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Congenital disorder of glycosylation type Ig (ALG12-CDG) is a rare inherited metabolic disease caused by a defect in alpha-mannosyltransferase 8, encoded by the ALG12 gene (22q13.33). To date, only 15 patients have been diagnosed with ALG12-CDG globally. Due to a newborn Slovak patient's clinical and biochemical abnormalities, the isoelectric focusing of transferrin was performed with observed significant hypoglycosylation typical of CDG I. Furthermore, analysis of neutral serum N-glycans by mass spectrometry revealed the accumulation of GlcNAc2Man5-7 and decreased levels of GlcNAc2Man8-9, which indicated impaired ALG12 enzymatic activity. Genetic analysis of the coding regions of the ALG12 gene of the patient revealed a novel homozygous substitution mutation c.1439T>C p.(Leu480Pro) within Exon 10. Furthermore, both of the patient's parents and his twin sister were asymptomatic heterozygous carriers of the variant. This comprehensive genomic and glycomic approach led to the confirmation of the ALG12 pathogenic variant responsible for the clinical manifestation of the disorder in the patient described.

Aim Congenital disorders of glycosylation (CDG) belong to an expanding group of rare genetic metabolic disorders caused by defects in the complex chemical enzymatic process of glycosylation. The study is aimed at presenting a case report of a premature dysmorphic newborn, clinical presentation of the condition, the way it was diagnosed and treated, as well as its comparison with the known cases. Results The result of glycan analysis supports the assumption of a supposed glycosylation disorder and also specifies a specific subtype: CDG-1, subtype ALG12-CDG (Ig). Conclusion CDG have an extremely wide clinical spectrum and should be considered in any child with unexplained developmental delay, failure to thrive, seizures, and abnormalities in liver enzymes, coagulation and immunologic factors. The treatment of most forms of CDG depends upon numerous factors such as specific symptoms present, severity of the disorder, age and overall health of the patients and tolerance to certain medications or procedures. For these reasons, the treatment is specific for every individual. It is based on the symptoms and requires a coordination of efforts of a team of specialists (Tab. 4, Fig. 3, Ref. 19).

Mucopolysaccharidosis type II (Hunter syndrome, MPS II, OMIM 309900) is an X-linked lysosomal storage disorder caused by deficiency of iduronate-2-sulfatase (IDS). We analyzed clinical and laboratory data from 44 Slavic patients with this disease. In total, 21 Czech, 7 Slovak, 9 Croatian and 7 Serbian patients (43 M/1 F) were included in the study (median age 11.0 years, range 1.2-43 years). Birth prevalence ranged from 1:69,223 (Serbia) to 1:192,626 (Czech Rep.). In the majority of patients (71%), the disease manifested in infancy. Cognitive functions were normal in 10 patients. Four, six and 24 patients had mild, moderate, and severe developmental delay, respectively, typically subsequent to developmental regression (59%). Residual enzyme activity showed no predictive value, and estimation of glycosaminoglycans (GAGs) had only limited importance for prognosis. Mutation analysis performed in 36 families led to the identification of 12 novel mutations, eight of which were small deletions/insertions. Large deletions/rearrangements and all but one small deletion/insertion led to a severe phenotype. This genotype-phenotype correlation was also identified in six cases with recurrent missense mutations. Based on patient genotype, the severity of the disease may be predicted with high probability in approximately half of MPS II patients.

The authors present the ophthamological finding in a patient who at the age of 4.5 months was admitted due to a finding of total bilateral congenital cataract. The patient was observed by a neurologist for central hypotonia and mental retardation. Upon a complex examination of the patient, suspicion of Lowe syndrome was stated, which was confirmed by a metabolic examination and also by genetic tests. Upon an examination of the family, a genetic defect (mutation of OCRL1 gene) was confirmed also in the mother of the patient. A mild subcapsular opacification was present in the mother, beneath the posterior capsule. The patient was operated on for bilateral congenital cataract. Upon an examination under general anaesthesia, trabeculodysgenesis was diagnosed. Intraocular pressure remains within the norm. The patient is now aged 8 years, regularly monitored with regard to metabolic compensation, and by a neurologist and ophthalmologist, with satisfactory visual functions. Early diagnosis of the Lowe syndrome was determined on the basis of a complex examination of the patient within the framework of etiological diagnosis of bilateral congenital cataract. Key words: Lowe syndrome, oculo - cerebro - renal syndrome, congenital cataract, glaucoma, nystagmus.

Objectives The clinical, biochemical and genetic findings in two Slovak patients with glutaric aciduria type I (GAI) are presented. Background GAI is a rare autosomal recessive neuro-metabolic disorder caused by deficiency of glutaryl-CoA dehydrogenase, which is involved in the catabolic pathways of lysine, hydroxylysine and tryptophan. This enzymatic defect gives rise to elevated levels of glutaric acid (GA), 3-hydroxyglutaric acid (3-OH-GA) and glutarylcarnitine (C5DC) in body fluids. Methods Biochemical and molecular-genetic tests were performed. Urinary organic acids were analysed by Gas Chromatography/Mass Spectrometry (GC/MS) and the entire coding region of the GCDH gene, including flanking parts, was sequenced. Results We found the presence of typical metabolic profile and novel causal pathogenic variants in both GAI patients. Conclusion We present the first report of two Slovak patients with GAI, which differed in the clinical and biochemical phenotype significantly. They were diagnosed by two distinct approaches - selective and newborn screening. Their diagnosis was complexly confirmed by biochemical and later on molecular-genetic examinations. Though we agreed with a thesis that early diagnostics might positively influenced patient's health outcome, contradictory facts should be considered. Supposed extremely low prevalence of GAI patients in the general population and/or the existence of asymptomatic individuals with a questionable benefit of the applied therapeutic intervention for them lead to doubts whether the inclusion of disease into the newborn screening programme is justified well enough (Tab. 1, Fig. 3, Ref. 41).

Objective: To characterize the neuroradiological brain phenotype in severe and attenuated forms of mucopolysaccharidosis type II (MPSII). Methods: 43 clinical MRI scans from 24 males and 1 female with MPSII from 5 European countries were collected. Brain MRIs were analyzed using semi-quantitative MPS Brain MRI rating scale (MPSMRI) specifically developed for MPS population. The scale consists of three domains assessing white matter (WM) hyperintensities, enlarged perivascular spaces (PVS), and atrophy with ventricular enlargement. Results: The total of 26 scans from 19 males (15 severe, 4 attenuated) including longitudinal data sets of 4 subjects (follow-up 2-8 years) were analyzed. Severe form presented with higher atrophy (p&lt ; .0001), ventricular enlargement (VE) (p&lt ; .02), and lobar white matter hyperintensities (LWMH) (p=0.06) MPSMRI scores when compared to attenuated cases. There were associations between LWMH and VE scores (R=0.72, p&lt ; .001), LWMH and atrophy scores (R=0.70, p&lt ; .001) and VE and atrophy scores (R=0.73, p&lt ; .001). Longitudinal follow-up revealed a progressive increase in lobar and periventricular white matter hyperintensities, brain atrophy and ventriculomegaly scores, and minimal change in PVS scores. We identified the presence of delayed myelination in 42%, sella turcica enlargement in 81%, middle cranial fossae and posterior fossa CSF collection in 15% and 54% of all cases respectively. Conclusion: We show that white matter disease, enlarged ventricles or hydrocephalus, and brain atrophy are the main and interrelated hallmarks of MPS II, more highly expressed in severe than attenuated forms. All tend to progress overtime whereas the enlarged perivascular spaces show minimal or no progression. Our brain MRI findings propose endpoints suitable for disease registries to track disease outcomes and pinpoint brain abnormalities in MPSII that can serve as potential markers for clinical trials if assessed with a robust quantitative approach.

Intrathecal baclofen administration is commonly used in the treatment of children’s spasticity. In general, candidates for baclofen pump are patients with spastic form of cerebral palsy. Intrathecal baclofen in the treatment of spasticity due to a metabolic disorder is rarely reported. Authors report on an 11-year-old boy with mucopolysaccharidosis type II (Hunter syndrome) with progressive stiffness and contractures followed by profound loss of joint movement range and tiptoe walking pattern. Patient was indicated for baclofen test with subsequent pump insertion and continuous intrathecal baclofen administration. Postoperatively, patient was gradually set to current baclofen dose of 250 μg/day. At mentioned dose, we observed not only increased active and passive range of movements and facilitation in fine motor skills, but also better walking pattern. Despite intrathecal baclofen administration in patients with spasticity related to mucopolysaccharidosis type II is not widely reported, we consider it as feasible treatment. To emphasize, enzyme replacement therapy is the primary treatment, and improvement is attributed to both enzyme substitution and intrathecal baclofen therapy.

TMEM70 deficiency is the most common nuclear-encoded defect affecting the ATP synthase. In this multicentre retrospective study we characterise the natural history of the disease, treatment and outcome in 48 patients with mutations in TMEM70. Eleven centers from eight European countries, Turkey and Israel participated.All 27 Roma and eight non-Roma patients were homozygous for the common mutation c.317-2A G. Five patients were compound heterozygotes for the common mutation and mutations c.470 T A, c.628A C, c.118_119insGT or c.251delC. Six Arab Muslims and two Turkish patients were homozygous for mutations c.238C T, c.316 + 1G T, c.336 T A, c.578_579delCA, c.535C T, c.359delC. Age of onset was neonatal in 41 patients, infantile in six cases and two years in one child. The most frequent symptoms at onset were poor feeding, hypotonia, lethargy, respiratory and heart failure, accompanied by lactic acidosis, 3-methylglutaconic aciduria and hyperammonaemia. Symptoms further included: developmental delay (98%), hypotonia (95%), faltering growth (94%), short stature (89%), non-progressive cardiomyopathy (89%), microcephaly (71%), facial dysmorphism (66%), hypospadias (50% of the males), persistent pulmonary hypertension of the newborn (22%) and Wolff-Parkinson-White syndrome (13%). One or more acute metabolic crises occurred in 24 surviving children, frequently followed by developmental regression. Hyperammonaemic episodes responded well to infusion with glucose and lipid emulsion, and ammonia scavengers or haemodiafiltration. Ten-year survival was 63%, importantly for prognostication, no child died after the age of five years.TMEM70 deficiency is a panethnic, multisystemic disease with variable outcome depending mainly on adequate management of hyperammonaemic crises in the neonatal period and early childhood.

Electron microscopy has been for decades a basic morphological method still used in diagnostic protocols of some pathological conditions affecting the ultrastructure of cells and extracellular matrix. The aim of this study was an ultrastructural description of gingiva of patients with Hunter syndrome and hereditary gingival fibromatosis.Gingival biopsies were obtained during surgical periodontal treatment from a 9-year-old boy with Hunter disease (with enzyme replacement therapy with recombinant human idursulphase) and a 15-year-old girl with hereditary gingival fibromatosis. Gingival samples obtained from the upper anterior region were processed and examined with transmission electron microscope.In the case of Hunter syndrome due to the genetic lack of one lysosomal enzyme, an intercellular accumulation of glycosaminoglycans occurs. Within the gingiva of a patient with Hunter syndrome we observed membrane-bound storage vesicles in the cytoplasm of fibroblasts, endothelial cells of capillaries, surface epithelial cells, mast cells, and macrophages. Despite a long-term enzyme replacement therapy which improves clinical manifestations of Hunter syndrome, on the cellular level we still found marked accumulations of glycosaminoglycans in the cytoplasm of different cells as well as in the extracellular matrix. Hereditary gingival fibromatosis is a benign, slowly progressive and non-inflammatory gingival enlargement with a predominance of randomly oriented collagen fibrils in the gingival lamina propria. Some of these fibrils exhibited loops. Another unusual ultrastructural finding is the presence of empty perinuclear space in the cytoplasm of epithelial cells. The origin and significance of these non-membrane bound spaces are unknown.In both genetically determined diseases, the electron microscopic examination may be useful, and physicians get relevant information about the progress of illness.

Rett syndrome (RTT), an X-linked dominant neurodevelopmental disorder in females, is caused mainly by de novo mutations in the methyl-CpG-binding protein 2 gene (MECP2). Here we report mutation analysis of the MECP2 gene in 87 patients with RTT from the Czech and Slovak Republics, and Ukraine. The patients, all girls, with classical RTT were investigated for mutations using bi-directional DNA sequencing and conformation sensitive gel electrophoresis analysis of the coding sequence and exon/intron boundaries of the MECP2 gene. Restriction fragment length polymorphism analysis was performed to confirm the mutations that cause the creation or abolition of the restriction site. Mutation-negative cases were subsequently examined by multiple ligation-dependent probe amplification (MLPA) to identify large deletions. Mutation screening revealed 31 different mutations in 68 patients and 12 non-pathogenic polymorphisms. Six mutations have not been previously published: two point mutations (323T>A, 904C>T), three deletions (189_190delGA, 816_832del17, 1069delAGC) and one deletion/inversion (1063_1236del174;1189_1231inv43). MLPA analysis revealed large deletions in two patients. The detection rate was 78.16%. Our results confirm the high frequency of MECP2 mutations in females with RTT and provide data concerning the mutation heterogeneity in the Slavic population.

Ob­jec­ti­ve: An elevated thyroid stimulating hormone (TSH) level is a frequent finding in obese children, but its association with peripheral hormone metabolism is not fully understood. We hypothesized that in obesity, the changes in thyroid hormone metabolism in peripheral tissues might lead to dysregulation in the thyroid axis. The purpose of this study was to investigate the association of TSH with thyroid hormones in a group of obese children as compared to normal-weight controls. Methods: Serum TSH, free thyroxine (fT4) and free triiodothyronine (fT3) levels were measured in 101 obese children and in 40 controls. Serum reverse T3 (rT3) levels were also measured in a subgroup of 51 obese children and in 15 controls. Results: Serum TSH level was significantly higher in obese children compared to controls (2.78 vs. 1.99 mIU/L, p

Smith-Lemli-Opitz syndrome (SLOS; McKusick 270400) is an autosomal recessive inherited metabolic-malformation disorder caused by deficient activity of 7-dehydrocholesterol reductase (DHCR7, E.C. 1.3.1.21), which catalyses the final step in the cholesterol-biosynthesis pathway. The clinical picture is characterized by a combination of congenital anomalies: microcephaly, hypotonia, incomplete development of the male genitalia, polydactyly, syndactyly of toes 2 and 3, cleft palate, heart and kidney malformations, failure to thrive and severe mental and growth retardation (Smith et al 1964). A decrease of plasma cholesterol and the accumulation of its precursor 7-dehydrocholesterol (7-DHC) is the biochemical hallmark in SLOS patients (Tint et al 1994). Cloning and sequncing of DHCR7 cDNA (Moebius et al 1998) and characterization of the human DHCR7 gene (Fitzky et al 1998) enabled investigation of defects of this gene at the DNA level. Several mutations have been described (Wassif et al 1998; Waterham et al 1998). Here we report the results of molecular analysis of the DHCR7 gene in 10 unrelated families with Smith-Lemli-Opitz syndrome. Results of mutation analyses are presented and compared with the clinical and biochemical data.

Errors of cholesterol biosynthesis represent a heterogeneous group of metabolic disorders. The aim of the authors of this article is to present a case of a patient with typical symptoms of a rare post-squalene disorder of cholesterol biosynthesis, its diagnostics and progress in neonatal period. The differential diagnosis of a typical findings on the skin with spontaneous regression ichtyosiform erythroderma, craniofacial dysmorphic features, anomalies of organs or skeletal abnormalities in a newborn may also be the result of a disorder of cholesterol biosynthesis. The final diagnosis is definitely confirmed by DNA analysis. Prognosis depends on the different enzyme defects of cholesterol biosynthesis pathway, but typically on the post-squalene pathway. Cholesterol is an important substance that plays a significant role in membrane structure, as well as being the precursor for the synthesis of the steroid hormones and bile acids. Cholesterol synthesis occurs in the cytoplasm and microsomes from the two-carbon acetate group of acetyl coenzyme A (acetyl-CoA). The biosynthesis of cholesterol consists of several reactions. Acetyl-CoA units are converted to mevalonate by a series of reactions. Mevalonate is formed on squalene and then lanosterol. Lanosterol is converted by two different pathways, either with the creation of 7-dehydrocholesterol, or desmosterol with the creation of cholesterol. Errors of cholesterol biosynthesis represent a heterogeneous group of metabolic disorders that is characterized by multiple dysmorphic features underlining an important role for cholesterol in human embryogenesis and development. The differential diagnosis of atypical findings on the skin in newborn may be the result of disorder of cholesterol biosynthesis. It may be also associated with various dysmorphic features or anomalies including multiple anomalies of congenital and internal organs and skeletal abnormalities. Some of the post-squalene disorders may point to atypical findings on the skin in the form of psoriatic eruptions, psychomotoric delay or laboratory findings as hypocholesterolemia. Key words: newborn; hypocholesterolemia; stigma; chondrodysplasia punctata; ichthyosiform erythroderma

To present the case of a term newborn with rapid progression of signs of neurodegenerative disease.In a case of a term newborn with numerous dysmorphic features, with seizure activity from the 3rd day of life, hypertonia and serious changes on brain parenchyma were presented. Diagnosis of molybdenum cofactor deficiency was confirmed by the decreased level of uric acid, 31 μmol/l, in serum, increased excretion of thiosulfate and S-sulfocysteine in urine, taurine (1729.3 μmol/mmol crea; normal range 30-300 μmol/mmol crea) and xanthine (276.9 μmol/mmol crea; normal range25 μmol/mmol crea) in urine. Sulfite oxidase activity on skin fibroblasts in culture was not detectable. The patient died at the age of 28 days of life.Deficiency of molybdenum cofactor leads to accumulation of toxic metabolites (levels of sulfite), which causes disturbances of neurotransmitters even before delivery. Therapy is symptomatic, no effective therapy is available. Seizures are difficult to suppress. This case report is about the first patient in Slovakia.

To present clinical and laboratory findings in the case of a term newborn with conjugated hyperbilirubinaemia and to stress the importance of differential diagnosis.A term newborn delivered by caesarean section (birth weight 2550 g, birth length 47 cm, value of Apgar score 9/10) with good direct adaptation had on the first day of life increased levels of conjugated bilirubin (23 micromol/l), unconjugated bilirubin (55 micromol/l) and C-reactive protein 39.4 g/l. The diagnosis of mevalonic aciduria was confirmed by urine analysis (mevalonolactone 393 micromol/mmol crea, normal range2.0 micromol/mmol crea; mevalonic acid 40.5 micromol/mmol crea, normal range0.04 micromol/mmol crea).Mevalonic aciduria can be clinically distinguished based on symptoms of neurological involvement. It can also present itself with hepatosplenomegaly, lymphadenopathy, anaemia, leukocytosis, increased sedimentation rates and levels of C-reactive protein. In cases of conjugated hyperbilirubinaemia of unknown aetiology it is important to exclude mevalonic aciduria by urine investigation for organic acids.

Purpose: Fabry disease, a genetic deficiency of α-galactosidase A, is characterized by pathogenic cellular accumulation of globotriaosylceramide. During clinical trials, recombinant human α-galactosidase A (agalsidase beta; Fabrazyme®, Genzyme Corporation, Cambridge, MA), infused intravenously at 1.0 mg/kg every 2 weeks for 6 months, cleared or reduced globotriaosylceramide in renal, cardiac, and dermal microvascular endothelia and other cells, with results sustained for up to 5 years in most patients evaluated. This study explored whether a lower dose could maintain globotriaosylceramide clearance achieved with 1.0 mg/kg. Methods: Cellular globotriaosylceramide levels were assessed histologically in kidney and skin biopsies from 21 adult Fabry males treated for 6 months at 1.0 mg/kg/2 weeks followed by 18 months at 0.3 mg/kg/2 weeks. Results: In kidney interstitial capillary endothelium, the primary endpoint, globotriaosylceramide clearance was achieved in 100% of patients with 1.0 mg/kg and maintained in 90% with 0.3 mg/kg. In seven other renal cell types and superficial dermal capillary endothelium, globotriaosylceramide reduction or clearance was maintained with 0.3 mg/kg in ∼70% of patients. Conclusions: A lower dose of agalsidase beta may be sufficient in some, but not all, patients with Fabry disease to maintain the cellular globotriaosylceramide clearance achieved with 1.0 mg/kg/2 weeks. Long-term clinical effects of transitioning to the lower dose have not been evaluated.

To present a term newborn with severe asphyxial status due to dysrrhythmia induced by the neonatal form of carnitine palmitoyltransferase II deficiency (CPT II).Term newborn delivered spontaneously (birth weight 3450 grams, birth length 52 cm, values of Apgar score 10/10) with good direct adaptation, on second day of life he manifested severe asphyxial status followed by cardiorespiratory insufficiency with circulatory failure. After prolonged resuscitation of 3 hours, the child was admitted to our neonatological department. Diagnosis of CPT II was confirmed (free carnitine level in blood 12.2 micromol/l; ratio (C16+C18):1/C2 was 0.760 by tandem mass spectrometry; activity of CPT II in leukocytes was 0.082 micromol/min x gram protein). After appropriate treatment the patient survived the critical period.Neonatal form of CPT II deficiency is the most severe form and is considered to be invariably fatal. This kind of metabolic disease is congenital, but cardiac problems are not detectable during the prenatal period. Fasting in the early newborn period is a main trigger of CPT II deficiency signs. The authors emphasise the relevance of investigating acylcarnitine profiles and carnitine in serum in all cases of severe postnatal asphyxia and in cases of unusual newborn arrhythmias since some forms of disturbances in beta oxidation of fatty acids are partially treatable.

Transient hyperphosphatasemia of infancy and childhood (TH) is a temporary and isolated increase of serum alkaline phosphatase (ALP; EC 3.1.3.1) activity occurring without obvious cause during the first years of life. Despite several reports about this phenomenon, the origin of TH remains obscure. Over a period of 8 years (1992–1999), we detected 194 cases of TH in 106 boys and 88 girls. The hyperphosphatasemia was discovered fortuitously during routine investigations in outpatient and inpatient departments of a children’s hospital with a capacity of 500 beds. A wide variety of clinical disorders was associated with this condition (gastrointestinal diseases, 24%; respiratory infections, 21%; congenital anomalies and …

The Smith-Lemli-Opitz syndrome (SLOS, McKusick 270400) is an autosomal recessive multiple congenital malformation/mental retardation syndrome caused by a deficiency of 3β-hydroxysteroid Δ 7 -reductase (7-dehydrocholesterol Δ 7 -reductase). As a result, markedly reduced cholesterol (C) concentration and accumulation of the precursor 7-dehydrocholesterol (7-DHC) and derivatives 8-dehydrocholesterol (8-DHC) and 19-nor-5,7,9(10)-cholestatrienol are found in serum and tissues (Salen et al 1996; Tint et al 1994). Although the essential metabolic defect was well defined in the cells, the lipoprotein system responsible for cholesterol transport in the blood has not been evaluated in detail until now. Here we report findings of serum lipids and apolipoproteins determined in SLOS children not treated with cholesterol.

A study of the galactose-1-phosphate uridyltransferase (GALT) gene from 37 unrelated galactosemia families is reported here. A total of 16 sequence variations in eleven mutated alleles was found. The two most common molecular defects were the mutations Q188R (46.0%) and K285N (25.7%). Six novel mutations in the GALT gene, X380R, Y209S, E340K, L74fsdelCT, Q169K and L256/P257delGCC, were detected. Three mutations, V151A, L195P and R204X that were previously described in other populations, were also found. The mutation X380R, which breaks the stop codon of the GALT gene, causes elongation of the GALT enzyme's protein chain. A deletion of four nucleotides in the 5′ promoter region, in a position 116 - 119 nucleotides upstream from the initiate codon (5′UTR-119delGTCA), was revealed in Duarte (D2) alleles, in addition to N314D, IVS4nt-27gc, IVS5nt+62ga, and IVS5nt-24ga. An unusual molecular genotype was observed on 2 types of classical galactosemia alleles, with six variations from the normal nucleotide sequence presented in cis (mutation V151A or E340K plus five Duarte (D2) characteristic variations). In summary, galactosemia is a heterogeneous disorder at the molecular level, and mutation N314D, appears to be an ancient genetic variant of the GALT gene. Hum Mutat 15:206, 2000. © 2000 Wiley-Liss, Inc.

Smith-Lemli-Opitz syndrome (SLOS) has extremly variable phenotype, ranging from life-threatening congenital malformations to minor anomalies, but sacral dimple has not been includet in the phenotypic spectrum. Besides typical findings of SLOS, our newborn girl had unusual scin manifestation of sacral dimple.