autosomal recessive

Nanophthalmos with Retinitis Pigmentosa

Clinical Characteristics

Ocular Features

Poor vision is present beginning in childhood and may progress to hand motion or even loss of light perception when retinal detachments occur.  Nystagmus has been seen in one patient.  Corneal diameters were 11 mm, the angles were open, and axial lengths were shortened to about 17 mm.  Alternating areas of hypo- and hyperfluorescence are seen with fluorescein angiography corresponding to areas with pigment clumping seen throughout the fundi.  The fundus pigmentation is atypical for retinitis pigmentosa, however, in spite of the title given by the authors.  No scotopic or photopic responses are seen on the ERG.  Drusen were present in the optic nerves. 

Systemic Features

No systemic disease is associated. 

Genetics

A single family with affected male and female sibs has been reported and a homozygous nonsense mutation in exon 5 of the CRB1 gene (1q31-32.1) was present in both. 

Another recessive form of microphthalmia with retinitis pigmentosa plus has been reported (611040) without nanophthalmos features and having a mutation in the MFRP gene. True nanophthalmos with retinopathy (267760) has some features similar to the disorder described here but with macular cysts.  No responsible mutation has been identified in this disorder however. 

Treatment Options

Low vision aids might be helpful in early stages of the disease. 

References

Zenteno JC, Buentello-Volante B, Ayala-Ramirez R, Villanueva-Mendoza C. Homozygosity mapping identifies the Crumbs homologue 1 (Crb1) gene as responsible for a recessive syndrome of retinitis pigmentosa and nanophthalmos. Am J Med Genet A. 2011 Apr 11. doi: 10.1002/ajmg.a.33862. [Epub ahead of print]

PubMed ID: 
21484995

Microphthalmia with Retinitis Pigmentosa

Clinical Characteristics

Ocular Features

A decrease in visual acuity with night blindness begins in the third decade of life.  The axial length is decreased resulting in high hyperopia.  There is diffuse scleral thickening, macular schisis of the outer retinal layers, and drusen may be present in the optic nerve.  The retinal pigment epithelium is abnormal with both pigment clumping and bone-spicule formation.  Areas of hypo- and hyperfluorescence are seen on fluorescein angiograms.  The cornea is normal-sized with shallow anterior chambers but narrow angles were not reported.  Intraocular pressures were normal.  On ERG recordings rod responses are missing while cone tracings are severely diminished. 

Systemic Features

No systemic disease is associated. 

Genetics

Based on consanguinity in the parents of the single family reported, this seems to be an autosomal recessive disorder.  Molecular studies confirm that the four affected sibs are homozygous for mutations in the MFRP gene (11q23) while the parents are both heterozygous.

Another disorder of small eyes but with classical findings of nanophthalmos and retinitis pigmentosa has also been described (267760) (nanophthalmos with retinopathy) and may be the same disorder especially since no molecular mutation has been identified.  

Treatment Options

Low vision aids may be helpful, at least in early stages of the disease. 

References

Ayala-Ramirez R, Graue-Wiechers F, Robredo V, Amato-Almanza M, Horta-Diez I, Zenteno JC. A new autosomal recessive syndrome consisting of posterior microphthalmos, retinitis pigmentosa, foveoschisis, and optic disc drusen is caused by a MFRP gene mutation. Mol Vis. 2006 Dec 4;12:1483-9.

PubMed ID: 
17167404

Ablepharon-Macrostomia Syndrome

Clinical Characteristics

Ocular Features

The clinical features of this syndrome remain to be fully delineated.  Important ocular anomalies include malformations and sometimes absence of the upper and lower eyelids.  The eyelashes and eyebrows may be sparse or even missing.  The lid fissures, if present, may be shortened.  Deformities of the eyelids can lead to corneal exposure and secondary vision loss. 

Systemic Features

Other facial malformations include macrostomia which may be secondary to aberrant lip fusion.  Micrognathia has been described.  The external ears are often rudimentary, sometimes described as rosebuds.  The nasal bridge is low and the nostrils anteverted.  The zygomatic arches may be absent.  The nipples are often missing as well.  Scalp hair is sparse or even absent while the skin is dry, coarse, and often has redundant folds (cutis laxa).  Mild skin syndactyly, camptodactyly, finger contractures, and shortening of metacarpals have been noted.  The genitalia are often ambiguous and some patients have had ventral hernias.  Hearing loss can be a feature.  Growth retardation has been seen but developmental delays if present are mild.  Intelligence can be normal. 

Genetics

The majority of sibships suggest autosomal recessive inheritance although autosomal dominant inheritance has been proposed for several. One male child has been reported to have a partial deletion of chromosome 18 but other complex rearrangements were also present. 

Treatment Options

Cosmetic surgery can correct at least some of the malformations. Vigorous effort may be required to maintain corneal surface wetting. 

References

Rohena L, Kuehn D, Marchegiani S, Higginson JD. Evidence for autosomal dominant inheritance of ablepharon-macrostomia syndrome. Am J Med Genet A. 2011 Apr;155(4):850-4.

PubMed ID: 
21595001

Stevens CA, Sargent LA. Ablepharon-macrostomia syndrome. Am J Med Genet. 2002 Jan 1;107(1):30-7.

PubMed ID: 
11807864

Cruz AA, Souza CA, Ferraz VE, Monteiro CA, Martins FA. Familial occurrence of ablepharon macrostomia syndrome: eyelid structure and surgical considerations. Arch Ophthalmol. 2000 Mar;118(3):428-30.

PubMed ID: 
10721975

Ferraz VE, Melo DG, Hansing SE, Cruz AA, Pina-Neto JM. Ablepharon-macrostomia syndrome: first report of familial occurrence. Am J Med Genet. 2000 Oct 2;94(4):281-3.

PubMed ID: 
11038439

Adrenoleukodystrophy, Autosomal

Clinical Characteristics

Ocular Features

This early onset and rapidly progressive form of adrenoleukodystrophy is rare.  The early onset and rapidly fatal course of the disease has limited full delineation of the ocular features.  The most striking is the presence of ‘leopard-spots’ pigmentary changes in the retina.  Polar cataracts, strabismus, and epicanthal folds have also been reported. 

Systemic Features

Onset of symptoms occurs shortly after birth often with seizures and evidence of psychomotor deficits.  Rapid neurologic deterioration begins at about 1 year of age with death usually by the age of 3 years.  Hyperpigmentation of the skin may be apparent a few months after birth.  Opisthotonus has been observed.  The ears may be low-set, the palate is highly arched, and the nostrils anteverted.  Frontal bossing may be present.  Serum pipecolic acid and very-long-chain fatty acids (VLCFAs) can be markedly elevated.  Cystic changes in the kidneys have been reported. 

Genetics

This is an autosomal recessive peroxismal disorder resulting from homozygous mutations in receptor gene mutations such as PEX1, PEX5, PEX13, and PEX26.

There is also an X-linked recessive adrenoleukodystrophy (300100) sometimes called ALD but it lacks some of the morphologic features and is somewhat less aggressive. 

Neonatal adrenoleukodystrophy along with infantile Refsum disease (266510, 601539) and Zellweger syndrome (214100) are now classified as Zellweger spectrum or perioxismal biogenesis disorders.

Treatment Options

Treatment is mainly supportive for associated health problems. 

References

Chen WW, Watkins PA, Osumi T, Hashimoto T, Moser HW. Peroxisomal beta-oxidation enzyme proteins in adrenoleukodystrophy: distinction between X-linked adrenoleukodystrophy and neonatal adrenoleukodystrophy. Proc Natl AcadSci U S A. 1987 Mar;84(5):1425-8.

PubMed ID: 
3469675

Cohen SM, Green WR, de la Cruz ZC, Brown FR 3rd, Moser HW, Luckenbach MW, Dove DJ, Maumenee IH. Ocular histopathologic studies of neonatal and childhood adrenoleukodystrophy. Am J Ophthalmol. 1983 Jan;95(1):82-96.

PubMed ID: 
6295171

Neuraminidase Deficiency

Clinical Characteristics

Ocular Features

A cherry red spot is may be seen in late childhood or early adolescence.  It occurs in nearly 100% of patients with type I while only 75% of type II patients have this feature possibly because their early death from the more severe systemic disease prevents full ascertainment.  Visual acuity is reduced, sometimes severely.  Some but not all individuals have corneal and lens opacities.  A subtle corneal haze has also been seen.  Nystagmus has been reported. 

Systemic Features

This is a neurodegenerative disorder with progressive deterioration of muscle and central nervous system functions.  Myoclonus, mental deterioration, hepatosplenomegaly, muscle weakness and atrophy are common.  The defect in neuraminidase activity leads to abnormal amounts of sialyl-oligosaccharides in the urine.  Spinal deformities such as kyphosis are common.  Deep tendon reflexes are exaggerated.  Ataxia and hearing loss may be present.  Coarse facies, a barrel chest, and short stature are characteristic.  Hepatic cells contain numerous vacuoles and numerous inclusions.

Sialidosis types I and II are both caused by mutations in the neuroaminidase gene.  Type I is associated with milder disease than type II which has an earlier age of onset and may present in infancy or even begin in utero.  Early death within two years of age is common in the congenital or infantile forms.  There is, however, significant variability in age of onset and the course of disease among types. 

Genetics

The sialidoses are autosomal recessive lysosomal storage disorders resulting from mutations in the NEU1 gene (6p21.3) which lead to an intracellular accumulation of glycoproteins containing sialic acid residues.  Both types I and II are caused by mutations in the same gene. 

Treatment Options

Treatment is focused on symptom management. 

References

Heroman JW, Rychwalski P, Barr CC. Cherry red spot in sialidosis (mucolipidosis type I). Arch Ophthalmol. 2008 Feb;126(2):270-1.

PubMed ID: 
18268224

Goldberg MF. Macular cherry-red spot and corneal haze in sialidosis (mucolipidosis type 1). Arch Ophthalmol. 2008 Dec;126(12):1778; author reply 1778.

PubMed ID: 
19064869

Federico A, Cecio A, Battini GA, Michalski JC, Strecker G, Guazzi GC. Macular cherry-red spot and myoclonus syndrome. Juvenile form of sialidosis. J Neurol Sci. 1980 Nov;48(2):157-69.

PubMed ID: 
7431038

Sandhoff Disease

Clinical Characteristics

Ocular Features

Retinal ganglion cells become dysfunctional as a result of the toxic accumulation of intra-lysosomal GM2 ganglioside molecules causing early visual symptoms.  These cells in high density around the fovea centralis create a grayish-white appearance.  Since ganglion cells are absent in the foveolar region, this area retains the normal reddish appearance, producing the cherry-red spot.  Axonal decay and loss of the ganglion cells leads to optic atrophy and blindness. 

Systemic Features

Sandhoff disease may be clinically indistinguishable from Tay-Sachs disease even though the same enzyme is defective (albeit in separate subunits A and B that together comprise the functional enzymes).  The presence of hepatosplenomegaly in Sandoff disease may be distinguishing. The infantile form of this lysosomal storage disease seems to be the most severe.  Infants appear to be normal until about 3-6 months of age when neurological development slows and muscles become weak.  Seizures, loss of interest, and progressive paralysis begin after this together with loss of vision and hearing.  An exaggerated startle response is considered an early and helpful sign in the diagnosis.  Among infants with early onset disease, death usually occurs by 3 or 4 years of age.   

Ataxia with spinocerebellar degeneration, motor neuron disease, dementia, and progressive dystonia are more common in individuals with later onset of neurodegeneration.  The juvenile and adult-onset forms of the disease also progress more slowly.  

Genetics

Sandhoff disease results from mutations in the beta subunit of the hexosaminidase A and B enzymes.  It is an autosomal recessive disorder caused by mutations in HEXB (5q13). 

Tay-Sachs disease (272800) can be clinically indistinguishable from Sandoff disease and they are allelic disorders.  However, the mutation in Tay-Sachs (272800) is in HEXA resulting in dysfunction of the alpha subunit of hexosaminidase A enzyme. 

Treatment Options

No specific treatment is available beyond general support with proper nutrition and maintainence of airways.  Anticonvulsants may be helpful in some stages.  Gene therapy in fibroblast cultures has achieved some restoration of  hexosaminidase A activity in Tay-Sachs disease and may have potential in Sandhoff disease as well. 

References

Myerowitz R, Lawson D, Mizukami H, Mi Y, Tifft CJ, Proia RL. Molecular pathophysiology in Tay-Sachs and Sandhoff diseases as revealed by gene expression profiling. Hum Mol Genet. 2002 May 15;11(11):1343-50.

PubMed ID: 
12019216

Neufeld EF. Natural history and inherited disorders of a lysosomal enzyme, beta-hexosaminidase. J Biol Chem. 1989 Jul 5;264(19):10927-30. Review.

PubMed ID: 
2525553

Gilbert F, Kucherlapati R, Creagan RP, Murnane MJ, Darlington GJ, Ruddle FH. Tay-Sachs' and Sandhoff's diseases: the assignment of genes for hexosaminidase A and B to individual human chromosomes. Proc Natl Acad Sci U S A. 1975 Jan;72(1):263-7.

PubMed ID: 
1054503

Donnai-Barrow Syndrome

Clinical Characteristics

Ocular Features

A number of ocular features have been described in this disorder, including telecanthus, hypertelorism, and iris hypoplasia.  Patients may have marked iris transillumination.  Myopia is commonly present and retinal detachments are a risk.  Several patients had iris colobomas.  Cataracts, small optic nerves, and macular hypoplasia have been reported as well.  The lid fissures usually slant downward. 

Systemic Features

The facial dysmorphology, in addition to the periocular malformations, includes a prominent brow or frontal bossing, posterior rotation of the ears, a flat nasal bridge and a short nose.  Sensorineural hearing loss is universal and at least some patients have complete or partial agenesis of the corpus callosum, and an enlarged anterior fontanel.  Diaphragmatic and umbilical hernias often occur together.  Low-molecular-weight proteinuria in the absence of aminoaciduria is a frequent feature.  Developmental delays are often seen but occasional patients have normal intellect.  Rare patients have seizures. 

Genetics

This is a rare autosomal recessive disorder caused by homozygous mutations in the LRP2 (low-density lipoprotein receptor-related protein 2 or megalin) gene located at 2q24-q31.  Some patients have an ocular phenotype resembling the Stickler syndrome.

Treatment Options

Treatment is focused on specific manifestations such as cataract and retinal detachment surgery. Patients need to be monitored throughout life for retinal disease.  Omphaloceles and diaphragmatic hernias need to be repaired.  Hearing aids may be beneficial. 

References

Schrauwen I, Sommen M, Claes C, Pinner J, Flaherty M, Collins F, Van Camp G. Broadening the phenotype of LRP2 mutations: a new mutation in LRP2 causes a predominantly ocular phenotype suggestive of Stickler syndrome. Clin Genet. 2013 Aug 29. [Epub ahead of print] PubMed PMID: 23992033.

PubMed ID: 
23992033

Pober BR, Longoni M, Noonan KM. A review of Donnai-Barrow and facio-oculo-acoustico-renal (DB/FOAR) syndrome: clinical features and differential diagnosis. Birth Defects Res A Clin Mol Teratol. 2009 Jan;85(1):76-81. Review.

PubMed ID: 
19089858

Patel N, Hejkal T, Katz A, Margalit E. Ocular manifestations of Donnai-Barrow syndrome. J Child Neurol. 2007 Apr;22(4):462-4.

PubMed ID: 
17624530

Chassaing N, Lacombe D, Carles D, Calvas P, Saura R, Bieth E. Donnai-Barrow syndrome: four additional patients. Am J Med Genet A. 2003 Sep 1;121A(3):258-62. Review.

PubMed ID: 
12923867

Schowalter DB, Pagon RA, Kalina RE, McDonald R. Facio-oculo-acoustico-renal (FOAR) syndrome: case report and review. Am J Med Genet. 1997 Mar 3;69(1):45-9; discussion 44. Review.

PubMed ID: 
9066882

Neuronal Ceroid Lipofuscinoses

Clinical Characteristics

Ocular Features

At least 10 genotypically distinct forms of neuronal ceroid lipofuscinosis have been described.  The ocular features are highly similar in all forms with blindness the end result in all types (although not all cases with an adult onset suffer vision loss).  The onset of visual signs and symptoms is highly variable.  Optic atrophy is the most common finding which may occur as early as two years of age in the infantile form.  Night blindness is a symptom in those with a later onset but panretinal degeneration with unrecordable ERGs eventually occurs.  Pigmentary changes throughout the retina are often seen and sometimes occur in a bull’s-eye pattern.  Retinal blood vessels may be attenuated and lens opacities of various types are common. 

Systemic Features

The neuronal ceroid lipofuscinosis are a group of inherited neurodegenerative lysosomal-storage disorders characterized by the intracellular accumulation of autofluorescent lipopigment causing damage predominantly in the central nervous system.  The result is a progressive encephalopathy with cognitive and motor decline, eventual blindness, and seizures with early death.  While early descriptions distinguished several types based primarily on age of onset, genotyping has now identified responsible mutations in at least 10 genes and time of onset is no longer considered a reliable indicator of the NCL type. 

Genetics

The NCLs are usually inherited in autosomal recessive patterns with the exception of some adult onset cases in which an autosomal dominant pattern is sometimes seen.

The various forms of NCL are often divided according to ages of onset but overlap is common.  Thus the congenital form (CLN10; 610127), caused by a mutation in the CTSD gene at 11p15.5, can have an onset of symptoms at or around birth but also is responsible for an adult form (Vida infra).  The CLN1 infantile form (256730), caused by a mutation in the PPT1 gene at 1p32, has an onset between 6 and 24 months  There are several mutations causing late infantile disease (CLN2, 204500) involving the TPP1 gene (11p15.5) leading to symptoms between 2-4 years, the CLN5 gene (256731) at 13q21.1-q32 with onset between 4 and 7 years, the CLN6 gene (601780) at 15q21-q23 showing symptoms between 18 months and 8 years, and the CLN8 gene (610003) at 8p23 with symptoms beginning between 3 and 7 years.  Another early juvenile form (CLN7; 610951) is caused by mutations in MFSD8 (4q228.1-q28.2).

A juvenile form (sometimes called Batten disease or Spielmeyer-Vogt with onset between 4 and 10 years results from mutations in CLN3 (204200) as well as in TPP1, PPT1, and CLN9 (609055).  An adult form known as ANCL or Kuf’s disease results from mutations in CTSD, PPT, CLN3, CLN5, and CLN4 (204300) and has its onset generally between the ages of 15 and 50 years. 

Homozygous mutations in the ATP13A2 gene (1p36.13), known to cause Kufor-Rakeb type parkinsonism (606693), have also been found in NCL.

Treatment Options

Treatment is primarily symptomatic for sleep disorders, seizures, psychoses, malnutrition, dystonia and spasticity.  However, there is recent progress in the application of enzyme-replacement therapies in the soluble lysosomal forms of CNL.  Gene therapies and the use of stem cells also hold promise. 

References

Bras J, Verloes A, Schneider SA, Mole SE, Guerreiro RJ. Mutation of the Parkinsonism Gene ATP13A2 Causes Neuronal Ceroid-Lipofuscinosis. Hum Mol Genet. 2012 Mar 2. [Epub ahead of print].

PubMed ID: 
22388936

Wong AM, Rahim AA, Waddington SN, Cooper JD. Current therapies for the soluble lysosomal forms of neuronal ceroid lipofuscinosis. Biochem Soc Trans. 2010 Dec;38(6):1484-8.

PubMed ID: 
21118112

Goebel HH. The neuronal ceroid-lipofuscinoses. J Child Neurol. 1995 Nov;10(6):424-37.

PubMed ID: 
8576551

Hyperoxaluria, Primary, Type I

Clinical Characteristics

Ocular Features

About 30% of patients with type I develop retinopathy and about half of those have a diffuse optic atrophy.  Oxalate crystal deposition can cause a ‘fleck retina’ picture sometimes described as a crystalline retinopathy.  Retinal toxicity leads to early and progressive vision loss.  The RPE may respond with hyperpigmentation in the form of 'ringlets' in the posterior pole.  Retinal fibrosis has been described.  Some patients develop choroidal neovascularization.

Evaluation using EDI-OCT shows progressive deposition of oxalate crystals throughout the retina, pigment epiithelium, and choroid.

Systemic Features

The onset of this disease can occur any time from infancy to 25 years of age.  Failure to thrive can be a presenting sign in infants.  Most patients have glycolic aciduria and hyperoxaluria as the result of failure to transaminate glyoxylate to form glycine.  The result is deposition of insoluble oxalate crystals in various body tissues with nephrolithiasis and nephrocalcinosis often early signs.  Neurologic, cardiac, vascular, and kidney disease is often the result although oxalate crystals can be found throughout the body.  Arteriole occlusive disease may lead to gangrene, Raynaud phenomena, acrocyanosis and intermittent claudication.  Renal failure is common. 

Genetics

Hyperoxaluria type I is an autosomal recessive disorder resulting from a mutation in the alanine-glyoxylate aminotransferase gene (AGXT) located at 2q36-q37.  Failure of this liver peroxisomal enzyme to transaminate glyoxylate results in oxidation of this molecule to form oxalate.

Hyperoxaluria type II (260000) is caused by mutations in the GRHPR gene (9cen) and type III (613616) by mutations in DHDPSL (HOGA1) (10q24.2).  Urolithiasis is the only clinical feature in these types. 

Treatment Options

Some patients benefit from oral pyridoxine (B6) treatment in type I hyperoxaluria.  Renal transplantation by itself is only temporarily helpful since the enzymatic defect remains and the donor tissue becomes damaged as well.  Combined renal-liver transplantation should be considered instead because it corrects the primary metabolic error and can even reverse the accumulation of oxalate crystals. 

References

Cochat P, Rumsby G. Primary hyperoxaluria. N Engl J Med. 2013 Aug 15;369(7):649-58. Review.

PubMed ID: 
23944302

Roth BM, Yuan A, Ehlers JP. Retinal and Choroidal Findings in Oxalate Retinopathy Using EDI-OCT. Ophthalmic Surg Lasers Imaging. 2012 Nov 1;43(6):S142-4. doi: 10.3928/15428877-20121001-05.

PubMed ID: 
23357321

Beck BB, Hoyer-Kuhn H, Göbel H, Habbig S, Hoppe B. Hyperoxaluria and systemic oxalosis: an update on current therapy and future directions. Expert Opin Investig Drugs. 2012 Nov 21. [Epub ahead of print].

PubMed ID: 
23167815

Theodossiadis PG, Friberg TR, Panagiotidis DN, Gogas PS, Pantelia EM, Moschos MN. Choroidal neovascularization in primary hyperoxaluria. Am J Ophthalmol. 2002 Jul;134(1):134-7.

PubMed ID: 
12095827

Cochat P, Koch Nogueira PC, Mahmoud MA, Jamieson NV, Scheinman JI, Rolland MO. Primary hyperoxaluria in infants: medical, ethical, and economic issues. J Pediatr. 1999 Dec;135(6):746-50.

PubMed ID: 
10586179

Small KW, Letson R, Scheinman J. Ocular findings in primary hyperoxaluria. Arch Ophthalmol. 1990 Jan;108(1):89-93.

PubMed ID: 
2297338

Niemann-Pick Disease, Type C2

Clinical Characteristics

Ocular Features

The primary ocular feature of type C2 Niemann-Pick disease is supranuclear gaze palsy.  A cherry red spot is rarely seen. 

Systemic Features

Neurodegeneration is the outstanding clinical manifestation and often the cause of death.  The onset usually occurs in infancy and the course is rapid with death often in the first year of life.  The clinical disease is similar to that of the more common type C1 (257220) although there is considerable clinical heterogeneity in all types of NPC.  Pulmonary involvement can be a prominent feature of C2 disease.  Other neurologic symptoms include ataxia, facial dyskinesis, bradykinesia, expressive aphasia, dysarthria and cognitive decline.  Visceromegaly seems to be less common than in type C1 (257220).  Cholesterol esterification is impaired with accumulation in intracellular organelles. 

Genetics

Like other types of NPC disease, this disorder follows an autosomal recessive pattern of inheritance.  It results from mutations in the NPC2 gene (14q24.3).  These mutations are far less common than those in the NPC1 (257220)gene.  

Treatment Options

Treatment is available for symptoms such as seizures and dystonia.  Good pulmonary hygiene is important and precautions should be taken to prevent aspiration. 

References

Verot L, Chikh K, Freydière E, Honoré R, Vanier MT, Millat G. Niemann-Pick C disease: functional characterization of three NPC2 mutations and clinical and molecular update on patients with NPC2. Clin Genet. 2007 Apr;71(4):320-30.

PubMed ID: 
17470133

Verot L, Chikh K, Freydière E, Honoré R, Vanier MT, Millat G. Niemann-Pick C disease: functional characterization of three NPC2 mutations and clinical and molecular update on patients with NPC2. Clin Genet. 2007 Apr;71(4):320-30.

PubMed ID: 
17470133