[The punctum plug as an option for treating retrograde air flow from the lacrimal sac].

The causes of keratoconjunctivitis sicca are multifarious. Major causes include eyelid anomalies, Sjögren's disease, injuries, radiation or mucin deficiency. In our case, nasal positive airway pressure due to muscular dystrophy is described as another possible cause.

A 32-year-old male patient with advanced Duchenne muscular dystrophy requires nasal continuous positive airway pressure ventilation due to loss of the auxiliary respiratory muscles. The patient presented because permanent air flow from the lower right lacrimal point resulted in epiphora and keratoconjunctivitis sicca on the right side.

We reversibly occluded the lower lacrimal duct with a punctum plug flow regulator. The lacrimal flow regulator is available in two sizes, 0.8 and 0.9 mm, and is designed to be inserted into the punctal aperture. The soft silicone plug is delivered with a disposable dilator and can be used on an outpatient basis. It is actually used for punctal occlusion in patients with chronic dry eye syndrome and regulates the flow of lacrimal fluid. After insertion of a 0.9 mm punctal plug, the patient reported marked improvement of the findings, which was confirmed in a follow-up after 4 and 8 weeks. On a visual analog scale of 1 to 10, the subjective status was given a rating of 8.

By occluding the right lower lacrimal point with a punctal plug, we were able to markedly reduce the unpleasant retrograde air flow and the subjective complaints of the patient with nasal continuous positive airway pressure ventilation.

The causes of

    keratoconjunctivitis sicca
    DIAGNOSIS

 are multifarious. Major causes include

    eyelid anomalies
    SYMPTOMS

,

    Sjögren's disease
    DIAGNOSIS

,

    injuries
    SYMPTOMS

,

    radiation
    SYMPTOMS

 or

    mucin deficiency
    BIOCHEMICAL

. In our case,

    nasal positive airway pressure
    MEDICATION

 due to

    muscular dystrophy
    SYMPTOMS

 is described as another possible cause.

A

    32-year-old
    AGE

    male
    GENDER

 patient with

    advanced Duchenne muscular dystrophy
    DIAGNOSIS

 requires

    nasal continuous positive airway pressure ventilation
    MEDICATION

 due to

    loss of the auxiliary respiratory muscles
    SYMPTOMS

. The patient presented because

    permanent air flow from the lower right lacrimal point
    SYMPTOMS

 resulted in

    epiphora
    SYMPTOMS

 and

    keratoconjunctivitis sicca on the right side
    SYMPTOMS

.

We

    reversibly occluded the lower lacrimal duct with a punctum plug flow regulator
    MEDICATION

. The

    lacrimal flow regulator
    MEDICATION

 is available in two sizes,

    0.8 and 0.9 mm
    MEDICATION

, and is designed to be

    inserted into the punctal aperture
    MEDICATION

. The

    soft silicone plug is delivered with a disposable dilator
    MEDICATION

 and can be used on an outpatient basis. It is actually used for

    punctal occlusion
    MEDICATION

 in patients with

    chronic dry eye syndrome
    DIAGNOSIS

 and

    regulates the flow of lacrimal fluid
    BIOCHEMICAL

. After

    insertion of a 0.9 mm punctal plug
    MEDICATION

, the patient reported

    marked improvement of the findings
    SYMPTOMS

, which was confirmed in a

    follow-up
    PARACLINICAL

 after 4 and 8 weeks. On a visual analog scale of 1 to 10, the subjective status was given a rating of 8.

By

    occluding the right lower lacrimal point with a punctal plug
    MEDICATION

, we were able to

    markedly reduce the unpleasant retrograde air flow and the subjective complaints
    SYMPTOMS

 of the patient with

    nasal continuous positive airway pressure ventilation
    MEDICATION

.

keratoconjunctivitis sicca
Sjögren's disease
advanced Duchenne muscular dystrophy
chronic dry eye syndrome

mucin deficiency
regulates the flow of lacrimal fluid


Birth after transfer of frozen-thawed vitrified biopsied blastocysts.

To present a case describing the birth of a healthy female after the replacement of vitrified biopsied embryos after Preimplantation Genetic Diagnosis.

A descriptive case report of a single patient.

Our patient carrier of an X-linked disease became pregnant and as a result a healthy girl was born.

This report shows that blastocysts obtained from biopsied embryos can be successfully cryopreserved by a simple, secure and low-cost vitrification method using a Hemi-straw support.

To present a case describing the birth of a healthy

    female
    GENDER

 after the

    replacement of vitrified biopsied embryos
    MEDICATION

 after

    Preimplantation Genetic Diagnosis
    MEDICATION

.

Our patient

    carrier of an X-linked disease
    GENETICS

 became

    pregnant
    MEDICATION

 and as a result a healthy girl was born.

This report shows that

    blastocysts
    MEDICATION

 obtained from

    biopsied embryos
    MICROSCOPIC

 can be successfully

    cryopreserved
    MEDICATION

 by a simple,

    secure and low-cost vitrification method using a Hemi-straw support
    MEDICATION

.


Rapid prenatal diagnosis of Duchenne muscular dystrophy with gene duplications by ion-pair reversed-phase high-performance liquid chromatography coupled with competitive multiplex polymerase chain reaction strategy.

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are caused by various mutations in the dystrophin gene. Rapid prenatal diagnosis of DMD with gene duplications is difficult due to limitation in gene dosage determination and the requirement for a known disease-causing mutation in the pedigree to achieve a rapid and accurate diagnosis. We report, here, a case with rapid prenatal diagnosis of DMD-affected male with gene duplications in the absence of a known disease-causing variation in the pedigree by using ion-pair reversed-phase high-performance liquid chromatography (IP-RP-HPLC) coupled with competitive multiplex polymerase chain reaction (PCR) protocol. In cases with clinical diagnosis of DMD/BMD, this test should identify greater than 92% of disease-causing DNA variants. The postnatal genetic diagnosis of this case and the same disease-causing mutations subsequently identified in other members of the pedigree confirmed the accuracy of competitive multiplex PCR/IP-RP-HPLC assay in direct prenatal diagnosis of DMD.

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 and

    Becker muscular dystrophy (BMD)
    DIAGNOSIS

 are caused by

    various mutations in the dystrophin gene
    GENETICS

.

    Rapid prenatal diagnosis
    PARACLINICAL

 of

    DMD
    DIAGNOSIS

 with

    gene duplications
    GENETICS

 is difficult due to limitation in

    gene dosage determination
    PARACLINICAL

 and the requirement for a known

    disease-causing mutation
    GENETICS

 in the pedigree to achieve a rapid and accurate diagnosis. We report, here, a case with

    rapid prenatal diagnosis
    PARACLINICAL

 of

    DMD
    DIAGNOSIS

-affected

    male
    GENDER

 with

    gene duplications
    GENETICS

 in the

    absence of a known disease-causing variation in the pedigree
    NEG_FINDINGS

 by using

    ion-pair reversed-phase high-performance liquid chromatography (IP-RP-HPLC) coupled with competitive multiplex polymerase chain reaction (PCR) protocol
    PARACLINICAL

. In cases with clinical diagnosis of

    DMD/BMD
    DIAGNOSIS

, this test should identify greater than 92% of

    disease-causing DNA variants
    GENETICS

. The

    postnatal genetic diagnosis
    PARACLINICAL

 of this case and the

    same disease-causing mutations subsequently identified in other members of the pedigree
    FAMILY

 confirmed the accuracy of

    competitive multiplex PCR/IP-RP-HPLC assay
    PARACLINICAL

 in

    direct prenatal diagnosis
    PARACLINICAL

 of

    DMD
    DIAGNOSIS

.

Duchenne muscular dystrophy (DMD)
Becker muscular dystrophy (BMD)
DMD
DMD
DMD/BMD
DMD


Insights into extensive deletions around the XK locus associated with McLeod phenotype and characterization of two novel cases.

The McLeod phenotype is derived from various forms of XK gene defects that result in the absence of XK protein, and is defined hematologically by the absence of Kx antigen, weakening of Kell system antigens, and red cell acanthocytosis. Individuals with the McLeod phenotype usually develop late-onset neuromuscular abnormalities known as the McLeod syndrome (MLS). MLS is an X-linked multi-system disorder caused by absence of XK alone, or when the disorder is caused by large deletions, it may be accompanied with Duchenne muscular dystrophy (DMD), chronic granulomatous disease (CYBB), retinitis pigmentosa (RPGR), and ornithine transcarbamylase deficiency (OTC). XK defects derived from a large deletion at the XK locus (Xp21.1) have not been characterized at the molecular level. In this study, the deletion breakpoints of two novel cases of McLeod phenotype with extensive deletions are reported. Case 1 has greater than 1.12 million base-pairs (mb) deletion around the XK locus with 7 genes affected. Case 2 has greater than 5.65 mb deletion from TCTE1L to DMD encompassing 20 genes. Phylogenetic analyses demonstrated that DMD, XK and CYBB have close paralogs, some of which may partially substitute for the functions of their counterparts. The loci around XK are highly conserved from fish to human; however, the disorders are probably specific to mammals, and may coincide with the translocation of the loci to the X chromosome after the speciation in birds. The non-synonymous to synonymous nucleotide substitution rate ratio (omega=dN/dS) in these genes was examined. CYBB and RPGR show evidence of positive selection, whereas DMD, XK and OTC are subject to selective constraint.

The

    McLeod phenotype
    DIAGNOSIS

 is derived from various forms of

    XK gene defects
    GENETICS

 that result in the

    absence of XK protein
    BIOCHEMICAL

, and is defined hematologically by the

    absence of Kx antigen
    BIOCHEMICAL

,

    weakening of Kell system antigens
    BIOCHEMICAL

, and

    red cell acanthocytosis
    BIOCHEMICAL

. Individuals with the

    McLeod
    DIAGNOSIS

 phenotype usually develop

    late-onset neuromuscular abnormalities
    SYMPTOMS

 known as the

    McLeod syndrome (MLS)
    DIAGNOSIS

.

    MLS
    DIAGNOSIS

 is an

    X-linked
    GENETICS

    multi-system disorder
    DIAGNOSIS

 caused by

    absence of XK alone
    GENETICS

, or when the disorder is caused by

    large deletions
    GENETICS

, it may be accompanied with

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

,

    chronic granulomatous disease (CYBB)
    DIAGNOSIS

,

    retinitis pigmentosa (RPGR)
    DIAGNOSIS

, and

    ornithine transcarbamylase deficiency (OTC)
    BIOCHEMICAL

.

    XK defects
    GENETICS

 derived from a

    large deletion at the XK locus (Xp21.1)
    GENETICS

 have not been characterized at the molecular level. In this study, the deletion breakpoints of two novel cases of

    McLeod phenotype
    DIAGNOSIS

 with

    extensive deletions
    GENETICS

 are reported. Case 1 has

    greater than 1.12 million base-pairs (mb) deletion around the XK locus with 7 genes affected
    GENETICS

. Case 2 has

    greater than 5.65 mb deletion from TCTE1L to DMD encompassing 20 genes
    GENETICS

.

    Phylogenetic analyses
    PARACLINICAL

 demonstrated that

    DMD, XK and CYBB have close paralogs
    GENETICS

, some of which may partially substitute for the functions of their counterparts.

    The loci around XK are highly conserved
    GENETICS

 from fish to human; however, the disorders are probably specific to mammals, and may coincide with the

    translocation of the loci to the X chromosome
    GENETICS

 after the speciation in birds. The

    non-synonymous to synonymous nucleotide substitution rate ratio (omega=dN/dS) in these genes
    GENETICS

 was examined.

    CYBB and RPGR
    GENETICS

 show evidence of

    positive selection
    GENETICS

, whereas

    DMD
    GENETICS

,

    XK and OTC
    GENETICS

 are subject to selective constraint.

McLeod phenotype
McLeod
McLeod syndrome (MLS)
MLS
multi-system disorder
Duchenne muscular dystrophy (DMD)
chronic granulomatous disease (CYBB)
retinitis pigmentosa (RPGR)
McLeod phenotype


Deletion of exon 16 of the dystrophin gene is not associated with disease.

The DNA of a male harbored a deletion of exon 16 as well as most of introns 15 and 16 of the dystrophin gene. The person was completely healthy, with universal normal muscle strength, and normal muscle histology and creatine kinase levels. The deletion was also present in DNA from a muscle biopsy, excluding mosaicism as an explanation for the phenotype. We conclude that the protein segment encoded by exon 16 of the dystrophin gene is of no importance for the essential function of dystrophin. The findings suggest that even large gene re-arrangements of the dystrophin gene may not always be disease-causing, and caution a diagnosis of dystrophinopathy in sporadic cases of single exon in-frame deletions.

The DNA of a

    male
    GENDER

 harbored a

    deletion of exon 16 as well as most of introns 15 and 16 of the dystrophin gene
    GENETICS

. The person was completely healthy, with

    universal normal muscle strength
    NEG_FINDINGS

, and

    normal muscle histology and creatine kinase levels
    NEG_FINDINGS

. The deletion was also present in

    DNA from a muscle biopsy
    PARACLINICAL

,

    excluding mosaicism
    NEG_FINDINGS

 as an explanation for the phenotype. We conclude that

    the protein segment encoded by exon 16 of the dystrophin gene
    GENETICS

    is of no importance for the essential function of dystrophin
    NEG_FINDINGS

. The findings suggest that even

    large gene re-arrangements of the dystrophin gene
    GENETICS

 may not always be disease-causing, and caution a diagnosis of

    dystrophinopathy
    DIAGNOSIS

 in sporadic cases of

    single exon in-frame deletions
    GENETICS

.


Medulloblastoma in a child with Duchenne muscular dystrophy.

A 7-year-old boy diagnosed with Duchenne muscular dystrophy (DMD) presented with clinical features of raised intracranial tension. A CT scan revealed an enhancing vermian mass extending on to the fourth ventricle, which was excised and reported to be medulloblastoma. The patient was treated with craniospinal radiotherapy but progressed after 6 months.

Neoplasms associated with DMD are rare and the present case may well be the first one with medulloblastoma. Interestingly, all neoplasms associated with DMD reported so far have been round cell tumors, which may lead to insights into their possible molecular associations.

A

    7-year-old
    AGE

    boy
    GENDER

 diagnosed with

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 presented with

    clinical features of raised intracranial tension
    SYMPTOMS

. A

    CT scan
    PARACLINICAL

 revealed an

    enhancing vermian mass extending on to the fourth ventricle
    SYMPTOMS

, which was excised and reported to be

    medulloblastoma
    DIAGNOSIS

. The patient was treated with

    craniospinal radiotherapy
    MEDICATION

 but progressed after 6 months.

    Neoplasms
    DIAGNOSIS

 associated with

    DMD
    DIAGNOSIS

 are rare and the present case may well be the first one with

    medulloblastoma
    DIAGNOSIS

. Interestingly, all

    neoplasms
    DIAGNOSIS

 associated with

    DMD
    DIAGNOSIS

 reported so far have been

    round cell tumors
    DIAGNOSIS

, which may lead to insights into their possible molecular associations.

Duchenne muscular dystrophy (DMD)
medulloblastoma
Neoplasms
DMD
medulloblastoma
neoplasms
DMD
round cell tumors


Tandem duplication of DMD exon 18 associated with epilepsy, macroglossia, and endocrinologic abnormalities.

We describe a patient with Duchenne muscular dystrophy (DMD) who additionally suffered from intractable seizures, severe mental retardation, and a marked macroglossia. He also had endocrinologic abnormalities consisting of growth hormone deficiency, delayed puberty, and adrenal hypoplasia. We detected a duplication of DMD exon 18 and flanking introns that caused a frame-shift and was not removed by corrective splicing. A coincident mutation in the FKRP gene was excluded by direct sequencing. Complex DNA rearrangements, deletions, and duplications >100 kb were excluded through microarray-comparative genomic hybridization (CGH), although we were not able to exclude a second coincident mutation with certainty. In conclusion, we present a case of DMD that conflicts with current understanding of genotype-phenotype relations and discuss putative pathogenetic mechanisms for this uncommon phenotype.

We describe a patient with

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 who additionally suffered from

    intractable seizures
    SYMPTOMS

,

    severe mental retardation
    SYMPTOMS

, and a

    marked macroglossia
    SYMPTOMS

.

    He
    GENDER

 also had

    endocrinologic abnormalities
    SYMPTOMS

 consisting of

    growth hormone deficiency
    BIOCHEMICAL

,

    delayed puberty
    SYMPTOMS

, and

    adrenal hypoplasia
    SYMPTOMS

. We detected a

    duplication of DMD exon 18 and flanking introns that caused a frame-shift and was not removed by corrective splicing
    GENETICS

.

    A coincident mutation in the FKRP gene was excluded by direct sequencing
    NEG_FINDINGS

.

    Complex DNA rearrangements, deletions, and duplications >100 kb were excluded
    NEG_FINDINGS

 through

    microarray-comparative genomic hybridization (CGH)
    NEG_FINDINGS

, although we

    were not able to exclude a second coincident mutation
    NEG_FINDINGS

 with certainty. In conclusion, we present a case of

    DMD
    DIAGNOSIS

 that conflicts with current understanding of genotype-phenotype relations and discuss putative pathogenetic mechanisms for this uncommon phenotype.

intractable seizures
severe mental retardation
marked macroglossia
endocrinologic abnormalities
delayed puberty
adrenal hypoplasia


Cardiomyopathy with a unique finding of bicuspid aortic valve in Becker's muscular dystrophy.

We describe a patient with Becker's muscular dystrophy and cardiac failure caused by a combination of dilated cardiomyopathy and congenital bicuspid aortic valve with aortic stenosis. There is no documented association between congenital valve disease and human dystrophinopathies, and to our knowledge, this is the first reported case.

We describe a patient with

    Becker's muscular dystrophy
    DIAGNOSIS

 and

    cardiac failure
    SYMPTOMS

 caused by a combination of

    dilated cardiomyopathy
    SYMPTOMS

 and

    congenital bicuspid aortic valve with aortic stenosis
    SYMPTOMS

. There is no documented association between

    congenital valve disease
    DIAGNOSIS

 and

    human dystrophinopathies
    DIAGNOSIS

, and to our knowledge, this is the first reported case.

Becker's muscular dystrophy
congenital valve disease
human dystrophinopathies


Unexplained acidosis of malnutrition: a study by ion-exchange chromatography/mass spectrometry.

Keto-acidosis is usually associated with uncontrolled diabetes and typically poses few diagnostic problems when presenting as hyperglycaemia, metabolic acidosis and a high anion gap. An emaciated patient suffering from Duchenne Muscular Dystrophy and volume depletion presented with acidosis of unknown origin. Preliminary investigations appeared to rule out lactic acidosis, diabetic keto-acidosis and acidosis due to base loss. We have previously reported a technique utilizing liquid chromatography coupled to mass spectrometry (LC-MS) which can be used to characterize the underlying aetiology of acidosis and applied it to ultrafiltrate derived from a blood sample taken from this patient. The anion profile obtained on the chromatogram showed elevated levels of acetoacetate and hydroxybutyrate but no evidence of lactic acidosis, nor was the profile typical of that seen in 'unexplained' acidosis. We concluded that the patient was suffering from keto-acidosis associated with starvation and dehydration, the biochemical features being obscured by both the patient's chronic malnutrition and minimal muscle mass. A combination of enteral feeding and rehydration led to prompt resolution of the patient's metabolic acidosis.

    Keto-acidosis
    DIAGNOSIS

 is usually associated with

    uncontrolled diabetes
    DIAGNOSIS

 and typically poses few diagnostic problems when presenting as

    hyperglycaemia
    BIOCHEMICAL

,

    metabolic acidosis
    BIOCHEMICAL

 and a

    high anion gap
    BIOCHEMICAL

. An

    emaciated
    SYMPTOMS

 patient suffering from

    Duchenne Muscular Dystrophy
    DIAGNOSIS

 and

    volume depletion
    SYMPTOMS

 presented with

    acidosis of unknown origin
    SYMPTOMS

. Preliminary investigations appeared to

    rule out lactic acidosis
    NEG_FINDINGS

,

    diabetic keto-acidosis
    NEG_FINDINGS

 and

    acidosis due to base loss
    BIOCHEMICAL

. We have previously reported a technique utilizing

    liquid chromatography coupled to mass spectrometry (LC-MS)
    PARACLINICAL

 which can be used to characterize the underlying aetiology of

    acidosis
    BIOCHEMICAL

 and applied it to

    ultrafiltrate derived from a blood sample
    PARACLINICAL

 taken from this patient. The

    anion profile obtained on the chromatogram
    PARACLINICAL

 showed

    elevated levels of acetoacetate and hydroxybutyrate
    BIOCHEMICAL

 but

    no evidence of lactic acidosis
    NEG_FINDINGS

, nor was

    the profile typical of that seen in 'unexplained' acidosis
    SYMPTOMS

. We concluded that the patient was suffering from

    keto-acidosis
    DIAGNOSIS

 associated with

    starvation
    SYMPTOMS

 and

    dehydration
    SYMPTOMS

, the biochemical features being obscured by both the patient's

    chronic malnutrition
    SYMPTOMS

 and

    minimal muscle mass
    SYMPTOMS

. A

    combination of enteral feeding and rehydration
    MEDICATION

 led to

    prompt resolution of the patient's metabolic acidosis
    SYMPTOMS

.

Keto-acidosis
uncontrolled diabetes
Duchenne Muscular Dystrophy
keto-acidosis

rule out lactic acidosis
diabetic keto-acidosis
no evidence of lactic acidosis


Non-compaction on autopsy in Duchenne muscular dystrophy.

Left ventricular hypertrabeculation (LVHT)/non-compaction is frequently associated with neuromuscular disorders. Recently, LVHT has been detected in a 28-year patient with Duchenne muscular dystrophy. Here, the patho-anatomic findings of this patient are presented, which showed LVHT located within in the apex and the anterior and lateral wall, being the most demanded segments during systole. The septum and the left ventricular outflow tract were not involved. The patho-anatomic specimen also showed aberrant bands and false tendons, a frequent finding in hearts with LVHT. The patho-anatomic findings were in line with those of LVHT patients with or without neuromuscular disorders.

    Left ventricular hypertrabeculation (LVHT)/non-compaction
    SYMPTOMS

 is frequently associated with

    neuromuscular disorders
    DIAGNOSIS

. Recently,

    LVHT
    DIAGNOSIS

 has been detected in a

    28-year
    AGE

 patient with

    Duchenne muscular dystrophy
    DIAGNOSIS

. Here, the

    patho-
    PARACLINICAL

anatomic findings of this patient are presented, which showed

    LVHT located within in the apex and the anterior and lateral wall, being the most demanded segments during systole
    SYMPTOMS

.

    The septum and the left ventricular outflow tract were not involved
    NEG_FINDINGS

. The

    patho-anatomic specimen
    PARACLINICAL

 also showed

    aberrant bands and false tendons
    SYMPTOMS

, a frequent finding in hearts with

    LVHT
    SYMPTOMS

. The patho-anatomic findings were in line with those of

    LVHT
    DIAGNOSIS

 patients with or without

    neuromuscular disorders
    DIAGNOSIS

.

neuromuscular disorders
LVHT
Duchenne muscular dystrophy
LVHT
neuromuscular disorders


[Anesthesia with sevoflurane for tonsillectomy in a boy with Duchenne muscular dystrophy].

A 6-year-old boy with Duchenne muscular dystrophy (DMD) and foreseen difficult tracheal intubation underwent tonsillectomy under general inhaled anesthesia with sevoflurane. No neuromuscular blockers were administered and no perioperative complications emerged. In spite of advances in genetic diagnosis there continue to be patients with DMD because of spontaneous mutation of the dystrophin gene. Late detection leaves them vulnerable to administration of drugs like succinylcholine that can trigger fatal reactions involving hyperpotassemia, rhabdomyolysis, and malignant hyperthermia. Total intravenous anesthesia seems the best way to provide general anesthesia for a patient with DMD. Inhaled anesthesia is an alternative. Although halogenated agents can lead to rhabdomyolysis and malignant hyperthermia, the frequency seems low if we bear in mind that the use of sevoflurane is widespread in pediatrics. In this case sevoflurane induction facilitated safe tracheal intubation.

A

    6-year-old
    AGE

    boy
    GENDER

 with

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 and

    foreseen difficult tracheal intubation
    NEG_FINDINGS

 underwent

    tonsillectomy
    MEDICATION

 under

    general inhaled anesthesia with sevoflurane
    MEDICATION

.

    No neuromuscular blockers were administered
    NEG_FINDINGS

 and

    no perioperative complications
    NEG_FINDINGS

 emerged. In spite of advances in genetic diagnosis there continue to be patients with

    DMD
    DIAGNOSIS

 because of

    spontaneous mutation of the dystrophin gene
    GENETICS

. Late detection leaves them vulnerable to administration of drugs like

    succinylcholine
    MEDICATION

 that can trigger

    fatal reactions
    SYMPTOMS

 involving

    hyperpotassemia
    BIOCHEMICAL

,

    rhabdomyolysis
    SYMPTOMS

, and

    malignant hyperthermia
    SYMPTOMS

.

    Total intravenous anesthesia
    MEDICATION

 seems the best way to provide

    general anesthesia
    MEDICATION

 for a patient with

    DMD
    DIAGNOSIS

.

    Inhaled anesthesia
    MEDICATION

 is an alternative. Although

    halogenated agents
    MEDICATION

 can lead to

    rhabdomyolysis
    DIAGNOSIS

 and

    malignant hyperthermia
    DIAGNOSIS

, the frequency seems low if we bear in mind that the use of

    sevoflurane
    MEDICATION

 is widespread in

    pediatrics
    AGE

. In this case

    sevoflurane induction
    MEDICATION

 facilitated

    safe tracheal intubation
    MEDICATION

.

Duchenne muscular dystrophy (DMD)
DMD
DMD
rhabdomyolysis
malignant hyperthermia

fatal reactions
rhabdomyolysis
malignant hyperthermia


Home accessibility and adaptive equipment in duchenne muscular dystrophy: a case report.

This case report describes the history of a 26-year-old man with Duchenne muscular dystrophy. The report includes descriptions of the natural progression of his physical disability and the adaptive equipment and home modifications that were used to maintain independence.

The transition from childhood to adulthood for individuals with Duchenne muscular dystrophy requires a physical therapy care plan that focuses on the use of assistive technology to maintain independence in mobility and to minimize or to facilitate caregiver assistance.

Disability in Duchenne muscular dystrophy can be minimized by the use of properly fitting and functioning equipment. Assisting the family with available equipment options, documentation of medical necessity, and coordination of services are all important tasks for the physical therapist in carrying out a comprehensive plan of care.

This case report describes the history of a

    26-year-old
    AGE

    man
    GENDER

 with

    Duchenne muscular dystrophy
    DIAGNOSIS

. The report includes descriptions of the natural progression of his

    physical disability
    SYMPTOMS

 and the

    adaptive equipment and home modifications
    MEDICATION

 that were used to maintain independence.

The transition from

    childhood
    AGE

    to adulthood
    AGE

 for individuals with

    Duchenne muscular dystrophy
    DIAGNOSIS

 requires a

    physical therapy care plan
    MEDICATION

 that focuses on the

    use of assistive technology to maintain independence in mobility and to minimize or to facilitate caregiver assistance
    MEDICATION

.

Disability in

    Duchenne muscular dystrophy
    DIAGNOSIS

 can be minimized by the use of

    properly fitting and functioning equipment
    MEDICATION

. Assisting the family with available equipment options, documentation of medical necessity, and coordination of services are all important tasks for the

    physical therapist
    PARACLINICAL

 in carrying out a

    comprehensive plan of care
    MEDICATION

.

Duchenne muscular dystrophy
Duchenne muscular dystrophy
Duchenne muscular dystrophy


Spinal fusion surgery in children with non-idiopathic scoliosis: is there a need for routine postoperative ventilation?

The perioperative management of children with non-idiopathic scoliosis undergoing spinal deformity surgery has not been standardized and the current practice is to routinely ventilate these patients in the postoperative period. This study reports the experience from a single institution and evaluates the need and reasons for postoperative ventilation. Details of ventilated patients are presented.

All patients undergoing spinal fusion surgery for non-idiopathic scoliosis were recorded prospectively (2003-4). Patients were anaesthetized according to a standardized technique. Physical characteristics, cardiopulmonary function, intraoperative blood loss and fluid requirement, postoperative need for ventilation and all perioperative adverse events were recorded on a computer database.

A total of 76.2% of patients were safely extubated at the end of surgery without any further complications or need for re-ventilation; 23.8% of patients required postoperative ventilation with half of the cases being planned before operation and 40% of all patients with Duchenne muscular dystrophy (DMD) required postoperative ventilation. There were no specific factors that could predict the need for postoperative ventilation, although an increased tendency for children with DMD and those with a preoperative forced vital capacity <30% towards requiring postoperative ventilation was observed.

Early extubation can be safely performed after spinal deformity surgery for non-idiopathic scoliosis. The use of short-acting anaesthetics, drugs to reduce blood loss, experienced spinal anaesthetists and the availability of intensive care support are all essential for a good outcome in patients with neuromuscular disease and cardiopulmonary co-morbidity.

The

    perioperative management
    MEDICATION

 of

    children
    AGE

 with

    non-idiopathic scoliosis
    DIAGNOSIS

 undergoing

    spinal deformity surgery
    MEDICATION

 has not been standardized and the current practice is to

    routinely ventilate
    MEDICATION

 these patients in the

    postoperative period
    MEDICATION

. This study reports the experience from a single institution and evaluates the need and reasons for

    postoperative ventilation
    MEDICATION

. Details of

    ventilated
    MEDICATION

 patients are presented.

All patients undergoing

    spinal fusion surgery
    MEDICATION

 for

    non-idiopathic scoliosis
    DIAGNOSIS

 were recorded prospectively (2003-4). Patients were

    anaesthetized
    MEDICATION

 according to a standardized technique. Physical characteristics,

    cardiopulmonary function
    PARACLINICAL

,

    intraoperative blood loss and fluid requirement
    PARACLINICAL

,

    postoperative need for ventilation
    MEDICATION

 and all

    perioperative adverse events
    SYMPTOMS

 were recorded on a computer database.

A total of 76.2% of patients were

    safely extubated at the end of surgery
    MEDICATION

    without any further complications or need for re-ventilation
    NEG_FINDINGS

; 23.8% of patients required

    postoperative ventilation
    MEDICATION

 with half of the cases being planned before

    operation
    MEDICATION

 and 40% of all patients with

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 required

    postoperative ventilation
    MEDICATION

. There were no specific factors that could predict the need for

    postoperative ventilation
    MEDICATION

, although an increased tendency for

    children
    AGE

 with

    DMD
    DIAGNOSIS

 and those with a

    preoperative forced vital capacity <30%
    SYMPTOMS

 towards

    requiring postoperative ventilation
    MEDICATION

 was observed.

    Early extubation
    MEDICATION

 can be safely performed after

    spinal deformity surgery
    MEDICATION

 for

    non-idiopathic scoliosis
    DIAGNOSIS

. The

    use of short-acting anaesthetics
    MEDICATION

,

    drugs to reduce blood loss
    MEDICATION

,

    experienced spinal anaesthetists
    PARACLINICAL

 and the availability of

    intensive care support
    MEDICATION

 are all essential for a good outcome in patients with

    neuromuscular disease
    DIAGNOSIS

 and

    cardiopulmonary co-morbidity
    SYMPTOMS

.

perioperative management
spinal deformity surgery
routinely ventilate
postoperative period
postoperative ventilation
ventilated
spinal fusion surgery
anaesthetized
postoperative need for ventilation
safely extubated at the end of surgery
postoperative ventilation
operation
postoperative ventilation
postoperative ventilation
requiring postoperative ventilation
Early extubation
spinal deformity surgery
use of short-acting anaesthetics
drugs to reduce blood loss
intensive care support

non-idiopathic scoliosis
non-idiopathic scoliosis
Duchenne muscular dystrophy (DMD)
DMD
non-idiopathic scoliosis
neuromuscular disease

perioperative adverse events
preoperative forced vital capacity <30%
cardiopulmonary co-morbidity


A nonsense mutation-created intraexonic splice site is active in the lymphocytes, but not in the skeletal muscle of a DMD patient.

Production of semi-functional dystrophin mRNA from the dystrophin gene encoding a premature stop codon has been shown to modify the severe phenotype of Duchenne muscular dystrophy (DMD). In this study, we report the tissue-specific production of semi-functional dystrophin mRNA via activation of a nonsense mutation-created intraexonic splice acceptor site. In a DMD patient a novel nonsense mutation was identified in exon 42. In his lymphocytes semi-functional dystrophin mRNA with a 63-nucleotide deletion in exon 42 (dys-63) was found to be produced. In vitro splicing assay using hybrid minigenes disclosed that the mutation-created intraexonic splice acceptor site was activated. In his skeletal muscle cells, however, only the authentically spliced dystrophin mRNA was found. This finding identifies the modulation of the splicing of muscle dystrophin mRNA in cases of DMD as a potential target for therapeutic strategies to generate a milder phenotype for this disease.

Production of

    semi-functional dystrophin mRNA from the dystrophin gene encoding a premature stop codon
    GENETICS

 has been shown to modify the severe phenotype of

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

. In this study, we report the tissue-specific production of

    semi-functional dystrophin mRNA
    MICROSCOPIC

 via

    activation of a nonsense mutation-created intraexonic splice acceptor site
    GENETICS

. In a

    DMD
    DIAGNOSIS

 patient a

    novel nonsense mutation was identified in exon 42
    GENETICS

. In his lymphocytes

    semi-functional dystrophin mRNA with a 63-nucleotide deletion in exon 42 (dys-63)
    GENETICS

 was found to be produced.

    In vitro splicing assay using hybrid minigenes
    PARACLINICAL

 disclosed that

    the mutation-created intraexonic splice acceptor site was activated
    GENETICS

.

    In his skeletal muscle cells
    MICROSCOPIC

, however,

    only the authentically spliced dystrophin mRNA was found
    MICROSCOPIC

. This finding identifies the modulation of the splicing of

    muscle dystrophin mRNA
    GENETICS

 in cases of

    DMD
    DIAGNOSIS

 as a potential target for therapeutic strategies to generate a milder phenotype for this disease.

Duchenne muscular dystrophy (DMD)
DMD
DMD


Outpatient continuous inotrope infusion as an adjunct to heart failure therapy in Duchenne muscular dystrophy.

We report the use of continuous intravenous inotrope infusion as a palliative management strategy for the treatment of symptomatic, refractory, end stage cardiac dysfunction in patients with Duchenne muscular dystrophy. Milrinone and/or dobutamine administered by continuous intravenous infusion provided symptomatic and objective cardiovascular improvement up to 30 months in 3 individuals with Duchenne muscular dystrophy and severe dilated cardiomyopathy. Continuous inotrope infusion should be considered a practical treatment strategy for end stage cardiac dysfunction in Duchenne muscular dystrophy patients when cardiac transplantation is not a viable option.

We report the use of

    continuous intravenous inotrope infusion
    MEDICATION

 as a

    palliative management strategy
    MEDICATION

 for the treatment of

    symptomatic, refractory, end stage cardiac dysfunction
    SYMPTOMS

 in patients with

    Duchenne muscular dystrophy
    DIAGNOSIS

.

    Milrinone and/or dobutamine administered by continuous intravenous infusion
    MEDICATION

 provided

    symptomatic and objective cardiovascular improvement
    SYMPTOMS

    up to 30 months
    SYMPTOMS

 in 3 individuals with

    Duchenne muscular dystrophy
    DIAGNOSIS

 and

    severe dilated cardiomyopathy
    DIAGNOSIS

.

    Continuous inotrope infusion
    MEDICATION

 should be considered a practical treatment strategy for

    end stage cardiac dysfunction
    SYMPTOMS

 in

    Duchenne muscular dystrophy
    DIAGNOSIS

 patients when

    cardiac transplantation is not a viable option
    NEG_FINDINGS

.

Duchenne muscular dystrophy
Duchenne muscular dystrophy
severe dilated cardiomyopathy
Duchenne muscular dystrophy


Duchenne's cardiomyopathy: two case reports.

We describe two cases of Duchenne's cardiomyopathy with severe cardiac dysfunction, sporadic episodes of myoglobinuria induced by effort and increased levels of serum creatine kinase. Very mild signs of skeletal myopathy were clinically evident. Left ventriculography showed diffuse severe hypokinesia. Skeletal muscle biopsy demonstrated a dystrophic process. The patients had no familial background of the disease. These 2 patients might have a sporadic inheritance pattern with severe cardiac involvement.

We describe two cases of

    Duchenne's cardiomyopathy
    DIAGNOSIS

 with

    severe cardiac dysfunction
    SYMPTOMS

,

    sporadic episodes of myoglobinuria
    SYMPTOMS

    induced by effort
    SYMPTOMS

 and

    increased levels of serum creatine kinase
    BIOCHEMICAL

.

    Very mild signs of skeletal myopathy
    SYMPTOMS

 were clinically evident.

    Left ventriculography
    PARACLINICAL

 showed

    diffuse severe hypokinesia
    SYMPTOMS

.

    Skeletal muscle biopsy
    PARACLINICAL

 demonstrated a

    dystrophic process
    DIAGNOSIS

. The patients had

    no familial background of the disease
    FAMILY

. These 2 patients might have a

    sporadic inheritance pattern
    FAMILY

 with

    severe cardiac involvement
    SYMPTOMS

.

Duchenne's cardiomyopathy
dystrophic process

severe cardiac dysfunction
sporadic episodes of myoglobinuria
induced by effort
Very mild signs of skeletal myopathy
diffuse severe hypokinesia
severe cardiac involvement


A multiplex assay for the detection and mapping of complex glycerol kinase deficiency.

Glycerol kinase deficiency (GKD) is an X-linked recessive disorder that presents in both isolated and complex forms. The contiguous deletion that leads to GKD also commonly affects NR0B1 (DAX1), the gene associated with adrenal hypoplasia congenita, and DMD, the Duchenne muscular dystrophy gene. Molecular testing to delineate this deletion is expensive and has only limited availability.

We designed a multiplex PCR assay for the detection and mapping of a contiguous deletion potentially affecting the IL1RAPL1, NR0B1, GK, and DMD genes in a 29-month-old male patient with GKD.

Multiplex PCR detected a contiguous deletion that involved the IL1RAPL1, NR0B1, GK, and DMD genes. Although the patient had a creatine kinase concentration within the reference interval, further mapping with PCR revealed that exon 74 was the last intact exon at the 3' end of the DMD gene.

Multiplex PCR is an effective and inexpensive way to detect and map the contiguous deletion in cases of complex GKD. The extension of a deletion to include DMD exon 75 in a patient with a creatine kinase concentration within the reference interval suggests that this region of the gene may not be essential for protein function.

    Glycerol kinase deficiency (GKD)
    DIAGNOSIS

 is an

    X-linked recessive disorder
    GENETICS

 that presents in both isolated and complex forms. The

    contiguous deletion that leads
    GENETICS

 to

    GKD
    DIAGNOSIS

    also commonly affects NR0B1 (DAX1), the gene associated with adrenal hypoplasia congenita
    GENETICS

,

    and DMD, the Duchenne muscular dystrophy
    GENETICS

    gene
    GENETICS

.

    Molecular testing
    PARACLINICAL

 to delineate this deletion is expensive and has only limited availability.

We designed a

    multiplex PCR assay
    PARACLINICAL

 for the detection and

    mapping of a contiguous deletion potentially affecting the IL1RAPL1, NR0B1, GK, and DMD genes
    GENETICS

 in a

    29-month-old
    AGE

    male
    GENDER

 patient with

    GKD
    DIAGNOSIS

.

    Multiplex PCR
    PARACLINICAL

 detected

    a contiguous deletion that involved the IL1RAPL1, NR0B1, GK, and DMD genes
    GENETICS

. Although the patient had a

    creatine kinase concentration within the reference interval
    BIOCHEMICAL

,

    further mapping with PCR
    PARACLINICAL

 revealed that

    exon 74 was the last intact exon at the 3' end of the DMD gene
    GENETICS

.

    Multiplex PCR
    PARACLINICAL

 is an effective and inexpensive way to detect and map the

    contiguous deletion
    GENETICS

 in cases of

    complex GKD
    DIAGNOSIS

. The

    extension of a deletion to include DMD exon 75
    GENETICS

 in a patient with a

    creatine kinase concentration within the reference interval
    BIOCHEMICAL

 suggests that

    this region of the gene may not be essential for protein function
    GENETICS

.

Glycerol kinase deficiency (GKD)
GKD
GKD
complex GKD


Novel cryptic exons identified in introns 2 and 3 of the human dystrophin gene with duplication of exons 8-11.

The dystrophin gene, which is mutated in Duchenne muscular dystrophy, is the largest known human gene and characterized by the huge size of its introns. Intron 2 has been shown to include cryptic exons termed exons 2a and 2b, while intron 3 has been shown to include a cryptic exon designated exon 3a. In the present study, we identified 2 and 1 additional cryptic exons in introns 2 and 3, respectively. A previously unknown 157-bp insertion was identified between exons 2 and 3 of a dystrophin mRNA isolated from the lymphocytes of a dystrophinopathy patient with duplication of exons 8-11. Since this sequence exhibited the typical characteristics of a genomic exon, we designated it "exon 2c-l". A more detailed examination revealed that a position 4 bp downstream from the 5' end of exon 2c-l was also used as a splice acceptor site, and this exon was designated "exon 2c-s". In the same patient, a 357-bp insertion was identified between exons 3 and 4. Since this sequence also showed the typical characteristics of an exon, and its 3' end was the same as the splice donor site of exon 3a, we designated the novel cryptic exon "exon 3a-l", and changed the name of the previously reported exon 3a to "exon 3a-s". Among these novel cryptic exons, exon 3a-l was also incorporated into the dystrophin mRNA from normal lymphocytes, whereas exons 2c-l and 2c-s were not. The physiological or pathophysiological roles of these novel cryptic exons remain to be clarified.

The

    dystrophin gene
    GENETICS

, which is mutated in

    Duchenne muscular dystrophy
    DIAGNOSIS

, is the largest known human gene and characterized by the

    huge size of its introns
    GENETICS

. Intron 2 has been shown to include

    cryptic exons termed exons 2a and 2b
    GENETICS

, while intron 3 has been shown to include a

    cryptic exon designated exon 3a
    GENETICS

. In the present study, we identified 2 and 1

    additional cryptic exons in introns 2 and 3
    GENETICS

, respectively. A

    previously unknown 157-bp insertion was identified between exons 2 and 3 of a dystrophin mRNA
    GENETICS

 isolated from the lymphocytes of a

    dystrophinopathy
    DIAGNOSIS

 patient with

    duplication of exons 8-11
    GENETICS

. Since this

    sequence exhibited the typical characteristics of a genomic exon
    GENETICS

, we designated it "

    exon 2c-l"
    GENETICS

. A more detailed examination revealed that

    a position 4 bp downstream from the 5' end of exon 2c-l was also used as a splice acceptor site
    GENETICS

, and this exon was designated "

    exon 2c-s"
    GENETICS

. In the same patient, a

    357-bp insertion was identified between exons 3 and 4
    GENETICS

. Since this

    sequence also showed the typical characteristics of an exon, and its 3' end was the same as the splice donor site of exon 3a
    GENETICS

, we designated the

    novel cryptic exon "exon 3a-l"
    GENETICS

, and changed the name of the previously reported exon 3a to "

    exon 3a-s"
    GENETICS

. Among these

    novel cryptic exons
    GENETICS

,

    exon 3a-l
    GENETICS

 was also incorporated into the

    dystrophin mRNA
    GENETICS

 from normal lymphocytes, whereas

    exons 2c-l and 2c-s
    GENETICS

 were not. The physiological or pathophysiological roles of these

    novel cryptic exons
    GENETICS

 remain to be clarified.

Duchenne muscular dystrophy
dystrophinopathy


Proof of principle and first cases using preimplantation genetic haplotyping--a paradigm shift for embryo diagnosis.

Preimplantation genetic haplotyping (PGH) proof-of-principle was demonstrated by multiple displacement amplification (MDA) of single buccal cells from a female donor and genotyping using 12 polymorphic markers within the dystrophin gene; the known paternal genotype enabled identification of the paternal haplotype in the MDA products despite 27% allele dropout. MDA amplified DNA from 49 single human blastomeres with 100% success. The MDA products were genotyped using a total of 57 polymorphic markers for chromosomes 1, 7, 13, 18, 21, X and Y; 72% of alleles amplified providing results at 90% of the loci tested. A PGH cycle was carried out for Duchenne muscular dystrophy. One embryo was biopsied: PGH showed a non-carrier female, which was transferred with no resulting pregnancy. A PGH cycle was carried out for cystic fibrosis. Seven embryos were biopsied and PGH allowed the exclusion of 2 affected embryos; a carrier and a non-carrier embryo were transferred resulting in an on-going twin pregnancy. PGH represents a paradigm shift in embryo diagnosis, as one panel of markers can be used for all carriers of the same monogenic disease, bypassing the need for development of mutation-specific tests, and widening the scope and availability of preimplantation genetic testing.

    Preimplantation genetic haplotyping (PGH)
    PARACLINICAL

 proof-of-principle was demonstrated by

    multiple displacement amplification (MDA) of single buccal cells from
    PARACLINICAL

 a

    female
    GENDER

 donor and

    genotyping using 12 polymorphic markers within the dystrophin gene
    PARACLINICAL

; the

    known paternal genotype
    GENETICS

 enabled

    identification of the paternal haplotype in the MDA products
    GENETICS

 despite 27% allele

    dropout
    GENETICS

.

    MDA amplified DNA from 49 single human blastomeres
    PARACLINICAL

 with 100% success. The

    MDA products
    PARACLINICAL

 were

    genotyped using a total of 57 polymorphic markers for chromosomes 1, 7, 13, 18, 21, X and Y
    PARACLINICAL

; 72% of alleles amplified providing results at 90% of the loci tested. A

    PGH cycle
    MEDICATION

 was carried out for

    Duchenne muscular dystrophy
    DIAGNOSIS

. One

    embryo was biopsied
    PARACLINICAL

:

    PGH
    PARACLINICAL

 showed a

    non-carrier female, which was transferred with no resulting pregnancy
    NEG_FINDINGS

. A

    PGH cycle
    MEDICATION

 was carried out for

    cystic fibrosis
    DIAGNOSIS

.

    Seven embryos
    PARACLINICAL

 were

    biopsied
    PARACLINICAL

 and

    PGH
    PARACLINICAL

 allowed the exclusion of 2 affected embryos; a

    carrier and a non-carrier embryo were transferred resulting in an on-going twin pregnancy
    MEDICATION

.

    PGH
    PARACLINICAL

 represents a paradigm shift in

    embryo diagnosis
    PARACLINICAL

, as one panel of markers can be used for all carriers of the same

    monogenic disease
    GENETICS

, bypassing the need for development of mutation-specific tests, and widening the scope and availability of

    preimplantation genetic testing
    MEDICATION

.

Duchenne muscular dystrophy
cystic fibrosis


Splicing analysis disclosed a determinant single nucleotide for exon skipping caused by a novel intraexonic four-nucleotide deletion in the dystrophin gene.

Mutations in exonic splicing enhancer sequences are known to cause splicing errors. Although exonic splicing enhancers have been identified as a stretch of purine-rich sequences, it has been difficult to precisely pinpoint the determinant nucleotides in these sequences. This article reports that a 4-bp deletion in exon 38 of the dystrophin gene induced complete exon 38 skipping in vivo. Moreover, the third nucleotide of the deletion was shown to be determinant for the exonic splicing enhancer activity in in vivo splicing analysis of hybrid minigenes encoding mutant exons.

Genomic DNA analysis of a 2-year-old boy with a raised level of serum creatine kinase yielded a 4-bp deletion 11 bp upstream of the 3' end of exon 38 of the dystrophin gene (c. 5434-5437del TTCA), disrupting a predicted SC35-binding site.

Interestingly, his dystrophin mRNA was shown to completely lack exon 38 (exon 38- transcript). As the exon 38- transcript coded for a truncated dystrophin protein, this exon skipping was determined to be a modifying factor of his phenotype. In an in vivo splicing assay, a hybrid minigene encoding exon 38 with the 4-bp deletion was shown to induce complete exon 38 skipping, confirming the deleted region as a splicing enhancer sequence. Site-directed mutagenesis of the deleted sequence showed that the complete exon 38 skipping was caused by mutation of the third nucleotide position of the deletion (C5436), whereas mutations at the other three nucleotide positions induced partial exon skipping.

Our results underline the potential of understanding the regulation of exonic splicing enhancer sequences and exon skipping therapy for treatment of Duchenne's muscular dystrophy.

    Mutations in exonic splicing enhancer sequences
    GENETICS

 are known to cause

    splicing errors
    SYMPTOMS

. Although exonic splicing enhancers have been identified as a stretch

    of purine-rich sequences
    GENETICS

, it has been difficult to precisely pinpoint the determinant nucleotides in these sequences. This article reports that a

    4-bp deletion in exon 38 of the dystrophin gene
    GENETICS

 induced

    complete exon 38 skipping
    GENETICS

 in vivo. Moreover,

    the third nucleotide of the deletion
    GENETICS

 was shown to be determinant for the exonic splicing enhancer activity in

    in vivo splicing analysis of hybrid minigenes encoding mutant exons
    PARACLINICAL

.

    Genomic DNA analysis
    PARACLINICAL

 of a

    2-year-old
    AGE

    boy
    GENDER

 with a

    raised level of serum creatine kinase
    BIOCHEMICAL

 yielded

    a 4-bp deletion 11 bp upstream of the 3' end of exon 38 of the dystrophin gene (c. 5434-5437del TTCA), disrupting a predicted SC35-binding site
    GENETICS

.

Interestingly,

    his
    GENDER

    dystrophin mRNA was shown to completely lack exon 38 (exon 38- transcript)
    GENETICS

. As the

    exon 38- transcript
    GENETICS

 coded for a

    truncated dystrophin protein
    BIOCHEMICAL

, this

    exon skipping
    GENETICS

 was determined to be a modifying factor of his phenotype. In an

    in vivo splicing assay
    PARACLINICAL

, a

    hybrid minigene encoding exon 38 with the 4-bp deletion
    PARACLINICAL

 was shown to induce

    complete exon 38 skipping
    GENETICS

, confirming the deleted region as a splicing enhancer sequence.

    Site-directed mutagenesis of the deleted sequence
    PARACLINICAL

 showed that the

    complete exon 38 skipping
    GENETICS

 was caused by

    mutation of the third nucleotide position of the deletion (C5436)
    GENETICS

, whereas

    mutations at the other three nucleotide positions induced partial exon skipping
    GENETICS

.

Our results underline the potential of understanding the regulation of exonic splicing enhancer sequences and

    exon skipping therapy
    MEDICATION

 for treatment of

    Duchenne's muscular dystrophy
    DIAGNOSIS

.

raised level of serum creatine kinase
truncated dystrophin protein


Becker muscular dystrophy with marked divergence between clinical and molecular genetic findings: case series.

Both Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are caused by mutations of the X-linked dystrophin gene. BMD patients are less affected clinically than DMD patients. We present five patients with a diagnosis of BMD. First, two identical twins, with a deletion of exon 48 of the dystrophin gene, who experienced prominent muscle cramps from the age of three. The histopathological examination of muscle biopsies of these two twins revealed only very slight muscle fiber alterations. Second, two brothers who displayed marked, unusual intrafamilial variability of the clinical picture as well as showing a new point mutation in the dystrophin gene. And finally, a fifth boy who displayed a new point mutation in the dystrophin gene. Although he was clinically asymptomatic at the age of 15 and muscle biopsy only showed very minor myopathic signs, serum Creatine Kinase (CK) levels had been considerably elevated for years. Taken together, these cases add to the spectrum of marked discrepancies in clinical, histopathological and molecular genetic findings in BMD.

Both

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 and

    Becker muscular dystrophy (BMD)
    DIAGNOSIS

 are caused by

    mutations of the X-linked dystrophin gene
    GENETICS

.

    BMD
    DIAGNOSIS

 patients are less affected clinically than

    DMD
    DIAGNOSIS

 patients. We present five patients with a diagnosis of

    BMD
    DIAGNOSIS

. First, two

    identical twins, with a deletion of exon 48 of the dystrophin gene
    FAMILY

, who experienced

    prominent muscle cramps
    SYMPTOMS

    from the age of three
    AGE

. The

    histopathological examination of muscle biopsies
    PARACLINICAL

 of these two twins revealed

    only very slight muscle fiber alterations
    SYMPTOMS

. Second, two

    brothers
    GENDER

 who displayed

    marked, unusual intrafamilial variability of the clinical picture
    FAMILY

 as well as showing a

    new point mutation in the dystrophin gene
    GENETICS

. And finally, a fifth

    boy
    GENDER

 who displayed a

    new point mutation in the dystrophin gene
    GENETICS

. Although

    he
    GENDER

 was

    clinically asymptomatic at the age of 15
    NEG_FINDINGS

 and

    muscle biopsy
    PARACLINICAL

 only showed

    very minor myopathic signs
    SYMPTOMS

,

    serum Creatine Kinase (CK) levels had been considerably elevated for years
    BIOCHEMICAL

. Taken together, these cases add to the spectrum of marked discrepancies in clinical, histopathological and molecular genetic findings in

    BMD
    DIAGNOSIS

.

Duchenne muscular dystrophy (DMD)
Becker muscular dystrophy (BMD)
BMD
DMD
BMD
BMD


[Two cases of Duchenne muscular dystrophy complicated with dilated cardiomyopathy and cerebral infarction].

We report two cases of Duchenne muscular dystrophy (DMD) complicated with dilated cardiomyopathy (DCM), who were affected with cerebral infarction. Case 1 suddenly developed dysarthria and right facial weakness at age 21. Cranial CT study disclosed a low density area in the left basal ganglia and internal capsule. Case 2 had a history of transient ischemic attack (TIA) at age 21. Five months after the TIA, he developed right hemiplegia and dysarthria, and a low density area in the corona radiate in left cerebral hemisphere was observed in cranial CT. These two cases showed the radiographic cardiomegaly with cardio thoracic ratio (CTR) of 72.8% and 66.6%, the decreased echocardiographic left ventricular ejection fraction below 20%, and the elevated titer of thrombin-anti-thrombin III complex (TAT) and D-dimer. The autopsy of Case 2 at age 26 disclosed the remarkable degeneration and fibrosis of myocardium and old ischemic lesion in the left cerebral frontal cortex. Despite the negative finding of the emboli in the left heart, cardiogenic cerebral infarction secondary to DCM was strongly suspected in both cases.

We report two cases of

    Duchenne muscular dystrophy (DMD) complicated with dilated cardiomyopathy (DCM)
    DIAGNOSIS

, who were affected with

    cerebral infarction
    SYMPTOMS

. Case 1 suddenly developed

    dysarthria
    SYMPTOMS

 and

    right facial weakness
    SYMPTOMS

 at

    age 21
    AGE

.

    Cranial CT study
    PARACLINICAL

 disclosed a

    low density area in the left basal ganglia and internal capsule
    SYMPTOMS

. Case 2 had a history of

    transient ischemic attack (TIA)
    SYMPTOMS

 at

    age 21
    AGE

. Five months after the

    TIA
    SYMPTOMS

,

    he
    GENDER

 developed

    right hemiplegia
    SYMPTOMS

 and

    dysarthria
    SYMPTOMS

, and a

    low density area in the corona radiate in left cerebral hemisphere
    SYMPTOMS

 was observed in

    cranial CT
    PARACLINICAL

. These two cases showed the

    radiographic cardiomegaly with cardio thoracic ratio (CTR) of 72.8% and 66.6%
    SYMPTOMS

, the

    decreased echocardiographic left ventricular ejection fraction below 20%
    SYMPTOMS

, and the

    elevated titer of thrombin-anti-thrombin III complex (TAT) and D-dimer
    BIOCHEMICAL

. The

    autopsy
    PARACLINICAL

 of Case 2 at

    age 26
    AGE

 disclosed the

    remarkable degeneration and fibrosis of myocardium
    SYMPTOMS

 and

    old ischemic lesion in the left cerebral frontal cortex
    SYMPTOMS

.

    Despite the negative finding of the emboli in the left heart
    NEG_FINDINGS

,

    cardiogenic cerebral infarction
    SYMPTOMS

 secondary to

    DCM
    DIAGNOSIS

 was strongly suspected in both cases.


Intravenous infusion of an antisense oligonucleotide results in exon skipping in muscle dystrophin mRNA of Duchenne muscular dystrophy.

Duchenne muscular dystrophy (DMD) is a fatal muscle wasting disease that is characterized by muscle dystrophin deficiency. We report that intravenous (IV) infusion of an antisense oligonucleotide created an in-frame dystrophin mRNA from an out-of-frame DMD mutation (via exon skipping) which led to muscle dystrophin expression. A 10-year-old DMD patient possessing an out-of-frame, exon 20 deletion of the dystrophin gene received a 0.5 mg/kg IV infusion of an antisense 31-mer phosphorothioate oligonucleotide against the splicing enhancer sequence of exon 19. This antisense construct was administered at one-week intervals for 4 wk. No side effects attributable to infusion were observed. Exon 19 skipping appeared in a portion of the dystrophin mRNA in peripheral lymphocytes after the infusion. In a muscle biopsy one week after the final infusion, the novel in-frame mRNA lacking both exons 19 and 20 was identified and found to represent approximately 6% of the total reverse transcription PCR product. Dystrophin was identified histochemically in the sarcolemma of muscle cells after oligonucleotide treatment. These findings demonstrate that phosphorothioate oligonucleotides may be administered safely to children with DMD, and that a simple IV infusion is an effective delivery mechanism for oligonucleotides that lead to exon skipping in DMD skeletal muscles.

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 is a

    fatal muscle wasting disease
    DIAGNOSIS

 that is characterized by

    muscle dystrophin deficiency
    BIOCHEMICAL

. We report that

    intravenous (IV) infusion of an antisense oligonucleotide
    MEDICATION

 created an

    in-frame dystrophin mRNA from an out-of-frame DMD mutation (via exon skipping)
    GENETICS

 which led to

    muscle dystrophin expression
    BIOCHEMICAL

. A

    10-year-old
    AGE

    DMD
    DIAGNOSIS

 patient possessing an

    out-of-frame, exon 20 deletion of the dystrophin gene
    GENETICS

 received

    a 0.5 mg/kg IV infusion of an antisense 31-mer phosphorothioate oligonucleotide against the splicing enhancer sequence of exon 19
    MEDICATION

. This

    antisense construct was administered at one-week intervals for 4 wk
    MEDICATION

.

    No side effects attributable to infusion
    NEG_FINDINGS

 were observed.

    Exon 19 skipping appeared in a portion of the dystrophin mRNA in peripheral lymphocytes
    GENETICS

 after the infusion. In a

    muscle biopsy
    PARACLINICAL

 one week after the final infusion, the

    novel in-frame mRNA lacking both exons 19 and 20
    GENETICS

 was identified and found to represent

    approximately 6% of the total reverse transcription PCR product
    MICROSCOPIC

.

    Dystrophin was identified histochemically in the sarcolemma of muscle cells
    MICROSCOPIC

 after

    oligonucleotide treatment
    MEDICATION

. These findings demonstrate that

    phosphorothioate oligonucleotides
    MEDICATION

 may be administered safely to

    children
    AGE

 with

    DMD
    DIAGNOSIS

, and that a

    simple IV infusion
    MEDICATION

 is an effective delivery mechanism for oligonucleotides that lead to exon skipping in

    DMD skeletal muscles
    MICROSCOPIC

.

Duchenne muscular dystrophy (DMD)
fatal muscle wasting disease
DMD
DMD

muscle dystrophin deficiency
muscle dystrophin expression


PGD for dystrophin gene deletions using fluorescence in situ hybridization.

Duchenne muscular dystrophy and Becker muscular dystrophy (DMD and BMD) are caused by mutations in the dystrophin gene (Xp21). In two-thirds of DMD/BMD cases, the mutation is a large deletion of one or several exons. We have established PGD for DMD/BMD using interphase fluorescence in situ hybridization (FISH) analysis on single nuclei from blastomeres for the detection of deletions of specific exons in the dystrophin gene. We performed PGD for two carrier females; one had a deletion of exons 45-50 (DMD), and the other had a deletion of exons 45-48 (BMD). An exon 45-specific probe was used in combination with probes for the X and Y centromeres. Using this straightforward approach, we can distinguish affected and unaffected male embryos as well as carrier female and normal female embryos. Three cycles were performed for each patient, which resulted in a pregnancy and the birth of a healthy girl. To the best of our knowledge, this approach for PGD has not been previously reported. The use of interphase FISH is an attractive alternative to sexing or PCR-based mutation detection for PGD patients with known deletions of the dystrophin gene.

    Duchenne muscular dystrophy
    DIAGNOSIS

 and

    Becker muscular dystrophy (DMD and BMD)
    DIAGNOSIS

 are caused by

    mutations in the dystrophin gene (Xp21)
    GENETICS

. In two-thirds of

    DMD/BMD
    DIAGNOSIS

 cases, the mutation is a

    large deletion of one or several exons
    GENETICS

. We have established

    PGD
    MEDICATION

 for

    DMD/BMD
    DIAGNOSIS

 using

    interphase fluorescence in situ hybridization (FISH) analysis on single nuclei from blastomeres
    PARACLINICAL

 for the detection of

    deletions of specific exons in the dystrophin gene
    GENETICS

. We performed

    PGD
    MEDICATION

 for two carrier

    females
    GENDER

; one had a

    deletion of exons 45-50 (DMD)
    GENETICS

, and the other had a

    deletion of exons 45-48 (BMD)
    GENETICS

. An

    exon 45-specific probe
    PARACLINICAL

 was used in combination with

    probes for the X and Y centromeres
    PARACLINICAL

. Using this straightforward approach, we can distinguish affected and unaffected male embryos as well as carrier female and normal female embryos. Three cycles were performed for each patient, which resulted in a

    pregnancy
    MEDICATION

 and the birth of a healthy

    girl
    GENDER

. To the best of our knowledge, this approach for

    PGD
    MEDICATION

 has not been previously reported. The use of

    interphase FISH
    PARACLINICAL

 is an attractive alternative to

    sexing
    PARACLINICAL

 or

    PCR-based mutation detection
    PARACLINICAL

 for

    PGD
    MEDICATION

 patients with

    known deletions of the dystrophin gene
    GENETICS

.

Duchenne muscular dystrophy
Becker muscular dystrophy (DMD and BMD)
DMD/BMD
DMD/BMD


Cloning and sequencing of junction fragment with exons 45-54 deletion of dystrophin gene.

To study the mechanisms of dystrophin gene deletion, the junction fragment with exons 45-54 deletion were cloned and sequenced.

A Duchenne muscular dystrophy (DMD) patient with exons 45-54 deletion has been substantiated by PCR amplification of the exons. Then we used a PCR-based genome-walking method for localizing the breakpoints in introns 44 and 54. At last, the deletion-junction fragment was directly amplified by PCR approach with forward and reverse primers annealing to a DNA sequence as close as possible to the breakpoints in introns 45 and 54. The sequencing result of the deletion-junction fragment was compared with the normal intronic sequences.

A total of 2716 bp sequence containing the junction fragment was obtained. The 5' breakpoint was located in LINE/L1 element of intron 44 and close to a matrix attachment region (MAR). The 3' breakpoint was located in the minor potential MAR with topoisomerase II cleavage sites around. Beside the 3' breakpoint there was a 6 bp palindromic sequence. A 4 bp microhomologous sequence (AGAG) was in the joint of the deletion-junction fragment.

The nonhomologous recombination caused by L1 repeated element, topoisomerase II cleavage sites, MARs and the nonhomologous end joining of microhomologous sequence may be the important factors in this huge gene fragment deletion.

To study the mechanisms of

    dystrophin gene deletion
    GENETICS

,

    the junction fragment with exons 45-54 deletion
    PARACLINICAL

    were cloned and sequenced
    PARACLINICAL

.

A

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 patient with

    exons 45-54 deletion
    GENETICS

 has been substantiated by

    PCR amplification of the exons
    PARACLINICAL

. Then we used a

    PCR-based genome-walking method
    PARACLINICAL

 for localizing the breakpoints in

    introns 44 and 54
    GENETICS

. At last, the

    deletion-junction fragment was directly amplified by PCR approach
    PARACLINICAL

 with forward and reverse primers annealing

    to a DNA sequence as close
    GENETICS

 as possible

    to the breakpoints in introns 45 and 54
    GENETICS

. The

    sequencing result of the deletion-junction fragment was compared with the normal intronic sequences
    PARACLINICAL

.

A

    total of 2716 bp sequence containing the junction fragment
    PARACLINICAL

 was obtained. The 5' breakpoint

    was located in LINE/L1 element of intron 44 and close to a matrix attachment region (MAR)
    GENETICS

. The 3' breakpoint was located

    in the minor potential MAR with topoisomerase II cleavage sites around
    GENETICS

.

    Beside the 3' breakpoint there was a 6 bp palindromic sequence. A 4 bp microhomologous sequence (AGAG) was in the joint of the deletion-junction fragment
    GENETICS

.

The

    nonhomologous recombination caused by L1 repeated element
    GENETICS

,

    topoisomerase II cleavage sites
    GENETICS

, MARs and the

    nonhomologous end joining of microhomologous sequence
    GENETICS

 may be the important factors in this

    huge gene fragment deletion
    GENETICS

.


Assessment of somatosensory evoked potentials during resuscitation of a 15-year-old boy with Duchenne muscular dystrophy.

Patients with Duchenne muscular dystrophy (DMD) are likely to suffer from cardiac insufficiency. Subclinical cardiac insufficiency may decompensate intraoperatively. During spinal surgery, recording of somatosensory evoked potentials (SSEP) is the standard method of spinal cord monitoring. Assessment of SSEP has proven to be a highly prognostic measure of neurological outcome after cardiopulmonary resuscitation (CPR). In the case presented, scalp SSEP as response to stimulation of both median and tibial nerves were recorded during spinal surgery in a 15-year-old boy with DMD. The patient developed severe hypotension and circulatory collapse intraoperatively. SSEP were measured before, during and up to 3h after circulatory collapse. He was successfully resuscitated and fully recovered. Latencies of SSEP remained stable from all extremities whereas amplitudes significantly decreased during CPR, but recovered completely within 3h. The amplitudes of SSEP serve as a more sensitive marker for brain ischaemia than latencies. Stability of latencies and full recovery of amplitudes within 3h indicated sufficient CPR and predicted a good neurological recovery.

Patients with

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 are likely to suffer from

    cardiac insufficiency
    SYMPTOMS

.

    Subclinical cardiac insufficiency
    SYMPTOMS

 may decompensate intraoperatively. During

    spinal surgery
    MEDICATION

,

    recording of somatosensory evoked potentials (SSEP)
    PARACLINICAL

 is the standard method of

    spinal cord monitoring
    PARACLINICAL

.

    Assessment of SSEP
    PARACLINICAL

 has proven to be a highly prognostic measure of neurological outcome after

    cardiopulmonary resuscitation (CPR)
    MEDICATION

. In the case presented,

    scalp SSEP
    PARACLINICAL

 as response to

    stimulation of both median and tibial nerves
    PARACLINICAL

 were recorded during

    spinal surgery
    MEDICATION

 in a

    15-year-old
    AGE

    boy
    GENDER

 with

    DMD
    DIAGNOSIS

. The patient developed

    severe hypotension
    SYMPTOMS

 and

    circulatory collapse
    SYMPTOMS

 intraoperatively.

    SSEP were measured before, during and up
    PARACLINICAL

 to 3h after

    circulatory collapse
    SYMPTOMS

.

    He
    GENDER

 was successfully

    resuscitated
    MEDICATION

 and

    fully recovered
    SYMPTOMS

.

    Latencies of SSEP remained stable from all extremities
    SYMPTOMS

 whereas

    amplitudes significantly decreased
    SYMPTOMS

 during

    CPR
    SYMPTOMS

, but

    recovered completely
    SYMPTOMS

 within 3h. The amplitudes of SSEP serve as a more sensitive marker for

    brain ischaemia
    SYMPTOMS

 than latencies.

    Stability of latencies
    SYMPTOMS

 and

    full recovery of amplitudes
    SYMPTOMS

 within 3h indicated

    sufficient CPR
    MEDICATION

 and predicted a

    good neurological recovery
    SYMPTOMS

.

spinal surgery
cardiopulmonary resuscitation (CPR)
spinal surgery
resuscitated
sufficient CPR


Coexisting muscular dystrophies and epilepsy in children.

Muscular dystrophies are composed of a variety of genetic muscle disorders linked to different chromosomes and loci and associated with different gene mutations that lead to progressive muscle atrophy and weakness. Fukuyama congenital muscular dystrophy is frequently associated with partial and generalized epilepsy and congenital brain anomalies, including cobblestone complex and other neuronal migration defects. We report generalized convulsive epilepsy in a boy with normal brain magnetic resonance imaging and Duchenne muscular dystrophy with deletion of dystrophin gene, and we report absence epilepsy with normal brain magnetic resonance imaging in another boy with limb girdle muscular dystrophy with partial calpain deficiency. We, therefore, review coexisting muscular dystrophies and epilepsy in children. In addition to Fukuyama congenital muscular dystrophy, partial or generalized epilepsy has also been reported in the following types of muscular dystrophies, including Duchenne/Becker dystrophy, facioscapulohumeral dystrophy, congenital muscular dystrophy with partial and complete deficiency of laminin alpha2 (merosin) chain, and limb girdle muscular dystrophy with partial calpain deficiency.

    Muscular dystrophies
    DIAGNOSIS

 are composed of a variety of

    genetic muscle disorders
    DIAGNOSIS

    linked to different chromosomes and loci
    GENETICS

 and associated with different

    gene mutations
    GENETICS

 that lead to

    progressive muscle atrophy
    SYMPTOMS

 and

    weakness
    SYMPTOMS

.

    Fukuyama congenital muscular dystrophy
    DIAGNOSIS

 is frequently associated with

    partial and generalized epilepsy
    SYMPTOMS

 and

    congenital brain anomalies
    SYMPTOMS

, including

    cobblestone complex and other neuronal migration defects
    SYMPTOMS

. We report

    generalized convulsive epilepsy
    SYMPTOMS

 in a

    boy
    GENDER

 with

    normal brain magnetic resonance imaging
    NEG_FINDINGS

 and

    Duchenne muscular dystrophy
    DIAGNOSIS

 with

    deletion of dystrophin gene
    GENETICS

, and we report

    absence epilepsy
    SYMPTOMS

 with

    normal brain magnetic resonance imaging
    NEG_FINDINGS

 in another

    boy
    GENDER

 with

    limb girdle muscular dystrophy
    DIAGNOSIS

 with

    partial calpain deficiency
    BIOCHEMICAL

. We, therefore, review

    coexisting muscular dystrophies
    DIAGNOSIS

 and

    epilepsy
    DIAGNOSIS

 in

    children
    AGE

. In addition to

    Fukuyama congenital muscular dystrophy
    DIAGNOSIS

,

    partial or generalized epilepsy
    SYMPTOMS

 has also been reported in the following types of

    muscular dystrophies
    DIAGNOSIS

, including

    Duchenne/Becker dystrophy
    DIAGNOSIS

,

    facioscapulohumeral dystrophy
    DIAGNOSIS

,

    congenital muscular dystrophy
    DIAGNOSIS

 with

    partial and complete deficiency of laminin alpha2 (merosin) chain
    BIOCHEMICAL

, and

    limb girdle muscular dystrophy
    DIAGNOSIS

 with

    partial calpain deficiency
    BIOCHEMICAL

.

Muscular dystrophies
genetic muscle disorders
Fukuyama congenital muscular dystrophy
Duchenne muscular dystrophy
limb girdle muscular dystrophy
coexisting muscular dystrophies
epilepsy
Fukuyama congenital muscular dystrophy
muscular dystrophies
Duchenne/Becker dystrophy
facioscapulohumeral dystrophy
congenital muscular dystrophy
limb girdle muscular dystrophy

normal brain magnetic resonance imaging
normal brain magnetic resonance imaging


Becker's muscular dystrophy and orthotopic heart transplantation: perioperative considerations.

Patients with Becker's and Duchenne's muscular dystrophy occasionally have myocardial involvement leading to end-stage heart failure. Heart transplantation is established as an effective therapy. Achieving successful outcomes in this challenging group requires special consideration during the perioperative period to limit preoperative deconditioning, minimize anesthesia complications, and rapidly institute rehabilitation with appropriate precautions. We reviewed our recent experience with Becker's muscular dystrophy patients and discuss the management of perioperative issues specific to this patient group.

Patients with

    Becker's
    DIAGNOSIS

 and

    Duchenne's muscular dystrophy
    DIAGNOSIS

 occasionally have

    myocardial involvement
    SYMPTOMS

 leading to

    end-stage heart failure
    SYMPTOMS

.

    Heart transplantation
    MEDICATION

 is established as an effective therapy. Achieving successful outcomes in this challenging group requires special consideration during the perioperative period to

    limit preoperative deconditioning
    MEDICATION

,

    minimize anesthesia complications
    SYMPTOMS

, and

    rapidly institute rehabilitation with appropriate precautions
    MEDICATION

. We reviewed our recent experience with

    Becker's muscular dystrophy
    DIAGNOSIS

 patients and discuss the management of perioperative issues specific to this patient group.

Becker's
Duchenne's muscular dystrophy
Becker's muscular dystrophy

myocardial involvement
end-stage heart failure
minimize anesthesia complications


[Four siblings with becker muscular dystrophy (BMD) manifesting severe mental retardation].

A 33-year-old man with BMD manifesting severe mental retardation is reported. This patient has mild pseudohypertrophy in his calf muscles and showed an elevation of creatine kinase (CK) level in the serum (2215 IU/L). He was diagnosed as autistic at the age of three. His intellectual level was estimated to be two years old in social intelligence and four months old in speech ability at the age of 33. However his muscle strength remains within the normal range. All of his three siblings have similar symptoms, such as severe mental retardation and elevated CK level in the serum (1735-3641 IU/L) and lack apparent muscular weakness. Gene analyses by multiplex PCR and Southern blotting showed all of the siblings had the deletion of exon 4 in the dystrophin gene. Pathological findings of a muscle biopsy specimen showed a mild irregular dystrophin stain of the muscle surface membrane. This is a rare familial case of Becker muscular dystrophy manifesting severe mental retardation with scarce muscular weakness.

A

    33-year-old
    AGE

    man
    GENDER

 with

    BMD
    DIAGNOSIS

 manifesting

    severe mental retardation
    SYMPTOMS

 is reported. This patient has

    mild pseudohypertrophy in his calf muscles
    SYMPTOMS

 and showed an

    elevation of creatine kinase (CK) level in the serum (2215 IU/L)
    BIOCHEMICAL

.

    He
    GENDER

 was diagnosed as

    autistic
    DIAGNOSIS

    at the age of three
    AGE

.

    His
    GENDER

    intellectual level was estimated to be two years old in social intelligence and four months old in speech ability at the age of 33
    AGE

. However

    his
    GENDER

    muscle strength remains within the normal range
    NEG_FINDINGS

.

    All of his three siblings have similar symptoms
    FAMILY

, such as

    severe mental retardation
    SYMPTOMS

 and

    elevated CK level in the serum (1735-3641 IU/L)
    BIOCHEMICAL

 and

    lack apparent muscular weakness
    NEG_FINDINGS

.

    Gene analyses
    PARACLINICAL

 by

    multiplex PCR and Southern blotting
    PARACLINICAL

 showed

    all of the siblings had the deletion of exon 4 in the dystrophin gene
    FAMILY

.

    Pathological findings of a muscle biopsy specimen
    PARACLINICAL

 showed a

    mild irregular dystrophin stain of the muscle surface membrane
    MICROSCOPIC

. This is a rare familial case of

    Becker muscular dystrophy
    DIAGNOSIS

 manifesting

    severe mental retardation
    SYMPTOMS

 with

    scarce muscular weakness
    SYMPTOMS

.


Co-occurrence of mutations in both dystrophin- and androgen-receptor genes is a novel cause of female Duchenne muscular dystrophy.

Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder. Here, we report a novel mechanism for the occurrence of DMD in females. In a Vietnamese DMD girl, conventional PCR amplification analysis disclosed a deletion of exons 12-19 of the dystrophin gene on Xp21.2, with a karyotype of 46, XY. Furthermore, a novel mutation in the androgen-receptor gene on Xq11.2-q12 was identified in this girl, which led to male pseudohermaphroditism. Co-occurrence of mutations of these two genes constitutes a novel mechanism underlying female DMD.

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 is an

    X-linked recessive disorder
    GENETICS

. Here, we report a novel mechanism for the occurrence of

    DMD
    DIAGNOSIS

 in

    females
    GENDER

. In a

    Vietnamese
    ETHNICITY

    DMD
    DIAGNOSIS

    girl
    GENDER

,

    conventional PCR amplification analysis
    PARACLINICAL

 disclosed a

    deletion of exons 12-19 of the dystrophin gene on Xp21.2
    GENETICS

, with a

    karyotype of 46, XY
    GENETICS

. Furthermore, a

    novel mutation in the androgen-receptor gene on Xq11.2-q12
    GENETICS

 was identified in this

    girl
    GENDER

, which led to

    male pseudohermaphroditism
    SYMPTOMS

.

    Co-occurrence of mutations of these two genes
    GENETICS

 constitutes a novel mechanism underlying

    female
    GENDER

    DMD
    DIAGNOSIS

.

Duchenne muscular dystrophy (DMD)
DMD
DMD
DMD


Immobility reduces muscle fiber necrosis in dystrophin deficient muscular dystrophy.

Duchenne/Becker muscular dystrophy is a progressive muscle disease, which is caused by the abnormality of dystrophin. Spina bifida is characterized by paralysis of the feet, with most of the upper extremities not being affected. We report here on the first case of Becker muscular dystrophy coinciding with spina bifida. The muscle biopsy specimens of the patient showed dystrophic changes in upper extremities, but clearly less in lower extremities. The results show that the restriction of excessive exercise is important for dystrophin deficiency disease.

    Duchenne/Becker muscular dystrophy
    DIAGNOSIS

 is a

    progressive muscle disease
    DIAGNOSIS

, which is caused by the

    abnormality of dystrophin
    GENETICS

.

    Spina bifida
    DIAGNOSIS

 is characterized by

    paralysis of the feet, with most of the upper extremities not being affected
    SYMPTOMS

. We report here on the first case of

    Becker muscular dystrophy
    DIAGNOSIS

 coinciding with

    spina bifida
    DIAGNOSIS

. The

    muscle biopsy specimens
    PARACLINICAL

 of the patient showed

    dystrophic changes in upper extremities, but clearly less in lower extremities
    SYMPTOMS

. The results show that the

    restriction of excessive exercise
    MEDICATION

 is important for

    dystrophin deficiency disease
    DIAGNOSIS

.

Duchenne/Becker muscular dystrophy
progressive muscle disease
Spina bifida
Becker muscular dystrophy
spina bifida
dystrophin deficiency disease


Noncompaction in Duchenne muscular dystrophy: frustrated attempt to create a compensatory left ventricle?

The histological workup of the myocardium of a patient with Duchenne muscular dystrophy and left ventricular hypertrabeculation/noncompaction (LVHT) revealed an extremely thin left ventricular wall and a noncompacted layer double in size compared to the compacted layer. Within the compacted layer islets of fibrous tissue predominated, surrounded by areas of myxoid appearance hardly producing collagen, and occasionally normal or dystrophic cardiomyocytes. The noncompacted layer consisted largely of intact cardiomyocytes rarely intermingled with collagen-producing, fibrous tissue. This variant appearance of the compacted and noncompacted layer was found in all areas of noncompaction. These histopathological findings suggest that LVHT represents a compensatory attempt to overcome the failing compacted but dystrophic myocardium.

The

    histological workup of the myocardium
    PARACLINICAL

 of a patient with

    Duchenne muscular dystrophy
    DIAGNOSIS

 and

    left ventricular hypertrabeculation/noncompaction (LVHT)
    SYMPTOMS

 revealed an

    extremely thin left ventricular wall
    SYMPTOMS

 and a

    noncompacted layer double in size compared to the compacted layer
    SYMPTOMS

.

    Within the compacted layer islets of fibrous tissue predominated, surrounded by areas of myxoid appearance hardly producing collagen, and occasionally normal or dystrophic cardiomyocytes
    MICROSCOPIC

. The

    noncompacted layer consisted largely of intact cardiomyocytes rarely intermingled with collagen-producing, fibrous tissue
    MICROSCOPIC

. This

    variant appearance of the compacted and noncompacted layer
    MICROSCOPIC

 was found in all areas of

    noncompaction
    SYMPTOMS

. These histopathological findings suggest that

    LVHT
    DIAGNOSIS

 represents a compensatory attempt to overcome the

    failing compacted but dystrophic myocardium
    SYMPTOMS

.


The postoperative cardiovascular arrest of a 5-year-old male: an initial presentation of Duchenne's muscular dystrophy.

Anesthesia may be administered to patients with Duchenne's muscular dystrophy, but cases are reported in which apparently healthy children suffer hyperkalemic cardiac arrest. We present the case of a 5-year-old boy whose muscular dystrophy was discovered following a fatal, perioperative cardiac arrest in the postanesthesia care unit.

    Anesthesia
    MEDICATION

 may be administered to patients with

    Duchenne's muscular dystrophy
    DIAGNOSIS

, but cases are reported in which apparently healthy

    children
    AGE

 suffer

    hyperkalemic cardiac arrest
    SYMPTOMS

. We present the case of a

    5-year-old
    AGE

    boy
    GENDER

 whose

    muscular dystrophy
    DIAGNOSIS

 was discovered following a

    fatal, perioperative cardiac arrest
    SYMPTOMS

 in the

    postanesthesia care unit
    MEDICATION

.

Duchenne's muscular dystrophy
muscular dystrophy

hyperkalemic cardiac arrest
fatal, perioperative cardiac arrest


Clinicopathologic conference: Barth Syndrome.

A case of Barth Syndrome is presented and discussed by both clinician and pathologist, in this traditional clinico-pathologic conference. The current understanding of etiology is included, including elevation of 3-methylglutaconic acid (3MGC).

A case of

    Barth Syndrome
    DIAGNOSIS

 is presented and discussed by both clinician and pathologist, in this traditional clinico-pathologic conference. The current understanding of etiology is included, including

    elevation of 3-methylglutaconic acid (3MGC)
    BIOCHEMICAL

.


Tracheo-arterial fistula in tracheostomy patients with Duchenne muscular dystrophy.

A tracheo-arterial fistula is a serious and life threatening potential complication of a tracheostomy. Since 1984, we experienced nine fatal cases of tracheo-arterial fistula among 60 Duchenne muscular dystrophy (DMD) patients who underwent a tracheostomy. Representative cases included a patient with lordosis (Case 8), in whom the fistula was located in the brachiocephalic artery close to the trachea, and another with severe scoliosis (Case 9), which caused the aorta to compress the trachea. Such anatomical changes can be the cause of a fistula between the trachea and brachiocephalic artery. The anatomical locations between the trachea and brachiocephalic artery are modified by thoracic deformities in DMD patients, and should be confirmed using computed tomography (CT) prior to a tracheostomy procedure. Further, during such a procedure, the tracheal stoma must be placed in a location clearly away from the arteries, and should be followed by regular post-operative examinations using CT and careful management to avoid a tracheo-arterial fistula.

A

    tracheo-arterial fistula
    SYMPTOMS

 is a serious and life threatening potential complication of a

    tracheostomy
    MEDICATION

. Since 1984, we experienced nine fatal cases of

    tracheo-arterial fistula
    SYMPTOMS

 among 60

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 patients who underwent a

    tracheostomy
    MEDICATION

. Representative cases included a patient with

    lordosis
    SYMPTOMS

 (Case 8), in whom the

    fistula was located in the brachiocephalic artery close to the trachea
    SYMPTOMS

, and another with

    severe scoliosis
    SYMPTOMS

 (Case 9), which caused

    the aorta to compress the trachea
    SYMPTOMS

. Such anatomical changes can be the cause of a

    fistula between the trachea and brachiocephalic artery
    SYMPTOMS

. The

    anatomical locations between the trachea and brachiocephalic artery
    SYMPTOMS

 are modified by

    thoracic deformities
    SYMPTOMS

 in

    DMD
    DIAGNOSIS

 patients, and should be confirmed using

    computed tomography (CT)
    PARACLINICAL

 prior to a

    tracheostomy procedure
    MEDICATION

. Further, during such a procedure, the

    tracheal stoma
    MEDICATION

 must be placed in a location clearly away from the arteries, and should be followed by

    regular post-operative examinations using CT
    PARACLINICAL

 and careful management to avoid a

    tracheo-arterial fistula
    SYMPTOMS

.

tracheostomy
tracheostomy
tracheostomy procedure
tracheal stoma


Noninvasive ventilation during gastrostomy tube placement in patients with severe duchenne muscular dystrophy: case reports and review of the literature.

Individuals with Duchenne muscular dystrophy may benefit from gastrostomy tube feeding due to progressive dysphagia and malnutrition. However, due to their severely impaired pulmonary function, these individuals are at risk of severe complications when they are sedated or undergo anesthesia for the procedure. We previously described a technique of noninvasive positive pressure ventilation to provide respiratory support during gastrostomy tube placement in such patients, but this technique had risks and limitations. In this case report, we examine two alternative techniques we used to provide respiratory support successfully to patients with severe muscular dystrophy and malnutrition who underwent percutaneous endoscopic gastrostomy tube placement. We then review the literature and discuss the potential benefits, risks, and limitations of the above techniques and of other options for gastrostomy placement in people with severe muscular dystrophy.

Individuals with

    Duchenne muscular dystrophy
    DIAGNOSIS

 may benefit from

    gastrostomy tube feeding
    MEDICATION

 due to

    progressive dysphagia
    SYMPTOMS

 and

    malnutrition
    SYMPTOMS

. However, due to their

    severely impaired pulmonary function
    SYMPTOMS

, these individuals are at risk of

    severe complications
    SYMPTOMS

 when they are

    sedated
    MEDICATION

 or

    undergo anesthesia
    MEDICATION

 for the procedure. We previously described a technique of

    noninvasive positive pressure ventilation to provide respiratory support during gastrostomy tube placement
    MEDICATION

 in such patients, but this technique had risks and limitations. In this case report, we examine two alternative techniques we used to

    provide respiratory support
    MEDICATION

 successfully to patients with

    severe muscular dystrophy
    DIAGNOSIS

 and

    malnutrition
    SYMPTOMS

 who underwent

    percutaneous endoscopic gastrostomy tube placement
    MEDICATION

. We then review the literature and discuss the potential benefits, risks, and limitations of the above techniques and of other options for

    gastrostomy placement
    MEDICATION

 in people with

    severe muscular dystrophy
    DIAGNOSIS

.

Duchenne muscular dystrophy
severe muscular dystrophy
severe muscular dystrophy

progressive dysphagia
malnutrition
severely impaired pulmonary function
severe complications
malnutrition


Cardiomyopathy in Becker muscular dystrophy--does regional fibrosis mimic infarction?

We present a case of a 39-year-old man with Becker muscular dystrophy and severe congestive cardiac failure. Cardiac magnetic resonance imaging revealed subendocardial late gadolinium enhancement, similar to that seen in myocardial infarction. He had no risk factors for atherosclerotic coronary artery disease and coronary angiography was normal. We propose that regional subendocardial myocardial fibrosis which has been described histologically in the cardiomyopathy associated with Becker muscular dystrophy may resemble previous infarction at contrast enhanced cardiac magnetic resonance imaging.

We present a case of a

    39-year-old
    AGE

    man
    GENDER

 with

    Becker muscular dystrophy
    DIAGNOSIS

 and

    severe congestive cardiac failure
    SYMPTOMS

.

    Cardiac magnetic resonance imaging
    PARACLINICAL

 revealed

    subendocardial late gadolinium enhancement, similar to that seen in myocardial infarction
    SYMPTOMS

.

    He
    GENDER

 had

    no risk factors for atherosclerotic coronary artery disease
    NEG_FINDINGS

 and

    coronary angiography was normal
    NEG_FINDINGS

. We propose that

    regional subendocardial myocardial fibrosis
    SYMPTOMS

 which has been described histologically in the

    cardiomyopathy
    DIAGNOSIS

 associated with

    Becker muscular dystrophy
    DIAGNOSIS

 may resemble

    previous infarction
    SYMPTOMS

 at

    contrast enhanced cardiac magnetic resonance imaging
    PARACLINICAL

.

Becker muscular dystrophy
cardiomyopathy
Becker muscular dystrophy


Preimplantation genetic diagnosis (PGD) for Duchenne muscular dystrophy (DMD) by triplex-nested PCR.

Duchenne muscular dystrophy (DMD) is a lethal X-linked recessive disorder with an incidence of approximately 1 in 3500 males, caused by mutation in the DMD gene. About 2/3 of DMD cases are caused by gross DMD gene deletion mutations. The purpose of this study was to develop a series of single-cell multiplex-nested PCR protocols for preimplantation genetic diagnosis (PGD) of the most prevalent DMD deletions.

The protocols were developed on single blood leukocytes from normal males and females and patients with known DMD gene deletion. In the first reaction, 2 of 11 different primer sets (exons 4, 8, 12, 13, 17, 46, 47, 49, 50, 52 and intron 52) were used to allow the simultaneous amplification of different DMD loci and the SRY gender marker, in a single triplex-nested polymerase chain reaction (PCR). Aliquots of this reaction were then subjected to nested PCR in which each locus was amplified individually. Following the successful establishment of single-cell triplex-nested PCR in single leukocytes, the technique was employed in five clinical PGD cases.

For each DMD locus, more than 50 single leukocytes from healthy controls and more than 100 single leukocytes from affected individuals with known deletions were analyzed. Amplification efficiency for each tested locus was 98-100%. The false-negative rates for each analysis taken separately was <1%. Taken together, however, the results of the triplex-nested PCR analysis had a false-negative rate of 0%. No contamination was detected in all wash-drop blanks tested. We subsequently performed 18 PGD cycles in 5 DMD carriers. A total of 156 embryos were biopsied and successfully analyzed. Of these, 39 affected embryos were detected and 50 unaffected embryos were transferred (mean = 2.9 +/- 1.1 embryos per cycle). These resulted in three biochemical pregnancies and three clinical pregnancies, all of which have culminated in the birth of normal offspring.

Triplex-nested PCR using 2 of 11 DMD loci and the SRY gender marker allow PGD for >90% of DMD families with known deletions. These protocols are associated with a high amplification efficiency and accuracy.

    Duchenne muscular dystrophy (DMD)
    DIAGNOSIS

 is a

    lethal X-linked recessive disorder
    GENETICS

 with an incidence of approximately 1 in 3500

    males
    GENDER

, caused by

    mutation in the DMD gene
    GENETICS

. About 2/3 of

    DMD
    DIAGNOSIS

 cases are caused by

    gross DMD gene deletion mutations
    GENETICS

. The purpose of this study was to develop a series of

    single-cell multiplex-nested PCR
    PARACLINICAL

 protocols for

    preimplantation genetic diagnosis (PGD)
    PARACLINICAL

 of the most prevalent

    DMD deletions
    GENETICS

.

The protocols were developed on

    single blood leukocytes
    PARACLINICAL

 from normal

    males
    GENDER

 and

    females
    GENDER

 and patients with known

    DMD gene deletion
    GENETICS

. In the first reaction, 2 of

    11 different primer sets (exons 4, 8, 12, 13, 17, 46, 47, 49, 50, 52 and intron 52)
    PARACLINICAL

 were used to allow the simultaneous

    amplification of different DMD loci and the SRY gender marker
    PARACLINICAL

, in a single

    triplex-nested polymerase chain reaction (PCR)
    PARACLINICAL

. Aliquots of this reaction were then subjected to

    nested PCR
    PARACLINICAL

 in which each locus was amplified individually. Following the successful establishment of

    single-cell triplex-nested PCR in single leukocytes
    PARACLINICAL

, the technique was employed in five clinical

    PGD
    DIAGNOSIS

 cases.

For each

    DMD locus
    PARACLINICAL

, more than 50 single leukocytes from healthy controls and more than 100 single leukocytes from affected individuals with known deletions were analyzed. Amplification efficiency for each tested locus was 98-100%. The false-negative rates for each analysis taken separately was <1%. Taken together, however, the results of the

    triplex-nested PCR analysis
    PARACLINICAL

 had a false-negative rate of 0%. No contamination was detected in all wash-drop blanks tested. We subsequently performed 18

    PGD cycles
    MEDICATION

 in 5

    DMD
    DIAGNOSIS

 carriers. A total of 156 embryos were

    biopsied
    PARACLINICAL

 and successfully analyzed. Of these, 39 affected embryos were detected and

    50 unaffected embryos were transferred (mean = 2.9 +/- 1.1 embryos per cycle)
    MEDICATION

. These resulted in three

    biochemical pregnancies
    SYMPTOMS

 and three

    clinical pregnancies
    MEDICATION

, all of which have culminated in the birth of

    normal offspring
    SYMPTOMS

.

    Triplex-nested PCR using 2 of 11 DMD loci and the SRY gender marker
    PARACLINICAL

 allow

    PGD
    MEDICATION

 for >90% of

    DMD
    DIAGNOSIS

 families with

    known deletions
    GENETICS

. These protocols are associated with a high amplification efficiency and accuracy.

Duchenne muscular dystrophy (DMD)
DMD
PGD
DMD
DMD

lethal X-linked recessive disorder
mutation in the DMD gene
gross DMD gene deletion mutations
DMD deletions
DMD gene deletion
known deletions

biochemical pregnancies
normal offspring