横井 克幸

症例は5歳女児で、発熱、悪心、胸痛を主訴とした。砂遊びによる両手指の慢性湿疹に対して外用加療中であり、近医受診後も発熱が持続し、入院時には胸骨直上に辺縁不明瞭な発赤、腫脹を認め、CT検査で胸骨体の両側に低吸収帯を認めた。感染症の疑いで抗菌薬治療を開始し、血液培養でメチシリン耐性黄色ブドウ球菌(MRSA)が同定されたため、バンコマイシン(VCM)を併用した。その結果、解熱と胸痛の軽快が得られ、MRSAによる原発性胸骨骨髄炎と診断した。その後はCRP陰性化を確認してリネゾリド内服に変更し、VCMと併せて計6週間の抗MRSA薬による治療を行ったところ、炎症の再燃や血小板減少は認めなかった。本症例では手指の慢性湿疹が感染経路と考えられ、慢性湿疹を背景に持つ患児では薬剤耐性菌による全身性の感染症に留意する必要があると考えられた。

Mutations in transport and Golgi organization 2 homolog (TANGO2) have recently been described as a cause of an autosomal recessive syndrome characterized by episodes of metabolic crisis associated with rhabdomyolysis, cardiac arrhythmias, and neurodegeneration. Herein, we report a case of a one-and-a-half-year-old Japanese girl, born to nonconsanguineous parents, who presented with metabolic crisis characterized by hypoglycemia with hypoketonemia, rhabdomyolysis, lactic acidosis, and prolonged corrected QT interval (QTc) at the age of 6 months. Acylcarnitine analysis during the episode of crisis showed prominent elevation of C14:1, suggesting very-long-chain acyl-CoA dehydrogenase (VLCAD) deficiency. In addition, worsening rhabdomyolysis was observed after intravenous administration of L-carnitine. VLCAD deficiency was initially suspected; however, the enzyme activity in lymphocytes was only mildly decreased at the gene carrier level, and no mutation in the VLCAD gene (ADADVL) was detected. Subsequently, acylcarnitine analysis was nonspecific at 17-h fasting and almost normal during the stable phase. Eventually, a trio whole-exome sequencing revealed a compound heterozygous variant of two novel variants in the TANGO2 gene, a missense variant, and a deletion of exon 7. This is the first case of TANGO2 deficiency in Asians. Our case suggests that elevated C14:1 may be seen in severe metabolic crises and that the use of L-carnitine should be avoided during metabolic crises.

Maple syrup urine disease (MSUD) is a rare autosomal recessive inherited disorder of branched-chain amino acid metabolism caused by mutations in BCKDHA, BCKDHB, and DBT that encode the E1α, E1β, and E2 subunits of the branched-chain α-ketoacid dehydrogenase (BCKD) complex. Various MSUD-causing variants have been described; however, no structural rearrangements in BCKDHA have been reported to cause the classic MSUD phenotype. Here, we describe the classic patient with MSUD with compound heterozygous pathogenic variants in BCKDHA: a missense variant (NM_000709.3:c.757G > A, NP_000700.1:p.Ala253Thr) and a paracentric inversion disrupting Intron 1 of BCKDHA, which was identified by whole-genome sequencing and validated by fluorescence in situ hybridization. Using the sequence information of the breakpoint junction, we gained mechanistic insight into the development of this structural rearrangement. Furthermore, the establishment of junction-specific polymerase chain reaction could facilitate identification of the variant in case carrier or future prenatal/preimplantation tests are necessary.

Thrombotic microangiopathy (TMA) is a disease that causes organ damage due to microvascular hemolytic anemia, thrombocytopenia, and microvascular platelet thrombosis. Streptococcus pneumoniae-associated TMA (spTMA) is a rare complication of invasive pneumococcal infection. In addition, atypical hemolytic uremic syndrome (aHUS) is TMA associated with congenital or acquired dysregulation of complement activation. We report the case of a nine-month-old boy with refractory nephrotic syndrome complicated by spTMA in the setting of heterozygous complement factor-I (CFI) gene mutation and CFHR3-CFHR1 deletion. He repeatedly developed thrombocytopenia, anemia with schistocytes, hypocomplementemia, and abnormal coagulation triggered by infection, which manifested clinically with convulsions and an intraperitoneal hematoma. Eculizumab (a monoclonal humanized anti-C5 antibody) provided transient symptomatic benefit including improvement in thrombocytopenia; however, he developed unexplained cardiac arrest and was declared brain dead a few days later. In this report, we highlight the diagnostic challenges of this case and the causal relationship between spTMA and complement abnormalities and consider the contribution of heterozygous mutation of CFI and CFHR3-CFHR1 deletion.

Maturity-onset diabetes of the young (MODY) is a form of diabetes mellitus characterized by autosomal dominant inheritance, early onset, and the absence of pancreatic autoimmune markers. MODY-causing mutations have been identified in 14 genes, and carboxyl ester lipase (CEL) has been implicated in MODY8. We report a Japanese patient with MODY who harbored a heterogeneous mutation in CEL exon 2 (NM_001807.4:c.146_147delCT; NP_001798.2:p.Ser49CysfsTer52). A 13-year-old girl experienced her first episode of diabetic ketoacidosis, during which her endogenous insulin secretion was poor. However, her insulin secretion had apparently recovered 2 months after the commencement of insulin treatment, and no further treatment was required for the following 2 years. Diabetic ketoacidosis recurred when the patient was 15 years old, when her insulin secretion was again poor. Since that time, the patient, who is now 18 years old, has been undergoing continuous insulin treatment. The large fluctuations in her insulin secretory capacity led us to suspect MODY. MODY8 patients that carry a mutation in the variable number of tandem repeats in the last exon of the CEL gene typically show pancreatic exocrine dysfunction. However, in the present case, which features premature termination, there is no involvement of exocrine dysfunction, potentially demonstrating a genotype-phenotype correlation.

Urea cycle disorders (UCDs), inborn errors of hepatocyte metabolism, cause hyperammonemia and lead to neurocognitive deficits, coma, and even death. Sodium 4-phenylbutyrate (NaPB), a standard adjunctive therapy for UCDs, generates an alternative pathway of nitrogen deposition through glutamine consumption. Administration during or immediately after a meal is the approved usage of NaPB. However, we previously found that preprandial oral administration enhanced its potency in healthy adults and pediatric patients with intrahepatic cholestasis. The present study evaluated the effect of food on the pharmacokinetics and pharmacodynamics of NaPB in five patients with UCDs. Following an overnight fast, NaPB was administered orally at 75 mg/kg/dose (high dose, HD) or 25 mg/kg/dose (low dose, LD) either 15 min before or immediately after breakfast. Each patient was treated with these four treatment regimens with NaPB. With either dose, pre-breakfast administration rather than post-breakfast administration significantly increased plasma PB levels and decreased plasma glutamine availability. Pre-breakfast LD administration resulted in a greater attenuation in plasma glutamine availability than post-breakfast HD administration. Plasma levels of branched-chain amino acids decreased to the same extent in all tested regimens. No severe adverse events occurred during this study. In conclusion, preprandial oral administration of NaPB maximized systemic exposure of PB and thereby its efficacy on glutamine consumption in patients with UCDs.

<title>Abstract</title>We report a case of a 13-year<bold>-</bold>old boy with arginase 1 deficiency carrying a new variant in <italic>ARG1</italic>. Sanger sequencing identified the compound heterozygous variants: NM_000045.4: c.365G&gt;A (p.Trp122*)/c.820G&gt;A (p.Asp274Asn). Although not previously reported, the p.Asp274Asn variant is predicted to have strong pathogenicity because it is located in a highly conserved domain in the protein core and arginase activity in the patient was below measurement sensitivity.

Cancer treatment with a fluoropyrimidine (FP) is often accompanied by severe toxicity that may be dependent on the activity of catalytic enzymes encoded by the DPYD, DPYS, and UPB1 genes. Genotype-guided dose individualization of FP therapy has been proposed in western countries, but our knowledge of the relevant genetic variants in East Asian populations is presently limited. To investigate the association between these genetic variations and FP-related high toxicity in a Japanese population, we obtained blood samples from 301 patients who received this chemotherapy and sequenced the coding exons and flanking intron regions of their DPYD, DPYS, and UPB1 genes. In total, 24 single nucleotide variants (15 in DPYD, 7 in DPYS and 2 in UPB1) were identified including 3 novel variants in DPYD and 1 novel variant in DPYS. We did not find a significant association between FP-related high toxicity and each of these individual variants, although a certain trend toward significance was observed for p.Arg181Trp and p.Gln334Arg in DPYS (P = .0813 and .087). When we focused on 7 DPYD rare variants (p.Ser199Asn, p.IIe245Phe, p.Thr305Lys, p.Glu386Ter, p.Ser556Arg, p.Ala571Asp, p.Trp621Cys) which have an allele frequency of less than 0.01% in the Japanese population and are predicted to be loss-of-function mutations by in silico analysis, the group of patients who were heterozygous carriers of at least one these rare variants showed a strong association with FP-related high toxicity (P = .003). Although the availability of screening of these rare loss-of-function variants is still unknown, our data provide useful information that may help to alleviate FP-related toxicity in Japanese patients with cancer.

高安動脈炎は大動脈とその主要分枝などに病変を生じる大型血管炎で、若年女性に好発する。疾患特異的なマーカーがなく、微熱や全身倦怠感が数週間〜数ヵ月続き、不明熱の鑑別の中で診断されることが多い。我々はけいれん重積で搬送された児が精査の結果、高安動脈炎による腎動脈狭窄が原因の高血圧性脳症だったことが判明した症例を経験したので報告する。症例は13歳、女児。生来健康で、既往歴、家族歴に特記すべきことなし。受診の1ヵ月ほど前から頭痛・嘔気を度々訴えていたが、登校できていた。受診前日の夜より眠れない程の強い頭痛を訴え、翌日朝に児がけいれんしているところを家族が発見し当院へ救急搬送された。けいれん重積および収縮期200mmHg以上の高血圧を認め、それぞれ抗けいれん薬および降圧薬の投与を開始した。頭部MRIの所見より高血圧性脳症と診断した。身体所見では腹部の収縮期血管雑音を認め、四肢の血圧の左右差は認めなかった。またCRPを含めた血液検査は正常であった。後に判明したRA系の亢進と、入院2日目に実施した胸腹部の造影CTで広範囲にわたる大動脈ならびに腎動脈を含む主要分枝の狭窄所見から、高血圧の原因は高安動脈炎による腎血管性高血圧と診断した。バイパス術など専門的な治療を要すると判断し入院4日目に他院に転院となった。本症例はけいれん重積で搬送され診断に至った比較的稀な例である。発熱の病歴はなく、受診時のCRPなどの炎症マーカーも陰性であり、さらにPET-CTにおいても病変部位の炎症反応を検出できず、すでに高度に狭窄した血管病変がみられた。本疾患では一般にCRPや赤沈値などの非特異的な炎症性蛋白の上昇を伴うことが多いが、慢性の経過を辿る症例では炎症所見に乏しい症例も存在する。高学年〜思春期の特に女児に原因不明の重度高血圧を認める場合は本症の可能性を考える必要がある。(著者抄録)

ビタミンB12(VitB12)は代謝産物であるアデノシルコバラミン(AdoCbl)がメチルマロニルCoAムターゼ(MCM)の補酵素であるため、VitB12摂取・腸管での吸収・輸送の諸段階の障害でMCMの活性低下をきたし、メチルマロン酸血症(MMA)を来す。また、母体疾患に伴うVitB12欠乏症では、新生児マススクリーニング(NBS)で児のプロピオニルカルニチン(C3)およびそのアセチルカルニチンに対する比(C3/C2比)高値が検出されることがある。我々はNBSでC3高値、C3/C2比高値を認め、母体からの移行抗内因子抗体により児の尿中メチルマロン酸排泄増加を来たした2例を経験したため報告する。2例とも精査時の血中VitB12は正常範囲であったが、尿中メチルマロン酸・メチルクエン酸の排泄増加、血漿中総ホモシステイン高値を認め、精査受診時にVitB12の内服を開始した。その後、母への詳細な問診の結果、両症例の母はともに悪性貧血の既往がある事が判明した。いずれの母もVitB12投与による治療歴を認めたが、治療中止後も貧血とVitB12低下を認めないことから、妊娠期に治療は継続されていなかった。両症例の母と児の抗内因子抗体を確認したところ陽性であった。両児のメチルマロン酸血症関連遺伝子検査では変異は検出されなかった。2例はそれぞれ生後1.5歳時、6ヵ月時に抗内因子抗体の陰性化を確認し、これらの結果より抗内因子抗体は母体由来の移行抗体であったと考えられた。血中ビタミンB12濃度が正常であっても、母体由来の抗内因子抗体による潜在的なVitB12欠乏の可能性を念頭に置く必要がある。我々はNBSにてC3・C3/C2比高値を示す児の母への詳細な問診の重要性を再認識した。(著者抄録)

Background: Hypophosphatasia (HPP) is a rare inborn error of metabolism that results from a dysfunctional tissue non-specific alkaline phosphatase enzyme (TNSALP). Although genotype-phenotype correlations have been described in HPP patients, only sparse information is currently available on the genetics of mild type HPP. Methods: We investigated 5 Japanese patients from 3 families with mild HPP (patients 1 and 2 are siblings; patient 4 is a daughter of patient 5) who were referred to Fujita Health University due to the premature loss of deciduous teeth. Physical and dental examinations, and blood, urine and bone density tests were conducted. Genetic analysis of the ALPL gene was performed in all patients with their informed consent. Results: After a detailed interview and examination, we found characteristic symptoms of HPP in some of the study cases. Mobile teeth or the loss of permanent teeth were observed in 2 patients, and 3 out of 5 patients had a history of asthma. The serum ALP levels of all patients were 30% below the lower limit of the age equivalent normal range. ALPL gene analysis revealed compound heterozygous mutations, including Ile395Val and Leu520Argfs in family 1, Val95Met and Gly491Arg in family 2, and a dominant missense mutation (Gly456Arg) in family 3. The 3D-modeling of human TNSALP revealed three mutations (Val95Met, Ile395Val and Gly456Arg) at the homodimer interface. Severe collisions between the side chains were predicted for the Gly456Arg variant. Discussion: One of the characteristic findings of this present study was a high prevalence of coexisting asthma and a high level serum IgE level. These characteristics may account for the fragility of tracheal tissues and a predisposition to asthma in patients with mild HPP. The genotypes of the five mild HPP patients in our present study series included 1) compound heterozygous for severe and hypomorphic mutations, and 2) dominant-negative mutations. All of these mutations were at the homodimer interface, but only the dominant-negative mutation was predicted to cause a severe collision effect between the side chains. This may account for varying mechanisms leading to different effects on TNSALP function.

BACKGROUND: Several immunosuppressants have been used to treat children with steroid-dependent nephrotic syndrome (SDNS). Mizoribine (MZR) is an immunosuppressant used to maintain remission in children with SDNS, although its effectiveness for treating SDNS remains controversial. Therefore, in this study, we assessed the clinical factors associated with children having SDNS who were successfully treated with MZR. METHODS: A total of 47 children with SDNS who underwent MZR treatment were retrospectively evaluated. Clinical features including pharmacokinetics after MZR administration were compared between MZR responders and non-responders. RESULTS: The comparison of the two groups revealed no significant differences in age, body weight (BW), daily dose of MZR per BW, serum concentration 2 h after administration (C2), peak serum concentration (Cmax), and area under the concentration curve 0-4 h after administration (AUC0-4). C2/(single dose/BW), Cmax/(single dose/BW), and AUC0-4/(single dose/BW) were significantly higher in the MZR responders than in the non-responders (all p < 0.01). Receiver operating characteristic analysis revealed that the cutoff values of C2 (single dose/kg), Cmax/(single dose/BW), and AUC0-4/(single dose/BW) were 0.55, 0.58, and 1.37, respectively. CONCLUSIONS: MZR is a useful immunosuppressant for treating frequent-relapse NS in children who are susceptible to the drug. The efficacy of MZR may be associated with not only serum concentrations defined by the dosage or absorption efficiency through MZR transporters, but also the susceptibility defined by the expression level and performance of MZR transporters on the target cells.

溶連菌感染後急性糸球体腎炎(PSAGN)は、A群β溶連菌感染症後に血尿、浮腫、高血圧を三主徴として発症する小児には比較的頻度の高い腎疾患であるが、時に乏尿によりはっきりした尿所見を認めずに浮腫や高血圧のみが前面になって発症する例があり、腎外症候性急性糸球体腎炎といわれる。今回、無熱性けいれんで発症した1例を経験したので報告する。症例は10歳男児。入院1週間前より腹痛、嘔吐、下痢といった胃腸炎症状を認めていた。入院前日より頭痛があり、入院当日に急激な意識レベルの低下、両側上肢の強直性けいれんを認め当院に搬送された。来院時の血液検査・髄液検査・頭部CTでは明らかな異常所見認めず、無熱性けいれんとして精査、加療目的に入院とした。第4病日頃より強い頭痛の訴えと血圧191/103mmHgと著明高値を認め、高血圧緊急症と診断した。同日に行った頭部MRI T2強調像、FLAIR像にて後頭葉に高信号域を認め可逆性後頭葉白質脳症(PRES)と診断した。血液検査では補体価の著減を認め、さらにASLO、ASKの著増、咽頭よりA群溶連菌迅速抗原陽性を認めたことより、PSAGNとこれに伴う二次性高血圧と診断した。高血圧症に対してニカルジピン塩酸塩持続静注等の緊急治療を行い諸症状は改善した。その後の全身状態は良好で第13病日に頭部MRI再検、PRESの所見は不明瞭化していることを確認し退院とした。PSAGNの中に、本例のように臨床的に高血圧のみが前面に出現する例があり、溶連菌感染症流行期に高血圧や浮腫を呈する症例の鑑別疾患として本症があることを考慮する必要があると考えられた。(著者抄録)

症例は9ヵ月男児。当院初診の約3ヵ月前に熱源不明の発熱で近医に入院治療を受け、その後2ヵ月間で約1.5kgの体重減少と活気不良を認めたため精査加療目的で当科紹介受診した。初診時、脱水兆候と無呼吸発作がみられ、血液検査で著明な電解質異常と代謝性アルカローシス、高レニン・高アルドステロン血症を認めた。入院後に直ちに電解質補正を実施し徐々に全身状態、検査値とも改善した。輸液中止後も電解質が正常であることを確認して退院とした。しかし退院1ヵ月後に誘因なく同様の活気不良、電解質異常と代謝性アルカローシスを生じ、再び入院治療を行った。Bartter症候群(BS)・Gitelman症候群(GS)など遺伝性塩類喪失性尿細管機能異常症を疑い遺伝子解析を行ったところCLCNKAにヘテロでの変異を認めたが、既存の病型分類には当てはまらずBS/GSは否定的と考えられた。一方、本例は発症の約3ヵ月前に熱源不明の発熱で入院治療を行った後から体重減少を認めており、腎盂腎炎や尿細管間質性腎炎などの感染症、もしくは薬剤性による間質性腎炎に伴う広汎な尿細管障害をきっかけとする慢性的な電解質異常や哺乳不良の結果、偽性BSを呈した可能性が考えられた。(著者抄録)

症例:12歳女児。重症新生児仮死による脳性麻痺、慢性腎不全の診断で重症心身障害児として外来管理を行なっていた。入院の3日前から頻回嘔吐、喘鳴が出現し徐々に増悪、経管栄養も困難となったため当院救急外来を受診した。発熱、喘鳴、ツルゴールの低下、10%の体重減少を認め、検査にて高Na血症および右上肺野の浸潤影を認めたことから、誤嚥性肺炎、高張性脱水の診断で入院となった。高張性脱水に対し、等張液を用いた輸液を開始したところ、脱水所見は改善したものの血清Na濃度は上昇を続けた。輸液を低張Na製剤に変更した後も血清Naが上昇するため、最終的に5%グルコース液にて1日水分量を最低100ml/kgとなるよう輸液量を維持したところ、数日で血清Na濃度は改善した。高Na血症下で慢性腎不全状態としては不相応に血清K濃度が低下する傾向があったことから、アルドステロン作用の関与を疑い追加検査を行ったところ、著明な高アルドステロン血症および抗利尿ホルモン(AVP)の高値を認めた。全身状態の改善後、自宅での充分な水分管理を続けたところ、約3ヵ月後には血漿アルドステロン値およびAVPの改善がみられ、電解質の異常は認められなかった。患児は胃食道逆流により日常的に嘔吐が認められ、慢性的な水分、栄養注入量の不足状態にあったことに加え、腎不全によるAVP反応性低下による希釈尿排泄が慢性的な脱水状態を生じ、アルドステロンの過剰分泌を来したものと考えられた。このようなNa排泄障害下でのNa含有製剤による輸液が容易に高Na血症を招いたと考えられた。本例のような特殊な背景がある患児に対して輸液を行う際には、基礎疾患とそれに伴う病態を十分に把握しておくことが重要と考えられた。(著者抄録)

Phosphoglucomutase 1 (PGM1) deficiency is a recently defined disease characterized by glycogenosis and a congenital glycosylation disorder caused by recessive mutations in the PGM1 gene. We report a case of a 12-year-old boy with first-cousin parents who was diagnosed with a PGM1 deficiency due to significantly decreased PGM1 activity in his muscle. However, Sanger sequencing revealed no pathogenic mutation in the PGM1 gene in this patient. As this case presented with a cleft palate in addition to hypoglycemia and elevated transaminases and creatine kinase, karyotyping was performed and identified homozygous inv(1)(p31.1p32.3). Based on the chromosomal location of the PGM1 gene at 1p31, we analyzed the breakpoint of the inversion. Fluorescence in situ hybridization (FISH) combined with long PCR analysis revealed that the inversion disrupts the PGM1 gene within intron 1. Since the initiation codon in the PGM1 gene is located within exon 1, we speculated that this inversion inactivates the PGM1 gene and was therefore responsible for the patient's phenotype. When standard molecular testing fails to reveal a mutation despite a positive clinical and biochemical diagnosis, the presence of a gross structural variant that requires karyotypic examination must be considered.

BACKGROUND: Ornithine transcarbamylase deficiency (OTCD) is an X-linked recessive disorder involving a defect in the urea cycle caused by OTC gene mutations. Although a total of 417 disease-causing mutations in OTC have been reported, structural abnormalities in this gene are rare. We here describe a female OTCD case caused by an exonic duplication of the OTC gene (exons 1-6). CASE PRESENTATION: A 23-year-old woman with late-onset OTCD diagnosed by biochemical testing was subjected to subsequent genetic testing. Sanger sequencing revealed no pathogenic mutation throughout the coding exons of the OTC gene, but multiplex ligation-dependent probe amplification (MLPA) revealed duplication of exons 1-6. Further genetic analyses revealed an inversion of duplicated exon 1 and a tandem duplication of exons 2-6. Each of the junctions of the inversion harbored a microhomology and non-templated microinsertion, respectively, suggesting a replication-based mechanism. The duplication was also of de novo origin but segregation analysis indicated that it took place in the paternal chromosome. CONCLUSION: We report the first OTCD case harboring an exonic duplication in the OTC gene. The functional defects caused by this anomaly were determined via structural analysis of its complex rearrangements.