Normal Titers Research Articles

Paraneoplastic cerebellar degeneration (PCD) with a normal serum paraneoplastic panel and high anti-Yo titers in the cerebrospinal fluid (CSF): case report and literature review (P6.189)

Paraneoplastic cerebellar degeneration (PCD) with a normal serum paraneoplastic panel and high anti-Yo titers in the cerebrospinal fluid (CSF): case report and literature review (P6.189)

Anti streptolysin O (ASO) titers in normal healthy children aged between 5 to 15 years in Ujjain region

Introduction: Rheumatic fever is an inflammatory disease that may develop after an infection with Streptococcus pyogenes bacteria, believed to be caused by antibody cross reactivity that can involve heart, joints, skin and brain. Measurement of Anti Streptolysin O (ASO) antibodies to specific streptococcal antigens is therefore necessary for the diagnosis of the preceding Group A Streptococcal (GAS) infection. Aims and objectives: To determine the upper limit of the normal ASO titers in normal healthy school going children aged 5-15 years and to determined a baseline value to compare with when a single ASO titer is available. Material and method: A community based cross sectional study was done on normal healthy children aged 5-15 years divided into group 1 (5-10 years) and group 2 (11-15 years) after taking informed consent from parents. Blood sample were collected after thorough sterilization of the area. ASO testing from serum sample was done using TURBILYTE Antistreptolysin ‘O’ diagnostic reagent for quantitative in-vitro determination of ASO in serum on photometric systems. Results: Out of total 200 children included in the study, 100 were in group 1 and 100 in group 2, 118 (59%) were males and 82 (41%) were females. The mean ASO titer for group 1 was 105.69 IU and that of group 2 was 144.73 IU with a standard deviation of 3.675 and 5.823 respectively (P value <0.05). Out of total 200 students 160 were living in overcrowded conditions. The mean ASO titer of children with overcrowded living conditions was 131.41 IU with a standard deviation of 53.472, and those with non-overcrowded living condition was 100.42 IU with a standard deviation of 39.30 (P value < 0.05). Conclusion: The upper limit of normal (ULN) was greater in the children of Group 1 (P value <0.05, 200 Vs 135). No statistically significant difference was found in the ASO titer according to gender. Statistically significant high mean ASO titer (131.41 IU) was found in children living in overcrowded conditions as compared to those living under non-overcrowded conditions (100.41 IU).

Flow cytometry as an important tool in the diagnosis of immunodeficiencies demonstrated in a patient with ataxia-telangiectasia

Abstract Background: Ataxia-telangiectasia (AT) is a rare hereditary genetic disease caused by one of more than 500 mutations in the ataxia-telangiectasia mutated gene (ATM). AT is characterized by cerebellar ataxia, telangiectasia of blood vessels, immunodeficiency with frequent lung infections, susceptibility to cancer, and sensitivity to ionizing radiation. A correct immunophenotyping of lymphocytes is necessary to identify the cause of the immunodeficiency. Methods: We evaluated a patient (female, 15 years) with AT by estimation of antibody titers, characterization of peripheral B- and T-cell subsets and investigation of proliferation response of B- and T-cells undergoing specific stimulation with PHA, CD3/CD28, and R848/CD40L. A healthy volunteer was used as a control. Results: The patient showed a heterozygous mutation in the ATM gene (c.5932G&gt;T[p.E1978X]/c.7788+3A&gt;G). Interestingly, despite a very low level of class-switched memory B-cells normal levels of serum immunoglobulins and antibody titers to viral and bacterial antigens could be observed. Furthermore, the analysis revealed an increase in total numbers of T-cells, caused by an extraordinarily high amount of γ/δ T-cells (CD3+CD4–CD8) (&gt;75% of T-cells). Remaining CD4+/CD8+T-cells were decreased, naïve cells and recent thymic emigrants (RTEs) were strongly deficient. Subsequently, the proliferation activity of T-cells was strongly impaired, in contrast to normal B-cell proliferation both compared to the healthy control. Conclusions: Initial lymphocyte immunophenotyping suggested a defect in T- and B-cell differentiation, but normal humoral antibody titers and B-cell proliferation were inconsistent with this suspicion. Therefore, the results revealed an underlying T-cell defect and low levels of class-switched B-cells results from the lacking assistance from T-cells.

Brief Report: Arthritis in KRN T Cell Receptor-Transgenic Mice Does Not Require Interleukin-17 or Th17 Cells.

Th17 cells and interleukin-17 (IL-17) cytokine family members are implicated in the pathogenesis of many rheumatic diseases. Most studies in mouse models of inflammatory arthritis have demonstrated a key role for the proinflammatory cytokine IL-17A and its receptor, the IL-17 receptor (IL-17R) A/C heterodimer. The aim of this study was to use a rigorous genetic approach to evaluate the contribution of Th17 cells and IL-17 in the autoantibody-dependent KRN T cell receptor-transgenic mouse model of arthritis. We bred KRN mice expressing the major histocompatibility complex class II molecule A(g7) (referred to as K/B/g7 mice) and genetically lacking the related cytokines IL-17A and IL-17F or their critical receptor subunit, IL-17RA. Using bone marrow transplantation, we generated mice in which hematopoietic cells from K/B/g7 donor mice lacked the key Th17-differentiating transcription factor, retinoic acid receptor-related orphan nuclear receptor γt (Rorγt). K/B/g7 mice lacking both IL-17A and IL-17F produced normal titers of pathogenic autoantibodies, and arthritis developed in a typical manner. Similarly, neither IL-17RA nor Rorγt expression by hematopoietic cells was required for disease development in this model. Despite prior reports suggesting that Th17 cells and IL-17A are crucially involved in the pathogenesis of arthritis in K/BxN mice, the results presented here provide genetic evidence that IL-17A and IL-17F, IL-17RA, and Rorγt expression by hematopoietic cells are dispensable for normal arthritis progression in the K/B/g7 mouse model system. We discuss potential explanations for the discrepancies between these 2 highly similar model systems. These findings plus those in other mouse models of arthritis provide insight regarding why therapeutic biologic agents targeting the Th17/IL-17 axis are beneficial in some human rheumatic diseases but not others.

THE INFLUENCE OF NEUTRALIZING ANTIBODIES TO INTERFERON-BETA ON PROGRESSION OF MULTIPLE SCLEROSIS

Background: Neutralizing antibodies (NAbs) affect the effectiveness of interferon therapy in patients with multiple sclerosis; however, this influence cannot be considered as unequivocal. NAbs formation is determined by several factors, such as frequency and duration of administration, interferon-β (IFN-β) formulation and the patient's genotype. It has been found that NAb titers vary over time. Aim: To assess the levels of NAbs to IFN-β in patients with multiple sclerosis and to investigate their relationship to disease progression. Materials and methods: We analyzed serum samples from 83 multiple sclerosis patients after a long-term IFN-β-1b treatment; NAbs detection reaction was performed by assessment of their cytopathic effect. Results: NAbs were found in 63.9% (53 of 83) of patients with dura???tion of IFN-β-1b treatment of 33.3±17.6 months. All NAb-positive patients were treated with high???dose IFN-β. Patients with titers>800 LU (n=28) demonstrated a trend towards more advanced neurologic deficit on the Expanded Disability Status Scale (EDSS), compared to the patients with normal NAbs titers (0 to 20 LU, n=30) and intermediate titers (20 to 800 LU, n=25) (p>0.05). The exacerbation rate in the group with NAbs titers from 20 to 800 LU was insignificantly lower than that in the group with NAbs>800 and in the NAb-negative patients (p>0.05). Conclusion: Testing for NAbs may be a promising method for monitoring of IFN-β therapy in multiple sclerosis. There was a trend towards more pronounced neurological deficit in patients with high NAbs titers, but paradoxical data on a high rate of exacerbations in NAb-negative patients requires further study.

The choice of surgery in patients with diffuse toxic goiter

to define clear individual indications for different operations for diffuse toxic goiter by research of immunological markers of thyrotoxicosis recurrence probability. Long-term results of survey and treatment of 215 patients with diffuse toxic goiter are presented. Patients were divided into 2 groups. The 1st group consisted of 31 patienrs who underwent conventional partial thyroidectomy. Group 2 included 184 patients. They were divided into 2 subgroups depending on type of surgery. Subgroup A included 59 patients after partial thyroidectomy and subgroup B - 125 patients after total thyroidectomy. In group 2 surgery was defined based on only level of antibodies against TSH-receptors. Recurrence incidence was 16 and 0% in groups 1 and 2 respectively. In patients with diffuse toxic goiter partial thyroidectomy is possible if normal titer of antibodies against TSH-receptors is present (<1.5 U/l). Total thyroidectomy is advisable in titer ≥1.5 U/l.

Altered differential hemocyte count in 3rd instar larvae of Drosophila melanogaster as a response to chronic exposure of Acephate.

Acephate, an organophosphate (OP) pesticide, was used to investigate the effects of its chronic exposure on hemocyte abundance in a non-target dipteran insect Drosophila melanogaster. For this purpose, six graded concentrations ranging from 1 to 6 μg/ml were selected, which are below the reported residual values (up to 14 μg/ml) of the chemical. 1st instar larvae were fed with these concentrations up to the 3rd instar stage and accordingly hemolymph smears from these larvae were prepared for differential hemocyte count. Three types of cells are found in Drosophila hemolymph, namely, plasmatocytes, lamellocytes and crystal cells. Plasmatocyte count was found to decrease with successive increase in treatment concentrations. Crystal cells showed an increasing trend in their number. Though the number of lamellocytes was very low, a bimodal response was noticed. Lamellocyte number was found to increase with the initial three concentrations, followed by a dose dependent reduction in their number. As hemocytes are directly linked to the immune system of fruit flies, fluctuations in normal titer of these cells may affect insect immunity. Hemocytes share homologies in their origin and mode of action with the immune cells of higher organisms including man. Thus the present findings suggest that immune cells of humans and other organisms may be affected adversely under chronic exposure to Acephate.

Study of the baseline widal titres among healthy individuals of rural population in puducherry

Background: Enteric fever is endemic in developing countries like India. Widal test in a single serum sample is often the only test relied upon for laboratory diagnosis. The test is considered positive if the antibody titres are higher than the cut - off value in a single test or a rising titre in paired sera. But normal baseline titres in healthy population and cutoff values have not been established in our area. So the aim of our study was to determine the base line titres of antibodies among apparently healthy populations and to define the significant titres of widal test. Materials and Methods: Samples were initially screened by Widal slide agglutination test and further confirmed by the Quantitative tube agglutination test. Results: Among the 500 samples from apparently healthy individuals, 260 samples were positive for agglutinins. 141 were positive for ‘O’ agglutinin and 163 were positive for ‘H’ agglutinin of Salmonella typhi. Among 141 samples, 30 showed agglutination up to 1in 20 titre, 100 up to 1in 40 and 25 (4.8%) up to 1in 80. Among 163 samples, 18 showed a titre of 1 in 20, 120 showed a titre of 1 in 40 and 21(4.2%) up to 1 in 80. Conclusion: When a single widal titre is used for the diagnosis of enteric fever in our locality, it will be more appropriate to change the currently used cutoff levels against S.typhi to ≥ 1 in 160 for anti-O and ‘H’ agglutinins remains the same of ≥ 1 in 160.

Diabetes and the thyroid

Thyroid disorders are more common in diabetic patients than in the general population. Abnormal thyroid function can be found in as many as 11% to 30% of patients with diabetes mellitus (DM) type 1 or 2. Thus, the Polish Society of Endocrinology and Polish Diabetes Association recommends screening for thyroid dysfunction in all patients with DM. According to these recommendations, concentrations of thyrotropin (TSH) and thyroid peroxidase antibodies (TPOAb) should be measured in every patient with newly diagnosed DM1, and in all patients with DM1 who have never undergone thyroid function tests. In exactly the same situations, patients with DM2 require TSH assessment, while TPOAb titer should be measured only if TSH reaches ≥ 2.0 mIU/L. In diabetic patients with TSH concentration ≥ 2.0 mIU/L and elevated TPOAb level, free thyroxin level should be assessed and – if normal – subsequently TSH should be monitored once a year. If the TSH concentration ≥ 2.0 mIU/L co-occurs with TPOAb titer within the reference range, TSH assessment should be repeated every other year. Patients with TSH < 2.0 mIU/L and normal TPOAb titer should undergo TSH testing every five years. Diabetic patients with a family history of chronic autoimmune thyroiditis require TSH testing once a year. If TPOAb titer is elevated in patients with DM2, the type of DM should be reassessed by measuring the level of antibodies against glutamic acid decarboxylase. Special attention should be paid to women who are pregnant or planning pregnancy. In the preconception period, TSH concentration should be measured in every woman with DM, and in DM1 patients together with TPOAb level. When pregnancy is confirmed, assessment of TSH and TPOAb is advised at the first obstetrician appointment (before 9th week of pregnancy). In all pregnant diabetic patients with a past medical history of Graves’ disease, anti-TSH receptor antibodies (TRAb) should be additionally measured at the first obstetrician appointment and repeated at the end of the second trimester (before the 22nd week of pregnancy). If carbohydrate balance is unimpaired, hyperthyroidism is rarely accompanied by hyperglycemia. Abnormal fasting or postprandial glucose levels in patients with hyperthyroidism indicate increased risk of developing diabetes. In such patients, oral glucose tolerance test (OGTT) should be performed once the euthyroidism is achieved. In diabetic patients, hyperthyroidism causes deterioration of metabolic control of DM and leads to all the systemic consequences of hyperglycemia, including increased risk of ketoacidosis. Additionally, even slight thyroid hormone excess significantly increases the risk of cardiovascular disease in patients with DM. Thus, both overt and subclinical hyperthyroidism should be treated in this group of patients. In diabetic patients with thyroid orbitopathy, the risk of optic neuropathy is increased, and intensive anti-inflammatory treatment should be introduced in every active disease except for the mild course cases. On the other hand, administering high steroid doses in patients with DM adversely influences the metabolic control of diabetes. Hence, in patients treated with oral anti-diabetic medications, periodic insulin therapy should be introduced along with steroid administration. In diabetic patients, also the hypothyroidism is proven to be an independent risk factor for cardiovascular episodes. Therefore, treatment of subclinical hypothyroidism is strongly recommended in this condition. Hypoglycemia or reduced insulin requirement in diabetic patients may indicate concomitant development of hypothyroidism and/ or – especially in patients with DM1 – adrenal insufficiency and polyglandular autoimmune syndrome. Unexplained hypoglycemic states always require hormonal testing to exclude these endocrine disorders.

Prolonged Pyrexia and Hepatitis: Q fever

PRESENTATION Despite an ever-expanding spectrum of available tests, fever of unknown origin remains a diagnostic dilemma. A 40-year-old Nepalese man living in Rhode Island presented with a 1-week history of nausea, vomiting, fevers, and frontal headache. He denied neck stiffness, abdominal pain, diarrhea, rash, or urinary symptoms. In the emergency department, he had a temperature of 100.4 F (38.0 C) and was tachycardic to 108 beats per minute. His physical examination was otherwise normal. Lumbar puncture demonstrated no pleocytosis. Polymerase chain reaction testing of cerebrospinal fluid was negative for herpes simplex virus and enterovirus; a western blot was negative for Lyme IgM and IgG. Whole-body computed tomography was unrevealing. The patient was discharged but returned 4 days later with persistent headaches and fever, so he was admitted for further workup. His past medical history was notable for hypertension, for which he took chlorthalidone, and anxiety, for which he was prescribed paroxetine. Three years earlier, he had completed a 9-month course of isoniazid for latent tuberculosis infection. He lived with his wife and denied new sexual contacts, as well as use of any alcohol, tobacco, or illicit drugs. The patient had not travelled outside of New England following his emigration from Nepal 3 years before. He lived in an urban area and worked as a maintenance worker at a suburban warehouse where he had rodent contact and cut the grass but he denied tick bites. He had visited a farm

THU0029 Inflammation is Strongly Associated with Lupus Anticoagulant Positivity, Independent of Known Autoimmune Disease and Recent Venous or Arterial Thrombosis

BackgroundThe antiphospholipid syndrome (APS) is an auto-immune disorder defined by presence of antiphospholipid antibodies and either thrombosis or obstetric complications (1). Laboratory part of the diagnosis of APS comprise of...

Production of class switched antibody secreting cells and antibody is inversely correlated with expression of the adaptor protein HSH2 (IRM8P.712)

Abstract Control and HSH2 transgenic (HSH2-Tg) mice were compared to mice that express approximately 1/6th the normal level of HSH2 (HSH2-Lo) to determine if there is an inverse relationship between HSH2 expression and class switched antibody (Ab) production. In contrast to HSH2-Tg mice, HSH2-Lo mice have normal serum Ig titers for IgG1 and IgG2b and elevated titers of IgG3. HSH2-Lo mice also exhibit enhanced production of IgG1, and IgG2b, or IgG3 in response to challenge with either TD or TI Ag, respectively. Stimulation of B cells isolated from HSH2-Lo mice with anti-CD40 and IL-4 results in the production of significantly more antibody secreting cells (ASC) that produce IgG1 and IgE versus control B cells, whereas HSH2-Tg B cells produce significantly fewer class switched ASCs. Although HSH2 expression is associated with a modest effect on class switch recombination, changes in class switched ASC production are most closely linked to alterations in terminal differentiation of GC B cells into plasma cells. Terminal differentiation of class switched B cells from HSH2-Lo mice is significantly increased following in vitro stimulation, resulting in enhanced production of class switched ASCs compared to control B cells. Conversely, class switched B cells generated from HSH2-Tg mice exhibit a significant decrease in differentiation into ASCs in vitro. Thus, differential expression of HSH2 in the B lineage regulates multiple steps associated with the generation of class switched ASCs.

Hurler-Scheie syndrome with subclinical hypothyroidism: A case report

Hurler-Scheie syndrome is an intermediate form of mucopolysaccharidosis (I H/S) and an autosomal recessive disorder caused by the deficiency of the enzyme L-iduronidase. We present the case report of a 7-year-old girl referred to us for evaluation of developmental delay with difficulty in walking, first detected at an age of 5 years. She was born to consanguineous parents with no family history of mucopolysaccharidoses. She had coarse facial features, short stature, hepatomegaly and her X-ray findings were consistent with mild form of dysostosis multiplex. Enzyme assay revealed deficient alpha-L-iduronidase activity in leukocytes. In addition to Hurler-Scheie syndrome, thyroid function tests indicated subclinical hypothyroidism with normal titers of thyroid microsomal and thyroglobulin antibodies. Hurler-Scheie syndrome with suclinical hypothyroidism is uncommon and has not been reported as yet.

Long-Term Follow-Up of a Child with Autoimmune Thyroiditis and Recurrent Hyperthyroidism in the Absence of TSH Receptor Antibodies.

Hashitoxicosis is an initial, transient, hyperthyroid phase that rarely affects patients with Hashimoto thyroiditis. We present here an unusual case of a child with Hashimoto thyroiditis and recurrent hyperthyroidism. A 4 yr 6/12 old male was diagnosed by us with autoimmune subclinical hypothyroidism (normal free T4, slightly elevated TSH, and elevated TG antibody titer). Two years and 6/12 later he experienced increased appetite and poor weight gain; a laboratory evaluation revealed suppressed TSH, elevated free T4, and normal TSI titer. In addition, an I123 thyroid uptake was borderline-low. A month later, the free T4 had normalized. After remaining asymptomatic for 3 years, the patient presented again with increased appetite, and he was found with low TSH and high free T4. Within the following 3 months, his free T4 and TSH normalized. At his most recent evaluation, his TSH was normal and the free T4 was borderline-high; the TG antibody titer was still elevated and the TSI titer was negative. To our knowledge, this is the first patient reported with Hashimoto thyroiditis and recurrent hyperthyroidism. This case exemplifies the variability of the manifestations and natural history of Hashimoto thyroiditis and supports the need for a long-term evaluation of patients with autoimmune thyroid disease.

The use of ABO-incompatible grafts in living donor liver transplantation—First report from India

ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.

Tissue Factor On The Herpes Simplex Virus Type 1 Surface Enhances Infection In Vivo

Tissue factor (TF) is a multifunctional transmembrane receptor. As the pivotal initiator of the coagulant response to vascular damage, it accelerates factor (F) VIIa-dependent generation of FXa. However, TF also functions in FVIIa/FXa-dependent cell signaling via protease activated receptors (PARs), and has consequently been implicated in a wide variety of physiological and pathological conditions. Our previous work adds to this repertoire by revealing that TF, originating from the host cell membrane, is on the surface of enveloped viruses. Using herpes simplex virus type 1 (HSV1) as a model for enveloped viruses, we recently produced TF +/- HSV1 variants, which showed that viral TF enhances infection of cultured cells through a mechanism involving FXa/FVIIa-mediated activation of PAR-2. In the current project we extended these studies in vivo, hypothesizing that TF on the HSV1 surface would enhance infection by influencing the activation of coagulation proteases and/or their role in cell signaling. As before, HSV1 NS strain (with restored glycoprotein C) was propagated in TF- or genetically engineered TF+ human melanoma A7 cells, then purified and quantified. HSV1 TF+ or HSV1 TF- virus (5 x 105 virus plaque forming units of similar particle number) was injected slowly in 100 µL into the tail vein of female, eight-week old balb/c mice. On the third day, organs and blood were harvested. Live virus and total HSV1 genome were evaluated by plaque assays and rtPCR, respectively. Strikingly, production of live HSV1 TF+ (n=13) in the lung, heart, spinal cord, liver and brain was greater by an order of magnitude compared to HSV1 TF- (n=13), which was not detected in some tissues. The presence of TF on HSV1 furthermore increased virus titers in spleen and blood by several fold. Viral replication in organs was corroborated by rtPCR. The procoagulant and signaling functions of TF can be dissected using epitope-specific monoclonal antibodies (mAbs) selective for human TF. These mAbs only recognize HSV1 surface TF and not the endogenous mouse TF. These mAbs or an irrelevant mAb (TIB115, n=8) were administered by intraperitoneal injection 4 hours pre-inoculation (1 mg/mouse). When TF-dependent coagulation and the related effects on cell signaling due to attenuated protease activation was blocked by a potent combination of three mAbs to non-overlapping epitopes (5G9/6B4/9C3; 0.33 mg/mouse each, n=10), reduced levels of live HSV1 TF+ were seen in lung, heart, liver, brain and blood, with concordantly reduced viral genome levels measured by rtPCR. Similar results were obtained with mAb 5G9 alone (n=6), which selective blocks FXa generation. Interestingly, titers of HSV1 TF+ in blood and spleen were not affected by mAB 10H10 (n=6) that has no effect on coagulation, but is an effective direct inhibitor of TF signaling. Despite normal blood titers, mAb 10H10 (n=6) reduced virus titers in heart and brain, but not in other organs. These data demonstrate that virus surface TF is important for HSV1 infection in vivo and indicate that distinct functions of TF contribute to organ-specific tropism. Disclosures:No relevant conflicts of interest to declare.

Adeno-Associated Virus Capsid Proteins May Play a Role in Transcription and Second-Strand Synthesis of Recombinant Genomes

A group of four interacting amino acids in adeno-associated virus type 8 (AAV8) called the pH quartet has been shown to undergo a structural change when subjected to acidic pH comparable to that seen in endosomal compartments. We examined the phenotypes of mutants with mutations in these amino acids as well as several nearby residues in the background of AAV2. We found that three of the mutations in this region (Y704A, E562A, and E564A) produce normal titers of mature capsids but are extremely defective for transduction (>10(7)-fold). The remaining mutants were also defective for transduction, but the defect in these mutants (E563A, E561A, H526A, and R389A) is not as severe (3- to 22-fold). Two other mutants (Y700A and Y730A) were found to be defective for virus assembly. One of the extremely defective mutants (Y704A) was found to enter the cell, traffic to the nucleus, and uncoat its DNA nearly as efficiently as the wild type. This suggested that some step after nuclear entry and uncoating was defective. To see if the extremely defective mutants were impaired in second-strand synthesis, the Y704A, E562A, and E564A mutants containing self-complementary DNA were compared with virus containing single-stranded genomes. Two of the mutants (Y704A and E564A) showed 1-log and 3-log improvements in infectivity, respectively, while the third mutant (E562A) showed no change. This suggested that inhibition of second-strand synthesis was responsible for some but not most of the defect in these mutants. Comparison of Y704A mRNA synthesis with that of the wild-type capsid showed that accumulation of steady-state mRNA in the Y704A mutant was reduced 450-fold, even though equal genome numbers were uncoated. Our experiments have identified a novel capsid function. They suggest that AAV capsids may play a role in the initiation of both second-strand synthesis and transcription of the input genome.

Widespread red oral lesions

A 46-year-old man was referred to us by his physician with a chief complaint of red patches on the tongue associated with a burning sensation that had occurred for approximately one year. His medical and dental histories were unremarkable. The patient had not encountered anything, including any type of food, that made the lesions improve or worsen. During a routine examination of the head and neck region, we observed no extraoral alterations, such as changes in the color of the face, swelling, facial asymmetry and palpable lymph nodes. When we conducted an intraoral examination, we observed multiple extensive erythematous areas on the inferior labial mucosa, buccal mucosa, tongue (dorsal, ventral and lateral aspects) and hard palate (Figures 1-3). Because the patient had diffuse mucosal erythema with a generalized burning sensation, we prescribed 20 milligrams of prednisone daily and topical benzocaine three times per day. After we noted no improvement following one week of treatment, we discontinued the prednisone and topical benzocaine and performed incisional biopsies on the tongue and buccal mucosa. Microscopic examination of the biopsied tissues revealed an atrophic surface of stratified squamous epithelium with a mild chronic inflammatory infiltrate within the lamina propria. One month after undergoing the biopsy, the patient complained of gastric distress, cramps, bloating, constipation, hair loss, and lack of energy and appetite. We requested testing for complete blood cell count, vitamin B12 level, and anti-endomysial, antitransglutaminase and anti-immunoglobulin A antibodies. The results of these tests showed a vitamin B12 deficiency with a level of serum cobalamin less than 150 picograms per milliliter (normal range [male], 193-982 pg/mL), a red blood cell (RBC) count of 3.96 million per cubic millimeter (normal range [male], 4.60-6.20 million/mm), a mean corpuscular volume (MCV) of 105.5 femtoliters (normal range [male], 76-96 fL), a mean corpuscular hemoglobin (MCH) weight of 35.1 pg (normal range [male], 27-32 pg) and an RBC distribution width of 17.3 percent (normal range [male], 11.5-14.5 percent). In addition, we found that the patient had negative levels of antiendomysial antibodies (normal titer, 35 units) and anti-immunoglobulin A antibody levels of 259 mg per deciliter (normal range [adults], 40-350 mg/dL).

Acquired haemophilia A in a patient with chronic hepatitis C virus infection receiving treatment with pegylated interferon plus ribarivin: role of rituximab.

Acquired haemophilia is an uncommon condition caused by the development of clotting factor inhibitors. To eliminate them, immunosuppressive therapy with corticosteroids and cytotoxic drugs is required. We describe a case of rituximab use in acquired haemophilia refractory to conventional therapy in a 63 year old male patient with chronic hepatitis C virus infection who was receiving treatment with pegylated-interferon-a-2a plus ribavirin. After 21 weeks of antiviral therapy, the patient was admitted to hospital with a large haematoma in the abdominal muscles. Factor VIII level was zero and inhibitor titer was 345 Bethesda units. Oral immunosuppressive therapy with methylprednisolone and cyclophosphamide was administered for 1 month, with limited improvement. Therefore, cyclophosphamide was replaced by a four once-weekly dose of intravenous rituximab. Two months later, factor VIII level was normal and inhibitor titer was undetectable. Rituximab may be useful for the treatment of acquired haemophilia resistant to standard therapy.

Risk factors of congenital hypothyroidism using propensity score: a matched case-control study.

The aim of this study was to investigate the relationship between congenital hypothyroidism and several variables using two different adjustment methods. This matched case-control study was conducted in Hamadan Province, the west of Iran, in 2012 enrolling neonates born between 2005 and 2011 and covered by screening program for congenital hypothyroidism. The neonates with TSH titer more than 10 mU/l or T4 titer less than 6.4 μg/dl were considered as cases. Each case was individually matched for birth place and year with four neonates with normal TSH and T4 titers as controls. The data were analyzed using two different approaches including propensity score and multiple conditional logistic regression model. Of 1313 enrolled neonates, 277 (159 girls) were cases and 1036 (531 girls) were controls. The most important prognostic factors which had significant effect on congenital hypothyroidism included twin, birth season, maturity, jaundice at birth, birth weight, age at pregnancy, maternal anemia and goiter, gestational age, delivery type, father's education and smoking status, and consanguinity. The associations reported by logistic regression were stronger that of than propensity score analysis in most items, although the differences were not statistically significant. We addressed the effect of numerous potential risk factors on congenital hypothyroiditis and the impact of these factors on the disease occurrence. However, future prospective studies are needed to test these findings and hypothesis and to investigate the true effect of these potential risk factors on congenital hypothyroiditis.