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 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 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 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 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