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314 Missed newborn screening for CF presenting to the haematologists
Posters
13. Case reports
314 Missed newborn screening for CF presenting to the haematologists E. Kavaliunaite1 , E. Owen2 , C. Wallis1 . 1 Great Ormond Street Hospital for Children NHS Foundation Trust, Cystic Fibrosis Unit, London, United Kingdom; 2 Great Ormond Street Hospital for Children NHS Foundation Trust, Dietetic Department, London, United Kingdom LG is the first child of Caucasian parents living in UK. There is no family history of CF. LG was born in France at 39+3 weeks of gestation with a birth weight of 2780 g (9th centile). Guthrie test performed in France was negative for CF. LG lived in France for the first 5 weeks of life and came back to UK. She had been breastfed and regained her birth weight at 1 month of age. At 8 weeks of age, LG was seen in Paediatric clinic for failure to thrive. Family went to Jordan for work reasons at 10 weeks of age, where she was found falling off her centiles. Paediatrician requested blood tests which showed significant anaemia (Hb 6.8 g/L). LG came back to UK and was admitted to the hospital at 13 weeks of age. On admission her weight had dropped to 0.4th centile. She had hyperferritinaemia, hypoalbuminaemia, hypotransferrinaemia, raised GGT, normal ALT, normal bilirubin, raised ALP, low fibrinogen, anaemia with rest of FBC normal and splenomegaly. Extensive haematological tests were performed including bone marrow aspirate. Investigation for failure to thrive and malabsorption revealed exocrine pancreatic insufficiency (stool elastase <15) and she was commenced on TPN and MCT enteral feed. No specific diagnostic label was proposed. Liver biopsy demonstrated lobular and focal cholestasis and marked steatosis suggestive of CF. Despite a previously negative newborn screening, CF genetics was checked, this showed p.Phe508del homozygote and CF diagnosis was made at 4 months of age. Despite NBS, CF should not be forgotten in a baby with faltering growth and anaemia. False negative tests for CF newborn screening can delay the diagnosis of CF with important clinical consequences.
315 Late diagnosis of CF in a family with R117H J. McNeilly1 , J.C. Rendall1 , J.S. Elborn1 , D.G. Downey1 . 1 Belfast City Hospital, Belfast Health & Social Care Trust (BHSCT), NI Regional Adult Cystic Fibrosis Centre, Belfast, United Kingdom A 60-year-old man with bronchiectasis, nasal polyps, loose stools and a FEV1 38% predicted was referred for further investigation. He also had bilateral absence of the vas deferens. Extensive bronchiectasis was shown on high resolution CT (HRCT) scanning. Sweat chloride was positive (71.78 mmol/l). Mutation analysis demonstrated F508del and R117H;T[5]. His sputum cultured B. vietnamiensis and S. aureus. Faecal elastase was 114 mg/g. He was established on Dornase alpha and pancreatic enzyme replacement therapy. His FEV1 improved with an associated reduction in his frequency of exacerbations. Genetic screening of his 6 siblings resulted in 3 of them being diagnosed with CF. They all have F508del and R117H;T[5]. His 57-year-old brother had a history of recurrent chest infections, nasal congestion and infertility. He has moderate bronchiectasis on HRCT and his sputum cultures S. aureus. His 47-year-old sister had a sweat chloride of 89 mmol/l with moderate bronchiectasis on HRCT. She has cultured Mycobacteria avium complex. His 58-year-old brother presented with an FEV1 47% predicted, a sweat chloride of 118 mmol/l and widespread bronchiectasis on HRCT. He has pancreatic insufficiency (faecal elastase <15 mg/g). His sputum cultures S. maltophilia. Discussion: It has been suggested that R117H be removed from CF screening panels. R117H may not cause sufficient malfunction of the CFTR protein, however when it is found in cis with a shortened polythymidine sequence, the combination can lead to significantly decreased CFTR function and clinical cystic fibrosis, as demonstrated in this case series. Such individuals may benefit further from CFTR corrector therapy.
S139
316 A longitudinal investigation of genomic and phenotypic factors leading to adaptation of Pseusomonas aeruginosa in a cystic fibrosis patient S. D’Arcangelo1 , K.E. Bailey1 , O. Jousson1 . 1 Universit`a di Trento, CIBIO, Trento, Italy Pseudomonas aeruginosa plays an important role in morbidity of cystic fibrosis (CF) patients. Infection of CF patients occurs via primary colonisation of the airways followed by the accumulation of adaptive mutations in the bacterial genome which increase fitness in the lung environment to result in chronicization. We obtained 45 P. aeruginosa isolates from a single CF patient collected over an 8 year period (2007–2014). By applying a suite of genotypic and phenotypic assays to this strain collection our aim is to characterise the adaptive changes that have occurred over this period both in response to the host environment and the treatment regime of the patient. MLST analysis of the population identified one dominant genotype and 5 further closely related genotypes which emerged transiently across the sampling time. Phenotypic analysis revealed the population to show previously defined characteristics of adaptation to the CF lung including a reduction in motility and protease activity, changes in exopolysaccharides and pigment production, compared to the acute infection isolate, PA14. Multiple isolates from this collection have been sequenced and comparative analysis is currently underway with the aim of identifying genes showing accumulation of SNPs which may be implicated in host adaptation.
317 When Pseudomonas aeruginosa and orthodontic appliances go together! R. Rivas Caldas1 , A. Diriou2 , G. Rault2 , S. Gouriou1 , M. Virmaux1 , G. Barbier1 , S. Boisrame1 . 1 Laboratoire Universitaire de Biodiversit´e et d’Ecologie Microbienne (LUBEM − EA 3882), Brest, France; 2 Cystic Fibrosis Reference Center, Roscoff, France Context: P. aeruginosa lung infection is an important cause of morbidity and mortality in cystic fibrosis (CF). Management of mouthbreathing associated with chronic nasal and sinus obstruction in CF patients requires orthodontic treatment. The oral cavity, containing hundreds of different commensal microorganisms, is a colonisation place for opportunistic bacteria such P. aeruginosa. We reported a case of an 11-years-old CF girl that became first colonized to P. aeruginosa after an orthodontic treatment. Objective: The aim was to investigate clonality of oral and pulmonary P. aeruginosa isolates in this patient. Methods: Twenty-eight strains were isolated from oral samples and lung expectorations between January to June 2014. The longitudinal study involved prospective cultures of different oral swabs and sputum. Strains were characterized by cultural methods, disc diffusion antibiograms, Pulsed Field Gel Electrophoresis (PFGE) and Multi Locus Sequence Typing (MLST). Results: Strains showed different morphotypes and resistance phenotypes, probably involving mechanisms such as overproduction of the active MexXY efflux system and b-lactamase overproduction. Moreover, the study of the sequential isolates revealed a unique and novel sequence type, ST1852. In addition, all isolates revealed the same PFGE pattern, representing consequently a unique clonal cluster. Conclusion: This study demonstrated for this patient that a single clone was found in oral cavity and lung expectoration. These results suggested that the oral cavity is a reservoir of P. aeruginosa for lung (re-)colonization. Orthodontic appliances containing methyl methacrylate favors the maintenance of these strains.
13. Case reports
314 Missed newborn screening for CF presenting to the haematologists E. Kavaliunaite1 , E. Owen2 , C. Wallis1 . 1 Great Ormond Street Hospital for Children NHS Foundation Trust, Cystic Fibrosis Unit, London, United Kingdom; 2 Great Ormond Street Hospital for Children NHS Foundation Trust, Dietetic Department, London, United Kingdom LG is the first child of Caucasian parents living in UK. There is no family history of CF. LG was born in France at 39+3 weeks of gestation with a birth weight of 2780 g (9th centile). Guthrie test performed in France was negative for CF. LG lived in France for the first 5 weeks of life and came back to UK. She had been breastfed and regained her birth weight at 1 month of age. At 8 weeks of age, LG was seen in Paediatric clinic for failure to thrive. Family went to Jordan for work reasons at 10 weeks of age, where she was found falling off her centiles. Paediatrician requested blood tests which showed significant anaemia (Hb 6.8 g/L). LG came back to UK and was admitted to the hospital at 13 weeks of age. On admission her weight had dropped to 0.4th centile. She had hyperferritinaemia, hypoalbuminaemia, hypotransferrinaemia, raised GGT, normal ALT, normal bilirubin, raised ALP, low fibrinogen, anaemia with rest of FBC normal and splenomegaly. Extensive haematological tests were performed including bone marrow aspirate. Investigation for failure to thrive and malabsorption revealed exocrine pancreatic insufficiency (stool elastase <15) and she was commenced on TPN and MCT enteral feed. No specific diagnostic label was proposed. Liver biopsy demonstrated lobular and focal cholestasis and marked steatosis suggestive of CF. Despite a previously negative newborn screening, CF genetics was checked, this showed p.Phe508del homozygote and CF diagnosis was made at 4 months of age. Despite NBS, CF should not be forgotten in a baby with faltering growth and anaemia. False negative tests for CF newborn screening can delay the diagnosis of CF with important clinical consequences.
315 Late diagnosis of CF in a family with R117H J. McNeilly1 , J.C. Rendall1 , J.S. Elborn1 , D.G. Downey1 . 1 Belfast City Hospital, Belfast Health & Social Care Trust (BHSCT), NI Regional Adult Cystic Fibrosis Centre, Belfast, United Kingdom A 60-year-old man with bronchiectasis, nasal polyps, loose stools and a FEV1 38% predicted was referred for further investigation. He also had bilateral absence of the vas deferens. Extensive bronchiectasis was shown on high resolution CT (HRCT) scanning. Sweat chloride was positive (71.78 mmol/l). Mutation analysis demonstrated F508del and R117H;T[5]. His sputum cultured B. vietnamiensis and S. aureus. Faecal elastase was 114 mg/g. He was established on Dornase alpha and pancreatic enzyme replacement therapy. His FEV1 improved with an associated reduction in his frequency of exacerbations. Genetic screening of his 6 siblings resulted in 3 of them being diagnosed with CF. They all have F508del and R117H;T[5]. His 57-year-old brother had a history of recurrent chest infections, nasal congestion and infertility. He has moderate bronchiectasis on HRCT and his sputum cultures S. aureus. His 47-year-old sister had a sweat chloride of 89 mmol/l with moderate bronchiectasis on HRCT. She has cultured Mycobacteria avium complex. His 58-year-old brother presented with an FEV1 47% predicted, a sweat chloride of 118 mmol/l and widespread bronchiectasis on HRCT. He has pancreatic insufficiency (faecal elastase <15 mg/g). His sputum cultures S. maltophilia. Discussion: It has been suggested that R117H be removed from CF screening panels. R117H may not cause sufficient malfunction of the CFTR protein, however when it is found in cis with a shortened polythymidine sequence, the combination can lead to significantly decreased CFTR function and clinical cystic fibrosis, as demonstrated in this case series. Such individuals may benefit further from CFTR corrector therapy.
S139
316 A longitudinal investigation of genomic and phenotypic factors leading to adaptation of Pseusomonas aeruginosa in a cystic fibrosis patient S. D’Arcangelo1 , K.E. Bailey1 , O. Jousson1 . 1 Universit`a di Trento, CIBIO, Trento, Italy Pseudomonas aeruginosa plays an important role in morbidity of cystic fibrosis (CF) patients. Infection of CF patients occurs via primary colonisation of the airways followed by the accumulation of adaptive mutations in the bacterial genome which increase fitness in the lung environment to result in chronicization. We obtained 45 P. aeruginosa isolates from a single CF patient collected over an 8 year period (2007–2014). By applying a suite of genotypic and phenotypic assays to this strain collection our aim is to characterise the adaptive changes that have occurred over this period both in response to the host environment and the treatment regime of the patient. MLST analysis of the population identified one dominant genotype and 5 further closely related genotypes which emerged transiently across the sampling time. Phenotypic analysis revealed the population to show previously defined characteristics of adaptation to the CF lung including a reduction in motility and protease activity, changes in exopolysaccharides and pigment production, compared to the acute infection isolate, PA14. Multiple isolates from this collection have been sequenced and comparative analysis is currently underway with the aim of identifying genes showing accumulation of SNPs which may be implicated in host adaptation.
317 When Pseudomonas aeruginosa and orthodontic appliances go together! R. Rivas Caldas1 , A. Diriou2 , G. Rault2 , S. Gouriou1 , M. Virmaux1 , G. Barbier1 , S. Boisrame1 . 1 Laboratoire Universitaire de Biodiversit´e et d’Ecologie Microbienne (LUBEM − EA 3882), Brest, France; 2 Cystic Fibrosis Reference Center, Roscoff, France Context: P. aeruginosa lung infection is an important cause of morbidity and mortality in cystic fibrosis (CF). Management of mouthbreathing associated with chronic nasal and sinus obstruction in CF patients requires orthodontic treatment. The oral cavity, containing hundreds of different commensal microorganisms, is a colonisation place for opportunistic bacteria such P. aeruginosa. We reported a case of an 11-years-old CF girl that became first colonized to P. aeruginosa after an orthodontic treatment. Objective: The aim was to investigate clonality of oral and pulmonary P. aeruginosa isolates in this patient. Methods: Twenty-eight strains were isolated from oral samples and lung expectorations between January to June 2014. The longitudinal study involved prospective cultures of different oral swabs and sputum. Strains were characterized by cultural methods, disc diffusion antibiograms, Pulsed Field Gel Electrophoresis (PFGE) and Multi Locus Sequence Typing (MLST). Results: Strains showed different morphotypes and resistance phenotypes, probably involving mechanisms such as overproduction of the active MexXY efflux system and b-lactamase overproduction. Moreover, the study of the sequential isolates revealed a unique and novel sequence type, ST1852. In addition, all isolates revealed the same PFGE pattern, representing consequently a unique clonal cluster. Conclusion: This study demonstrated for this patient that a single clone was found in oral cavity and lung expectoration. These results suggested that the oral cavity is a reservoir of P. aeruginosa for lung (re-)colonization. Orthodontic appliances containing methyl methacrylate favors the maintenance of these strains.