shows a multifaceted tissue-specific stress response: (1) transcriptional response, including metabolic cytokines FGF21 and GDF15; (2) remodeling of one-carbon metabolism; and (3) mitochondrial unfolded protein response. We show that these processes are part of one integrated mitochondrial stress response (ISRmt), which is controlled by mTORC1 in muscle. mTORC1 inhibition by rapamycin downregulated all components of ISRmt, improved all MM hallmarks, and reversed the progression of even late-stage MM, without inducing mitochondrial biogenesis. Our evidence suggests that (1) chronic upregulation of anabolic pathways contributes to MM progression, (2) long-term induction of ISRmt is not protective for muscle, and (3) rapamycin treatment trials should be considered for adult-type MM with raised FGF21.

MKRN3, located on chromosome 15q11.2, encodes makorin ring-finger 3, which is an upstream suppressor of the hypothalamic-pituitary-gonadal axis. Mutation of this gene induces central precocious puberty (CPP). As MKRN3 is maternally imprinted, only the paternal allele is expressed. This is the first report of an 8-year-old Japanese girl with CPP caused by a novel frameshift mutation in MKRN3 (p.Glu229Argfs*3).

We report a male patient with hypothalamic hamartoma (HH) who manifested central precocious puberty (CPP) at 4 years of age. Gonadotropin-releasing hormone (GnRH) analogue treatment was started at 6 years of age and his pubertal signs were suppressed. At 9 years of age, the patient was emotionally unstable, aggressive, and antisocial. He had severe attention deficit hyperactivity disorder (ADHD)-like behavior and conduct disorder. No seizure activity was observed. GnRH analogue treatment was discontinued for 8 months from 9 years and 4 months of age due to his mother’s illness. During this period sexual urges were observed. Treatment with daily methylphenidate markedly improved his behavioral problems. However, his sexual urges were not suppressed until 3 months after the GnRH analogue treatment was restarted. The present case is unique because the patient’s behavioral problems were observed despite the parahypothalamic type of HH and absence of seizures. This case is also rare because behavioral problems were observed without seizures, and no ADHD cases with hamartoma have been reported previously. Recently, clinical studies have described an association between psychiatric morbidity, including ADHD, and hyperandrogenism disorders. Our patient’s ADHD-like symptoms might be due to hyperandrogenism. In such cases, GnRH analogue with methylphenidate could be effective for improving ADHD-like symptoms.

Based on the hypothesis that mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes (MELAS) are caused by impaired vasodilation in an intracerebral artery, the authors evaluated the effects of administering l-arginine, a nitric oxide precursor. Patients were administered L-arginine intravenously at the acute phase or orally at the interictal phase. L-arginine infusions significantly improved all strokelike symptoms, suggesting that oral administration within 30 minutes of a stroke significantly decreased frequency and severity of strokelike episodes.

Background/Aims: Missense, nonsense, and splice mutations in the Fibroblast Growth Factor 8(FGF8) have recently been identified in patients with hypothalamo-pituitary dysfunction and craniofacial anomalies. Here, we report a male patient with a frameshift mutation in FGF8. Case Report: The patient exhibited micropenis, craniofacial anomalies, and ventricular septal defect at birth. Clinical evaluation at 16 years and 8 months of age revealed delayed puberty, hyposmia, borderline mental retardation, and mild hearing difficulty. Endocrine findings included gonadotropin deficiency and primary hypothyroidism. Results: Molecular analysis identified a de novo heterozygous p.S192fsX204 mutation in the last exon of FGF8. RT-PCR analysis of normal human tissues detected FGF8 expression in the genital skin, and whole-mount in situ hybridization analysis of mouse embryos revealed Fgf8 expression in the anlage of the penis. Conclusion: The results indicate that frameshift mutations in FGF8 account for a part of the etiology of hypothalamo-pituitary dysfunction. Micropenis in patients with FGF8 abnormalities appears to be caused by gonadotropin deficiency and defective outgrowth of the anlage of the penis.

Introduction Resistance to thyroid hormone is a syndrome caused by thyroid hormone receptor β mutations, which are usually inherited in an autosomal-dominant pattern. Case presentation Our patient, a Japanese neonate boy, showed hyperthyroid symptoms at age two days. Although our patient was diagnosed as having resistance to thyroid hormone, his hyperthyroid symptoms continued for two weeks. Therefore, our patient was treated with methimazole and iodine for two weeks from birth, showing no side effects and no symptoms upon treatment. At age 70 days, an R243W mutation in thyroid hormone receptor β was detected in our patient; while absent in his mother, the mutation was present in his father, who never showed any symptoms. Conclusions To the best of our knowledge this is the first case report of a resistance to thyroid hormone in a neonate presenting with hyperthyroid symptoms born to a mother with Graves’ disease and treated with methimazole and iodine. These results suggest that methimazole and iodine may be a good short-term option for treatment.