Síndrome de DiGeorge/velocardiofacial: reporte de un caso / DiGeorge/velocardiofacial syndrome: a case report

El síndrome de DiGeorge, también conocido como síndrome velocardiofacial o síndrome de deleción 22q11, se caracteriza por la ausencia congénita del timo y la glándula paratiroides. La tríada clásica de este trastorno es cardiopatía congénita, endocrinopatía con hipocalcemia e inmunodeficiencia primaria. Sin embargo, el síndrome puede exhibir múltiples alteraciones y manifestaciones clínicas pleiotrópicas que, a menudo, resultan en dismorfismo facial y alteraciones en el paladar. Clínicamente se evidencia mayor susceptibilidad a infecciones respiratorias o gastrointestinales recurrentes y, en los casos de aplasia tímica, se requiere tratamiento con antibióticos profilácticos y trasplante tímico, mientras que en los demás se hace manejo expectante. En este manuscrito se presenta el caso de un paciente masculino de 18 meses de edad, remitido al servicio de genética por presentar diversas alteraciones fenotípicas. Se describe el proceso mediante el cual se llegó al diagnóstico de síndrome de DiGeorge, a su manejo y pronóstico, y se hace una breve revisión de la literatura

DiGeorge syndrome, also known as velocardiofacial syndrome or 22q11 deletion syndrome, is characterized by the congenital absence of the thymus and the parathyroid gland. The classic triad of this disorder is congenital heart disease, endocrinopathy with hypocalcemia and primary immunodeficiency. However, the syndrome may exhibit multiple pleotropic abnormalities and clinical manifestations that often result in facial dysmorphism and changes in the palate. Clinically, a high susceptibility to recurrent respiratory or gastrointestinal infections is observed. In cases of thymic aplasia, treatment with prophylactic antibiotics and thymic transplantation is necessary, while in others, expectant management is used. This manuscript presents the case of an 18-month old male patient, referred to the genetics service due to several phenotypic alterations. The process by which the Di- George syndrome diagnosis, management and prognosis was reached, as well as a brief review of the literature, are presented.

Genomic imbalances in syndromic congenital heart disease / Desequilíbrios genômicos na cardiopatia congênita sindrômica

Abstract Objective: To identify pathogenic genomic imbalances in patients presenting congenital heart disease (CHD) with extra cardiac anomalies and exclusion of 22q11.2 deletion syndrome (22q11.2 DS). Methods: 78 patients negative for the 22q11.2 deletion, previously screened by fluorescence in situ hybridization (FISH) and/or multiplex ligation probe amplification (MLPA) were tested by chromosomal microarray analysis (CMA). Results: Clinically significant copy number variations (CNVs ≥300 kb) were identified in 10% (8/78) of cases. In addition, potentially relevant CNVs were detected in two cases (993 kb duplication in 15q21.1 and 706 kb duplication in 2p22.3). Genes inside the CNV regions found in this study, such as IRX4, BMPR1A, SORBS2, ID2, ROCK2, E2F6, GATA4, SOX7, SEMAD6D, FBN1, and LTPB1 are known to participate in cardiac development and could be candidate genes for CHD. Conclusion: These data showed that patients presenting CHD with extra cardiac anomalies and exclusion of 22q11.2 DS should be investigated by CMA. The present study emphasizes the possible role of CNVs in CHD.

Resumo Objetivo: Identificar desequilíbrios genômicos patogênicos em pacientes que apresentam cardiopatias congênitas (CC) e anomalias extracardíacas e exclusão da síndrome de deleção 22q11.2 (SD22q11.2). Métodos: Foram avaliados por microarray cromossômico (CMA) 78 pacientes negativos para a deleção 22q11.2, previamente testados por hibridação in situ com fluorescência (FISH) e/ou amplificação de múltiplas sondas dependentes de ligação (MLPA). Resultados: Foram identificadas variações do número de cópias de DNA (CNVs) clinicamente significativas (≥ 300 kb) em 10% (8/78) dos casos, além de CNVs potencialmente relevantes em dois casos (duplicação de 993 kb em 15q21.1 e duplicação de 706 kb em 2p22.3). Genes envolvidos como IRX4, BMPR1A, SORBS2, ID2, ROCK2, E2F6, GATA4, SOX7, SEMAD6D, FBN1 e LTPB1 são conhecidos por atuar no desenvolvimento cardíaco e podem ser genes candidatos a CC. Conclusão: Esses dados mostram que pacientes que apresentam CC, com anomalias extracardíacas e exclusão da SD22q11.2, devem ser investigados por CMA. Ainda, este estudo enfatiza a possível função das CNVs nas CC.

Delayed diagnosis of 22q11 deletion syndrome due to late onset hypocalcemia in a 11-year-old girl with imperforated anus

Neonatal hypocalcemia and congenital heart defects has been known as the first clinical manifestation of the chromosome 22q11.2 deletion syndrome (22q11DS). However, because of its wide clinical spectrum, diagnosis of 22q11DS can be delayed in children without classic symptoms. We report the case of a girl with the history of imperforate anus but without neonatal hypocalcemia or major cardiac anomaly, who was diagnosed for 22q11DS at the age of 11 after the onset of overt hypocalcemia. She was born uneventfully from phenotypically normal Korean parents. Imperforate anus and partial cleft palate were found at birth, which were surgically repaired thereafter. There was no history of neonatal hypocalcemia, and karyotyping by GTG banding was normal. At the age of 11, hypocalcemia (serum calcium, 5.0 mg/dL) and decreased parathyroid hormone level (10.8 pg/mL) was noted when she visited our Emergency Department for fever and vomiting. The 22q11DS was suspected because of her mild mental retardation and velopharyngeal insufficiency, and a microdeletion on chromosome 22q11.2 was confirmed by fluorescence in situ hybridization. The 22q11DS should be considered in the differential diagnosis of hypocalcemia at any age because of its wide clinical spectrum.

Abordaje inmunológico del síndrome por deleción 22q11 / Immunological approaches to 22q11 deletion syndrome

El síndrome por deleción 22q11 (SD22q11) es el síndrome por deleción cromosómica más frecuente en humanos y se caracteriza por la tríada clínica que incluye cardiopatía congénita, hipocalcemia e inmunodeficiencia primaria. El 85-90% de los pacientes tienen microdeleciones en el cromosoma 22q11.2. Tomando como punto cardinal la cardiopatía congénita, se diseñó una estrategia para tamización y diagnóstico de SD22q11 con énfasis en la evaluación inmune. Es imprescindible realizar una historia clínica detallada y, posteriormente, un análisis cuantitativo y funcional de las subpoblaciones de linfocitos en sangre periférica para clasificarlo en SD22q11 completo (<1%) o parcial (95-99%) e instaurar las pautas de tratamiento en aspectos como: aislamiento del paciente, vacunación, profilaxis contra microorganismos oportunistas, uso de productos sanguíneos irradiados y reconstitución inmunológica. Sin embargo, el abordaje del paciente debe ser multidisciplinario para detectar y prevenir complicaciones a largo plazo que pueden ser graves, especialmente en los pacientes con SD22q11 completo.

In humans, 22q11 deletion syndrome (22q11DS) is considered the most common chromosome deletion syndrome. It is characterised by a clinical triad that includes congenital heart disease, hypocalcaemia and primary immunodeficiency. Approximately 85-90% of patients with this syndrome exhibit microdeletions in chromosome 22q11.2. Using congenital heart disease as a starting point, we designed a strategy for the screening and diagnosis of 22q11DS with an emphasis on immunological evaluation. A detailed clinical history and the subsequent quantitative and functional analyses of the lymphocyte subpopulations in the peripheral blood is crucial to classify as complete (<1%) or partial (95-99%) the disease and to guide clinicians in terms of patient isolation, vaccination, prophylaxis for opportunistic infections, use of irradiated blood products and immunological reconstitution. However, multidisciplinary care is necessary to detect and prevent long-term complications that could be severe, particularly in cases of complete 22q11DS.

Early onset intellectual disability in chromosome 22q11.2 deletion syndrome / Inicio temprano de discapacidad intelectual en el Síndrome de deleción del cromosoma 22q11.2

Chromosome 22q11.2 deletion syndrome, or DiGeorge syndrome, or velocardiofacial syndrome, is one of the most common multiple anomaly syndromes in humans. This syndrome is commonly caused by a microdelection from chromosome 22 at band q11.2. Although this genetic disorder may reflect several clinical abnormalities and different degrees of organ commitment, the clinical features that have driven the greatest amount of attention are behavioral and developmental features, because individuals with 22q11.2 deletion syndrome have a 30-fold risk of developing schizophrenia. There are differing opinions about the cognitive development, and commonly a cognitive decline rather than an early onset intellectual disability has been observed. We report a case of 22q11.2 deletion syndrome with both early assessment of mild intellectual disabilities and tetralogy of Fallot as the only physic manifestation.

El síndrome del cromosoma 22q11.2, también conocido como supresión o síndrome de DiGeorge o síndrome velocardiofacial, es uno de los síndromes más comunes de anomalías múltiples en los seres humanos. Este síndrome es comúnmente causado por una microdeleción del cromosoma 22 en q11.2 banda. Aunque este trastorno genético muestra varias anomalías clínicas y diferentes grados de compromiso orgánico, las características clínicas que han atraído la mayor atención son el comportamiento y el desarrollo, porque las personas con síndrome de deleción 22q11.2 tienen un riesgo 30 veces mayor de desarrollar esquizofrenia. Hay diferentes opiniones sobre el desarrollo cognitivo, y comúnmente se se ha observado un deterioro cognitivo en lugar de un inicio temprano de discapacidad intelectual. Presentamos un caso de síndrome de deleción 22q11.2 tanto con la evaluación temprana de discapacidades intelectuales leves como con la tetralogía de Fallot como única manifestación física.

Genetic Syndromes associated with Congenital Heart Disease

Recent research has demonstrated that genetic alterations or variations contribute considerably to the development of congenital heart disease. Many kinds of genetic tests are commercially available, and more are currently under development. Congenital heart disease is frequently accompanied by genetic syndromes showing both cardiac and extra-cardiac anomalies. Congenital heart disease is the leading cause of birth defects, and is an important cause of morbidity and mortality during infancy and childhood. This review introduces common genetic syndromes showing various types of congenital heart disease, including Down syndrome, Turner syndrome, 22q11 deletion syndrome, Williams syndrome, and Noonan syndrome. Although surgical techniques and perioperative care have improved substantially, patients with genetic syndromes may be at an increased risk of death or major complications associated with surgery. Therefore, risk management based on an accurate genetic diagnosis is necessary in order to effectively plan the surgical and medical management and follow-up for these patients. In addition, multidisciplinary approaches and care for the combined extra-cardiac anomalies may help to reduce mortality and morbidity accompanied with congenital heart disease.

Manifestaciones Orales en el Síndrome de Deleción 22q11 / Oral Manifestations in 22q11 Deletion Syndrome

Las supresiones intersticiales del cromosoma 22q11 son las microdeleciones más frecuentes observadas en humanos, con una frecuencia de aproximadamente 1:4000-1:8000 nacidos. Incluye diversos síndromes como el síndrome de DiGeorge y Cayler. Los pacientes con deleción 22q11 presentan diversas combinaciones de las siguientes entidades clínicas: defectos cardíacos congénitos, facies característica, malformaciones del paladar, hipoparatiroidismo, hipocalcemia, inmunodeficiencia congénita debido a la hipoplasia tímica, retraso del crecimiento y problemas psiquiátricos. La etiología en la mayoría de los pacientes es una deleción recurrente 3-Mb en la región 22q11. Los objetivos del estudio fueron examinar y describir las manifestaciones orales en las personas con síndrome de deleción 22q11 y analizar sus condiciones médicas y sus implicaciones en odontología. Se realizó una búsqueda sistemática en Octubre de 2012 en la base de datos PubMed, Scielo y Cochrane Library con las palabras clave: 22q11 deletion syndrome, oral health y dentist. Se observó una alta prevalencia de anomalías dentales. Las alteraciones del esmalte son las más frecuentes. Se presenta mayor número de hipomineralizaciones que de hipoplasias del esmalte. El hipoparatiroidismo y/o hipocalcemia no se consideran los factores etiológicos en las alteraciones del esmalte y no existe relación directa entre las condiciones médicas sistémicas y las alteraciones del esmalte. En el síndrome de deleción 22q11 la cavidad oral está afectada por alteraciones en el esmalte, en la morfología de los dientes, en el número de dientes y en la erupción dental. Es importante conocer que los pacientes con síndrome de deleción 22q11 suelen padecer malformaciones cardíacas congénitas y problemas inmunológicos.

Interstitial deletions of chromosome 22q11 are the most commonly seen microdeletions observed in humans, with a frequency of approximately 1:4000­1:8000 live births. It includes various syndromes such as DiGeorge and Cayler syndrome. Patients with the 22q11 deletion present various combinations of the following clinical features: congenital cardiac defects, characteristic facies, palate malformations, hypoparathyroidism, congenital hypocalcemia, immunodeficiency due to thymic hypoplasia, growth retardation and psychiatric problems. The etiology in the majority of patients is a 3-Mb recurrent deletion in region 22q11. The aim of the study were to examine and describe oral manifestations in individuals with 22q11 deletion syndrome and to analyze associations with medical conditions and the implications in dentist. A systematic search in October 2012 in PubMed, Scielo and Cochrane Library database with keywords: 22q11 deletion syndrome, oral health and dentist. Dental anomalies were registered in high numbers. Enamel disturbances were frequently seen. There were more hypomineralizations than hypoplasias. Hypoparathyroidism and/or hypocalcemia are not clear etiological factors for enamel disturbances and there were no major correlations between medical conditions and enamel disturbances. In 22q11 deletion syndrome the oral cavity is affected by anomalies in dental enamel, tooth shape, numbers of teeth and eruption. It is important to know that patients with 22q11 deletion syndrome often have congenital heart defects and immune problems.

Monosomy 22 Mosaicism Associated Thrombocytopenia Presenting as Behcet's Disease / 임상소아혈액종양

We describe an 18 year old female with monosomy 22 mosaicism and thrombocytopenia. She had some unique facial appearance such as small eyes and thin lip, similar to those with 22q11 deletion syndrome and thrombocytopenia with slightly increased mean platelet volume and recurrent orogenital ulcers presented as Behcet's disease. There are very few published case reports and a great variability of phenotypic presentations among the anomalies of the patients with monosomy 22 mosaicism. We report this case with a brief review of the literature suggesting that thrombocytopenia can be a new component manifestation of monosomy 22 mosaicism.

Monosomy 22 Mosaicism Associated Thrombocytopenia Presenting as Behcet's Disease / 임상소아혈액종양

We describe an 18 year old female with monosomy 22 mosaicism and thrombocytopenia. She had some unique facial appearance such as small eyes and thin lip, similar to those with 22q11 deletion syndrome and thrombocytopenia with slightly increased mean platelet volume and recurrent orogenital ulcers presented as Behcet's disease. There are very few published case reports and a great variability of phenotypic presentations among the anomalies of the patients with monosomy 22 mosaicism. We report this case with a brief review of the literature suggesting that thrombocytopenia can be a new component manifestation of monosomy 22 mosaicism.

Proceso enfermero de un adolescente que presenta alucinaciones por síndrome de deleción 22q11 / Infirmary process in an adolescent presenting hallucinations due to 22q11 deletion syndrome", "_i": "

El estudio de caso basado teóricamente con el modelo de VirginiaHenderson permite vislumbrar la vinculación teórico-prácticade la disciplina de enfermería; esta revisión incluye comovariables las necesidades humanas alteradas en un adolescenteen el período postoperatorio tardío de cirugía cardíaca con síndromede deleción 22q11 que según la literatura es manifestadopor dismorfia facial distintiva, déficit intelectual y alteracionespsiquiátricas; estos datos clínicos fueron identificados a travésde una valoración, la cual permitió establecer el estado de salud,causas de dependencia, nivel de relación y un plan de cuidadoenfermero orientado hacia la recuperación e integraciónde la persona a su entorno social.

The case-study theoretically based upon Viginia Henderson’smodel (Virginia Henderson’s Need Theory) allows viewing thetheoretical-practical relationship in infirmary discipline. This reviewincludes, as the studied variables, the altered human needsin an adolescent presenting 22q11 deletion syndrome during thelate post-operative period at cardiac surgery. According to the literature,the aforementioned syndrome is manifested by distinctivefacial dysmorphism, intellectual deficit, and psychiatric alterations.This clinical data were identified through an assessment,which allowed to establish health condition, dependence causes,relation level, and a infirmary care plan directed to the patient’srecovery and integration into his/her social background.

Progress on chromosome 22q11 deletion syndrome / 国际儿科学杂志

Chromosome 22qll deletion syndrome(22q11DS) is a common chromosomal microdeletion syndrome. Its clinical manifestation is complex, comprising congenital heart disease, dysmorphic facial, immunodeficiency, endocrine dysfunction and so on. The syndrome has a population prevalence of approximately 1/2500-1/4000. There have been many recent advances in understanding of the clinical manifestation, behavior and psychiatric problems and the mechanisms leading to the specific phenotypic features in chromosome 22q11 deletion syndrome. Asymmetric recombination of homologous low copy repetitives in the deletion region causes the deletion of 22q11. TBX1 is the dominant gene contributing to the phenotype.