Transcript normal findings

The 5th international Congress
of the International Prof. Dr. Alireza Yalda Academic Forundation
in Medical Sciences
6-10th 2014, Tehran University of Medical Sciences
The rising importance of the progress and application of the
molecular and cellular medicine in clinical medicine
Prof. Prof.h.c. Alireza Ranjbar, M.D.,Ph.D
,
Research Institute of Interventional
Allergology and Immunology
Cologne/Bonn, Germany
History
Rudolf Virchow published a concept that the origin of diseases should
be found in error of cellular function.
Robert Koch showed that some illnesses are caused by
microorganisms. It was the base of today´s understanding of
pathogenesis of infectious diseases.
Paul Ehrlich expanded the approach of cellular and molecular levels.
His perception of substances which react specifically with
microorganisms or body´s own cells through of specific receptors,
introduced the beginning of molecular orientated therapy.
The Max Delbrück´s work about the nature of gene mutation and
gene structure was the base of modern molecular Genetics and
molecular biology.
Introduction
The development of modern cellular and molecular biology will lead
in next years to paradigm change in diagnostic and therapy as well as in
prevention of diseases.
The use of molecular approach gives us the opportunity to explain the
function of each cell und of particular cellular components, and to
recognize the mechanisms and rules of their interactions in
tissues and organs.
By understanding of these biological processes the possibility arises
for rational and specific therapy as opposed to up to now mostly
symptomatic approach .
Clinical application of molecular and
ceullar medicine in infectious diseases
and immunology
Case
Chief complaints
• A 17-years-old male patient, related parents
• Persistent cerebral TB and chronic meningitis since
the past 12 months with severe headache
• Skin abscess
• Resistance to anti TB and antibiotic therapy
Past medical history
• Episodes of recurrent otitis, sinusitis, pneumonia
and skin abscesses
• Recurrent hospitalization and surgical cleaning of
skin abscesses
• At 2 years of age CGD was diagnosed by use of
NBT-Test(Nitroblue Tetrazolim Test)
Therapy and course of disease:
 appropriate antibiotic therapy
 repeated surgical cleaning of skin abscess
 appropriate anti-tuberculosis treatment with INH, Rifampicine,
Pyrazinamide, Ethambutol, Streptomycine
 Subcutanous interferron gamma with a dosage of 50 µg/ m2
body surface 3 times per week
 All therapy interventions were without success
Lab. at referring
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Leuc
PMN
Hb
Hct
Thromb.
ESR
CRP
RF
ANA
Anti-ss-DNS
IgG
IgM
IgA
20000 µl
92%
9,2
29%
520000 µl
82 mm
78 mg/l
negativ
negativ
negativ
2400 mg/dl
180 mg/dl
80 mg/dl
Lab. at referring
 Aspiration of skin abscess:
 CSF :
Staph. aureus
Mycobacterium tuberculosis by use of PCR und cultur,
sensitive to INH und Rifampicine
 HIV-Ab : negative
 HIV-Ag mittels PCR: negative
 Zinc, copper within normal range, iron deminished, Ferritin
increased
Selenium: 32 µg/l (normal range 100-150 µg/l)
Granulocyte function test by use of Dehydrorodamin-Test (DHR)
123:
Phagocytosis
58%
84-96
Respiratory burst low
0,2%
3-17
(fMLP)
Respi. burst high
2%
91-97
(PMA)
Respi. burst E.Coli
2%
91-97%
Respi. burst Staph. aur. 1%
91-97%
Monocyte function test:
Phagocytosis
52%
Respiratory burst
4%
Respi. burst Staph. aur. 1%
60-76
48-80
48-80
Granulocyte function after Stimulation with IFN-gamma:
before
after
Phagocytosis
58%
62 %
Respiratory burst low
0,2%
0,2%
(fMLP)
Respi. burst high
2%
4%
(PMA)
Respi. burst E.Coli
2%
3%
Respi. burst Staph. aur. 1%
1%
Monocyte function test:
Phagocytosis
52%
Respiratory burst
4%
Respi. burst Staph. aur. 1%
64%
7%
4%
IFN-gamma receptor (CD 119): normal
IL-12 receptor (IL-12Rbeta1): normal
 Lymphocyte subpopulation by flow cytometry: normal
IL-4 and IFN-gamma und IL-4 levels in PBMC
IL-4 levels (pg/ml)
1000
142,4
37,2
Patient
Control
group
IFN-gamma levels
(U/ml)
150
124
28,2
Patient
Control
group
Therapy and follow up
 Prednisolone pulse therapy weekly for 2 cycles
 Selenium in term of sodium selenite with a dosage of 10µg/kg
BW per day
 Unchanged continuation of antituberculous therapy.
 Significant improvement of subjective symptoms and headache
2 weeks after therapy
Brain MRI 2 weeks after therapy
before therapy
after therapy
IL-4 and IFN-gamma und IL-4 levels in PBMC
2 wks. after therapy
IL-4 levels (pg/ml)
1000
142,4
37,2
Vor Th
Nach Th
IFN-gamma levels
(U/ml)
150
28,2
Vor Th
124
Nach Th
Granulocyte function 2 wks. after therapy:
before
Phagocytosis
58%
Respiratory burst low
0,2%
(fMLP)
Respi. burst high
2%
(PMA)
Respi. burst E.Coli
2%
Respi. burst Staph. aur. 1%
after
66 %
0,4%
12%
22%
18%
Monocyte function:
Phagocytosis
52%
Respiratory burst
4%
Respi. burst Staph. aur. 1%
58%
17 %
12 %
Granulocyte function after stimulation with IFN-gamma 2
wks. after therapy:
before
after
Phagocytosis
66 %
66%
Respiratory burst low
0,4%
12%
(fMLP)
Respi. burst high
12%
80%
(PMA)
Respi. burst E.Coli
22%
82%
Respi. burst Staph. aur. 18%
78%
Monocyte function:
Phagocytosis
Respiratory burst
Respi. burst Staph. aur.
58%
17 %
12 %
60%
62%
84%
Therapy and follow up
 Continuation of selenium therapy
 Continuation of antituberculous treatment
 Interferron gamma 50 µg/ m2 body surface, subcutanous 3
times per week
 Symptom-free 4 wks. after therapy,no headache, no skin
abscess
Brain MRT 6 wks. after therapy
Before therapy
After therapy
Lab. 3 months after therapy
 CSF : Cultur: steril, M. tuberculosis was not grown,
PCR : still positive
 Selenium : 82 µg/l
 CBC: mild anemia and leucocytosis, otherwise normal findings
 CRP : 12 µg/l (Norm <5)
 ESR: 42 mm
Lab. 6 months after therapy
 CSF : Cultur: steril, M. tuberculosis was not grown,
PCR for M. tuberculosis: negative
 Selenium : 140 µg/l
 CBC: normal
 CRP : 3 µg/l (Norm <5)
 ESR: 32 mm
Clinical application of molecular medicine
in endocrinology
Case
9-yr-old male, unrelated parents
PH: gestation, birth, somatic and mental development
normal
FH: Diabetes mellitus in 4 persons in 2 generations
CC: since 6 months tiredness, listlessness,low performance
after diagnosing of Diabetes mellitus type I and insulin
therapy in an external pediatric clinic.
The patient showed a significant variability of BS levels
and hypoglycemic shocks despite low dose insulin
therapy
Findings at diagnosing by us:
-
Physical and neurological exam: normal findings
- no fever, no weight loss, no night sweats, weight 50 P
Findings at diagnosing by us:
- FBS: 220 mg/dl
-Urin: Glucose++, Keton +, otherwise normal findings
- HbA1c: 6,5 (normal range: 4,7-6,4)
- FT3,FT4,TSH, free corstisol in serum and all rotine lab: normal
- TPO-Ab,TG-Ab, TSH-Receptor-Ab: negative
- Islet cells-Ab, GADII-Ab, Tyrosinphosphatase IA 2-Ab and
Insulin-Ab: negative
Suspicion diagnosis:
MODY 2 (Maturity Onset Diabetes of the Young type 2)
MODY
Maturity Onset Diabetes of the Young (MODY) is a group of diabetes
disorders that affects about 2-5% of people with diabetes. MODY is
often not recognised and people may be treated as Type 1 or Type 2
diabetes.
MODY diabetes is based on genes mutations which are responsible
for glucose transport and metabolism and insulin secretion.
Till now 6 different genes have been recognised.
•hepatic nuclear factor (HNF)-1alpha (MODY 1)
•Glucokinase (GCK) (MODY 2)
•HNF-1beta (MODY 3)
•HNF-4alpha (MODY 4)
•insulin promoter factor-1 (MODY 5)
•NeuroD/BETA2 (MODY 6)
MODY
The following characteristics suggest the possibility of a diagnosis of MODY in
hyperglycemic and diabetic patients:
- Mild to moderate hyperglycemia (typically 130-250 mg/dl, or 7-14 mM)
- Discovered before 25 years of age.
- A first degree relative with a similar degree of diabetes.
- Absence of positive antibodies or other autoimmunity (e.g.,thyroiditis) in
patient and family.
- Persistence of a low insulin requirement (e.g., less than 0.5 u/kg/day) past the
usual "honeymoon" period.
- Absence of obesity (though obese people can get MODY), or other problems
associated with type 2 diabetes or metabolic syndrome (e.g. hypertension,
hyperlipidemia, polycystic ovary syndrome)
- Cystic kidney disease, hypoplasia or malformations of sexual organs (e.g.
vaginal hypoplasia) in patient or close relatives (MODY 5)
- Non-transient neonatal diabetes, or apparent type 1 diabetes with onset before
6 months of age.
MODY 2
- MODY 2 is due to any of several mutations in the GCK gene on
chromosome 7 for glucokinase.
- Glucokinase serves as the glucose sensor for the beta cell and is an
important enzyme for the glycogen synthesis in the lever.
Findings at diagnosing by us:
Because MODY 2 does not show any significant pathological rising
of postprandial BS , we discharged insulin and meseured BS pre
and postprandial within 5 days.
The results did not show pathological postprandial BS levels
Findings at diagnosing by us:
Molecular genetic exam:
Mutation of Glucokinase-Gene K420E
Therapy:
Insulin discharged
Dietary measures and sport
The degree of hyperglycemia does not usually worsen with
age and long-term diabetic complications are rare
Clinical application of molecular medicine
in diabetology
Case
4-yr-old female , related healthy parents (cousin 1. grade)
PH: gestation, birth, somatic and mental development normal
CC: before 3 wks. detection of glucose in urin (glucose ++++) by a preventional
exam
The child was symptom free, no polydipsia or polyuria, no signs for
infections
FH: Gestational diabetes by the mother, diabetes type 2 by the grandmother
Findings in an external pediatric clinic
- Urin exam: Glucose ++++, Keton negative, otherwise normal
findings, amino acids: negative
SDS-Electrophoresis in 24h-urin: normal findings
- FBS, HbA1c, FT3,FT4,TSH, free corstisol in Serum and all
routine lab: normal
- Oral Glucose Tolerance Test: normal
- Islet cells-Ab, GADII-AK, Tyrosinphosphatase IA 2-Ab: negative
- Ultrasound of abdomen and kidney: normal findings
- Ophtholmologic and ENT exam: normal findings
Findings at diagnosing by us:
- Physical and neurological exam: normal findings
-Urin: Glucose ++++, Keton negative, otherwise negative
- Urin exam by the parents: normal
- Suspicion diagnosis: benigne renal glucosuria
autosomal recessive form
Molecular genetic exam on mutation of
Na+/Glucose-Cotransporter-Gene typ 2 (SGLT2=SLC5A2):
Child:
Gene mutation E421K in homozygotic form
Both parents: Gene mutation E421K in heterozygotic form
Therapy:
- No therapy , no dietary measures
- No relationship with diabetes mellitus
Clinical application of molecular medicine
in infection induced hepatitis
Case
Oxidative Stress
and
Infectious Diseases
Free oxygen radicals (reactive oxygen species=ROS) are atoms,
molecules or residues which carry single electrones in the outer
membane. They possess a great potential to damage the vital cells
because of reaction with proteins, lipids and DNA.
Die important ROS in the biological systems :
Singulett-Oxygen (1O2)
Superoxide anions (O2- )
H2O2
OHOrganic peroxide (ROOH)
Cell damages by ROS
Aus: “Free Radicals
Randox Ltd.
The important origins of ROS are:
- Respiratory chain
- NAD(P)H-Oxidase of neutrophils, macrophages and endothelial
cells of blood vessels
The human body has a complex protecting system to eleminate
these toxic substances which is called as antioxidants.
The imbalance between anti- and prooxidants in favour of
prooxidants is defined as oxidative stress, by which different illness
can be initiated.
Schematic outline of the immunologic process in
(Ranjbar A.)
the inflammation
Macrophage
IL-1
LTB4
fMLP
C5a
T cells
IL-6
TNF-alpha
B cells
GM-CSF
IL-8
Neutrophils
Lysozyme
Oxygen free radicals
Elastase
Collagenase
Muraminidase
H2O2
OH O2
-
Myeloperoxidase
Elimination of
microorganism
Destruction of
connective and
mesenchymal tissues
ROS and mutation of microorganism
• ROS may cause mutation of microorganisms,
which lead to an increase of pathogenicity of
microorgnisms, to resistance to antibiotics and
to araise of cancerogenicity.
Case report
10-yr-old male , unrelated healthy parents
PH: gestation, birth, somatic and mental development
normal

CC: chronic active hepatitis , interferon therapy in
the department of paediatric hepatology of
university children hospital in Germany
because of negative Anti-HBe , high Hep. B
virus load in blood (measured by PCR) and
increas of transaminase
The therapy was not tolerated , did not lead to
improvement and was discharged after 4 wks.
Case report
PE: normal physical and neurological findings, mild
icterus , tiredness, listlessness , low performance,
decline in physical and mental standards
Case report
Abdomen ultrasound:
Mild increased echogenicity of liver paranchyme,
otherwise normal findings
Lab.
Normal range
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CBC
Thromb.
ESR
CRP
Protein-Electr.
Bilirubin total
Bilirubin direct
Gamma GT
SGOT
SGPT
HBs-Ag qualitative
HBc-IgM
HBc-IgG
HBs-Ab
HBe-Ab
HBV-DNA quantitaive (PCR)
Hepatitis A ,C,D,E serology
All autoantibodies
AFP and CEA
normal
251000 µl
8 / 14 mm
< 5 mg/l
normal
1,73 mg/dl
1,2 mg/dl
47 U/l
170 U/l
224 U/l
positive
negative
positive
negative
negative
9,2 exp7 Copy/ml
negative
negative
negative
<5
<1
< 19
< 47
< 39
Lab
Normal range
 Selenium
58 µg/l
100-150
 Beta-Carotin
0,38 mg/l
0,47-4,1
 Ery.-Malondialdehyde (MDA)
432 nmol/g Hb
48-123
 Gluthation-Peroxidase
26,2 U/g Hb
25-54
Lab.
 Genotype of Hepatitis B-Virus:
Point mutation rtA194T
Therapy
- Sodium-Selenit oral 300µg/day
- Beta-Carotin 10 mg /day
- fruit and vegetables approx. 500 gr. /day
- Reduction of saturated fatty acids
- Reduction of red meats
Therapy results
 significant improvement of physical and mental
standards 2 wks. after therapy
Lab. 4 wks. after therapy
before Therapy
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Bilirubin total
Bilirubin direct
Gamma GT
SGOT
SGPT
HBs-Ag qualitative
HBc-IgM
HBc-IgG
HBs-Ab
HBe-Ab
HBV-DNA quantitaive(PCR)
 Genotype
1,73 mg/dl
1,2 mg/dl
47 U/l
170 U/l
224 U/l
positive
negative
positive
negative
negative
9,2 exp7 copy/ml
Point mutation
rtA 194t
after 4 W
1,32
0,8
22
98
128
positive
negative
positive
negative
negative
8,8 exp7
no point mutation
detectable
Lab. 4 wks. after therapy
before therapy
after 4 W
 Selenium
58 µg/l
82
 Beta-Carotin
0,38 mg/l
4,2
 Ery.-Malondialdehyde (MDA)
432 nmol/g Hb
82
 Gluthation-Peroxidase
26,2 U/g Hb
38,6
Therapy
- Interferon s.c. 5 Mio. E/m2 3 x per week
- Sodium-Selenit oral 200µg/day
- Fruit and vegetables approx. 500 gr. /day
- Reduction of saturated fatty acids
- Reduction of red meats
Lab. 6 wks. after Interferon therapy
before
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Bilirubin gesamt
Gamma GT
SGOT
SGPT
HBs-Ag qualitative
HBc-IgM
HBc-IgG
HBs-Ab
HBe-Ab
HBV-DNA quantitaive (PCR)
1,32 mg/dl
22 U/l
98 U/l
128 U/l
positive
negativ
positive
negative
negative
8,8 exp7 copy/ml
after 6 W
0,8
12
46
56
positive
negative
positive
negative
positive
3,8 exp3
Thank you for your attention
Antioxidants („Scavenger“)
Vitamins
etc ...
Enzyme
-A -C -E
- Catalase
- SOD Superoxiddismutase
- Glutathion peroxidase
- ...
Carotinoids
-  -Carotin
-  -Carotin
- Lycopin
- Lutein
- Zeaxanthin
- ...
Trace elements
- Selenium
Free
Radicals
as cofactors
- Iron - Copper
- Zinc - Mangan
Sulfide
- Allicin
- ...
Phytoestrogens
- Isoflavonoide
- ...
Polyphenole
- Phenolic acid
- Flavonoids
- ...
Synergie!
Ubichinon
XR-GSH
Vitamin E
GST( ,,,)
ROS
Vitamin C
-
X-R
Cu,Zn SOD
-
Mn SOD
CATALASE
LDL
8-OHdGnk
ATP
DNS
Methionin
Cystein
Spermin
Spermidin
NAC
-Liponsre
GSH
GR
GSSG
© Bieger 05/2000
HNE
MDA
PGF2
SAM
GPX
8-OHdG
mt
Requirements for an effective antioxidant therapy
• Quality of antioxidants (antioxidative capacity)
• Presence of suitable carriers
Requirements for an effective antioxidant therapy
• Quality of antioxidants (antioxidative capacity)
Synergismus of nature
100 gr fresh apple contins approx.
5,7 mg Vit C
The antioxidative capacity
is equal to
1500 mg synthetic Vit C
Nature 2000, 430: 903-4
Nutrition: Antioxidant activity of fresh apples
MARIAN V. EBERHARDT1, CHANG YONG LEE1 & RUI HAI LIU1
Department of Food Science, 108 Stocking Hall, Cornell University, Ithaca, New York 14853-7201, USA
Nature 405, 903 - 904 (June 22th, 2000)
The antioxidative
capacity of 100g
apple (5,7mg Vit. C)
Is equal to 1500 mg
synthetic vitamin C
total oxyradical-scavenging capacity
(TOSC; mol vitamin C equivalents per g)
Requirements for an effective antioxidant therapy
• Presence of suitable carriers
Selenium levels in serum of children with
AD (n = 62) in comparison
100
with control group (n = 78)
90
80
70
p < 0.01
60
40
Text
Selenium levels in serum µg/l,
mean +/- SD
50
30
198
20
10
Children with AD
Control group
150
Selenium levels in whole blood of children with
AD (n = 62) in comparison
with control group (n = 78)
135
120
105
90
p < 0.01
Text
Selenium levels in serum µg/l,
mean +/- SD
75
60
45
180
30
15
Children with AD
Control group
Selenium levels of children with moderate AD
before and after oral therapy with sodium selenite
responder (n=52)vs. non-responder(n=10)
Whole blood
20
Serum
20
p < 0.01
100
p < 0.01
p < 0.01
80
µg/l, mean +/- SD
ns
60
40
104
20
1
3
2
0
198
170
162
130
115
100
4
0
Responder
4
Non-Responder
Weeks
Selenium levels of non-responder children with
moderate AD before and after oral therapy
with sodium selenite and
fruit /vegetables (n=8)
Whole blood
p < 0.05
100
ns
µg/l, mean +/- SD
80
60
170
40
20
1
3
0
0
210
165
4
Weeks
Serum
20
20
Free radicals and
oxidative stress
„If you don‘t get
enough
antioxidants, it is
the equivalent of
irradiating
yourself.“
„It‘s the same as
stepping
unprotected in
front of an xray
machine.“
B.N. Ames, JAMA 1995