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0Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2015) 16, 69-73
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Egyptian Journal of Ear, Nose, Throat and Allied
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EJENTAS
ORIGINAL ARTICLE
Plasma level of transforming growth factor b 1 c^m^
in children with autism spectrum disorder
Tarek Mohamed El Gohary a, Nahal Abd El Aziz b, Mohamed Darweesh c'*, Ebtihal Shukery Sadaa a
a Department of Pediatric, Faculty of Medicine, Tanta University, Egypt b Department of Clinical Pathology, Faculty of Medicine, Tanta University, Egypt c Unit of Phoniatrics, ENT Department, Tanta University, Egypt
Received 6 May 2014; accepted 9 December 2014 Available online 26 December 2014
KEYWORDS
Autism;
Neurodevelopmental
disorders;
TGFßl;
DSM-IV (TR)
Abstract Background: Autism spectrum disorders (ASDs) are a group of neurodevelopmental disorders characterized by pervasive abnormalities in social interaction and communication, and repetitive and restricted behavioral patterns and interests. ASD include autistic disorder, Asperger's disorder, pervasive developmental disorder not otherwise specific and childhood disintegrative disorders.
Objectives: To detect plasma level of transforming growth factor beta 1 (TGFpl) in children with ASD and to find out correlation between the plasma level of TGFP1 and severity of ASD.
Patients and methods: Our study included 30 patients with autistic spectrum disorder (ASD) diagnosed on the basis of criteria of autistic spectrum disorders as defined in Diagnostic and Statistical Manual of Mental Disorders fourth edition text revised (DSM-IV) (TR). They were 26 males and 4 females, their ages ranged from 3 years to 13 years. Thirty apparently healthy sex and age matched children served as controls (22 males and 8 females). They were subjected to full history taking, clinical examination and severity rating using Child Autistic Rating Scale of Children (CARS) and Diagnostic and Statistical Manual of Mental Disorders fourth edition text revised (DSM-IV) (TR).
Results: Our study revealed: (a) sex distribution among the patient group with male/female ratio 6.5:1; (b) mean value of maternal age was significantly higher among patients than controls; (c) about 50% of patients had a history of prenatal complication; (d) the patient group shows lower plasma level of TGFP1 compared to the control group.
Conclusion: There may be an important role for the immune system in autism spectrum disorders that may have profound implications for diagnosis and treatment of this disorder. A negative correlation was found between severities of ASD and TGFP1 plasma level.
© 2014 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier
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* Corresponding author. Tel.: +20 01223947970, +20 403320033. E-mail address: mohameddarwish@hotmail.com (M. Darweesh). Peer review under responsibility of Egyptian Society of Ear, Nose, Throat and Allied Sciences.
http://dx.doi.org/10.1016/j.ejenta.2014.12.002
2090-0740 © 2014 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. All rights reserved.
1. Introduction
Autistic spectrum disorder is a complex developmental disorder with social and communication dysfunction at its core. Autistic spectrum disorders are a wide spectrum of conditions having a common triad of impairments. Deficits include those in social communication, social interaction and social imagination. It first gives signs during early childhood. Impairments result from maturation-related changes in various systems of the brain.1
The prevalence of ASD has increased substantially over the last decade rising from 5 to 60/10,000. The male to female ratio is three or four to one, but when it occurs in females it is more severe.3 The exact etiology of autism and ASD remains unknown, it is likely to result from a complex combination of environmental, immunological and genetic factors. Strong genetic links have been shown for cases with Tuberous sclerosis, Fragile X, neurofibromatosis, and chromosomal abnormalities.4'5
There is growing awareness of an immunological involvement in children with ASD. Evidence of immune dysregulation has been observed in some individuals with ASD including increase levels of pro-inflammatory cytokines in brain tissue, CSF and plasma and increased production of pro-inflammatory cytokines by peripheral blood mononuclear cell culture when compared to typically developing control.6-8 The regulatory immune response is also critical in the down-regulation of the inflammatory immune response following infection, thus limiting potential tissue damage. Immunosuppressive cyto-kines such as transforming growth factor beta 1 (TGFP1) are critical for immune homeostasis, important in induction of unresponsiveness in activated T cell.9,10
There are several studies that demonstrate an alteration or dysregulation of immune response in autism compared with matched controls.7,11-13 Altered TGFP1 levels have been observed in brain specimens of subjects with autism.8 Another study revealed decreased plasma TGFP1 in adults with
autism.14
This work was designed to evaluate patients with autistic disorders through detailed history and rating their severity using CARS, together with detection of the plasma level of TGFP1, in order to find out if it is altered in ASD thus it can help in understanding the nature of the problem and it may be used as an early marker in diagnosis.
2. Subjects and methods
2.1. Subjects
The study sample was composed of 30 children suffering from autism spectrum disorders (ASDs), attending outpatient clinic of Pediatric Neuropsychiatry and Phoniatrics of Tanta University Hospital.
2.2. Inclusion criteria
(DSM-IV) (TR) and Child Autistic Rating Scale of Children (CARS).
2.3. Exclusion criteria
1- Other mental or neurobehavioral disorders.
2- Chronic diseases or infections.
3- Medications modulating immunity.
4- Immune deficiency states.
The control group was composed of 30 clinically healthy properly matched children (22 males and 8 females), their ages ranged from 3 to 13 years. None of them had a history of chronic illness. Their total score fell in the range of 15-29 according to CARS.
2.4. Ethical issues
A formal written consent of parents or guardians was taken separately after explanation and assurance that the procedure will not harm patient or delay his improvement.
All participants' names were hidden and replaced by code number to maintain privacy of the participant.
2.5. Methods
All children in this study were subjected to the following:
1- Full history taking especially developmental history and prenatal complications.
2- Physical examination and especially neurological examination.
3- Cognitive age (mental age) using Stanford Bine intelligence scale (1960) or the non-verbal intelligence test of Snijder Oomen (1979) to exclude other mental or neurobehavioral disorders.15
4- Psychometric study using:
• Diagnostic and Statistical Manual of Mental Disorders fourth edition text revised (DSM-IV) (TR).1
• Child Autistic Rating Scale (CARS).16
5- Laboratory detection of plasma level of transforming growth factor beta 1 (TGFP1) by ELISA.13
2.6. Child Autistic Rating Scale (CARS)
The child is considered non-autistic when his/her total score falls in the range of 15-29, mildly-moderately autistic when the total score falls in the range of 30-36 and severely autistic when the total score falls in the range of 36-60.
2.7. Monitoring of the data
Data were recalled in a confidential manner and the privacy of all patients was maintained.
1- Age range of 3-13 years.
2- Children diagnosed by using Diagnostic and Statistical
Manual of Mental Disorders fourth edition text revised
2.8. Duration of the study
The study duration was 15 months.
Plasma level of transforming growth factor b 1
2.9. Benefits of the study
• Detection of plasma level of TGF P1 in children suffering from ASD.
• Finding out a correlation between plasma level of TGF P1 and severity of ASD.
2.10. Statistical design
Statistical analysis in the present study was conducted, using SPSS-V17. Descriptive statistics, Student's t-test, and Linear Correlation Coefficient tests were used in analyzing the data of the study.
3. Results
The present study showed 24 mildly-moderately autistic with total score falls in the range of 30-36 and 6 severely autistic with total score falls in the range of 36-60 according to CARS. Fifteen of patients had a history of prenatal complications such as maternal prenatal medication use (3 cases), bleeding (one case), gestational diabetes (2 cases), previous fetal loss (3 cases) and maternal hypertension (2 cases), proteinuria (one case), pre-eclampsia and swelling (3 cases).
Table 1 shows maternal age of patient group range (2339 years) with a mean 29.33 ± 4.67 which is higher than the maternal age of control group range (22-25 years) with a mean 23 ± 1.03. The comparison in-between showed statistical significance at P value <0.05.
Table 2 shows a comparison between patient and control group regarding plasma level of TGFP1 and showed a significant difference between the two groups where P value <0.05.
Table 3 shows a correlation between plasma level of TGFP1 and CARS, age, weight, length, head circumference (HC) and
Table 3 Correlation between plasma level of TGFßl and
CARS, age, weight, length, HC, and mother's age.
Correlations
Item TGF
R P-value
CARS -0.574 0.001*
Age 0.041 0.828
Weight 0.136 0.472
Length 0.014 0.944
HC 0.036 0.849
Mother's age 0.242 0.198
Non-significant = P > 0.05.
* Significant = P < 0.05.
mother's age. The comparison between the two groups showed a significant difference only regarding CARS (P value <0.05).
4. Discussion
Autism Spectrum Disorders (ASDs) are neurodevelopmental diseases characterized by restricted interests, repetitive behaviors, and deficient language and social skills.17 While there are no concrete biological markers for the disorder, immune anomalies are frequently described among individuals with ASD and their family members.18,19
Immunological anomalies involving cytokines, immuno-globulins, inflammation, and cellular activation have been noted in individuals with autism.20 Cytokines are secreted proteins that control the intensity, duration, and character of an immune response. Cytokines also interact with neural systems, and are involved in neural development and maintenance.21
Transforming growth factor beta (TGFP) has been linked to ASD in multiple studies.6,8,14 TGFP is involved in diverse aspects of development, cell migration, apoptosis, and regulation in both the immune system and central nervous system
(CNS).22,23
Our study was conducted on 30 autistic children and 30 controls, their age ranged from 3 to 13 years with average age 5.95 years. In the current study 86.67% of patients were male and 13.33% were female in a ratio 6.5:1. These findings are in agreement with other studies that ensure that males are predominantly affected with autism than females. Webb et al.24 in the UK found that the male:female ratio was 6.5:1; Fombonne et al.25 found that the M/F ratio was 5:1 similar to Lazoff et al.26 in Canada.
The mean maternal age at the time of conception was 29.33 ± 4.61 years in a group of patients. These findings are in accordance with a large number of studies which reported an association of ASD with advanced maternal age.27-29 Later on El-Baz et al.30 in their study about ASDs in Arab countries recruited a total of 37 boys and 23 girls from three Arab countries (Egypt, Saudi Arabia, Jordan). High maternal age (mother, >35 years) at birth was found in 23% of autistic children.
The present study showed that 50% of the patient group has a history of prenatal complication. Such findings go hand in hand with the work of Glasson et al.31 who showed that fetal/infant characteristics such as low APGAR scores, breech
Table 1 Comparison between patient and control as regards maternal age at conception.
Groups Mother's age (years) t-Test
Range Mean ± SD t P-value
Patients Controls 23.00-39.00 22.000-25.000 29.333 ± 4.611 23.600 ± 1.037 6.644 <0.001*
Non-significant = P > 0.05. * Significant = P < 0.05.
Table 2 Comparison between patient and control as regards plasma level of TGFP1.
Groups TGFß1 (ng/ml) t-Test
Range Mean ± SD t P-value
Patients 2.000-30.000 15.667 ± 8.691 -2.162 0.035*
Controls 15.000-30.000 20.200 ± 4.137
Non-significant = P > 0.05. * Significant = P < 0.05.
presentation, and fetal distress have been observed in autism. Also, El-baz et al.30 found that postnatal factors such as history of hypoxia, resuscitation and history of jaundice were considered significant risk factors for autism.
We examined the regulatory cytokine transforming growth factor beta 1 (TGFb1) because of its role in controlling immune responses8. Plasma levels of active TGFb1 were evaluated in 30 children with ASD compared with 30 controls. Children with ASD had significantly lower plasma TGFb1 levels (15.67 ± 8.69) compared with typically developing controls with the mean of 20.2 3:4.1 ng/ml with P value =0.035. This is in agreement with previous researchers. Vargas et al.6 observed altered TGFb1 levels in brain specimens of subjects with autism; Okada et al.14 showed in adult patients with ASD that the serum levels of TGFb1 were significantly lower than those of normal controls. Ashwood et al.8 found that plasma levels were significantly lower in children with ASD compared with typically developing general population controls.
Moreover, several studies have shown peripheral immune abnormalities in patients with autism including abnormal or skewed T helper cell cytokine profiles, decreased lymphocyte numbers, decreased T cell mitogen response, and an imbalance of serum immunoglobulin levels.7
The administration of anti-inflammatory cytokines as TGFb1 or anti-inflammatory medications, such as the thiazo-lidinedione pioglitazone (unless contra-indicated) or hista-mine-receptor blockers to the pregnant mother alleviates depression and reduces the risk of developing an autistic child.32 Also the treatment of autistic children with the anti-inflammatory medication pioglitazone, a nonsteroidal anti-inflammatory drug (NSAID) of the thiazolidinedione class, improved autistic symptoms through reducing the activation of microglia and subsequent neuroinflammation.33
There was a negative correlation between the level of TGFb1 and CARS which is a diagnostic tool for autism and reflects the severity of autism in the current study. The lower the level of TGFb1 the higher the score with CARS which indicates more severity. Such findings were in agreement with Ash-wood et al.8 who found that decreasing levels of TGFP1 in plasma correlated with worse behavioral scores on the ABC (aberrant behavior checklist).
The data suggest that immune responses in autism may be inappropriately regulated due to reductions in TGFb1. Such immune dysregulation may predispose to the development of the symptoms and behaviors that are associated with ASD.
From the previous data we may conclude that proper exploration of immunological features in autism presents an exciting opportunity to tease apart the biology of disorder, and may lead to therapeutic interventions.
5. Conclusion
Based on the results of this study, it could be concluded that:
• There is reduction in TGFP1 level in plasma of children who have ASD.
• There is a negative correlation between TGFb1 plasma level and the severity of the disease; the lower the level of TGFb1, the higher the scores of CARS indicating more severity.
Recommendations
From this study we can recommend the use of TGFP1 as a
serological marker in children who have recently been diagnosed with ASD as well as its use as a biological marker to
monitor the efficacy of therapy.
Conflict of interest
No funds and conflicts of interest.
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