Hindawi
Case Reports in Pediatrics
Volume 2019, Article ID 2070619, 10 pages
https://doi.org/10.1155/2019/2070619

Case Report
Improvement in Impaired Social Cognition but Not Seizures by
Everolimus in a Child with Tuberous Sclerosis-AssociatedAutism through Increased Serum Antioxidant Proteins andOxidant/Antioxidant Status
Kunio Yui ,1 George Imataka,2 Hitomi Sasaki,1 Yohei Kawasaki,3 Tohru Okanshi,4
Ryoichi Shiroki,1 and Shigemi Yoshihara2
1

Department of Urology, Fujita Health University School of Medicine, Aichi 470-1192, Japan
Department of Pediatrics, Dokkyo Medical University, Mibu, Tochigi 321-0293, Japan
3
Clinical Research Center, Chiba University Hospital, Chiba 260-8677, Japan
4
Department of Child Neurology, Seirei Hamamatsu General Hospital, Hamamatsu 430-8558, Japan
2

Correspondence should be addressed to Kunio Yui; yui16@bell.ocn.ne.jp
Received 11 April 2019; Revised 11 July 2019; Accepted 1 August 2019; Published 23 November 2019
Academic Editor: Yusuke Shiozawa
Copyright © 2019 Kunio Yui et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
We investigated the eﬀect of the mammalian target of rapamycin (mTOR) inhibitor everolimus on tuberous sclerosis complex(TSC-) associated autistic symptoms and focal seizures with impaired awareness in a female child with TSC. We further evaluatedthe relationship between improved autistic symptoms and seizures and increased the serum levels of the antioxidant proteins,ceruloplasmin (Cp) and transferrin (Tf ), and oxidant-antioxidant status indicated by the oxidant marker oxidized low-density
lipoprotein (ox-LDL) and the antioxidant marker total antioxidant power (TAP). Everolimus treatment improved impaired social
cognition and autistic behaviors; however, seizure and epileptic activity persisted. Serum Cp and Tf levels gradually increased in
response to improved autistic symptoms. Serum TAP levels gradually decreased from baseline to the lowest value at 16 weeks andthen increased at 24 weeks, showing a trend toward decreased total score of the Aberrant Behavior Checklist. This study revealed
that everolimus treatment improved impaired social cognition with increased serum levels of the copper mediator (Cp) and ironmediator (Tf ) via homeostatic control of mTOR activity accompanied by overlap of the oxidant-antioxidant system. Everolimus
had no eﬀect on TSC-related epileptiform discharges, and thus, the autistic symptoms and epileptic activity may be two independent end results of a common central nervous system disorder including mTOR hyperactivity. This trial is registeredwith JMAS-IIA00258.

1. Introduction
Tuberous sclerosis complex (TSC) is a rare multisystemmonogenic hamartomatous disorder [1] with a high prevalence of epilepsy and neuropsychiatric symptoms [2, 3].
Accumulating evidence has highlighted high comorbidity
rates of autism spectrum disorder (ASD) and impaired social
cognition in patients with TSC [4, 5]. However, few casereports have described ASD-associated impairments insocial cognition in patients with TSC. Social cognition refers
to the cognitive function of information processing,interpretation of socioemotional information in others [6],and cognitive processes such as recognition, accurate processing, and the eﬀective use of social cues [7].
TSC is caused by a mutation in either the tuberous
sclerosis complex 1 (TSC1) or complex 2 (TSC2) genes [1]. A
heterozygous mutation results in the hyperactivation of the
mammalian target of rapamycin (mTOR), inducing tumorous symptoms and autistic symptoms. These symptoms
can be inhibited by mTOR inhibitors such as rapamycin[3, 8]. Indeed, several previous studies have suggested thatmTOR inhibitors improved deﬁcient social interactions and2abnormal autistic behaviors in patients with TSC [9].
However, few studies have investigated the therapeutic efﬁcacy of the mTOR inhibitor everolimus on impaired social
cognition. Although mutations of TSC1 or TSC2 induce
mTOR hyperactivity, how this mechanism contributes to thedevelopment of ASD remains unclear [2, 10]. Interestingly,
animal models with heterozygous mutations in TSC1 or
TSC2 exhibit ASD-like social deﬁcits in the absence ofcortical lesions [10], suggesting that other neurobiologicalmechanisms may contribute to the development of autistic
symptoms. The mTOR pathway is closely related to oxidative stress [11] and antioxidant capacity [12]. Oxidative
stress-induced reactive oxygen species enhance mTOR activity [11], whereas antioxidant eﬀects block the mTOR
signaling pathway [13]. In particular, iron-related transferrin(Tf ) [14] has been implicated in mTOR activation. Tf is themain protein involved in the delivery of iron to the brain.
The abnormal accumulation of iron in the brain contributes
to neurodegenerative processes; thus, Tf is believed to have an
important role in the regulation of brain iron homeostasis [15].
Tf uptake modulates the mTOR signaling pathway [16] via
tristetraprolin [14], which regulates cellular signaling [17] toreduce the toxic eﬀects of iron accumulation and to promote cell
growth [16]. In addition, ceruloplasmin (Cp) is the primary
copper-binding protein [18] with an essential role in regulating
copper and iron homeostasis to prevent the formation of free
radicals [19]. Moreover, Cp is involved in determining the rateof iron eﬄux from cells with iron stores [20]. The accumulationof iron or decreased Cp activity in the brain has been associatedwith neurodegeneration [19]. Thus, Tf and Cp play essential
roles in the development of neurodegenerative diseases, including TSC [21].
Several studies have investigated the relationship between Cp and mTOR pathway alterations. We previously
described how everolimus improved both social impairment
and repetitive behaviors, and these improvements wereaccompanied by increases in the serum levels of both Cp andTf [22]. Copper inhibits mTOR pathway-activated autophagy [23]. Furthermore, oxidized low-density lipoprotein(ox-LDL) is an oxidative stress marker [24], and inhibitionof reactive oxygen species (ROS) production may reduce
autophagy to suppress ox-LDL-induced platelet activationby activating the PI3K/AKT/mTOR pathway [25], indicatingthat ox-LDL inhibits mTOR activity. Collectively, everolimus treatment may attenuate the upregulated mTOR
activity accompanying increased serum Cp and Tf levels andalterations in the oxidant-antioxidant system. To investigate
the oxidant-antioxidant status, serum levels of ox-LDL andtotal antioxidant power (TAP) were measured [26].
As mTOR regulates neuronal excitability in alreadyestablished neural circuits, mTOR hyperactivation enhances
neural excitability related to seizures [27], inducing epileptiform discharges (referred to as spikes) in the electroencephalogram (EEG) and may contribute to progressive
brain dysfunction, including autistic symptoms [28].
However, the association between epileptic encephalopathy
and ASD remains open to debate [28].
In this study, we demonstrate the therapeutic potential ofthe mTOR inhibitor everolimus in the amelioration of ASD-

Case Reports in Pediatrics
associated impaired social cognition and behavioral symptoms accompanied by increased serum levels of Tf and Cp,
which were partially consistent with changes in the oxidantantioxidant system, in a young girl with TSC. The present
ﬁndings shed further light on novel mechanisms underlying
TSC-associated autistic symptoms. This study further examined the association between epileptiform discharges and
TSC-related autistic symptoms.

2. Case2.1. Technical Information. ASD was diagnosed by one
psychiatrist and one pediatrician who specialized in ASD using
the DSM-5, Autism Diagnostic Interview-Revised (ADI-R),
and the Autism Diagnostic Observation Schedule (ADOS).
The ADI-R was usually used as a diagnostic instrument, but
the ADOS was useful for studying longitudinal changes in core
autistic symptom severity. The serum levels of Tf, Cp, ox-LDL,
and TAP were assayed at baseline and 4, 8, 12, 16, and 24
weeks after the initiation of everolimus treatment. Serum
VEGF-D levels were assessed to examine the patient’s responseto everolimus at baseline and 4, 8, 12, 16, and 24 weeks after
the initiation of everolimus treatment. Serum everolimus levels
were measured at 12, 16, and 24 weeks after the initiation of
the treatment. Social cognition was assessed using the Social
Communication Questionnaire (SCQ) and the Social Responsiveness Scale (SRS) [29]. Behavioral symptoms wereassessed using the Aberrant Behavior Checklist (ABC).
2.2. Patient Clinical Characteristics. The patient was aneight-year-old girl with TSC that was accompanied by thecore social and behavioral symptoms of ASD and focal
seizures with impaired awareness. At the age of four months,
the patient exhibited a focal seizure with impaired awareness, which was characterized by clusters of epileptic spasms
from the right face to the left hand clonic seizure without
hypsarrhythmia, following language development delay. She
was treated with anticonvulsants such as sodium valproate,
which reduced the frequency of her seizures. The patient
continued to take anticonvulsants. At the age of two years,
she experienced recurrence of her partial seizure. Anticonvulsant therapy reduced her seizure frequency; however,her seizures sometimes recurred. Her refractory seizures
resulted in her complete corpus callosotomy.
At seven years of age, her EEG recording indicated highvoltage irregular slow waves intermixed with spikes and polyspikes, which are sometimes observed in patients with focal
seizures characterized by impaired awareness [30] that weredetected bilaterally in the frontal and central areas (Figure 1).
2.3. Ultrasound Examination and Magnetic Resonance Imaging (MRI) Findings. At three years of age, abdominal
ultrasonography revealed several small angiomyolipomas(AMLs) in both kidneys. At seven years of age, MRI revealed
a subependymal nodule (SEN) (Figure 2). These ﬁndings,
including the SEN and AML, met the diagnostic criteria of
TSC [31]. Thus, a TSC diagnosis was conﬁrmed without
genomic analysis.

Case Reports in Pediatrics

3

(a)

(b)

Figure 1: Electroencephalography before everolimus treatment (a) and after everolimus treatment (b).

2.4. Autistic Symptoms. At six years of age, the patient
gradually developed impairment of social cognition, whichprimarily included impaired social interaction and communication. She sometimes spoke broken Japanese in a falteringmanner. She did not respond to various forms of nonverbal
communication with the typical facial expressions or physicalgestures. She was unable to understand the interests and needsof other children. The patient was often observed to be engaged
in “parallel play” at the edge of a group. In addition, she did not
engage in pretend play. Although she exhibited a desire to form
friendships with other children, she often demonstrated inappropriate friendliness and a lack of awareness of otherchildren’s interests and needs because she was unable to understand these factors. Therefore, it was diﬃcult for her to formand sustain interactions with other children, thus resulting in awithdrawal into repetitive play and behaviors. The patient was
unable to understand what her teachers and classmates said;
thus, her teachers sometimes had to provide guidance on what
to expect from others. She sometimes lost her temper whenthings did not go the way she wanted. These clinical featuresindicated deﬁcits in social cognitive processes, such as an impairment in understanding the mental state of others [32, 33],
impaired interpretation of socioemotional information [6], anddeﬁcits in the eﬀective use of social cues [7].
The patient displayed a continuous acquisition of motor
abilities but with stagnated performance. Her play tended tohave a persistent sensorimotor or ritualistic quality, and her
behaviors were characterized by repetitive and stereotyped
patterns of activities, such as repeated ﬁnger sucking. She
exhibited a delayed acquisition of motor skills and had
diﬃculty with motor coordination, postural control, andimitation of the movements of other children.
Collectively, the patient displayed autistic symptoms,
including impaired social cognitive function and impaired
social communication. Her behavioral symptoms consistedof repetitive and stereotyped behaviors.
2.5. Psychometric Assessment of Autistic Symptom. At sevenyears of age, she was diagnosed by one psychiatrist and one

pediatrician who specialized in ASD using the DSM-5, ADIR, and ADOS. As shown in Table 1, her ADI-R scores wereabove the autism diagnostic cutoﬀ scores for qualitative
abnormalities in reciprocal interaction (21; cutoﬀ � 10),
qualitative abnormalities in communication for both theverbal and nonverbal total scores (19; cutoﬀ � 15), and repetitive/stereotyped patterns of behavior (3; cutoﬀ � 3).
These ADI-R scores conﬁrmed the diagnosis of mild ASD.
As the social cognition domain is related to information
processing about others [6] and the eﬀective use of social
cues [7], parental reports of communication and reciprocalsocial skills such as the SRS [29] and SCQ [29, 34] have beenused to assess social cognition [3]. These SRS and SCQ
subscales assess social awareness, social information processing, capacity for reciprocal social communication, social
motivation, and repetitive/restricted interests [29]. The SCQ
is a useful tool for screening ASD and to determine whether
further assessment is needed in children with suspected ASD[35]; however, it is more diﬃcult to detect changes in theseverity of ASD using the SCQ. Therefore, we used the SCQ
to detect ASD symptoms in this TSC patient with autistic
symptoms. The autistic behavioral symptoms were assessedusing the ABC. The ABC is intended to evaluate treatment
responses in psychopharmacological and behavioral intervention trials for children and adolescents with normal
intelligence quotient (IQ) levels [36]. Figure 3 shows thetotal scores on the SRS, ABC, SCQ, and ADOS. The patient
had a total score of 16.0 on the ADOS module 2 algorithm,
which was greater than the average total ADOS score(8.94 ± 9.71) reported in 33 adolescents with high-functioning ASD [37]. Her SRS total scores (107) were comparable to the scores for patients with ASD, and the total
ABC score (50) was greater than the scores of 29 ASD individuals with an age range of 13–27 years (total SRS and
ABC scores were 120.21 and 60.14, respectively) [38]. Because total SRS scores greater than 76 indicate severe levelsof social reciprocity diﬃculties [39], the patient was considered to have impaired social interaction. In addition,
because total SCQ scores above 17 indicate social communication diﬃculties [40], the patient’s SCQ score of 6 was4Case Reports in Pediatrics

Figure 2: MRI ﬁnding of a subependymal nodule (SEN) (white arrow).

within the normal range. Collectively, the patient wasconsidered to have impaired social reciprocity but not social
communication. At six years of age, she underwent an intelligence test using the Wechsler Intelligence Scale (WISC)5, and her total IQ was 75, indicating normal levels of intellectual functioning [41]. Other evaluations revealed no
additional abnormalities.
2.6. Biochemical Measurement. Serum vascular endothelial
growth factor-D (VEGF-D) is a useful biomarker of TSCassociated lymphangioleiomyomatosis and can be used intherapeutic decision making [42]. Importantly, serum
VEGF-D may be useful for monitoring responses to treatment strategies using mTOR inhibitors, including changes
in the kidney AML size [43] and TSC severity [44] in patientswith TSC. The inhibition of phospho-mTOR signiﬁcantly
decreased tumor cell VEGF-D levels in vitro, indicating theexistence of the Akt/mTOR-VEGF-C/VEGF-D axis [45].
Therefore, to examine the patient’s response to everolimus,
serum VEGF-D levels were assessed in this study. As

described above, the copper mediator Cp [46] and ironmediator Tf [14] are known to be associated with mTOR
activity.
Furthermore, ox-LDL suppresses the P13K/AKT/mTOR
signaling pathway [25]. Therefore, the serum levels of Cp, Tf,
ox-LDL, and TAP were measured at baseline and 4, 8, 12, 16,
20, and 24 weeks after initiation of everolimus treatment.

3. Results
The patient’s total scores on the ABC as well as the SRS
gradually decreased during treatment, indicating an improvement in autistic symptoms (Figure 3). In particular,when comparing scores at baseline to those at the end of the
24-week treatment, her SRS total score decreased from 107
before treatment to 78 (a 27.2% decrease) and her SCQ total
score decreased from 6 before treatment to 3 (a 50% decrease) (Table 2). An approximate 20% reduction in the SRS
total score may be considered a response to treatment [47].
Thus, the patient’s cognitive proﬁles, including impaired
social cognition, also improved. Thus, treatment with

Case Reports in Pediatrics

5
Table 1: Clinical characteristics of the case.

Age
Age at onset of ASD

Female, 8 years
6 years(i) AML on bilateral kidneys(ii) SEN left on the anterior horn of lateral ventricle(i) Impaired communication(ii) Wrapping up doll play with repeated ﬁngersucking.
ADI-R
Reciprocal interaction: 21
Communication: 19
Repetitive behaviors: 13
SRS: 50
ABC: 10767
2.5 mg/day for 24 weeks
ABC score: 50% decrease
SRS score: 26% decrease
Social response and repetitive behaviors were
improved
Serum Cp and Tf levels increased from baseline to 24
weeks of treatment in accordance with symptom
improvement
Serum TAP levels showed trend toward opposite
decreased ABC scores
Serum creatine levels showed no deﬁnite alteration

MRI or echo
ASD features

ADI-R score
Total scores of SRS and ABC
WISC IQ
Everolimus doses
Results

Serum levels of Tf and Cp

Serum levels of TP, ox-LDL, and creatine

AML: angiomyolipomas; SEN: subependymal nodule; ADI-R; Autism Diagnostic Interview-Revised; ABC: Aberrant Behavior Checklist; SRS: Social Responsiveness Scale; Cp: ceruloplasmin; Tf: transferrin; TAP: total antioxidant power; ox-LDL: oxidized low-density lipoprotein.

24 weeks

20 weeks

16 weeks

12 weeks

8 weeks

4 weeks

0

Baseline20(a)

24 weeks

40SCQ

20 weeks

ABC

16 weeks

60

12 weeks

80

ADOS

8 weeks

100

18
16
14
12
10
8
6
4
2
0

4 weeks

SRS

Baseline

120(b)Figure 3: Changes of total scores of (a) SRS and ABC and (b) SCQ and ADOS during everolimus treatment.

everolimus induced improvements in impaired social
cognition.
As shown in the bar graph in Figure 4, serum Tf and Cp
levels gradually increased from baseline to 8 and 12 weeks,in accordance with symptom improvement as indicated bydecreased total scores on the ABC as well as the SRS.
Serum ox-LDL levels gradually increased from baseline tothe peak value at 8 weeks and then gradually decreased.
Serum TAP levels gradually decreased from baseline totheir lowest value at 16 weeks of treatment and thengradually increased. Thus, there appeared to be a positive
yet nonsigniﬁcant relationship between Tf and ox-LDL
levels in serum. The total scores on the SRS, ABC, ADOS,
and SCQ tended to increase at 8–12 weeks after everolimus

treatment; plasma Tf and ox-LDL levels also increased witha trend toward decreased total scores on the SRS and ABC(Figures 3 and 4).
The dosage of everolimus was 2.5 mg/day during the 24week treatment. Serum everolimus levels during themaintenance dosing period were 9.88, 6.37, and 22.10 ng/mL
at 16, 20, and 24 weeks after initiation of treatment, respectively. The patient’s serum levels of VEGF-D were505.8 mg/mL at baseline, 657.0 at 4 weeks, 698.7 ng/mL at 8
weeks, and 567.0 ng/mL at 12 weeks and gradually increased
to 777.9 ng/mL at 16 weeks, 769.3 mg/mL at 20 weeks, and1119.7 pg/mL at 24 weeks after initiation of treatment. No
severe or life-threatening side eﬀects related to the everolimus treatment were observed.

6

Case Reports in Pediatrics
Table 2: Changes of ADI-R, ADOS, ABC, and SRS total scores between baseline and 24 weeks after everolimus treatment.

Variable
ADI-R total
ADI-R social interaction domain
ADI-R communication domain
ADI-R restricted/repetitive behavior domain
ADOS
ABC
SRS
SCQ

Baseline

24 weeks% decrease

21
19
3
16
50
107
6

14
10
0
7
15
78
3

33.3
47.4
100.0
56.2
70.0
27.2
50.0

ADI-R: Autism Diagnostic Interview-Revised; ADOS: Autism Diagnostic Observation Schedule; ABC: Aberrant Behavior Checklist; SRS: Social Responsiveness Scale; SCQ: Social Communication Questionnaire. % decrease � scores at 24 weeks − the baseline scores/baseline scores × 100.

270

50

260

40

240

mg/dL

230
220

20

12 weeks

16 weeks

20 weeks

24 weeks

16 weeks

20 weeks

24 weeks

(b)

1700

120

1600

100
80
60

24 weeks

20 weeks

16 weeks

12 weeks

8 weeks

0

4 weeks

20

1200

(c)

8 weeks

40

1300

4 weeks

1400

Baseline

U/L

1500

Baselineμmol/L(a)

12 weeks

8 weeks

24 weeks

20 weeks

16 weeks

12 weeks

8 weeks

4 weeks

Baseline0

4 weeks

10

210
200

30

Baseline

mg/dL

250

(d)

Figure 4: Changes of serum levels of (a) Tf, (b) Cp, (c) TAP, and (d) ox-LDL.

Her several small AMLs disappeared; however, the size of
the SEN did not change after the 24-week everolimus treatment.
Antiepileptic medications, including lamotrigine andsodium valproate, did not have any observable therapeutic
eﬀects in the patient. The frequency of seizures did not
signiﬁcantly change after treatment with everolimus at adose of 2.5 mg. Everolimus treatment improved impaired
social interaction with others, repetitive ﬁnger sucking, andability to comprehend others’ intentions, and her feelings
increased as she exhibited an eﬀective response to hermother’s scolding. However, her seizures and epileptiformdischarges persisted. Thus, at nine years of age, she received acomplete corpus callosotomy, which eliminated the seizuresand epileptiform discharges. She was able to enjoy time withher classmates in school. These ﬁndings indicated that
2.5 mg/day of everolimus improved social functioning.
However, seizure and epileptiform discharges persisted.

4. Discussion
Social cognition is involved in multiple forms of information
processing, including sensitivity to various social signals,
facial expressions, and eye gaze directions [48]. The patient
exhibited deﬁcits in social communication areas, including
poor eye contact, failure to respond to others, poor attention
related to impairment of understanding other’s mental
status [32], and impairment of social communication, including gestures and shared enjoyment. These clinical features are consistent with those previously reported in TSC
patients with impaired social cognition [5, 6, 32, 48].
The present study indicated that treatment of a girl with
TSC with everolimus for 24 weeks increased the serum levelsof antioxidant proteins such as Tf as well as Cp, gradually
improved ASD-related social impairment, such as social
cognition and social withdrawal, and reduced autistic

Case Reports in Pediatrics
behaviors including repetitive behavior. However, seizuresand epileptiform discharges persisted.
Serum everolimus levels were 9.88, 6.37, and 22.2 ng/mL
at weeks 16, 20, and 24 after initiation of treatment, respectively. A previous study found that serum everolimus
levels in the range of 3–8 ng/mL were associated with goodeﬃcacy and safety proﬁles [49]; thus, serum everolimus
levels during everolimus treatment in this patient may havebeen appropriate for improving social and behavioral impairments. The patient’s serum levels of VEGF-D gradually
increased in response to improvements in autistic symptoms, indicating a response to everolimus treatment.
Total SRS scores decreased by 27.2%. A previous randomized, double-blind, parallel-group study reported that theantidepressant sertraline induced a >25% decrease in the
Hamilton Depression Rating Scale (HAMD) scores and wassigniﬁcantly more eﬀective than control drugs [50]. Anotherrandomized, double-blind, parallel-group study reported thatthe antidepressant sertraline induced a >25% decrease in theplacebo-controlled study, indicating that a 25% decrease in theassessment scale was an improvement [51]. Moreover, a 50%
reduction from the initial score was considered a clinicallysigniﬁcant improvement [52]. Thus, a 27.2% decrease in the
total SRS score and a 50% decrease in the total SCQ scoreindicated that everolimus treatment signiﬁcantly improvedsocial impairment, including social cognition.
Impairment of social cognition was evident approximately six years after the onset of her seizures. These ﬁndings
may be comparable to those in a previous research article,
which indicated that cognitive diﬃculties as indicated by IQ
were evident four years after the onset of seizures [53]. As
described above, the everolimus dose was 2.5 mg/day, which
did not eliminate her focal seizures with impaired awareness.
However, her social functioning gradually improved. Several
review articles have suggested a close association between
cognitive function and epileptic encephalopathy in patientswith TSC [3, 28]. However, whether improved seizure
control results in secondary improvements in social cognition remains open to debate [3, 28]. It is important to notethat TSC-related autistic symptoms and TSC-related epileptiform discharges may have been independent consequences of brain dysfunction in this patient.
Serum VEGF levels gradually increased from baseline(505.8 pg/mL) to a peak value (1119.7 pg/mL) at week 24. A
previous study found that the average serum level of VEGF
in 19 healthy children was 306.1 ± 39.4 pg/mL [54]. The
baseline serum VEGF-D level in this patient was higher thanin healthy children [54]. As serum VEGF-D levels have been
considered a biomarker of the response to treatment with an
mTOR inhibitor [43, 44], gradual increases in the serum
VEGF-D levels indicated the response to everolimus.
The SEN size was not changed after the 24-weektreatment with everolimus. Although several previous
studies have found a 50% reduction in the subependymal
giant cell astrocytoma (SEGA) size, other studies have shown
only slight decreases in the SEGA size after everolimus
treatment [10, 55]. A previous study indicated that everolimus treatment did not change the histopathologicalcharacteristics of the SEGA in a 15-year-old girl [55].

7
Moreover, the eﬀect of everolimus was not easily characterized using TSC lesions such as SEGA and AML [55]. No
reduction in the SEN size observed in this patient may thus
be reasonable. Previous studies have demonstrated that
everolimus treatment may prevent the development of AML
and SEGA [56]; therefore, other neurobiological mechanisms may contribute to the beneﬁcial eﬀect of everolimus
treatment on autistic symptoms.
VEGF-D deﬁciency may result in oxidative stress [57];exogenous stimulation with VEGF-D induces an antioxidant
response in human endothelial cells [58]. Moreover, everolimus attenuated oxidative stress by altering antioxidant
capacity [12] and/or reversing the accumulation of oxidative
stress-related ROS [59]. Notably, everolimus treatment
gradually elevated serum VEGF-D levels during the courseof everolimus treatment. Therefore, everolimus treatment
may contribute to increased serum levels of antioxidants
such as serum Cp and Tf via elevated serum VEGF-D levels.
Cp is the main copper-binding protein in blood plasma [18]and an important serum antioxidant [60]. Increased levels of
intracellular copper suppressed mTOR activation [61], andcopper treatment downregulated mTOR signaling [62]. In
addition, the mTOR signaling pathway modulated Tf uptake[16] and iron homeostasis through the Tf receptor [14].
Moreover, the Tf receptor can be used to measure intracellular changes in mTOR activity [63]. Collectively, ourpresent ﬁndings suggest that everolimus may have increased
cellular antioxidant capacity by enhancing serum Cp and Tf
levels. Both Cp and Tf regulate the transfer of iron, with theactivity of Cp modulated by Tf [64]. These ﬁndings indicateda close association between Cp and Tf. Although the patient
exhibited increased Cp levels during the 8–24 weeks oftreatment, her serum Cp levels (26–47 mg/dL) were within
the normal limits or higher value according to the SRL
information (reference levels, 21–37 mg/mL) (http://
testguide.srl.info/hachioji/test/detail/011732702). The patient did not exhibit any general symptoms of copper toxicity, such as burning stomach pain, nausea, vomiting,diarrhea, jaundice, hair loss, anemia, anorexia, anxiety, attention deﬁcit disorder, arthritis, or asthma [65]. Thus,
increased serum levels of Cp were not related to copper
toxicity. Although elevated serum Tf levels are a clinical signof malignant lymphomas [66], the patient never exhibited
symptoms of this disease. Tf saturation reﬂects iron availability [67]. Tf levels gradually increased from 250 mg/dL atweek 8 to a peak value of 262 mg/dL at week 12 andremained at higher values (231–235 mg/mL) than thebaseline value (225 mg/mL) (Figure 4). The Tf levels werehigher than the reference range (200–340 mg/mL) based on
the SRL information database (http://testguide.srl.info/
hachioji/test/detail/011741302). Thus, this patient may or
may not have had an iron deﬁciency. Collectively, a gradualincrease in serum Tf and Cp levels appeared to be a responseto everolimus treatment. As described above, evidence fromprevious studies supports the present ﬁnding that everolimus attenuates mTOR hyperactivity by increasing both
serum Cp and Tf levels.
Oxidized low-density lipoprotein (ox-LDL) suppresses
the P13K/AKT/mTOR signaling pathway [25]. The mTOR

8
pathway is closely related to oxidative stress [11] and antioxidant capacity [12]. Indeed, there appears to be a positive
yet nonsigniﬁcant relationship between Tf and ox-LDL levels
in plasma (Figure 4). Clinical evidence suggests that plasma
ox-LDL levels are signiﬁcantly associated with plasma antioxidant markers such as glutathione peroxidase [68]. This
is in agreement with the hypothesis that a positive association between ox-LDL and glutathione peroxidase activity
might reﬂect an adaptive mechanism to prevent furtheroxidative imbalance in the face of high ox-LDL concentrations [68]. However, another review article reported nosigniﬁcant association between LDL and total antioxidant
capacity [69]. These previous studies support our seemingly
overlapping curves for Tf and ox-LDL as well as the relationships between plasma Tf and ox-LDL levels. The total
scores on the SRS, ABC, ADOS, and SCQ tended to increase
at 8–12 weeks after everolimus treatment in response toincreased plasma TAP and ox-LDL levels (Figure 4). Thus,
antioxidant properties may partially overlap with theaforementioned homeostatic mechanisms.

5. Conclusion
The current study indicated that everolimus treatment for 24
weeks increased serum levels of antioxidant proteins, including Cp and Tf, inducing a gradual improvement in
impaired social cognition and repetitive behavior in a female
child with TSC. However, everolimus treatment did not
eliminate her seizure or epileptiform discharges. The present
ﬁndings suggested that epileptiform activity and autistic
symptoms may be independent consequences of brain
dysfunction related to mTOR hyperactivation.

Ethical Approval
All of the procedures in this study were in accordance withthe ethical standards of Dokkyo Medical University, Tochigi,
Japan (No. 27014, Japanese Medical Association, Clinical
Trial Registration (JMAS-IIA00258)) and with the 1964
Declaration of Helsinki.

Consent
Written informed consent was obtained from the patient’s
mother because the patient was unable to understand informed consent. Because the patient was a minor child, thepatient’s mother provided her written consent for the
publication of this case report on the behalf of the patient.
This case report conformed to the International Committeeof Medical Journal.

Conflicts of Interest
The authors declare that there are no conﬂicts of interest
regarding the publication of this paper.

Authors’ Contributions
Kunio Yui contributed to the literature search and draftingof the paper. Touru Okanioshi, Ryoichi Shiroki, and Shigemi

Case Reports in Pediatrics
Yoshihara helped in writing the paper, reviewing the literature, and analysis. Yohei Kawasaki and Hitomi Sasaki
contributed to the review and analysis for the paper.

Acknowledgments
The authors would like to thank the patient’s parent forproviding clinical data of this patient.

References[1] P. Curatolo, R. Moavero, and P. J. de Vries, “Neurological andneuropsychiatric aspects of tuberous sclerosis complex,” The
Lancet Neurology, vol. 14, no. 7, pp. 733–745, 2015.
[2] S. V. Kothare, K. Singh, T. Hochman et al., “Genotype/phenotype in tuberous sclerosis complex: associations withclinical and radiologic manifestations,” Epilepsia, vol. 55,
no. 7, pp. 1020–1024, 2024.
[3] D. A. Krueger, A. Sadhwani, A. W. Byars et al., “Everolimus
for treatment of tuberous sclerosis complex-associated neuropsychiatric disorders,” Annals of Clinical and Translational
Neurology, vol. 4, no. 12, pp. 877–887, 2017.
[4] R. Tuchmaan, “Autism and cognition within epilepsy: social
matters,” Epilepsy Currents, vol. 15, no. 4, pp. 202–205, 2015.
[5] S. S. Jeste, K. J. Varcin, G. S. Hellemann et al., “Symptom
proﬁles of autism spectrum disorder in tuberous sclerosis
complex,” Neurology, vol. 87, no. 8, pp. 766–772, 2016.
[6] L. Bishop-Fitzpatrick, C. A. Mazefsky, S. M. Eack, andN. J. Minshew, “Correlates of social functioning in autism
spectrum disorder: the role of social cognition,” Research inAutism Spectrum Disorders, vol. 35, pp. 25–34, 2017.
[7] P. D. Harvey and D. P. Penn, “Social cognition: the key factor
predicting social outcome in people with schizophrenia?,”
Psychiatry (Edgmont), vol. 7, no. 2, pp. 41–44, 2010.
[8] J. Cao, M. E. Tyburczy, J. Moss, T. N. Darling, H. R. Widlund,and D. J. Kwiatkowski, “Tuberous sclerosis complex inactivation disrupts melanogenesis via mTORC1 activation,”
Journal of Clinical Investigation, vol. 127, no. 1, pp. 349–364,
2017.
[9] A. Kilincaslan, B. E. Kok, P. Tekturk, C. Yalcinkaya,
C. Ozkara, and Z. Yapici, “Beneﬁcial eﬀects of everolimus on
autism and attention-deﬁcit/hyperactivity disorder symptoms
in a group of patients with tuberous sclerosis complex,”
Journal of Child and Adolescent Psychopharmacology, vol. 27,
no. 4, pp. 383–388, 2017.
[10] T. T. Gipson, G. Gerner, M. A. Wilson, E. V. Blue, and
M. V. Johnston, “Potential for treatment of severe autism intuberous sclerosis complex,” World Journal of Clinical Pediatrics, vol. 2, no. 3, pp. 16–25, 2013.
[11] P. Kumar, T. Raman, M. M. Swain, R. Mishra, and A. Pal,
“Hyperglycemia-induced oxidative-nitrosative stress inducesinﬂammation and neurodegeneration via augmented tuberous sclerosis complex-2 (TSC-2) activation in neuronal cells,”
Molecular Neurobiology, vol. 54, no. 1, pp. 238–254, 2017.
[12] A. Das, D. Durrant, S. Koka, F. N. Salloum, L. Xi, and
R. C. Kukreja, “Mammalian target of rapamycin (mTOR)
inhibition with rapamycin improves cardiac function in type 2
diabetic mice: potential role of attenuated oxidative stress andaltered contractile protein expression,” Journal of Biological
Chemistry, vol. 289, no. 7, pp. 4145–4160, 2015.
[13] D. A. Guimaraes, M. A. dos Passos, E. Rizzi et al., “Nitrite
exerts antioxidant eﬀects, inhibits the mTOR pathway andreverses hypertension-induced cardiac hypertrophy,” Free
Radical Biology and Medicine, vol. 120, pp. 25–32, 2018.

Case Reports in Pediatrics[14] M. Bayeva, A. Khechaduri, S. Puig et al., “mTOR regulates
cellular iron homeostasis through tristetraprolin,” Cell
Metabolism, vol. 16, no. 5, pp. 645–657, 2012.
[15] D. F. Leitner and J. R. Connor, “Functional roles of transferrin
in the brain,” Biochimica et Biophysica Acta (BBA)—General
Subjects, vol. 1820, no. 3, pp. 393–402, 2012.
[16] T. Galvez, M. N. Teruel, W. D. Heo et al., “siRNA screen of thehuman signaling proteome identiﬁes the PtdIns (3,4,5) P3mTOR signaling pathway as a primary regulator of transferrin
uptake,” Genome Biology, vol. 8, no. 7, p. R142, 2007.
[17] S. Sanduja, F. F. Blanco, L. E. Young, V. Kaza, and
D. A. Dixon, “The role of tristetraprolin in cancer and inﬂammation,” Frontiers in Bioscience, vol. 17, no. 1, pp. 174–
188, 2012.
[18] D. Ramos, D. Mar, M. Ishida et al., “Mechanism of copper
uptake from blood plasma ceruloplasmin by mammaliancells,” PLoS One, vol. 11, no. 3, Article ID e0149516, 2016.
[19] B. Wang and X. P. Wang, “Does ceruloplasmin defend against
neurodegenerative diseases?,” Current Neuropharmacology,
vol. 17, no. 6, pp. 539–549, 2018.
[20] Z. L. Harris, A. P. Durley, T. K. Man, and J. D. Gitlin,“Targeted gene disruption reveals an essential role for ceruloplasmin in cellular iron eﬄux,” Proceedings of the National
Academy of Sciences, vol. 96, no. 19, pp. 10812–10817, 1999.
[21] N. T. Olney, C. Alquezar, E. M. Ramos et al., “Linking tuberous sclerosis complex, excessive mTOR signaling, and agerelated neurodegeneration: a new association between TSC1
mutation and frontotemporal dementia,” Acta Neuropathology, vol. 134, no. 5, pp. 813–816, 2017.
[22] K. Yui, G. Imataka, T. Okanishi, H. Oka, and Y. Kawasaki,“Therapeutic potential of everolimus on core autism symptoms and increasing serum ceruloplasmin and transferrin
levels in a pubescent boy with tuberous sclerosis,” Neonatal
and Pediatric Medicine, vol. 3, no. 1, p. 1, 2017.
[23] Y. Wang, H. Zhao, Y. Sho et al., “Copper or/and arsenic
induces autophagy by oxidative stress-related PI3K/AKT/mTOR pathways and cascaded mitochondrial ﬁssion inchicken skeletal muscle,” Journal of Inorganic Biochemistry,
vol. 188, pp. 1–8, 2018.
[24] H. Itabe, R. Kat, N. Sasabe, T. Obama, and M. Yamamoto,“Signiﬁcance of oxidized low-density lipoprotein in body
ﬂuids as a marker related to diseased conditions,” Current
Medicinal Chemistry, vol. 26, no. 9, pp. 1576–1593, 2018.
[25] X. Wang, Y.-F. Fu, X. Liu et al., “ROS promote Ox-LDLinduced platelet activation by up-regulating autophagy
through the inhibition of the PI3K/AKT/mTOR pathway,”
Cellular Physiology and Biochemistry, vol. 50, no. 5,
pp. 1779–1793, 2018.
[26] G. Rowicka, H. Dyla˛g, J. Ambroszkiewicz et al., “Total oxidant
and antioxidant status in prepubertal children with obesity,”
Oxidative Medicine and Cellular Longevity, vol. 2017, Article
ID 5621989, 6 pages, 2017.
[27] J. O. Lipton and M. Sahin, “The neurology of mTOR,” Neuron,vol. 84, no. 2, pp. 275–291, 2014.
[28] S. Srivastava and M. Sahin, “Autism spectrum disorder andepileptic encephalopathy: common causes, many questions,”
Journal of Neurodevelopmental Disorders, vol. 9, no. 23, 2017.
[29] F. van der Fluit, M. S. Gaﬀrey, and B. P. Klein-Tasman, “Social
cognition in Williams Syndrome: relations between performance on the social attribution task and cognitive and behavioral characteristics,” Frontiers in Psychology, vol. 3, p. 197,
2012.
[30] C. Amo, C. Saldaña, M. G. Hidalgo et al., “Magnetoencephalographic localization of peritumoral temporal

9epileptic focus previous surgical resection,” Seizure, vol. 12,
no. 1, pp. 19–22, 2003.
[31] B. A. Staley, E. A. Vail, and E. A. Thiele, “Tuberous sclerosis
complex: diagnostic challenges, presenting symptoms, andcommonly missed signs,” Pediatrics, vol. 127, no. 1,
pp. e117–e125, 2011.
[32] S. B. Gaigg, “The interplay between emotion and cognition in
autism spectrum disorder: implications for developmental
theory,” Frontiers in Integrative Neuroscience, vol. 6, no. 113,
2012.
[33] M. V. Lombardo, B. Chakrabarti, M. C. Lai, and S. BaronCohen, “Self-referential and social cognition in a case ofautism and agenesis of the corpus callosum,” Molecular
Autism, vol. 3, no. 1, p. 14, 2012.
[34] H. A. Henderson, N. E. Zahka, N. M. Kojkowski et al., “Selfreferenced memory, social cognition, and symptom presentation in autism,” Journal of Child Psychology and Psychiatry, vol. 50, no. 7, pp. 853–861, 2009.
[35] S. R. Chesnut, T. Wei, L. Barnard-Brak, and D. M. Richman,“A meta-analysis of the social communication questionnaire:
screening for autism spectrum disorder,” Autism, vol. 21,
no. 8, pp. 920–928, 2017.
[36] E. Hollander, W. Chaplin, L. Soorya et al., “Divalproex sodium vs placebo for the treatment of irritability in children
and adolescents with autism spectrum disorders,” Neuropsychopharmacology, vol. 35, no. 4, pp. 990–998, 2010.
[37] A. Rynkiewicz, B. Schuller, E. Marchi et al., “An investigationof the “female camouﬂage eﬀect” in autism using a computerized ADOS-2 and a test of sex/gender diﬀerences,”
Molecular Autism, vol. 7, no. 1, p. 10, 2016.
[38] K. Singh, S. L. Connors, E. A. Macklin et al., “Sulforaphane
treatment of autism spectrum disorder (ASD),” Proceedings of
the National Academy of Sciences of the United States ofAmerica, vol. 111, no. 43, pp. 15550–15555, 2014.
[39] J. N. Constantino and G. Gruber, The Social Responsiveness
Scale (SRS), Western Pyschological Services, Los Angeles, CA,
USA, 2005.
[40] S. Johnson, C. Hollis, E. Hennessy, P. Kochhar, D. Wolke, and
N. Marlow, “Screening for autism in preterm children: diagnostic utility of the social communication questionnaire,”
Archives of Disease in Childhood, vol. 96, no. 3, pp. 73–77,
2011.
[41] L. Haysom, D. Indig, E. Moore, and C. Gaskin, “Intellectual
disability in young people in custody in New South Wales,
Australia—prevalence and markers,” Journal of Intellectual
Disability Research, vol. 58, no. 11, pp. 1004–1014, 2014.
[42] E. Radzikowska, P. Jaguś, M. Sobiecka et al., “Correlation ofserum vascular endothelial growth factor-D concentration
with clinical presentation and course of lymphangioleiomyomatosis,” Respiratory Medicine, vol. 109, no. 11,
pp. 1469–1475, 2015.
[43] L. A. Malinowska, N. Lee, V. Kumar et al., “Similar trends inserum VEGF-D levels and kidney angiomyolipoma responses
with longer duration sirolimus treatment in adults with tuberous sclerosis,” PLoS One, vol. 8, Article ID e56199, 2013.
[44] K.-F. Xu, P. Zhang, X. Tian et al., “The role of vascular endothelial growth factor-D in diagnosis of lymphangioleiomyomatosis (LAM),” Respiratory Medicine, vol. 107, no. 2,
pp. 263–268, 2013.
[45] H. Chen, R. Guan, Y. Lei et al., “Lymphangiogenesis in gastriccancer regulated through Akt/mTOR-VEGF-C/VEGF-D
axis,” BMC Cancer, vol. 15, no. 1, 2015.
[46] F. Rojo, L. Domingo, M. Sala et al., “Gene expression proﬁling
in true interval breast cancer reveals overactivation of the10mTOR signaling pathway,” Cancer Epidemiology Biomarkers& Prevention, vol. 23, no. 2, pp. 288–299, 2014.
[47] R. P. Conley, D. L. Kelly, M. W. Nelson et al., “Risperidone,
quetiapine, and ﬂuphenazine in the treatment of patients withtherapy-refractory schizophrenia,” Clinical Neuropharmacology, vol. 28, no. 4, pp. 163–168, 2005.
[48] C. D. Frith, “Social cognition,” Philosophical Transactions of
the Royal Society B: Biological Sciences, vol. 363, no. 1499,
pp. 2033–2039, 2008.
[49] J. M. Kovarik, H. Tedesco, J. Pascual et al., “Everolimus
therapeutic concentration range deﬁned from a prospective
trial with reduced-exposure cyclosporine in de novo kidneytransplantation,” Therapeutic Drug Monitoring, vol. 26, no. 5,
pp. 499–505, 2004.
[50] M. Amore and M. C. Jori, “Faster response on amisulpride
50 mg versus sertraline 50–100 mg in patients with dysthymia
or double depression: a randomized, double-blind, parallelgroup study,” International Clinical Psychopharmacology,
vol. 16, no. 6, pp. 317–324, 2001.
[51] B. Mazieres, M. Hucher, M. Zaim, and P. Garnero, “Eﬀect ofchondroitin sulphate in symptomatic knee osteoarthritis: amulticentre, randomised, double-blind, placebo-controlled
study,” Annals of the Rheumatic Diseases, vol. 66, no. 5,
pp. 639–645, 2007.
[52] A. C. Page, N. K. Cunningham, and G. R. Hooke, “Using daily
monitoring of psychiatric symptoms to evaluate hospital
length of stay,” British Journal of Psychiatry Open, vol. 2, no. 6,
pp. 341–345, 2016.
[53] G. Vingerhoets, “Cognitive eﬀects of seizures,” Seizure, vol. 15,
no. 4, pp. 221–226, 2006.
[54] N. J. A. Webb, M. J. Bottomley, C. J. Watson, andP. E. C. Brenchley, “Vascular endothelial growth factor(VEGF) is released from platelets during blood clotting:
implications for measurement of circulating VEGF levels inclinical disease,” Clinical Science, vol. 94, no. 4, pp. 395–404,
1998.
[55] J. J. Bissler and J. C. Kingswood, “Optimal treatment of tuberous sclerosis complex associated renal angiomyolipomata:a systematic review,” Therapeutic Advances in Urology, vol. 8,
no. 4, pp. 279–290, 2016.
[56] S. Cheng, C. Hawkins, M. D. Taylor, and U. Bartels, “Pathological ﬁndings of a subependymal giant cell astrocytoma
following treatment with rapamycin,” Pediatric Neurology,
vol. 53, no. 3, pp. 238–242, 2015.
[57] N. Kweider, W. Rath, B. Huppertz et al., “PP015. Diﬀerential
expression of Nrf2 and VEGF in human placental beds fromnormal and pregnancies complicated with preeclampsia andIUGR,” Pregnancy Hypertension: An International Journal of
Women’s Cardiovascular Health, vol. 2, no. 3, pp. 248-249,
2012.
[58] I. Papiewska-Paja˛k, A. Balcerczyk, E. Stec-Martyna,
W. Koziołkiewicz, and J. Boncela, “Vascular endothelial
growth factor-D modulates oxidant-antioxidant balance ofhuman vascular endothelial cells,” Journal of Cellular andMolecular Medicine, vol. 21, no. 6, pp. 1139–1149, 2016.
[59] M. Dermit, P. Casado, V. Rajeeve et al., “Oxidative stressdownstream of mTORC1 but not AKT causes a proliferative
defect in cancer cells resistant to PI3K inhibition,” Oncogene,
vol. 36, no. 19, pp. 2762–2774, 2016.
[60] M. Aouﬀen, J. Paquin, E. De Grandpré, R. Nadeau, and
M. A. Mateescu, “Deglycosylated ceruloplasmin maintains its
enzymatic, antioxidant, cardioprotective, and neuronoprotective properties,” Biochemistry and Cell Biology,
vol. 79, no. 4, pp. 489–497, 2011.

Case Reports in Pediatrics[61] J. R. Lou, X. X. Zhang, J. Zheng, and W. Q. Ding, “Transient
metals enhance cytotoxicity of curcumin: potential involvement of the NFkappaB and mTOR signaling pathways,”
Anticancer Research, vol. 30, no. 3, pp. 3249–34255, 2010.
[62] X. Li, K. Zou, J. Gou et al., “Eﬀect of baicalin-copper on the
induction of apoptosis in human hepatoblastoma cancer
HepG2 cells,” Medical Oncology, vol. 32, no. 3, p. 72, 2015.
[63] C. Truillet, J. T. Cunningham, M. F. L. Parker et al., “Noninvasive measurement of mTORC1 signaling with 89Zrtransferrin,” Clinical Cancer Research, vol. 23, no. 12,
pp. 3045–3052, 2017.
[64] K. N. White, C. Conesa, L. Sánchez et al., “The transfer of ironbetween ceruloplasmin and transferrins,” Biochimica et Biophysica Acta (BBA)—General Subjects, vol. 1820, no. 3,
pp. 411–416, 2012.
[65] B. Ashish, K. Neeti, and K. Himanshu, “Copper toxicity: acomprehensive study,” Research Journal of Recent Sciences,vol. 2, pp. 58–67, 2013.
[66] J. Bjerner, L. M. Amlie, L. S. Rusten, and E. Jakobsen, “Serumlevels of soluble transferrin receptor correlate with severity of
disease but not with iron stores in patients with malignant
lymphomas,” Tumour Biology, vol. 23, no. 3, pp. 146–153,
2002.
[67] M. E. Elsayed, M. U. Sharif, and A. G. Stack, “Transferrin
saturation: a body iron biomarker,” Advances in Clinical
Chemistry, vol. 75, pp. 71–97, 2016.
[68] K. B. Barbosa, A. C. P. Volp, H. H. M. Hermsdorﬀ et al.,“Relationship of oxidized low density lipoprotein with lipid
proﬁle and oxidative stress markers in healthy young adults: atranslational study,” Lipids in Health and Disease, vol. 10,
no. 1, p. 61, 2011.
[69] E. Charles, C. E. Robison, G. Paul, P. G. Davis, A. Goldfarb,
and P. Mellick, “The association between oxidized low density
lipoprotein concentration and paraoxonase-1 activity, total
antioxidant capacity, and low density lipoprotein concentration in highly trained individuals,” Federation of American
Societies for Experimental Biology Journal, vol. 32, 2018.

MEDIATORSof

INFLAMMATIONThe ScientificWorld Journal
Hindawi Publishing Corporation
http://www.hindawi.com
www.hindawi.com

Volume 20182013

Gastroenterology
Research and PracticeHindawiwww.hindawi.com

Volume 2018

Journal of

Hindawiwww.hindawi.com

Volume 2018

Diabetes Research

Disease Markers

Hindawiwww.hindawi.com

Hindawiwww.hindawi.com

Volume 2018

Volume 2018

International Journal of

Journal of

Immunology Research

Endocrinology

Hindawiwww.hindawi.com

Hindawiwww.hindawi.com

Volume 2018

Volume 2018

Submit your manuscripts at
www.hindawi.com
BioMedResearch International

PPAR Research
Hindawiwww.hindawi.com

Hindawiwww.hindawi.com

Volume 2018

Volume 2018

Journal of

Obesity

Ophthalmology

Stem Cells
International

Hindawiwww.hindawi.com

Hindawiwww.hindawi.com

Journal ofVolume 2018

Evidence-BasedComplementary andAlternative Medicine
Volume 2018

Hindawiwww.hindawi.com

Volume 2018

Journal of

Oncology
Hindawiwww.hindawi.com

Volume 2018

Hindawiwww.hindawi.com

Volume 2013

Parkinson’s
DiseaseComputational andMathematical Methods
in Medicine

Behavioural
Neurology

Hindawiwww.hindawi.com

Hindawiwww.hindawi.com

Volume 2018

AIDS

Volume 2018

Hindawiwww.hindawi.com

Volume 2018

Research and Treatment

Oxidative Medicine andCellular Longevity

Hindawiwww.hindawi.com

Hindawiwww.hindawi.com

Volume 2018

Volume 2018