Reporte de un caso de síndrome de Noonan diagnosticado en atención primaria / A case report of Noonan syndrome diagnosed in primary healthcare

El síndrome de Noonan es un trastorno genético de herencia autosómica dominante, de expresión fenotípica variable. Pertenece al grupo de las enfermedades conocidas como rasopatías, trastornos producido por las mutaciones en los genes RAS. Los pacientes desarrollan síntomas como dismorfismo facial, talla baja, enfermedad cardíaca congénita, alteraciones músculos esqueléticas y discapacidad intelectual. En el presente reporte, se describe un caso de diagnóstico del síndrome de Noonan en un paciente de 14 años, realizado a nivel de atención primaria en Ecuador. El síndrome se identificó mediante diagnóstico clínico, permitiendo su derivación al segundo y tercer nivel de salud para una atención especializada.

Noonan syndrome is an autosomal dominant inherited disorder with variable phenotypic expression. It belongs to the group of diseases known as RASopathies, which are characterized by mutations in the RAS genes. Patients develop symptoms such as facial dysmorphism, short stature, congenital heart disease, musculoskeletal disorders and mental retardation. In this article, we report a case of Noonan syndrome in a 14-year-old patient, diagnosed in a primary health center in Ecuador. The syndrome was identified through clinical diagnosis, after which the patient was referred to the secondary and tertiary levels for specialized care.

Manifestaciones otorrinolaringológicas del síndrome de Noonan / Otorhinolaryngologic manifestations of Noonan síndrome / Manifestações otorrinolaringológicas da síndrome de noonan

El síndrome de Noonan (SN) es un trastorno genético de herencia autosómica dominante relativamente frecuente. Clásicamente se ha descrito como la asociación de talla baja, dismorfias craneofaciales (fundamentalmente hipertelorismo, inclinación hacia abajo de las hendiduras palpebrales, ptosis palpebral, pabellones auriculares rotados y de implantación baja, hélix grueso), cardiopatía congénita (característicamente estenosis pulmonar valvular -EP- y miocardiopatía hipertrófica -MCH-), malformaciones torácicas(pectus excavatum/carinatum, tórax amplio) y criptorquidia en los varones. Tiene una incidencia alta, de 1/1.000- ½.500 neonatos.

Noonan syndrome (NS) is a genetic disorder relatively common autosomal dominant inheritance. Classically described as the association of short stature, craniofacial dysmorphia (hypertelorism, palpebral ptosis, ear low – set ears), congenital heart disease (typically valvular pulmonary stenosis -PSand hypertrophic cardiomyopathy -HCM-), thoracic malformations (pectus excavatum / carinatum, broad chest) and cryptorchidism in men. It has a high incidence of 1 / 1,000- 1 / 2,500 newborns.(1).

A síndrome de Noonan (SN) é um transtorno genético de herança autossômica dominante relativamente frequente. Classicamente, foi descrita como a associação de baixa estatura, dismorfias craniofaciais (fundamentalmente hipertelorismo, inclinação para baixo das fendas palpebrais, ptose palpebral, pavilhões auriculares rotados e de implantação baixa, hélix grosso), cardiopatia congênita (caracteristicamente estenose pulmonar valvular -EP- e miocardiopatia hipertrófica -MCH-), más formações torácicas (pectus excavatum/carinatum, tórax amplo) e criptorquidia nos meninos. (1) Tem uma incidência alta de 1/1.000- ½.500 neo-natos.

Síndrome de Noonan / Noonan syndrome

Se presenta un caso de Síndrome de Noonan, enfermedad genética poco frecuente con manifestaciones clínicas diversas, con una característica afectación cardiovascular como es la estenosis valvular pulmonar. La paciente ingresa en insuficiencia cardiaca y durante la observación se detectan datos clínicos típicamente descritos en la enfermedad, tales como talla baja, hipertelorismo, pterigium coli y tórax carinatum. Se evalúa de manera conjunta con genética y se identifican los criterios diagnósticos. La paciente es compensada y egresada por mejoría

A case of Noonan´s Syndrome, is reported here. This is a rare genetic disease with diverse clinical manifestations, with a characteristic cardiovascular involvement of pulmonary valve stenosis. The patient was admitted with heart failure. Typical clinical features were found such as short stature, hypertelorism, pterygium coli and thorax carinatum. The patient was evaluated with the genetic specialists and diagnostic criteria were identified

Estudio clínico y molecular del síndrome de Noonan / Clinical and molecular study of the Noonan syndrome

El síndrome de Noonan es una entidad autosómica dominante relativamente común, clínicamente variable y genéticamente heterogénea, caracterizado por reducción del crecimiento postnatal, dismorfismo facial distintivo, alteraciones cardíacas y déficit cognitivo variable. El gen PTPN11 se encuentra localizado en el brazo largo del cromosoma 12 y es el principal responsable de los casos clínicamente diagnosticados de esta entidad. Se reporta el caso de un lactante mayor masculino, de 18 meses de edad, evaluado de forma multidisciplinaria con diagnóstico clínico y molecular de síndrome de Noonan, con la mutación en sentido errado del gen PTPN11, G503R (c.1507 G>A). Se discutieron los diversos hallazgos clínicos y las alteraciones genéticas asociadas con esta mutación.

Noonan syndrome is a relatively common autosomal dominant entity, clinically variable and genetically heterogeneous; characterized by postnatally reduced growth, distinctive facial dysmorphism, cardiac defects and variable cognitive deficits. The PTPN11 gene is located on the long arm of chromosome 12 and is primarily responsible for the clinically diagnosed cases of this entity. We report the case of a 18 month-old boy, evaluated in a multidisciplinary way, with clinic and molecular diagnosis of Noonan syndrome, with the missense mutation in PTPN11 gene, G503R (c.1507 G>A). Several clinical features and the genetic alterations associated with this mutation are discussed.

Avaliação do padrão de crescimento na síndrome de Noonan em pacientes com mutações identificadas nos genes PTPN11, SOS1, RAF1 e KRAS / Growth pattern of patients with Noonan syndrome with identified mutations in PTPN11, SOS1, RAF1 e KRAS genes

A Síndrome de Noonan (SN) é caracterizada por baixa estatura proporcionada de início pós-natal, dismorfismos faciais, cardiopatia congênita e deformidade torácica. A frequência da SN é estimada entre 1:1000 e 1:2500 nascidos vivos, com distribuição semelhante em ambos os sexos. A herança é autossômica dominante com penetrância completa, porém a maioria dos casos é esporádica. Até o momento, mutações em genes da via RAS-MAPK (PTPN11, KRAS, SOS1, RAF1, MEK1, NRAS e SHOC2) foram identificadas em aproximadamente 70% dos pacientes. Uma das principais características fenotípicas da SN é a baixa estatura pós-natal, embora o mecanismo fisiopatológico do déficit de crescimento nesta síndrome ainda não esteja totalmente esclarecido. Estudos que avaliaram o padrão de crescimento linear em crianças com SN foram realizados anteriormente ao conhecimento do diagnóstico molecular dessa síndrome. No presente estudo, avaliamos a frequência de mutação nos genes PTPN11, SOS1, RAF1 e KRAS em 152 pacientes com SN e o padrão de crescimento linear (altura) e ponderal [índice de massa corpórea (IMC)] dos pacientes com mutação identificada. No total, mutações nos genes relacionados foram encontradas em 99 pacientes (65%) do nosso estudo, com predominância do gene PTPN11 (47%), seguido do SOS1 (9%), RAF1 (7%) e KRAS (3%). Foram construídas curvas específicas para SN de Altura e IMC para idade e sexo utilizando o método LMS. Os pacientes com SN apresentaram crescimento pré-natal preservado, porém o comprometimento do crescimento pós-natal foi observado desde o primeiro ano de vida, atingindo uma altura final de -2,5 e -2,2 desvios-padrão da média para população brasileira em homens e mulheres, respectivamente. O prejuízo da altura foi maior nos pacientes com mutação no gene RAF1 em comparação com os genes PTPN11 e SOS1. O IMC dos pacientes com SN apresentou queda de 1 desvio-padrão em relação à média da população brasileira normal. O comprometimento do IMC foi menor...

Noonan Syndrome (NS) is characterized by distinctive facial features, short stature and congenital heart defects. The estimated prevalence is 1:1000 to 1:2500 live births, affecting equally both sexes. It is an autosomal dominant disorder with complete penetrance, but most cases are sporadic. To date, mutations in the RAS/MAPK pathway genes (PTPN11, KRAS, SOS1, RAF1, MEK1, NRAS and SHOC2) were identified in approximately 70% of patients. One of the cardinal signs of NS is proportional postnatal short stature although the physiopathological mechanism of growth impairment remains unclear. The current knowledge about the natural history of growth associated with NS was described before molecular diagnosis era. In this study, we performed PTPN11, SOS1, RAF1, and KRAS mutation analysis in a cohort of 152 NS patients and studied the natural linear (height) and ponderal growth [body mass index (BMI)] of NS patients with related mutations. Mutations in NS-causative genes were found in 99 patients (65%) of our cohort. The most common mutated gene was PTPN11 (47%), followed by SOS1 (9%), RAF1 (7%) and KRAS (3%). Sex-specific percentile curves for height and BMI were constructed using the LMS method. NS patients had birth weight and length within normal ranges but the postnatal growth impairment was observed during the first year of life, reaching a final height of -2.3 and -2.2 standard deviations from the mean for Brazilian healthy men and women, respectively. Postnatal growth impairment was higher in RAF1 mutation patients than in patients with SOS1 and PTPN11 mutations. BMI values in NS patients were lower in comparison with normal Brazilian population. BMI values were higher in patients with RAF1 mutations than in patients with other genotypes. Patients with mutations in PTPN11 and SOS1 genes were more likely to have pulmonary valve stenosis, whereas hypertrophic cardiomyopathy was more common in patients with mutations in the gene RAF1...

Determinantes genéticos na síndrome de Noonan e nas síndromes Noonan-like: investigação clínica e molecular / Genetic determinants in Noonan syndrome and in Noonan-like syndromes: clinical and molecular study

A síndrome de Noonan (SN) é uma doença de herança autossômica, relativamente frequente na população e que apresenta heterogeneidade genética. Caracteriza-se por dismorfismos faciais, baixa estatura, pescoço curto/alado, alterações cardíacas, deformidades esternais e criptorquia. A SN apresenta sobreposição dos achados clínicos com outras síndromes mais raras, denominadas síndromes Noonan-like (SNL): síndrome cardio-facio-cutânea (CFC), síndrome de Costello (SC), neurofibromatose-síndrome de Noonan (NFSN), síndrome de Noonan com manchas lentiginosas/síndrome de LEOPARD (SL), síndrome de Noonan-like com perda de cabelos anágenos (SNL-PCA) e síndrome de Noonan-like com leucemia mielomonocítica juvenil (SNL-LMMJ). As SN e SNL decorrem de mutações em genes pertencentes à via de sinalização RAS/MAPK alguns dos quais são protooncogenes, o que tem despertado o interesse na caracterização do risco de desenvolvimento de neoplasias nessas síndromes. Os objetivos deste estudo visam o sequencimento conjunto dos genes PTPN11, SOS1, RAF1, KRAS, SHOC2, BRAF e HRAS em pacientes com diagnóstico clínico das SN e SNL a fim de: determinar a frequência de mutação; estabelecer uma correlação genótipo-fenótipo; estabelecer um fluxograma para o estudo molecular a partir dos hotspots; e avaliar se a variabilidade fenotípica apresentada nos pacientes com SN pode ser explicada pela presença de mutações em mais de um gene da via RAS/MAPK. Foram avaliados 194 probandos - 152 com SN e 42 com SNL (19 CFC, 15 NFNS, 4 CS e 4 LS). Mutações foram identificadas em 99 pacientes 80 com SN (53%); 19 com SNL. Apenas um paciente com SN apresentou mutação em dois genes da via RAS/MAPK (PTPN11 e SOS1). O estudo molecular na SN mostrou, assim como na literatura, um maior envolvimento do gene PTPN11 (34%), seguido dos genes SOS1 (12%) e RAF1 (7%). A comparação dos achados clínicos, levando em consideração as alterações gênicas, também confirma as correlações já descritas na literatura; entre elas...

Noonan syndrome (NS) is a relatively common, autosomal dominant disease that presents a marked genetic heterogeneity. It is characterized by facial dysmorphisms, short stature, webbed/short neck, cardiac abnormalities, esternal anomalies and cryptorchidism. NS shows clinical overlap of some of its findings with other rarer syndromes, known as Noonan-like syndromes (NLS): cardio-facio-cutaneous syndrome (CFC), Costello syndrome (CS), neurofibromatosis-Noonan syndrome (NFNS), Noonan syndrome with lentiginous stains/LEOPARD syndrome (LS), Noonan-like syndrome with loose anagen hair (NLS-LAH) and Noonan-like syndrome with juvenile myelomonocytic leukemia (NLS-JMML). NS and NLS are related to mutations in genes belonging of RAS-MAPK signaling pathway. Some of these genes are classified as proto-oncogenes. This fact also arouses the interest in the characterization of the risk for cancer development in this group of patients. The objectives of this study are to sequence the genes associated with NS and NLS (PTPN11, SOS1, RAF1, KRAS, SHOC2, HRAS and BRAF) in patients that fulfilled clinical diagnostic criteria for NS or NLS to: determine the frequency of the mutations; establish a genotype-phenotype correlation; estabilish a flowchart for molecular study from the hotspots; and evaluate when the phenotypic variability presented in NS patients can be explained by the presence of mutations in more than one gene of the RAS/MAPK pathway. This study evaluated 194 probands 152 with NS e 42 with NLS (19 CFC, 15 NFSN, 4 SC e 4 SL). Mutations were identified in 99 patients 80 with NS (53%), 19 with NLS. Only one patient presented mutation in two different genes of the RAS/MAPK pathway (PTPN11 and SOS1). The molecular analysis showed a predominance of mutations in the PTPN11 gene (34%), followed by the SOS1 (12%) and RAF1 (7%) genes in patients with NS, in accordance with the literature. Patients with NS and mutation in the: PTPN11 gene, presented a higher frequency of...

Síndrome de Noonan: presentación de dos casos / Noonan's syndrome: presentation of two cases

Se presentan las características oftalmológicas y clínicas de dos pacientes hermanos (hembra y varón) con diagnóstico del síndrome de Noonan. Este es un trastorno genético que produce desarrollo anormal de múltiples partes del cuerpo. Se caracteriza por una serie de signos y particularidades físicas que pueden variar ampliamente en rango y severidad según los casos. Generalmente se transmite como un rasgo genético autosómico dominante. Los casos que presentamos se caracterizan por: estenosis valvular pulmonar, hipertelorismo, retardo mental moderado, aspecto típico de la cara con filtrum (surco vertical en el centro del labio superior), párpados gruesos, epicanto, exoftalmos y ptosis palpebral.

The ophthalmological and clinical characteristics of two sibling patients (male and female) diagnosed with Noonan´s syndrome were presented in this paper. This is a genetic disorder that causes abnormal development of many parts of the body. It is characterized by a series of signs and physical peculiarities that may widely vary in range and severity from one case to another. Generally, it is transmitted as a dominant autosomal genetic trait. The two cases had the following features: pulmonary valve stenosis, hypertelorism, moderate mental retardation, typical aspect of the individual's face with filtrum (vertical sulcus located in the center of the upper lip), thick eyelids, epicanthus, exophthalmos and palpebral ptosis.

Síndrome de Noonan: do fenótipo à terapêutica com hormônio de crescimento / Noonan syndrome: from phenotype to growth hormone therapy

A síndrome de Noonan (SN) é uma síndrome genética comum que constitui importante diagnóstico diferencial em pacientes com baixa estatura, atraso puberal ou criptorquidia. A SN apresenta grande variabilidade fenotípica e é caracterizada principalmente por dismorfismo facial, cardiopatia congênita e baixa estatura. A herança é autossômica dominante com penetrância completa. O diagnóstico é clínico, com base em critérios propostos por van der Burgt, em 1994. Recentemente, diversos genes envolvidos na via de sinalização RAS-MAPK foram identificados como causadores da SN: PTPN11, KRAS, SOS1, RAF1 e MEK1. O tratamento com hormônio de crescimento (hrGH) é proposto para corrigir a baixa estatura observada nestes pacientes. Estudos recentes apontam que pacientes com SN por mutações no gene PTPN11 apresentam pior resposta ao tratamento com hrGH quando comparado com pacientes sem mutações no PTPN11. Este artigo revisará os aspectos clínicos, moleculares e do tratamento da baixa estatura de crianças com SN com hrGH.

Noonan Syndrome (NS) is one of the most common genetic syndromes and it is an important differential diagnosis in children with short stature, delayed puberty and cryptorchidism. NS is characterized by dysmorphic facial features, congenital heart defects and short stature, but there is a great variability in phenotype. NS may occur in a pattern consistent with autosomal dominant inheritance with almost complete penetrance. The diagnosis is based on a clinical score system proposed by van der Burgt e cols. in 1994. In recent years, germline mutations in the components of RAS-MAPK (mitogen activated protein kinase) pathway have been shown to be involved in the pathogenesis of NS. Mutations in PTPN11, KRAS, SOS1, RAF1 e MEK1 can explain 60-70 percent of NS molecular cause. Growth hormone therapy is proposed to correct the short stature observed in these patients. Recent studies suggest that the presence of PTPN11 mutations in patients with NS indicates a reduced growth response to short-term hrGH treatment. In this article, it is reviewed clinical and molecular aspects of NS and hrGH treatment for short stature.

Noonan syndrome: a case report.

Noonan syndrome is a developmental disorder characterized by facial dysmorphia, short stature, cardiac defects and skeletal malformations. It may be sporadic or inherited as an autosomal dominant or recessive trait and occurs, one in 1,000-2,500 children. This is a case report of a 13 year-old girl who was referred by a general dental practitioner to a pediatric dentist for management. Full mouth dental rehabilitation was done and the child was brought to a dental institution for correction of orofacial and occlusal defects. Multidisciplinary treatment is the key to success in managing children with Noonan syndrome and the pediatric dentists play an important position to lead the health team.

Manifestaciones clínicas más frecuentes en pacientes con sindrome de Turner del Instituto de Genética, La Paz-Bolivia período 1990 - 2004 / Most frequent clinical features of patients whit Turner syndrome in the Instituto de Genética La Paz - Bolivia, From 1990 - 2004

Objetivo. Identificar los signos clínicos más frecuentes en pacientes con Síndrome de Turner.Diseño Corte transversal. Lugar: Instituto de Genética; La Paz, Bolivia.Población 36 pacientes con diagnóstico citogenético. Métodos: Recolección de datos clínicos de pacientes con Síndrome de Turner períodos 1990-2004. Se excluyeron pacientes que presentaban similares fenotipos y con cariotipo no compatible. Resultados: Manifestaciones clínicas más frecuentes: baja talla proporcionada 77.8%, disgenesia gonadal 61.1%, pterigium colli 27.8%, displasia de pabellones auriculares 33.3%. La edad de diagnóstico corresponde: < 5años 11.1%, entre 10 a 14 años 44.4%. Citogeneticamente el 72% fueron 45 X0, 28% mosaicos. Conclusión: Clínicamente el Síndrome de Turner es variable, y es diagnosticado más frecuentemente durante la adolescencia, etapa en la que se perdieron oportunidades para un adecuado tratamiento que coadyuve a prevenir complicaciones.El fenotipo de esta cromosomopatía actualmente a sido relacionado con mutaciones de genes como RPS4X y SOS.

Objective. Identify the most frequents clinical Turner syndrome patients features. Design Cross section. Place Genetic Institute, La Paz, Bolivia. Participants 36 patients with Turner Syndrome. Methods Clinical features data were collected from Genetic Institute records. Patients with similar clinical features with out cariotyping diagnosis where not included. Results We find small stature 77.8%, gonads dysgenesis 61.1%, pterigium colli 27.8%, anomalous auricles 33.3%. Age of diagnosis was less than 5 years 11.1%, between to 10 to 14 years 44.4%. Cytogenetic analysis report monosomy in 72% , mosaics (28%). Conclusions The clinical features of Turner Syndrome are variable, the diagnosis it's most frequency during puberty, age where could it be late to prevent consequences. The phenotype of Turner Syndrome has been related to RPS4X and SOS genes.

Síndrome de Turner, Noonan e cárdio-fáscio-cutânea: bases para a informação / Syndrome of Turner, Noonan and cardio-fascio-cutaneous: bases of information

Este artigo é um estudo de caso que fornecerá a definição e as características de três síndromes: Turner, Noonan e cardio-fáscio-cutânea; a fim de atingir uma hipótese de diagnóstico foi realizado uma pesquisa baseada em livros e artigos. As semelhanças entre os sinais e sintomas dessas patologias tornam o diagnóstico clínico mais difícil, contudo, a importância se concentra no quadro clínico.

Speech-language and hearing findings in the cardio-facial-cutaneous syndrome

Tema: sindrome Cárdio-fácio-cutâneo. Objetivo: descrever os achados clínicos de uma paciente com a síndrome Cárdio-fácio-cutâneo e caracterizar sua comunicação. Método: realizar avaliação genética, fonoaudiológica, otorrinolaringológica, e psicológica. Resultados: foram observadas as alterações cardíacas , cutâneas e craniofaciais, deficiência cognitiva e alteração significativa da linguagem com ausência de oralidade. Conclusão: ressalta-se a importancia da avaliação destes pacientes, para diagnóstico e intervenção, com o intuito de reflexões que direcionem o trabalho terapêutico fonoaudiológico no favorecimento de condutas comunicativas, mediante alterações severas da comunicação.

Síndrome de Noonan: relato de caso / Noonan's syndrome: case report

Os autores apresentam um caso de síndrome de Noonan em criança de 14 anos de idade, diagnosticada por meio de exame genético-clínico, demonstrando alterações oftalmológicas como hipertelorismo, alterações da fenda palpebral, hipotropia direita com pequena anisotropia em V, nistagmo, ptose palpebral bilateral e ambliopia do olho direito. Discute-se a importância do oftalmologista para esta síndrome e a necessidade do acompanhamento por equipe médica multidisciplinar.

Noonan syndrome: a case report.

In 1930 Ullrich and in 1938 Turner described females with a syndrome of short stature, sexual infantilism and a pattern of characteristic minor anomalies including pterygium colli. This syndrome named initially as the Urlich-Turner syndrome, was later called Noonan syndrome. It was later shown that the Ullrich-Turner Syndrome (UTS) is caused by monosomy X or a structural abnormality of the second X-chromosome. Presented here is a case of Noonan Syndrome in a four and half year old boy.

Achados cardíacos em 31 pacientes com síndrome de Noonan / Cardiac findings in 31 patients with Noonan's syndrome

OBJECTIVE: To evaluate cardiac findings in 31 Noonan syndrome patients. METHODS: Thirty-one (18 males and 13 females)patients from 26 families affected with Noonan's syndrome were evaluated from the cardiac point of view with electrocardiography and echodopplercardiography. RESULTS: Twenty patients had some type of cardiac abnormality. The most frequent was pulmonary valve stenosis followed by hypertrophic myocardiopathy, commonly associated with valve defects. Upper deviation of the QRS axis was observed in 80 percent of these patients. CONCLUSION: In view of the high frequency and diversity of cardiac abnormalities present in Noonan syndrome, cardiac evaluation with electrocardiography and echocardiography should be performed in all patients diagnostically suspected of having this disease

Noonan syndrome: a clinical and genetic study of 31 patients

Noonan syndrome is a multiple congenital anomaly syndrome, inherited in an autosomal dominant pattern. We studied 31 patients (18 males and 13 females) affected by this disorder regarding their clinical and genetic characteristics. The most frequent clinical findings were short stature (71 percent); craniofacial dysmorphisms, especially hypertelorism, ptosis, downslanting of the palpebral fissures; short or webbed neck (87 percent); cardiac anomalies (65 percent), and fetal pads in fingers and toes (70 percent). After studying the probands' first-degree relatives, we made the diagnosis of Noonan syndrome in more than one family member in three families. Therefore, the majority of our cases were sporadic