growth retardation

Smith-Lemli-Opitz Syndrome

Clinical Characteristics
Ocular Features: 

A large number of ocular anomalies have been found in SLO syndrome but the most common is blepharoptosis of some degree.  No consistent pattern of ocular abnormalities has been reported.  Atrophy and hypoplasia of the optic nerve, strabismus, nystagmus, and cataracts may be present.   Abnormally low concentrations of cholesterol and cholesterol precursors have been found in all ocular tissues studied.

Systemic Features: 

This is a syndrome of multiple congenital anomalies.  Among these are dwarfism, micrognathia, hard palate anomalies, hypotonia, anomalies of the external genitalia, polysyndactyly, microcephaly, and mental retardation.  It has been suggested that many individuals have a characteristic behavioral profile consisting of cognitive delays, hyperreactivity, irritability, language deficiency, and autism spectrum behaviors.  Some individuals exhibit aspects of self destructive behavior.  Tissue levels of cholesterol are low.

Genetics

SLO syndrome is an autosomal recessive disorder resulting from mutations in the sterol delta-7-reductase  (DHCR7) gene mapped to 11q12-q13. The result is a defect in cholesterol synthesis.

The clinical features significantly overlap those seen in Meckel (249000) and Joubert (213300) syndromes.

Pedigree: 
Autosomal recessive
Treatment
Treatment Options: 

A high cholesterol diet has been reported to have a beneficial effect on behavior and general well-being.

References
Article Title: 

Gaucher Disease

Clinical Characteristics
Ocular Features: 

Gaucher disease is often divided into three clinical types, I, II, and III although all are caused by mutations in the same gene.  Type I, sometimes called nonneuronopathic type I, has ocular features including white deposits in anterior chamber structures such as the corneal endothelium, pupillary margin, and the angle, as well as in the ciliary body.  Pingueculae can be prominent.  The perimacular retina often appears grayish and also can show some white spots.  These may also be seen in the posterior vitreous in at least some patients with type III  There may be pigmentary changes in the macula and uveitis occurs rarely.  Macular atrophy has been reported and the retinal vasculature may be abnormally permeable. Corneal opacities have been seen in some patients.  Oculomotor apraxia and abnormal opticokinetic responses are common in types II and III.  Visual acuity may be in the range of 20/200.

Other conditions with ataxia and oculomotor apraxia are: ataxia with oculomotor apraxia 1 (208920), ataxia with oculomotor apraxia 2 (602600), ataxia-telangiectasia (208900) and Cogan-type oculomotor apraxia (257550) which lacks other neurologic signs.

Systemic Features: 

This is a severe systemic disease with perinatal lethality in some patients.  The range of clinical heterogeneity is wide, however, and minimally affected adult patients have also been described.  Individuals with nonneuropathic type I lack central nervous system involvement.  They often do have hepatosplenomegaly and pancytopenia with bone marrow involvement which are common to all types.  The latter may be responsible for frequent bone fractures and other orthopedic complications such as vertebral compression.  Thrombocytopenia with bleeding complications contributes to the primary anemia which is also present.  Interstitial lung disease can be seen in type I disease but occurs in less than 5% of patients. This is the most common of the three types. 

Patients with type I Gaucher disease have an increased risk of cancer, especially those of the hematological system.  For example, the risk for multiple myeloma has been estimated to be 37 times higher than in the general population.  There is also evidence of an increased incidence of multiple consecutive cancers in this condition.  Enzyme replacement therapy may reduce the risk of malignancies.

Patient with types II (acute neuronopathic [230900]) and III (subacute neuronopathic [231000]) are more likely to have neurologic disease with bulbar and pyramidal signs and sometimes seizures.  In type II, onset is in infancy and lifespan is about 2 years.   They have hepatosplenomegaly with growth arrest and developmental delays after a few months.  The clinical signs in type III or subacute neuronopathic type the onset is later (2.5 years to adulthood) than in type II and progression of neurologic disease is slower.  Early childhood development may appear normal for several years until abnormal extraocular movements or seizures are observed.  Type III is sometimes called Norrbottnian type.

Genetics

All three types of Gaucher disease are caused by mutations in the GBA (glucocerebrosidase) gene (1q21) and are inherited in an autosomal recessive pattern.

Evidence indicates that SCARB2, which codes for lysosomal integral membrane protein type 2 (LIMP-2), is a modifier of the phenotype in Gaucher disease.

Pedigree: 
Autosomal recessive
Treatment
Treatment Options: 

Supportive care is required for all patients.  Splenectomy may be required for thrombocytopenia and blood transfusion can be helpful in severe anemia and excessive bleeding.  The course of disease is highly variable in all types, ranging from neonatal mortality to mild disease into adulthood, especially for individuals with type III.  Testing for deficiency in glucosylceramidase enzyme activity in leukocytes can be diagnostic.   Enzyme replacement or substrate reduction therapies can reduce the severity of clinical disease especially in type I disease but less so in types II and III.

References
Article Title: 

The clinical management of type 2 Gaucher disease

Weiss K, Gonzalez AN, Lopez G, Pedoeim L, Groden C, Sidransky E. The clinical management of type 2 Gaucher disease. Mol Genet Metab. 2014 Nov 14.  [Epub ahead of print] Review.

PubMed ID: 
25435509

A Mutation in SCARB2 is a Modifier in Gaucher Disease

Velayati A, Depaolo J, Gupta N, Choi JH, Moaven N, Westbroek W, Goker-Alpan O, Goldin E, Stubblefield BK, Kolodny E, Tayebi N, Sidransky E. A Mutation in SCARB2 is a Modifier in Gaucher Disease. Hum Mutat. 2011 Jul 27. doi: 10.1002/humu.21566. [Epub ahead of print]

PubMed ID: 
21796727

Cornelia de Lange Syndrome

Clinical Characteristics
Ocular Features: 

Many patients have few ocular findings beyond the usual synophyrs, a highly arched brow with hypertrichosis, and long eyelashes.  Synophrys is often prominent.  However, some also have significant ptosis, nystagmus, and high refractive errors.  Optic pallor and a poor macular reflex have also been reported.

Systemic Features: 

The facial features may be distinctive with low anterior hairline, anteverted nares, maxillary prognathism, long philtrum, crescent-shaped mouth and, of course, the bushy eyebrows and long lashes (in 98%).  Mental and growth retardation are common while many patients have features of the autism spectrum and tend to avoid social interactions.  The lips appear thin, the mouth is crescent-shaped, the head is often small, the teeth are widely spaced, and the ears are low-set.  The hands are often deformed with a proximally positioned thumb and metacarpophalangeal deformities.  It is stated that the middle phalanx of the index finger is always hypoplastic.  Other limb abnormalities of both upper (95%) and lower extremities are common.  Urinary tract abnormalities have been found in 41% of patients.  Middle ear effusions often lead to conductive hearing loss but 80% of patients have a sensorineural hearing deficit.

Genetics

This disorder is caused by mutations in genes encoding components of the cohesion complex.  Most cases occur sporadically but numerous familial cases suggest autosomal dominant inheritance. However, since at least three genes code for components of the cohesion complex including one located on the X-chromosome (610759), familial cases reported earlier without genotyping have created some confusion.  Hence, even autosomal recessive inheritance has been suggested in some families.  Genetic counseling should be family-specific based on the genotype and family pattern.

About 50% of cases result from mutations in the NIPBL gene (122470; 5p13.1) but less than 1% have an affected parent and the recurrence risk for sibs is similar.  The X-linked form of CDLS (300590; Xp11.22-p11.21) is caused by a mutation in the SMC1A gene, and a mild form (610759) results from mutations in the SMC3 gene (10q25).  Mutations in RAD21 (8q24) have been found in patients with milder disease and atypical presentations (614701).

A CDLS phenotype can also result from a specific duplication of a 3q 26-27 band.

Pedigree: 
Autosomal dominant
Autosomal recessive
Treatment
Treatment Options: 

No genetic treatment is available.

References
Article Title: 

Rhizomelic Chondrodysplasia Punctata

Clinical Characteristics
Ocular Features: 

Congenital cataracts are the outstanding ocular feature of this syndrome and are present in over 70% of patients.  They are usually bilateral and symmetrical and may not be present for several months after birth.

Systemic Features: 

The name of this disorder comes from the punctate calcification seen in cartilage.   The vertebrae have coronal clefting.  The cartilage abnormalities result in defective bone growth with severe growth retardation, short stature, and joint contractures.  Many infants die during the neonatal period and few survive beyond the first decade of life. However, milder forms have been reported. The skin can be ichthyotic and severe mental retardation is often accompanied by seizures.  Red cells are deficient in plasmalogens while phytanic acid and very long chain fatty acids accumulate in the plasma, a biochemical profile characteristic of RCDP1.

Other types of chondrodysplasia punctata also exist (RCDP2 and RCDP3). The X-linked recessive (CDPX1; 302950), autosomal dominant tibia-metacarpal (118651), and humero-metacarpal types are not associated with cataracts.

A phenocopy sometimes results from maternal ingestion of dicoumarol in early pregnancy.

Genetics

This rare autosomal recessive condition results from mutations in the PEX7 gene (6q22-q24) causing a peroxisomal biogenesis disorder.  Some clinical features overlap with those of Zellweger syndrome (214100) and infantile Refsum disease (266510), also peroxisomal biogenesis disorders. 

Mutations in the same gene are responsible for adult Refsum disease-2 (266500).  The latter, however, has other neurological symptoms as well as clinical features of retinitis pigmentosa with night blindness and restricted visual fields.

Pedigree: 
Autosomal recessive
Treatment
Treatment Options: 

No treatment is available beyond supportive measures. Cataract removal may improve vision but the poor prognosis for longevity requires caution be used.

References
Article Title: 

Baller-Gerold Syndrome

Clinical Characteristics
Ocular Features: 

The ocular features are a rather minor part of this syndrome and are found in less than a third of patients.  These primarily involve lids and adnexae with telecanthus, downslanting lid fissures, and epicanthal folds.  Some individuals have nystagmus while strabismus, blue sclerae, and ectropion have also been reported.

Systemic Features: 

The cardinal features of this syndrome are craniosynostosis and radial defects.  However, a large number of variable defects such as imperforate or anteriorly placed anus, rectovaginal fistula, absent thumbs, polydactyly, and mental retardation may also be present.  The radius may be completely absent or abnormally formed and occasionally the ulnar bone is involved as well.  Some patients have a conductive hearing loss.

Genetics

This syndrome is caused by a mutation in the RECQL4 gene at 8q24.3 and seems to be an autosomal recessive disorder.  Its syndromal status as a unique syndrome is in some doubt because of considerable phenotypic overlap with other entities such as Roberts (268300) and Saethre-Chotzen (101400) syndromes.  The latter however is caused by a mutation in the TWIST1 gene and the former by mutations in the ESCO2 gene.

The same gene is mutated in Rothmund-Thomson syndrome (268400) suggesting allelism of the two disorders.  The phenotype is vastly different in the two disorders however.

Pedigree: 
Autosomal recessive
Treatment
Treatment Options: 

No treatment is available.

References
Article Title: 

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