Natural history of 39 patients with Achondroplasia

OBJECTIVES: To characterize the natural history of 39 achondroplastic patients diagnosed by clinical, radiological and molecular assessments. METHODS: Observational and retrospective study of 39 patients who were attended at a public tertiary level hospital between 1995 and 2016. RESULTS: Diagnosis was made prenatally in 11 patients, at birth in 9 patients and within the first year of life in 13 patients. The most prevalent clinical findings were short stature, high forehead, trident hands, genu varum and macrocephaly. The most prevalent radiographic findings were rhizomelic shortening of the long bones and narrowing of the interpediculate distance of the caudal spine. There was motor developmental delay in 18 patients and speech delay in 16 patients. The most common clinical intercurrences were middle ear dysfunction, sleep apnea, limb pain and obesity from 2 to 9 years of age. One patient was large for the gestational age but did not develop obesity. One patient developed hydrocephalus at 10 years old. The current age of the patients varies from 15 months to 36 years. The molecular study performed by Sanger sequencing of the common heterozygous mutation 1138G>A in FGFR3 was positive in all patients. Four cases were inherited, and 35 were sporadic (paternal age from 19 to 66 years). CONCLUSIONS: The diagnoses were made early based on clinical and radiographic findings. All cases were confirmed molecularly. Despite presenting a benign course, it is necessary to establish a systematic protocol for the surveillance of these patients due to the common clinical intercurrences.

Williams Syndrome: development of a new scoring system for clinical diagnosis

OBJECTIVE: To develop a scoring system based on clinical findings to assist pediatricians in the diagnosis of William syndrome and to delineate when the fluorescent in-situ hybridization test to detect the microdeletion at 7q11.23 may be needed. METHODS: The fluorescent in-situ hybridization test was performed on 20 patients presenting William syndrome suggestive clinical features. Eleven studies were selected from the literature in which there were 2 groups: patients with positive or negative fluorescent in-situ hybridization tests. Forty-two clinical characteristics were compared to those reported in the literature to determine which ones were associated with the affected patients (ie, bearing deletions) using meta-analysis. The 2-tailed Fisher exact test were used so that the frequency of findings observed in fluorescent in-situ hybridization positive and fluorescent in-situ hybridization negative patients could be compared in the present study together with the patients from the literature. We developed a scoring system based on clinical findings and their significant associations with patients with positive fluorescent in-situ hybridization tests. From themean and standard-deviation values of the data from our patients, we determined the cut-off score that that indicated the need for a fluorescent in-situ hybridization test to confirm diagnosis. RESULTS: Seventeen patients were fluorescent in-situ hybridization positive, and 3 were fluorescent in-situ hybridization negative. The more discriminative findings among fluorescent in-situ hybridization positive patients were the following: typical facies, low birth weight, feeding difficulties, constipation, supravalvar aortic stenosis, mental retardation, and friendly personality. The distribution of the points among the 20 patients ranged from 19 to 28 points with a mean value of 23.3 out of a possible total of 31 points. The cut-off score that indicated the need for a fluorescent in-situ...

OBJETIVOS: Desenvolver um sistema de pontuação (Score) baseado nos achados clínicos para auxiliar os pediatras no diagnóstico clínico da Síndrome de Williams-Beuren e na indicação do teste de hibridização in situ por fluorescência para detectar a microdeleção em 7q11.23. MÉTODOS: O teste de hibridização in situ por fluorescência foi feito em 20 acometidos pela Síndrome de Williams-Beuren, nos quais 42 achados clínicos foram estudados. Para estabelecer quais desses achados estariam associados ao teste de hibridização in situ por fluorescência positivo, realizou-se uma metanálise com 11 trabalhos da literatura em que havia dois grupos, hibridização in situ por fluorescência positivo e negativo. As freqüências dos achados presentes nos indivíduos fluorescência positivo e fluorescência negativo neste estudo foram comparadas em conjunto com os pacientes da literatura através do teste exato de Fisher. Elaboramos um sistema de pontuação (score) baseado nos achados que mostraram correlação significante (p<0,001) para os pacientes hibridização in situ por fluorescência positivo. Determinamos os valores correspondentes aos percentis baseados na média e desvio-padrão, calculados a partir dos 20 pacientes do presente trabalho. RESULTADOS: Dezessete pacientes foram hibridização in situ por fluorescência positivo e três, negativo. Os achados mais discriminativos nos hibridização in situ por fluorescência positivo (3 pontos no score) foram: fáceis típico, baixo peso ao nascimento, dificuldades alimentares, obstipação, estenose aórtica supravalvar, deficiência mental e personalidade amigável.A distribuição dos valores entre os 20 pacientes variou de 19 a 28 pontos com uma média de 23,3 pontos. CONCLUSÕES: O score elaborado permitiu propor o valor de 20 pontos para a indicação do teste de hibridização in situ por fluorescência nos pacientes com suspeita clínica de Síndrome de Williams-Beuren.

Renal and urinary findings in 20 patients with Williams-Beuren syndrome diagnosed by fluorescence in situ hybridization (FISH)

OBJETIVO: A síndrome de Williams-Beuren é uma rara síndrome de deleção de genes contíguos que cursa com múltiplas anomalias congênitas, deficiência mental e anomalias renais e urinárias. O objetivo deste trabalho foi determinar a freqüência e os tipos de anomalias renais e urinárias em 20 pacientes com síndrome de Williams-Beuren diagnosticados pelo teste de hibridização in situ por fluorescência. MÉTODOS: Estudou-se prospectivamente os aspectos renais e urinários através de avaliação laboratorial da função renal, ultrassonografia de rins e vias urinárias, uretrocistografia miccional e estudo urodinâmico. O teste da hibridização in situ por fluorescência com a sonda LSI Williams Region foi feito nos 20 pacientes com síndrome de Williams-Beuren para a confirmação do diagnóstico. RESULTADOS E DISCUSSÃO: A deleção do gene da elastina (teste de hibridização in situ por fluorescência positivo) foi detectado em 17/20 afetados (85%). As alterações renais foram diagnosticadas em 5/17 (29%) dos pacientes com a deleção e em 1/3 dos indivíduos sem a deleção. Catorze pacientes com a deleção apresentavam disfunções miccionais. A hipertensão arterial foi diagnosticada em três pacientes com a deleção e um deles apresentava estenose bilateral das artérias renais. CONCLUSÕES: Devido à elevada incidência de anormalidades renais e do trato urinário na síndrome de Williams-Beuren, recomenda-se realizar uma avaliação laboratorial e de imagem sistematizada nos pacientes.

Síndrome de Williams-Beuren: anomalias cardiovasculares em 20 pacientes diagnosticados pela hibridazação in situ por fluorescência / Williams-Beuren syndrome: cardiovascular abnormalities in 20 patients diagnosed with fluorescence in situ hybridization

OBJECTIVE: To evaluate the cardiovascular findings and clinical follow-up of patients with Williams-Beuren syndrome. METHODS: We studied 20 patients (11 males, mean age at diagnosis: 5.9 years old), assessed for cardiovascular abnormalities with electrocardiography and Doppler echocardiography. Fluorescence in situ hybridization (FISH) was used to confirm the diagnosis of the syndrome. RESULTS: Elastin gene locus microdeletion was detected in 17 patients (85 percent) (positive FISH), and in 3 patients deletion was not detected (negative FISH). Sixteen patients with a positive FISH (94 percent) had congenital cardiovascular disease (mean age at diagnosis: 2,3 years old). We observed isolated (2/16) supravalvular aortic stenosis and supravalvular aortic stenosis associated (11/16) with pulmonary artery stenosis (4/11); mitral valve prolapse (3/11); bicuspid aortic valve (3/11); aortic coarctation (2/11), thickened pulmonary valve (2/11); pulmonary valvular stenosis (1/11); supravalvular pulmonary stenosis (1/11); valvular aortic stenosis (1/11); fixed subaortic stenosis (1/11); pulmonary artery stenosis (2/16) associated with pulmonary valvar stenosis (1/2) and with mitral valve prolapse (1/2); and isolated mitral valve prolapse (1/16). Four patients with severe supravalvular aortic stenosis underwent surgery (mean age: 5.7 years old), and 2 patients had normal pressure gradients (mean follow-up: 8.4 years). CONCLUSION: A detailed cardiac evaluation must be performed in all patients with Williams-Beuren syndrome due to the high frequency of cardiovascular abnormalities

Hematological findings in Noonan syndrome

OBJECTIVE: Noonan syndrome is a multiple congenital anomaly syndrome, and bleeding diathesis is considered part of the clinical findings. The purpose of this study was to determine the frequency of hemostatic abnormalities in a group of Noonan syndrome patients. METHOD: We studied 30 patients with clinical diagnosis of Noonan syndrome regarding their hemostatic status consisting of bleeding time, prothrombin time, activated partial thromboplastin time and thrombin time tests, a platelet count, and a quantitative determination of factor XI. RESULTS: An abnormal laboratory result was observed in 9 patients (30 percent). Although coagulation-factor deficiencies, especially factor XI deficiency, were the most common hematological findings, we also observed abnormalities of platelet count and function in our screening. CONCLUSIONS: Hemostatic abnormalities are found with some frequency in Noonan syndrome patients (30 percent in our sample). Therefore, we emphasize the importance of a more extensive hematological investigation in these patients, especially prior to an invasive procedure, which is required with some frequency in this disorder

Anomalias músculo-esqueléticas na síndrome de Williams-Beuren. Descrição de 20 crianças e adolescentes utilizando-se o teste de hidridização in situ por fluorescência (FISH) / Musculoskeletal anomalies in Williams-Beuren syndrome. Description of 20 children and adolescents utilizing the fluorescence in situ hybridization (FISH) analysis

A síndrome de Williams-Beuren (SWB) é uma síndrome de deleção de genes contíguos, caracterizada por fácies típico, anomalias oculares, cardiopatia congênita, deficiência mental, personalidade amigável, anomalias renais e esqueléticas. A causa da SWB é uma deleção submicroscópica no lócus do gene da elastina, localizada em 7q11.23, detectável pelo teste de Hibridização In Situ por Fluorescência (FISH) em 90% a 95% dos afetados. As anomalias músculo-esqueléticas características da SWB são hipermobilidade articular na lactância, contraturas articulares, limitação à supinação do antebraço com ou sem sinostose rádioulnar e pregas extra-sacrais. Outras anomalias freqüentes incluem escoliose, cifose e lordose acentuada. Objetivo: Descrever as manifestações clínicas e radiológicas em 20 pacientes com SWB e correlacioná-las com o teste de FISH. Métodos: Realizamos uma avaliação clínica e radiológica prospectiva em 20 afetados (11M:9F) pela SWB com média de idade de 9,5 anos (5 – 17 anos). Resultados: Dezessete (85%) pacientes apresentavam a deleção (FISH positivo). As seguintes anomalias foram observadas somente nos pacientes FISH positivo: contraturas articulares (18%), limitação à supinação dos antebraços (24%), sinostose rádio-ulnar (13%) e pregas extra-sacrais (71%). A fisioterapia foi indicada, em todos os pacientes, para as contraturas articulares que tendem a piorar com a idade. Conclusões: Devido a uma alta incidência de anomalias músculo-esqueléticas em pacientes com a SWB, recomendamos uma avaliação clínica das articulações e radiografia completa do esqueleto para todas as crianças afetadas na ocasião do diagnóstico.

Ataxia de Friedreich. Avaliação cardiáca de 24 pacientes com diagnóstico clínico e revisão da literatura / Friedreich's ataxia. Cardiac evaluation of 25 patients with clinical diagnosis and literature review

OBJECTIVE - Cardiac evaluation (clinical, electrocardiographic and echocardiographic) of 25 Brazilian patients with clinical diagnosis of Friedreich's ataxia (FA) related to the frequency and the size of GAA repeats (unstable expansion of trinucleotide repeats that results in the disease). METHODS - Clinical and cardiac study including electrocardiogram and echocardiogram of all patients and molecular analysis to detect the frequency and the size of GAA expansion, by polymerase chain reaction analysis. RESULTS - Homozygous GAA expansion was detected in 17 patients (68 percent) -- all typical cases. In 8 (32 percent) cases (6 atypical and 2 typical), no GAA expansion was observed, therefore it was not considered Friedreich's ataxia. All patients with GAA expansion (100 percent) had electrocardiographic abnormalities, and only 25 percent of the cases without GAA expansion had some abnormality on this exam. However, only 6 percent of all patients revealed some signals/symptoms suggestive of cardiac involvement. CONCLUSION - A molecular analysis is essential to confirm the diagnosis of Friedreich's ataxia; however, an adequate cardiac evaluation, including an electrocardiogram, was extremely useful to better screening the patients which should perform these molecular analysis

Anormalidades oculares em 20 pacientes com sindrome de Willians-Beuren / Ocular abnormalidades in 20 patients with Williams-Beuren syndrome

Objetivo: alertar pediatras, geneticistas e oftalmologistas para os aspectos oftalmologicos observados na sindrome de Williams-Beuren (SWB). Casuistica e metodos: realizou-se avaliacao...

Friedreich's ataxia: clinical and molecular study of 25 Brazilian cases

INTRODUCTION: Friedreich's ataxia is a neurodegenerative disorder whose clinical diagnostic criteria for typical cases basically include: a) early age of onset (< 20 or 25 years), b) autosomal recessive inheritance, c) progressive ataxia of limbs and gait, and d) absence of lower limb tendon reflexes. METHODS: We studied the frequency and the size of expanded GAA and their influence on neurologic findings, age at onset, and disease progression in 25 Brazilian patients with clinical diagnosis of Friedreich's ataxia - 19 typical and 6 atypical - using a long-range PCR test. RESULTS: Abnormalities in cerebellar signs, in electrocardiography, and pes cavus occurred more frequently in typical cases; however, plantar response and speech were more frequently normal in this group when the both typical and atypical cases were compared. Homozygous GAA expansion repeats were detected in 17 cases (68 percent) - all typical cases. In 8 patients (32 percent) (6 atypical and 2 typical), no expansion was observed, ruling out the diagnosis of Friedreich's ataxia. In cases with GAA expansions, foot deformity, cardiac abnormalities, and some neurologic findings occurred more frequently; however, abnormalities in cranial nerves and in tomographic findings were detected less frequently than in patients without GAA expansions. DISCUSSION: Molecular analysis was imperative for the diagnosis of Friedreich's ataxia, not only for typical cases but also for atypical ones. There was no genotype-phenotype correlation. Diagnosis based only on clinical findings is limited; however, it aids in better screening for suspected cases that should be tested. Evaluation for vitamin E deficiency is recommended, especially in cases without GAA expansion

Clinical and laboratorial study of 19 cases of mucopolysaccharidoses

The mucopolysaccharidoses (MPS) are a heterogeneous group of inborn errors of lysosomal glycosaminoglycan (GAG) metabolism. The importance of this group of disorders among the inborn errors of metabolism led us to report 19 cases. METHOD: We performed clinical, radiological, and biochemical evaluations of the suspected patients, which allowed us to establish a definite diagnosis in 19 cases. RESULTS: Not all patients showed increased GAG levels in urine; enzyme assays should be performed in all cases with strong clinical suspicion. The diagnosis was made on average at the age of 48 months, and the 19 MPS cases, after a full clinical, radiological, and biochemical study, were classified as follows: Hurler -- MPS I (1 case); Hunter -- MPS II (2 cases); Sanfilippo -- MPS III (2 cases); Morquio -- MPS IV (4 cases); Maroteaux-Lamy -- MPS VI (9 cases); and Sly -- MPS VII (1 case). DISCUSSION: The high relative frequency of Maroteaux-Lamy disease contrasts with most reports in the literature and could express a population variability

Uso da análise de Fish para diagnóstico em 11 pacientes com síndrome de Williams-Beuren / Use of Fish analysis to diagnosis approach of 11 Brazilian patients with Williams-Beuren syndrome

A síndrome de Williams-Beuren (SWB) é uma rara síndrome de deleçäo de genes contíguos que feta múltiplos sistemas. A doença é causada por uma deleçäo submicroscópica na regiäo 7q11.23, que é detectada pela análise de Fish em 90-95 por cento dos pacientes. Relatamos o estudo clínico e a análise citogenética por Fish realizados em 11 pacientes (6M:5F), todos esporádicos. Fácies típicos de "duende", atraso de desenvolvimento/retardo mental, anomalias dentárias e esqueléticas estavam presentes em todos os pacientes; anomalias oculares em dez (91 por cento); cardiopatias congênitas em oito (73 por cento), sendo metade, estenose supravalvar aórtica; baixa estatura em seis (54 por cento); hipercalcemia transitória em quatro (36 por cento); hérnia inguinal em três (27 por cento) e anomalias renais em dois (18 por cento). Analisanmos a hemizigosidade do gene da elastina por Fish, utilizando a sonda LSI Williams Syndrome Region DNA Fish (Vysis) nas células interfásicas e metafásicas. O paciente sem deleçäo apreentava fácies e comportamento tópico, exceto cardiopatia. A análise pelo Fish do locus da elastina é um teste útil para confirmaçäo diagnóstica da SWB, o que auxilia no seguimento clínico adequado e na prevençäo das complicaçöes

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

Importância do cianeto-nitroprussiato comoteste de triagem para diagnóstico presuntivo da homocistinúria / Importance of cyanide-nitroprusside test for the screning and presunptive diagnosis of homocystinuria

A homocictinúria é uma doença genética rara causada pela açäo deficiente de enzima cistationina-beta-sintetase (CBS), o que acarreta uma elevaçäo dos níveis de homocisteína em sangue e urina. O quadro clínico inclui retardo mental progressivo e ealteraçöes esqueléticas semelhates àquelas encontradas na doença de Marfan. A presença de homocisteína é triada por um teste rápido, sensível e barato, o cianeto-nitroprussiato (CNT). O teste laboratorial de referência para a doença é a cromatografia líquida de alto desempenho (HLPC), em amostras de urina e sangue, no entanto, trata-se de metodologia disponível em alguns poucos centros. Na prática, o diagnóstico da homocictinúria tem sido baseado única e exclusivamente em dados clínicos. No presente estudo, estamos propondo o uso do CNT como teste de triagem e de presunçäo diagnóstica. Para tanto, foram investigados 41 pacientes apresentado alteraçöes do tipo Marfan-símile e/ou retardo mental. O CNT foi positivo em quatro casos (4/41 ou 9,8), e nos quatro casos houve boa resposta terapêutica após a introduçäo da suplementaçäo com a piridoxina

Síndrome de Edwards com aplasia radial - relato de dois casos e revisäo das anomalias esqueléticas na síndrome / Edward's syndrome with radial aplasia - report of two cases and review of skeletal abnormalities associated with this syndrome

A síndrome de Edwards ou trissomia do cromossomo 18 é a segunda trissomia autossômica mais freqüente entre os nativivos. Os pacientes afetados apresentam múltiplas malformaçöes, atraso grave de crescimento e desenvolvimento neuropsicomotor e prognóstico reservado. A aplasia radial é uma anomalia esquelética raramente descrita na literatura. Os autores estudaram dois pacientes com trissomia 18 associada à aplasia radial e descrevem os achados clínicos e radiológicos e os diagnósticos diferenciais, com revisäo das anomalias esqueléticas na síndrome de Edwards.

Sindrome de Pallister Killian ou tetrassomia do braco curto do cromossomo 12 em mosaico : relato de dois casos diagnosticados pela hibridizacao in situ por fluorescencia (FISH) / Pallister Killian syndrome or tetrasomy of the short arm of the chromosome 12 mosaicism : report on two cases diagnosed by fluorescense in situ hybridization

A sindrome de Pallister Killian (SPK) e uma doenca rara caracterizada por multiplas malformacoes, retardo mental profundo e presenca de um isocromossomo...

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

Displasia cleidocraniana - relato de caso de revisäo da literatura / Cleidocranial dysplasia - a case and review of the literature

Resumo: A displasia cleidocraniana é doença rara de herança autossômica dominante, caracterizada por atraso no fechamento das fontenelas, hipoplasia ou aplasia das clavículas, permitindo uma facilidade anormal na aproximaçäo dos ombros, anomalias dentárias e malformaçöes vertebrais. Os autores estudaram um adolescente, de 13 anos de idade, com caracteristicas clínicas e radiológicas típicas dessa condiçâo.

Clinical and radiological aspects in Melnick-needles syndrome

A sindrome de Melnick-Needles e uma displasia esqueletica ligada ao X e letal no sexo masculino. Caracteriza-se pela presenca de um facies tipico e dos seguintes achados radiologicos : esclerose dos ossos da base do cranio e mastoide, tibia em forma de "S", irregularidades corticais e costelas com aspecto de fita ("ribbon-like"). A maioria dos 48 casos ja relatados na literatura (bem documentados), eram esporadicos, observando-se transmissao parenteral em apenas 11 familias...