Establishing the Mutational Spectrum of Hungarian Patients with Familial Hypercholesterolemia

Familial hypercholesterolemia (FH) is one of the most common autosomal, dominantly inherited diseases affecting cholesterol metabolism, which, in the absence of treatment, leads to the development of cardiovascular complications. The disease is still underdiagnosed, even though an early diagnosis would be of great importance for the patient to receive proper treatment and to prevent further complications. No studies are available describing the genetic background of Hungarian FH patients. In this work, we present the clinical and molecular data of 44 unrelated individuals with suspected FH. Sequencing of five FH-causing genes (LDLR, APOB, PCSK9, LDLRAP1 and STAP1) has been performed by next-generation sequencing (NGS). In cases where a copy number variation (CNV) has been detected by NGS, confirmation by multiplex ligation-dependent probe amplification (MLPA) has also been performed. We identified 47 causal or potentially causal (including variants of uncertain significance) LDLR and APOB variants in 44 index patients. The most common variant in the APOB gene was the c.10580G>A p.(Arg3527Gln) missense alteration, this being in accordance with literature data. Several missense variants in the LDLR gene were detected in more than one index patient. LDLR variants in the Hungarian population largely overlap with variants detected in neighboring countries.

Reviewing the Clinical Spectrum Related to Kmt2b Gene Mutations: Unusual Clinical Presentation and a Possible New Pathogenic Mutation

Introduction KMT2B related dystonia is a childhood onset generalized dystonia. Since its first description in 2016, different phenotypic spectrum have been reported. The aim of the case report is to provide data that may help to understand the spectrum of KMT2B-related disorders. We present two members of a family with a possible non-previously described pathogenic mutation and an unusual KMT2B related dystonia presentation: an adult onset and focal dystonia.Case Presentation The index patient is a 32 year-old woman with a generalized dystonia. Her maternal uncle presented a focal dystonia. Next-generation sequencing revealed a heterozygous missense mutation in KMT2B gene (19q13.12), described as a variant of uncertain significance (VUS). Although characteristic phenotype of KMT2B dystonia is a childhood onset generalized dystonia, different phenotypes have been related according to the kinds of mutations in this gene, also varying the age of symptom onset and the penetrance of the mutation. Asymptomatic or sub-clinical carriers and adult onset has been described. Due to the low prevalence of this variant in the general population and the low penetrance and high intrafamilial variability of this entity, we suggest that this mutation might be a pathogenic variant.ConclusionsKMT2B related dystonia is an emerging and prevalent monogenic dystonia whose incidence, genetic variability and clinical spectrum remain unknown. Despite the study of this gene is indicated in childhood onset dystonia, description of cases such as ours shows that its sequencing in patients with an adult-onset dystonia with family history can be useful for the diagnosis.

Clinical and epidemiological characteristics and effectiveness of antiviral therapy for COVID-19 in children: The experience of the first year of the pandemic

Background. The use of antiviral agents can shorten the duration of the viral infection. The aim: to study the clinical and epidemiological features and the effectiveness of antiviral therapy for new coronavirus infection (COVID-19) in outpatient children.Materials and methods. From April 2020 to March 2021, 9334 outpatient children aged from 0 months to 17 years were randomly tested for new coronavirus infection. SARS-CoV-2 RNA was detected in oropharyngeal and nasal material by PCR. Patients with confirmed new coronavirus infection were prescribed interferon-alpha (IFN-α) intranasally, antiviral agents of systemic action. The control group consisted of children with COVID-19 who did not receive treatment.Results. When examining clinically healthy contact children, SARS-CoV-2 RNA was detected in 7.4 % of cases. In the structure of ARI, the specific weight of COVID-19 was 12.3 % with the peak incidence in April-May (up to 22.8 %) and NovemberDecember (up to 30.0 %). In half of the cases, children became infected in the family, and usually adults were the index patient. In 47.7 % of cases, an asymptomatic form of COVID-19 was registered without significant differences in patients of different ages. In one third of children with concomitant pathology, the disease was asymptomatic, in half it was mild, in other cases moderate severity was diagnosed. The clinical picture of COVID-19 did not differ from other ARIs. Anosmia (9.4 %) in half of the cases was combined with ageusia (4.4 %) and was significantly more common in boys. The duration of clinical manifestations in children of the control group and those who received antiviral therapy did not statistically significantly differ in mild and severity of the disease. Also, various antiviral therapy options did not significantly affect the duration of SARS-CoV-2 detection in children with various forms of COVID-19.Conclusion. In the first year of the pandemic, the novel coronavirus infection did not dominate the pattern of respiratory diseases in outpatient children. Further research is required to develop pediatric guidelines for the treatment of COVID-19 at the outpatient stage.

Acute Liver Failure after Ingestion of Fried Rice Balls: A Case Series of Bacillus cereus Food Poisonings

Bacillus cereus foodborne intoxications and toxicoinfections are on a rise. Usually, symptoms are self-limiting but occasionally hospitalization is necessary. Severe intoxications with the emetic Bacillus cereus toxin cereulide, which is notably resistant heat and acid during cooking, can cause acute liver failure and encephalopathy. We here present a case series of food poisonings in five immunocompetent adults after ingestion of fried rice balls, which were massively contaminated with Bacillus cereus. The patients developed a broad clinical spectrum, ranging from emesis and diarrhoea to life-threatening acute liver failure and acute tubular necrosis of the kidney in the index patient. In the left-over rice ball, we detected 8 × 106Bacillus cereus colony-forming units/g foodstuff, and cereulide in a concentration of 37 μg/g foodstuff, which is one of the highest cereulide toxin contaminations reported so far from foodborne outbreaks. This report emphasizes the potential biological hazard of contaminated rice meals that are not freshly prepared. It exemplifies the necessity of a multidisciplinary approach in cases of Bacillus cereus associated food poisonings to rapidly establish the diagnosis, to closely monitor critically ill patients, and to provide supportive measures for acute liver failure and—whenever necessary—urgent liver transplantation.

Evaluation of Family Clusters of Children with SARS-CoV-2: Children Do Not Play the Leading Role

Objective The exact role of children in the household transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not clear. In this study, we investigated the role of children with coronavirus disease 2019 (COVID-19) in household transmission by identifying the index patient and contact tracing the household members. Methods A total of 103 children with COVID-19 who attended Marmara University Pendik Training and Research Hospital, Istanbul, between 25th March and 27th May 2020 were included in the study. A family cluster was defined as a group of ≥two confirmed cases of SARS-CoV-2 in the same family, and a household contact (HHC) was defined as any person who had stayed in the same residence. Results In total, 78 family clusters and 307 HHCs belonging to these clusters were screened. In only four clusters was the index case determined to be in the pediatric age group (5.1%). Fathers, mothers, grandparents, and adult siblings were identified as the index cases in 37 (47.4%), 18 (23.0%), 8 (10.2%), and 6 (7.7%) clusters, respectively. Of the 307 HHCs, 88 were in the pediatric age group, and 39 were SARS-CoV-2 RT-PCR positive. Conclusion Our data showed that SARS-CoV-2 is uncommon in children without any history of contact to a RT-PCR test positive patient. The role of children as the index patient in family clusters is 5.1%, and the actual index case is usually an adult individual who has had an outside contact.

Report of a family with three generations of undiagnosed familial nonautoimmune hyperthyroidism

Summary Familial nonautoimmune hyperthyroidism (FNAH) is rare and occurs due to a constitutively activating thyroid-stimulating hormone receptor (TSHR) germline mutation. Forty-one families with FNAH have been reported so far. In the study, 17 of 41 families were not diagnosed with FNAH until three generations or more were described with hyperthyroidism. We report a case of FNAH diagnosed in the third generation. The index patient was diagnosed with hyperthyroidism at age 3. Large fluctuations in thyroid hormone levels occurred during anti-thyroid drug treatment, and he developed a goiter. The patient’s mother had similar history, requiring two surgical interventions and radioiodine treatment. The younger brother of the index patient did not experience large thyroid hormone level fluctuations, nor increased thyroid growth. A heterozygous TSHR c.1357A>G mutation, resulting in a M453V amino acid exchange, was detected in all three patients leading to FNAH diagnosis, with complete genotype–phenotype segregation. Based on Sorting intolerant from tolerant (SIFT) and PolyPhen2 scores of 0.01 and 0.99, respectively, an effect on protein function can be assumed. As illustrated by this family with FNAH, total thyr oidectomy is necessary for patients with nonautoimmune hyperthyroidism. Development of goiter is common, anti-thyroid drug treatment is often difficult, and remission of hyperthyroidism does not occur after discontinuation of anti-thyroid drug treatment. Thus, early diagnosis and appropriate treatment of FNAH is necessary to avoid predictable, unnecessary complications and further surgical interventions. Learning points In the study, 19/42 cases of familial nonautoimmune hyperthyroidism (FNAH), including the reported case, were not diagnosed as FNAH until the third generation; this lead to suboptimal treatment and frequent relapses of nonautoimmune hyperthyroidism (NAH). Detection of thyroid-stimulating hormone receptor (TSHR) mutations in patients with suspected FNAH to confirm diagnosis is essential to ensure proper treatment for the patient and further affected family members. NAH will persist without proper treatment by total thyroidectomy. Symptoms and age of onset may vary between family members All family members with a TSHR germline mutation should be monitored with thyroid-stimulating hormone and for symptoms throughout their lives.

Tuberculosis contact investigation following the stone-in-the-pond principle in the Netherlands – Did adjusted guidelines improve efficiency?

Background In low tuberculosis (TB) incidence countries, contact investigation (CI) requires not missing contacts with TB infection or disease without unnecessarily evaluating non-infected contacts. Aim We assessed whether updated guidelines for the stone-in-the-pond principle and their promotion improved CI practices. Methods This retrospective study used surveillance data to compare CI outcomes before (2011–2013) and after (2014–2016) the guideline update and promotion. Using negative binomial regression and logistic regression models, we compared the number of contacts invited for CI per index patient, the number of CI scaled-up according to the stone-in-the-pond principle, the TB and latent TB infection (LTBI) testing coverage, and yield. Results Pre and post update, 1,703 and 1,489 index patients were reported, 27,187 and 21,056 contacts were eligible for CI, 86% and 89% were tested for TB, and 0.70% and 0.73% were identified with active TB, respectively. Post update, the number of casual contacts invited per index patient decreased statistically significantly (RR = 0.88; 95% CI: 0.79–0.98), TB testing coverage increased (OR = 1.4; 95% CI: 1.2–1.7), and TB yield increased (OR = 2.0; 95% CI: 1.0–3.9). The total LTBI yield increased from 8.8% to 9.8%, with statistically significant increases for casual (OR = 1.2; 95% CI: 1.0–1.5) and community contacts (OR = 2.0; 95% CI: 1.6–3.2). The proportion of CIs appropriately scaled-up to community contacts increased statistically significantly (RR = 1.8; 95% CI: 1.3–2.6). Conclusion This study shows that promoting evidence-based CI guidelines strengthen the efficiency of CIs without jeopardising effectiveness. These findings support CI is an effective TB elimination intervention.

Real-World Outcomes with Fedratinib Therapy in Patients Who Discontinued Ruxolitinib for Primary Myelofibrosis

Introduction: Myelofibrosis (MF) is a rare myeloproliferative disorder in whichdysregulation of the janus kinase 2 (JAK2) hematopoiesis-signaling pathway disruptsbone marrow production of blood cells, leading to anemia, fatigue and splenomegaly.Until recently, the dual JAK1/JAK2 inhibitor, ruxolitinib (RUX), has been the onlyapproved pharmacological therapy for intermediate/high-risk MF. However, manypatients receiving RUX experience a suboptimal response or develop cytopenia, leadingto discontinuation. Fedratinib (FEDR), an oral, selective inhibitor with activity againstwild-type and mutationally activated JAK2 and the receptor tyrosine kinase FLT3, wasapproved in the US in August 2019. The real-world effectiveness of FEDR in the post-RUX setting has not yet been assessed. Aim: To assess the baseline characteristics and survival outcomes among patientsdiagnosed with MF who discontinued RUX and were subsequently treated with FEDR ornot. Methods : Adult US patients who received RUX after an initial diagnosis of primary MF(identified by ICD-9/10-CM codes) were identified using Flatiron Health's nationwideelectronic health record (EHR)-derived database. Patients were stratified by whetherthey subsequently received post-ruxolitinib fedratinib (FEDR group) or not (non-FEDRgroup). The non-FEDR group was further stratified by time of RUX discontinuation(before [non-FEDR subgroup A] and after [non-FEDR subgroup B] US approval of FEDRin August 2019) to enable a contemporaneous comparison with the FEDR group. Indexdate was the start of FEDR therapy in the FEDR group, and last date of RUX therapy inthe non-FEDR groups. Patients were included if they had ≥2 recorded visits in theFlatiron network on or after January 1, 2011- Oct 31, 2020; were aged ≥18 years atindex; had ≥1 months' data before and also after index; and had no record of receivingunclassified clinical study drugs prior to index. Patient demographics and clinical characteristics were assessed at index. Overall survival (OS) was defined as time fromindex until death or censoring, and was assessed by Kaplan-Meier analysis. Landmarksurvival was defined as the proportion of patients who survived at a given point.Association of baseline variables and survival were assessed by Cox proportionalhazards model and p<0.05 was considered statistically significant. Results: Overall, 229 MF patients were evaluated (FEDR group: n=70; non-FEDRgroup: n=159). The median age at index for the FEDR group and non-FEDR group was71.0 and 70.0 years, 55.7% and 50.3% were female, 64.3% and 68.6% were white, andmedian follow-up from index was 7.0 and 6.0 months, respectively. Among patients withEastern Cooperative Oncology Group performance status (ECOG PS) at index, 90.2%(46/51) and 74.3% (84/113) had an ECOG score of 0-1, respectively (Table). Median(range) duration of FEDR therapy in the FEDR group was 3.7 (0-12.2) months; 47.1%(33/70) of patients receiving FEDR initiated therapy with 400 mg FEDR once daily, and21.4% (15/70) initiated with 200 mg FEDR once daily. Median OS was not reached in theFEDR group and was 17 months in the non-FEDR group. Landmark survival in theFEDR and non-FEDR groups was 91.3% and 76.5% at 3 months, and 71.6% and 53.5%at 12 months, respectively. In the non-FEDR subgroup B, the corresponding survivalrates at 3 months and 12 months were 75.0% and 47.9%. The Cox proportional hazardsmodel suggested that being male, 'other' (non-white, non-black/African-American, non-Asian, non-missing) race, Charlson comorbidity index ≥1, ECOG score 2-4, and bodymass index <18.5 kg/m were significantly associated with poorer survival. Conclusions: This real-world analysis demonstrates that these two groups of patientswith primary MF who had received prior RUX had broadly comparable baselinecharacteristics. FEDR appeared to be associated with improved survival up to 1 yearafter index compared with non-FEDR therapy. When the FEDR group and non-FEDR Bsubgroup were compared, the differences in survival rate remained. FEDR may offersubstantially improved survival probability in patients receiving post-ruxolitinib therapy of primary MF in routine clinical practice. Figure 1 Figure 1. Disclosures Passamonti: Novartis: Research Funding, Speakers Bureau; Celgene: Research Funding, Speakers Bureau. Do: Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Lou: Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Chevli: Bristol-Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Abraham: Bristol Myers Squibb: Current Employment.

Uncommon Hpgd Mutation Identified in Familial Erythrocytosis

Familial erythrocytosis (congenital erythrocytosis, FE), is a rare congenital disorder defined by elevated hemoglobin and hematocrit, with different genetic background. Clinically, FE is difficult to distinguish from polycythemia vera（PV）. A 53-years-old male was diagnosed with polycythemia vera without discovery of the JAK2 mutation when he was 31-years-old. The patient's family history revealed his father， a 86-years-old male， also suffered polycythemia for more than 20 years. The pedigree of the Chinese family with erythrocytosis is shown in Figure 1a. The index patient was a 53-years-old male (patient Ⅱ-1, Fig.1), who was hospitalized in our department in 2019 with a 22-year history of elevated red cell mass (RCM). When he was 31-years-old, he initially diagnosed with polycythemia vera without discovery of the JAK2 mutation. Over the last two decades he had irregular phlebotomy almost every two years and seldom prescribed any cytoreductive treatment. At our department he accepted 2 venesections because of Hct level of 64%. Upon medical history taking he reported that his father had suffered by polycythemia with more than 20 years, and were undergoing occasional phlebotomies.The father of the index patient was a 86-years-old male (patient Ⅰ-1, Fig.1), who was diagnosed with polycythemia for more than 20 years and suffered from diabetes. Similar to his son, he did not use any cytoreductive agent, and he had been phlebotomized occasionally. He was chronically treated with low-dose of aspirin . In our department he was treated with erythrocyte separation because of Hct level of 58.9%. He did not report any thrombembolic event. For the last one year of follow-up, the patient continued taking aspirin and her Hct level fluctuated between 54% and 57% while rejected to receive erythrocyte separation again.The elder sister (subject Ⅱ-2 Fig.1) of the index patient did not have any clinical and laboratory signs of elevated RCM as of January 2019, she was a 57-years-old female, who suffered from hypertension and diabetes.The daughter (subject Ⅲ-1 Fig.1) and the nephew (subject Ⅲ-2 Fig.1) of the index patient also did not have any clinical and laboratory signs of elevated RCM as of January 2019. They were subjected to whole exome sequencing (WES), the results revealed four mutations in all three of them, among, a frameshift mutation in the 15-hydroxyprostaglandin dehydrogenase（HPGD） gene is contained in both father and son, which at position c.310_311 ,translating into c.310_311delCT nucleotide mutation and p.L104Afs*3 amino acid mutation. In order to verify the mutation, we adopt the method of Sanger sequencing, then confirmed the presence of the same HPGD frameshift mutation in the index patient and his father. However, The mutation was absent in the elder sister of the index patient, when she was examined by WES and Sanger sequence. The ARHGAP26 mutation is contained in all three of them, but is a type of somatic mutation. The two mutations of VHL and FANCD2 are inexistent in the index patient, but are contained in his father and his elder sister. In conclusion, here we reported the first extensive genetic and clinical study of a family with two members carrying the HPGD gene frameshift mutation. Although functional studies were not made to confirm the pathogenic role of this mutation, the type and location of the mutation suggest that it can be the cause of the erythrocytosis observed in two patients. This study demonstrated the utility of the WES/NGS as the tool for identification of mutations in congenital erythrocytosis as well as helps to discovery these rare erythrocytosis-associated genes. The role and pathogenesis in haematopathy of HPGD mutation has been seriously underestimated, which is deserved to be explored in depth. Acknowledgment:The research was supported by the Public Technology Application Research Program of Zhejiang, China (LGF21H080003), the Key Project of Jinhua Science and Technology Plan, China (2020XG-29 and 2020-3-011), the Academician Workstation of the Fourth Affiliated Hospital of the Zhejiang University School of Medicine (2019-2024), the Key Medical Discipline of Yiwu, China (Hematology, 2018-2020) and the Key Medical Discipline of Jinhua, China (Hematology, 2019-2021). Correspondence to: Dr Jian Huang, Department of Hematology, The Fourth Affiliated Hospital of Zhejiang University School of Medicine. N1 Shangcheng Road. Yiwu, Zhejiang, Peoples R China. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Hypercholesterolemia in children and adolescents: focus on the familial variant

Familial hypercholesterolemia is characterized by a significant increase in serum low-density lipoprotein cholesterol concentration, which even in the absence of other risk factors leads to the development of atherosclerotic vascular lesions beginning in childhood. With significant prevalence in the population, familial hypercholesterolemia is rarely diagnosed in time due to the Long absence of clinical manifestations. Today the urgent task is to develop and implement programs of primary detection of familial hypercholesterolemia in children and adolescents. Early detection of patients with familial hypercholesterolemia and timely initiation of adequate lipid-lowering therapy will curb the rate of atherosclerosis progression, which will significantly reduce disability and mortality from cardiovascular diseases in older age groups. There are four types of screening: cascade, targeted, opportunistic and universal. Cascade screening is currently considered the most effective and cost-effective way to identify new patients with familial hypercholesterolemia among relatives of an index patient, the patient with the established diagnosis. Targeted screening is based on searching for individuals with familial hypercholesterolemia among groups of patients with the early development of atherosclerotic vascular lesions, for example, in cardiology or neurology hospitals. Opportunistic screening is a non-systematic, sporadic determination of cholesterol levels in patients seeking medical care for any reason. It is most applicable in primary care health care settings. Universal screening is a mass screening of certain age groups and is a highly effective way of early diagnosis, especially in combination with reverse cascade screening of parents, siblings, and other relatives of the index patient. Implementation of programs of early childhood detection of familial hypercholesterolemia, setting up systems of adequate routing of patients, timely prescription of effective lipid-lowering therapy will contribute to health preservation and prolongation of working age, development, and preservation of labor potential of the country.